OCULAR MANIFESTATIONSOCULAR MANIFESTATIONS
OFOF
SYSTEMIC DISEASESYSTEMIC DISEASE
Clint Gregg, M.D.Clint Gregg, M.D.TTUHSCTTUHSC
Department of OphthalmologyDepartment of Ophthalmology
Categories ofSystemic Disease
Congenital Traumatic Vascular Neoplastic Autoimmune
Idiopathic Infectious Metabolic/Endocrine Drugs/Toxins
EYE EXAMINATION
Vision External Pupils
• Relative afferent pupillary defect
Motility Exam of anterior
segment Dilated
ophthalmoscopy Visual Fields
CONGENITAL DISORDERS
Down syndrome Marfan syndrome Myotonic dystrophy Tuberous sclerosis Congenital metabolic disorders
• Lysosomal storage• Carbohydrate metabolism
Neurofibromatosis
HYPERTENSION: FACTORSAFFECTING RETINAL ARTERIOLES
Severity Duration
INTRACRANIAL HYPERTENSION:CAUSES
Brain tumor Meningitis Venous sinus thrombosis Hydrocephalus Idiopathic intracranial
hypertension
CENTRAL RETINAL ARTERYOCCLUSION: MANAGEMENT
Rebreathing CO2
Topical beta blockers Intravenous acetazolamide 500mg Massaging of globe with lids closed Anterior chamber paracentesis
Hyperbaric O2
AMAUROSIS FUGAX
Monocular dimming of vision
Temporary arterial obstruction
Sudden, transient, painless visual loss
AMAUROSIS FUGAX:EVALUATION
Cardiovascular Cerebrovascular Ophthalmologic
MIGRAINE:VISUAL SYMPTOMS
Scintillations Amaurosis fugax Transient homonymous
hemifield loss Transient cortical blindness
BLOOD DYSCRASIAS WITHOCULAR MANIFESTATIONS
Hyperviscosity syndromes
Thrombocytopenia Anemia, including
sickle cell anemia
HYPERVISCOSITY SYNDROMES:OCULAR SYMPTOMS
Amaurosis fugax Permanent visual loss
SICKLE CELL RETINOPATHY
HbSC disease (most common form) HbSS disease Sickle thalassemia
MALIGNANT NEOPLASMSINVOLVING THE EYE
Primary ocular melanoma Large cell lymphoma Metastatic carcinoma
METASTATIC CARCINOMA
Most common intraocular malignancy in adults
May be asymptomatic May produce decreased or
distorted vision
OCULAR METASTASIS:TREATMENT
Local radiation Chemotherapy Eye wall resection Enucleation if blind,
painful eye
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
SJÖGREN’S SYNDROME
Dry eyes Dry mouth + Connective tissue disorder Specific antibodies
DRY EYES:TREATMENT
Artificial tears Lubricating ointment at night Punctal occlusion Environmental modification
ANKYLOSING SPONDYLITIS:OCULAR SYMPTOMS
Photophobia Redness Decreased vision
Refer for evaluation and treatment
Topical corticosteroids may lead to serious ocular complications.
RHEUMATOID ARTHRITIS:OCULAR MANIFESTATIONS
Dry eyes Episcleritis Scleritis Corneal ulcers Uveitis
IRITIS IN JUVENILERHEUMATOID ARTHRITIS
Few symptoms or signs Usually chronic Secondary cataract and glaucoma
Refer for periodic ophthalmic screening.
SYSTEMIC LUPUSERYTHEMATOSUS:
OCULAR MANIFESTATIONS
Dry eyes Scleritis Peripheral corneal ulcers Retinopathy and optic neuropathy
POLYARTERITIS NODOSA:OCULAR MANIFESTATIONS
Dry eyes Corneal ulcers Scleritis Hypertensive retinopathy Retinal vasculitis
GIANT CELL ARTERITIS:SYMPTOMS
Headache Scalp tenderness Jaw claudication Polymyalgia rheumatica Acute visual loss
GIANT CELL ARTERITIS:DIAGNOSIS
Clinical history Stat ESR Fluorescein angiogram Temporal artery biopsy
If GCA is suspected,begin treatment immediatelywith 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
THYROID OPHTHALMOPATHY:CLASSES
0 No signs or symptoms
1 Only signs
2 Soft tissue involvement
3 Proptosis
4 Extraocular muscle involvement
5 Corneal damage
6 Sight loss
THYROID OPHTHALMOPATHY:TREATMENT OF CONGESTIVE PHASE
Tear substitutes Corticosteroids Orbital irradiation or
surgical decompression
THYROID OHPTHALMOPATHY:TREATMENT OF CICATRICIAL PHASE
Lid surgery Muscle surgery Orbital surgery
MYASTHENIA GRAVIS:SYSTEMIC INVOLVEMENT
Refer suspects for neurologic evaluation.
SARCOIDOSIS
More commonly affects African-Americans and Hispanics
Ocular involvement in + 25% of patients
OPTIC NEURITIS
May be initial manifestation of MS
Acute, painful vision loss in one or both eyes
Treat initial episode with intravenous methylprednisolone
AIDS:OCULAR MANIFESTATIONS
Dry eye Cotton-wool spots CMV retinitis Kaposi’s sarcoma
(eyelid or conjunctiva)
CMV RETINITIS:THERAPY
IV ganciclovir IV foscarnet Intravitreal ganciclovir Implantable pellets of
sustained-release ganciclovir into the vitreous
CD4 COUNTS
< 100 cells/ml: Opportunistic infections (e.g., CMV retinitis)
> 100 cells/ml: Other ocular infections (e.g., syphilis)
SYSTEMIC MEDICATIONS
Toxic Retinopathies• Thioridazine• Chloroquine• Hydroxychloroquine• Tamoxifen
Toxic Optic Neuropathies• Ethambutol• Isoniazid• Fluoroquinolones
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