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