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10/14/2015
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The EyeThe Window to the Body
Craig Cassidy D.O.
Phoenix
DISCLOSURES:
NONE
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OCULAR MANIFESTATION
SYSTEMIC DISEASE
CATEGORIES OF SYSTEMIC DISEASE
Congenital Traumatic Vascular Neoplastic Autoimmune
Idiopathic Infectious Metabolic/Endocrine Drugs/Toxins
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CONGENITAL DISORDERS
Down Syndrome Marfan Syndrome Myotonic Dystrophy Tuberous Sclerosis Congenital Metabolic Disorders
• Lysosomal Storage• Carbohydrate Metabolism
Neurofibromatosis
HYPERTENSION: FACTORS AFFECTING RETINAL ARTERIOLES
Severity Duration
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HYPERTENSIVE RETINOPATHY SYMPTOMS
Symptoms: Blurred Vision
**May cause occlusion of retinal artery or vein**
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INTRACRANIAL HYPERTENSION:CAUSES
Brain Tumor Meningitis Venous Sinus Thrombosis Hydrocephalus Idiopathic Intracranial Hypertension
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AMAUROSIS FUGAX
Monocular Dimming of Vision Temporary Arterial Obstruction Sudden, Transient, Painless Visual Loss
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AMAUROSIS FUGAX: EVALUATION
Cardiovascular Cerebrovascular Ophthalmologic
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CENTRAL RETINAL ARTERY OCCLUSION: MANAGEMENT
Rebreathing CO2 Topical Beta Blockers Intravenous Acetazolamide 500mg Massaging of Globe with lids closed Anterior Chamber Paracentesis Calcium Channel Blockers Hyperbaric O2
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BLOOD DYSCRASIAS WITH OCULAR MANIFESTATIONS
Hyperviscosity Syndrome Thrombocytopenia Anemia, including Sickle Cell Anemia
HYPERVISCOSITY SYNDROMES: OCULAR SYMPTOMS
Amaurosis Fugax Permanent Visual Loss
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SICKLE CELL RETINOPATHY
HbSC Disease (most common form) HbSS Disease Sickle Thalassemia
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MALIGNANT NEOPLASMS INVOLVING THE EYE
Primary Ocular Melanoma Large Cell Lymphoma Metastatic Carcinoma
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METASTATIC CARCINOMA
Most common intraocular malignancy in adults May be asymptomatic May produce decreased or distorted vision
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OCULAR METASTASIS: TREATMENT
Local radiation Chemotherapy Eye wall resection Enucleation if blind, painful eye
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AUTOIMMUNE DISORDERS
Connective tissue diseases Thyroid eye disease Myasthenia gravis
CONNECTIVE TISSUE DISORDERS
Dry eyes are the most common manifestation. Symptoms:
• Burning• Foreign Body Sensation• Photophobia
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SJÖRGRENS SYNDROME
Dry eyes Dry mouth ±Connective tissue disorder Specific antibodies
DRY EYES: TREATMENT
Artificial tears Lubricating ointment at night Punctal occlusion Restasis (Cyclosporine) Mild Topical Steroids Environmental modification
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RHEUMATOID ARTHRITIS: OCULAR MANIFESTATIONS
Dry eyes Episcleritis Scleritis Corneal ulcers Uveitis
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SYSTEMIC LUPUS ERYTHEMATOSUS: OCULAR MANIFESTATIONS
Dry eyes Scleritis Peripheral corneal ulcers Retinopathy and optic neuropathy
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GIANT CELL ARTERITIS: SYMPTOMS
Headache Scalp tenderness Jaw claudication Polymyalgia rheumatica Acute visual loss
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GIANT CELL ARTERITIS: DIAGNOSIS
Clinical history STAT ESR, CRP Fluorescein angiogram Temporal artery biopsy
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If GCA is suspected, begin treatment immediately with high-dose corticosteroids daily
Do not wait for results of temporal artery biopsy
THYROID OPHTHALMOPATHY
Not always correlated with serum thyroid levels Can progress after thyroid function is normal
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THYROID OPHTHALMOPATHY: CLASSES
1. No signs or symptoms2. Only signs3. Soft tissue involvement4. Proptosis5. Extraocular muscle involvement6. Corneal damage7. Sight loss
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THYROID OPHTHALMOPATHY: TREATMENT OF CONGESTIVE PHASE Tear subsitutes Corticosteroids Orbital irradiation or surgical decompression
THYROID OPHTHALMOPATHY: TREATMENT OF CICATRICIAL PHASE
Lid surgery Muscle surgery Orbital surgery
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MYASTHENIA GRAVIS: SYSTEMIC INVOLVEMENT
Refer suspects for neurologic evaluation
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AIDS:OCULAR MANIFESTATIONS
Dry eye Cotton-wool spots CMV retinitis Kaposi’s sarcoma (eyelid or conjunctiva)
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CMV RETINITIS:THERAPY
IV ganciclovir IV foscarnet Intravitreal ganciclovir Implantable pellets of sustained-release ganciclovir into vitreous
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SYSTEMIC MEDICATIONS
Toxic Retinopathies• Thioridazine• Chloroquine• Tamoxifen Toxic Optic Neuropathies
• Ethambutol• Isoniazid• Fluoroquinolones
PRIMARY CARE PHYSICIAN
OPHTHALMOLOGIST
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AGE-RELATED MACULAR DEGENERATION (ARMD)
Most common cause of elderly visual loss Loss of central vision Risk factors:
• Advanced age• Fair skin• Family history of ARMD• Smoking & CV disease
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TYPES OF ARMD
Atrophic (“dry”) macular degeneration• Gradual vision loss• Drusen Exudative (“wet”) macular degeneration
• Sudden vision loss• Subretinal neovascularization• Accumulation of fluid & blood
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TYPES OF ARMD
Atrophic (“dry”) ARMD Caused by aging and thinning of macular tissues when drusen are present Vision loss is usually gradual Most common form
72With AMD, drusen are seen in the retina.
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TYPES OF ARMD
Exudative (“wet”) ARMD It is caused by abnormal blood vessels forming underneath the retina These vessels leak blood/fluid and blur central vision Vision loss may be rapid and severe
Age-Related Macular DegenerationWith wet AMD, abnormal blood vessels are present under the retina.
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ARMD: SYMPTOMS
Early• Difficulty reading, driving, etc.• Straight lines may be crooked Advanced: central blind spot Peripheral vision remains
• Independent living skills
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ARMD: MINIMIZING EFFECTS
Monitor vision with Amsler grid Stop smoking Control cardiovascular disease Diet high in fruits & vegetables lowers risk Antioxidants from food may be helpful
DIABETIC RETINOPATHY (DR)
Fourth most common cause of visual loss in elderly Type II diabetes more likely in elderly Macular edema more common with type II
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DR: MINIMIZING EFFECTS
PCP and ophthalmologist work together Good glycemic control
• Type I: insulin• Type II: diet, exercise, weight loss
CRANIAL NERVE PALSIES
Systemic ischemic disease can lead to palsies Cranial nerves III, IV, & VI control extraocular movements PCP & ophthalmologist manage together
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What is the Diagnosis?
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ENTROPION
Inward turning of eyelid Treatment is referral for surgery
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ECTROPION
Outward turning of eyelid Treatment is referral for surgery
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INFLAMED PINGUECULA & PTERYGIUM: MANAGEMENT
Artificial tears Topical vasoconstrictors If severe – refer
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HORDEOLUM / CHALAZION TREATMENT
Warm compresses TID Topical antibiotics Gram positive coverage Drops for lower lid Ointment for upper lid
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RETINAL DETACHMENT
Floaters Flashes of light “Curtain” or “Veil”peripherally Vision may be decreased
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