Ocular Manifestations of Systemic Diseases Dr.Turki AL- Turki Consultant Ophthalmlogist

1. THE EYE & THE BODY Ocular Manifestations of Systemic DiseasesDr.Turki AL-TurkiConsultant Ophthalmlogist

4. NORMAL FUNDUS

5. Cardiovascular diseases

6. Flame shaped hemorrhages Cotton wool spots Hard exudates Flame shaped hemorrhages

7. Central retinal vein occlusion Grade IV Hypertensive Retinopathy Branch retinal vein occlusion • Second most common cause of vascular-related visual loss. • Risk factors • Hypertension • Coagulopathy • Vasculitis (Behcets,sarcoidosis,AIDS,SLE)

8. Cardiovascular diseases Diagnostic workup • BP measurement • Lipid profile • ECG • Echocardiography • Carotid Doppler Consider risk factors • Hypertension • Carotid artery diseases • Cardiac Arrhythmias • Coagulopathy Central retinal artery occlusion OCULAR EMERGENCY

9. Diabetes Mellitus • A cause of 4000 new case of blindness/year. • Risk factors • Family history • Duration of disease • Type of DM • Use of insulin • Poor metabolic control • Presence of Co-morbid conditions • Hypertension • Hyperlipidemia • Renal disease • Smoking • Alcohol consumption • Anemia • Obesity • Pregnancy

10. Mild non-prolifrative diabetic retinopathy Moderate non-prolifrative diabetic retinopathy Sever non-prolifrative diabetic retinopathy

12. Proliferative diabetic retinopathy

13. Tractional retinal detachment

14. Argon laser pan-retinal photocoagulation (PRP). • Focal laser treatment for macular edema. • Intravitreal injection of steroids • Intravitreal injections of anti-vascular endothelial growth factor (Anti-VEGF)

15. Diabetes Mellitus • Third (Oculomotor) cranial nerve palsy. MAKE SURE THAT THE PUPIL IS NORMALLY REACTING IN 3RD NERVE PALSY Complete 3rd nerve palsy

16. Thyroid eye disease Unilateral lid retraction Unilateral proptosis Bilateral lid retraction Bilateral proptosis In 50% of cases

17. Thyroid eye disease 1. Soft tissue involvement • Periorbital and lid swelling • Conjunctivalhyperemia • Chemosis • Superior limbic keratoconjunctivitis 2. Eyelid retraction 3. Proptosis 4. Optic neuropathy 5. Restrictive myopathy

19. Lid lag on down gaze movement

20. Proptosis • Occurs in about 50% • not influenced by treatment of hyperthyroidism Axial and permanent in about 70% May be associated with choroidal folds Treatment options • Systemic steroids • Radiotherapy • Surgical decompression

21. Soft tissue involvement Periorbital and lid swelling Conjunctivalhyperaemia Superior limbic keratoconjunctivitis Chemosis

22. Optic neuropathy • Occurs in about 5% • Early defective colour vision • Usually normal disc appearance Caused by optic nerve compression at orbital apex by enlarged recti muscles Often occurs in absence of significant proptosis

23. Restrictive myopathy • Occurs in about 40% • Due to fibrotic contracture Elevation defect - most common Abduction defect - less common Depression defect -uncommon Adduction defect - rare

24. Inflammatory conditions (Sarcoidosis) • Idiopathic multisystem disorder • Characterised by non-caseatinggranuloma • More common in women 20-50 yrs • More common in blacks and Asians • Eyes – 30%

25. Inflammatory conditions (Sarcoidosis) • Anterior segment lesions (30%) • Conjunctivalgranuloma • Acute or chronic uveitis • Lacrimal gland involvement& dry eye • Posterior segment lesions (20%) • Patchy venous sheathing • Cellular infiltrate around vessels • Chorioretinalgranulonmas • Vasculitis • Neovascularisation • Infiltrate in vitreous (vitritis)

26. Sickle cell retinopathy Hyphema New vessel formation Sea fan neovascularization

27. Leukemia Sterile hypopyon White centered hemorrhage (Roth’s spot)

28. Metastasis Metastatic lung cancer Metastatic renal cell carcinoma Metastatic lymphoma

29. Neurofibromatosis type-1 (NF-1) Café-au-lait spots Most common phacomatosis Affects 1:4000 individuals Presents in childhood Appear during first year of life Increase in size and number throughout childhood

30. Eyelid neurofibromas in NF-1 Nodular Plexiform May cause mechanical ptosis May be associated with glaucoma

31. Intraocular lesions in NF-1 Lisch nodules Congenital ectropion uveae Very common - eventually present in 95% of cases Uncommon - may be associated with glaucoma Choroidal naevi Retinal astrocytomas Rare - identical to those seen in tuberous sclerosis Common - may be multifocal and bilateral

32. Very common - presenile cataract Ocular features of NF-2 Common - combined hamartomas of RPE and retina

33. Peripheral corneal involvement in Rheumatoid arthritis,Wegenergranulomatosis, polyarteritisnodosa Without inflammation With inflammation • Chronic and asymptomatic • Circumferential thinning with intact • epithelium (‘contact lens cornea’) • Acute and painful • Circumferential ulceration and • infiltration Treatment - systemic steroids and/or cytotoxic drugs

34. GIANT CELL ARTERITIS Systemic signs & symptoms • Headache • Scalp tenderness • Thickened temporal arteries • Jaw claudication • Acute visual loss • Weight loss, anorexia, fever, night sweats, malaise & depression Ocular Complications • Transient monocular visual loss (amaurosisfugax) • Visual loss due to • Central retinal artery occlusion (CRAO) or • Anterior ischaemic optic neuropathy (AION) • Visual field defects

35. Systemic infections • Tuberculosis • Syphilis • HIV • Toxoplasmosis • Brucellosis • Herpes zoster • Candida infection • Can affect any part of the eye • Lids optic nerve. • Can be limited to the eye only Difficult Dx • Requires systemic antimicrobial therapy PLUS Steroids • Can cause severe visual loss secondary to inflammation and infection.

36. Systemic infections Retinitis with vasculitis Endogenous endophthalmitis

37. Systemic infections Anterior Uveitis Herpes Zoster Ophthalmicus