Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes...

82
Thom S. Thomassen, M.D.

Transcript of Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes...

Page 1: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

Thom S. Thomassen, M.D.

Page 2: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THE HISTORY

• One or both eyes affected?

• Has vision been affected?

• Are ocular symptoms present?

• Duration of the symptoms?

Page 3: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COMPLETE EYE EXAMINATION

• Vision

• External

• Pupils

• Motility

• Anterior segment (globe)

• Ophthalmoscopy (dilated)

• Intraocular pressure

• Visual fields

Page 4: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HYPERTENSION:

FACTORS AFFECTING

RETINAL ARTERIOLES

• Severity

• Duration

Page 5: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COMMON HYPERTENSIVE RETINAL CHANGES

• Flamed shaped

hemorrhages

• Cotton-wool

spots

Page 6: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

LONG-STANDING HYPERTENSION

•Arteriolar vascular

changes (copper

wiring)

•Hard (lipid) exudates

•Optic disc swelling

(malignant

hypertension)

Page 7: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

INTRACRANIAL HYPERTENSION

•Optic disc

swelling -

papilledema

•Mild or absent

visual symptoms

Page 8: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

INTRACRANIAL HYPERTENSION

CAUSES

• Brain tumor

• Meningitis

• Venous sinus thrombosis

• Hydrocephalus

• Idiopathic intracranial hypertension

Page 9: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

E

M

B

O

L

I

C

D

I

S

E

A

S

E

Page 10: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

AMAUROSIS FUGAX

• Temporary arterial obstruction

• Sudden, transient visual loss

• Monocular dimming of vision

Page 11: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

EMBOLIC DISEASE

• Narrowed

arterioles

• Cherry-red

spot

Page 12: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

CENTRAL RETINAL

ARTERY OCCLUSION:

MANAGEMENT

• IOP lowering drops

• IV Diamox

• Globe massage

• Rebreathing CO2

• Anterior chamber paracentesis

Page 13: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

AMAUROSIS FUGAX:

EVALUATION

• Cardiovascular

• Cerebrovascular

• Ophthalmologic

• Laboratory

Page 14: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

EMBOLIC DISEASE

•Cholesterol

embolus -

Hollenhorst

plaque

•Located at

bifurcation

Page 15: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

EMBOLIC DISEASE

•Cardiac origin

- abnormal heart

valve

•Cardiac tumor

Page 16: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

EMBOLIC DISEASE

•IV drug

abusers - talc

•Long bone

fractures- fat

Page 17: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

MIGRAINE:

VISUAL SYMPTOMS

• Scintillations

• Scotomas

• Amaurosis fugax

• Transient cortical blindness

• Homonymous hemifield loss

Page 18: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

MIGRAINE TYPES

• With headache – classic

• Without headache - acephalgic

Page 19: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

MIGRAINE TREATMENT

• Prevent frequent attacks ?triggers?

• Examine for visual loss

• Contributing medications ?oral contraceptives?

Page 20: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS WITH

OCULAR MANIFESTATIONS

• Hyperviscosity syndromes

• Sickle cell anemia

Page 21: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HYPERVISCOSITY SYNDROMES

OCULAR SYMPTOMS

• Amaurosis fugax

• Permanent visual loss

Page 22: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS Hyperviscosity Syndromes

•Retinal

hemorrhages

•Retinal vein

dilation

•Disc edema

Page 23: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS Hyperviscosity Syndromes

•Hemorrhagic

retinopathy

secondary to

leukemia

Page 24: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS Hyperviscosity Syndromes

•Swelling

and

congestion

secondary to

direct

leukemic

infiltration

Page 25: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SICKLE CELL RETINOPATHY

• HbSC disease (most common form)

• HbSS disease

• Sickle thalassemia

Page 26: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS

Sickle Cell Anemia

•Sickling

can produce

retinal

arterial

occlusions

Page 27: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

BLOOD DYSCRASIAS

Sickle Cell Anemia

•Ischemia

secondary to

capillary

occlusions can

lead to peripheral

neovascularization

(“sea fan”)

Page 28: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

METASTATIC CARCINOMA

• Most common intraocular malignancy in

adults

• May be asymptomatic

• May produce decreased or distorted vision

Page 29: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

METASTATIC CARCINOMA

•Iris mass

secondary to lung

CA

•Irregular pupil,

iritis, A/C blood

Page 30: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

METASTATIC CARCINOMA

•Choroid

most

common

site

Page 31: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

OCULAR METASTASIS:

TREATMENT

• Local radiation

• Chemotherapy

• Enucleation if blind, painful eye

Page 32: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

CONNECTIVE TISSUE DISORDERS

• Dry eyes are the most common manifestation

• Burning

• Foreign body sensation

• Photophobia

Page 33: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SJOGREN’S SYNDROME

• Dry eyes

• Dry mouth

• Connective tissue disorders

Page 34: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

DRY EYES: TREATMENT

• Artificial tears

• Lubricating ointment

• Medications to increase tear production

• Punctal occlusion

• Serum derived

• Nasal stimulation

Page 35: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

CONNECTIVE TISSUE DISORDERS

COLLAGEN VASCULAR DISEASES

Page 36: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

ANKYLOSING SPONDYLITIS:

OCULAR SYMPTOMS

• Photophobia

• Redness

• Decreased vision

• Rheumatology referral

Page 37: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

RHEUMATOID ARTHRITIS:

OCULAR MANIFESTATIONS

• Dry eyes

• Episcleritis

• Scleritis

• Corneal ulcers

Page 38: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

RHEUMATOID ARTHRITIS

EPISCLERITIS

•Inflammation of

tissue overlying

sclera

•Redness, +/- pain

Page 39: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

RHEUMATOID ARTHRITIS

SCLERITIS

•Inflammation

of the sclera

•Severe, deep

pain

Page 40: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

RHEUMATOID ARTHRITIS

SCLERITIS

•Active inflammation with

pain and redness

•Necrosis with perforation

may occur (necrotizing

scleritis)

Page 41: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

RHEUMATOID ARTHRITIS

SCLEROMALACIA PERFORANS

•Scleral melting

•Quiet eye

•Possible

perforation

Page 42: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

RHEUMATOID ARTHRITIS

PERIPHERAL CORNEAL ULCERATION

•Corneal melt

•May signify

potentially lethal

systemic

vasculitis

Page 43: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

JUVENILE RHEUMATOID ARTHRITIS

•Common in

pauciarticular

form

•Quiet eye with

low grade uveitis

•Cataract

•Band

keratopathy

Page 44: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

UVEITIS IN JUVENILE

RHEUMATOID ARTHRITIS

• Few symptoms or signs

• Usually chronic

• Secondary cataract and glaucoma

• Requires frequent ophthalmology follow-up

Page 45: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SYSTEMIC LUPUS

ERYTHEMATOSIS:

OCULAR MANIFESTATIONS

• Dry eyes

• Scleritis

• Peripheral corneal ulcers

• Retinopathy

• Optic neuropatthy

Page 46: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS

•Retinal

vasculitis

•Cotton wool

spots

•Hypertensive

retinopathy

Page 47: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS

•Ischemic

optic

neuropathy

Page 48: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

POLYARTERITIS NODOSA:

OCULAR MANIFESTATIONS

• Dry eyes

• Corneal ulcers

• Scleritis

• Hypertensive retinopathy

• Retinal vasculitis

Page 49: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

GIANT CELL (TEMPORAL)

ARTERITIS:

SYMPTOMS

• Headache

• Scalp tenderness

• Jaw claudication

• May have prior hx of polymyalgia

rheumatica

Page 50: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

GIANT CELL ARTERITIS

•Ischemic optic

neuropathy

•Pale disc edema

•Relative afferent

pupillary defect

Page 51: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

GIANT CELL ARTERITIS

•Non-embolic

central retinal

artery occlusion

•Ocular

presentation in

10% of cases

Page 52: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

COLLAGEN VASCULAR DISEASES

GIANT CELL ARTERITIS

•Cranial motor nerve

paralysis

•Presentation in 10%

of cases

•Oculomotor (3rd

cranial) nerve is

most common (pupil

sparing)

Page 53: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

GIANT CELL (TEMPORAL)

ARTERITIS : DIAGNOSIS

• ESR

• CRP

• CBC with diff

• Temporal artery biopsy

Page 54: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

IF GIANT CELL (TEMPORAL)

ARTERITIS IS SUSPECTED,

BEGIN TREATMENT WITH

SYSTEMIC

CORTICOSTEROIDS

Page 55: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

• Not always correlated with serum

thyroid levels

• Can progress after thyroid function

is normal

Page 56: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY:

CLASSIFCATION

• 0 No signs or symptoms

• 1 Only signs

• 2 Soft tissue involvement

• 3 Proptosis

• 4 Extraocular muscle involvement

• 5 Corneal damage

• 6 Sight loss

Page 57: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

CLASS 1 - (O)NLY SIGNS

•Lid retraction

•Lid lag

•Lid edema

Page 58: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

•Tearing

•Photophobia

•Redness

•Foreign body

sensation

CLASS 2 - (S)OFT TISSUE INVOLVEMENT

Page 59: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

CLASS 3 - (P)ROPTOSIS

•Most

common

cause of

proptosis

Page 60: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

CLASS 4 - (E)XTRAOCULAR MUSCLE INVOLVEMENT

•Restricted

movements

•Diplopia

•Inferior rectus

most commonly

involved

Page 61: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

CLASS 5 - (C)ORNEAL DAMAGE

•Secondary to

exposure from

proptosis and/or

lid retraction

Page 62: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

CLASS 6 - (S)IGHT LOSS

•Secondary to

optic nerve

compression

•Edematous

(early)

•Atrophic, pale

(late)

Page 63: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY

• CT - extraocular

muscle

enlargement

Page 64: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY:

TREATMENT OF CONGESTIVE PHASE

• Tear substitutes

• Corticosteroids

• Orbital irradiation or surgical

decompression

Page 65: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

THYROID OPHTHALMOPATHY:

TREATMENT OF CICATRICIAL PHASE

• Lid surgery

• Muscle surgery

• Orbital surgery

Page 66: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SARCOIDOSIS

• Affects primarily non-whites

• Ocular involvement in significant

percentage of patients

Page 67: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SARCOIDOSIS

GRANULOMATOUS UVEITIS

•Most

common

presentation

Page 69: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

SARCOIDOSIS

•Retinal vasculitis

(peri-phlebitis)

•“Candlewax

drippings”

•Disc edema,

granulomata

Page 70: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

MYASTHENIA GRAVIS

•Autoimmune myopathy

•75% present with

ocular manifestations

•Ptosis

•Limited EOM

•Diplopia

•20% will have eye

manifestations only

Page 71: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

MYASTHENIA GRAVIS:

SYSTEMIC INVOLVEMENT

• Refer for neurologic evaluation

Page 72: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

FLOPPY EYELID SYNDROME

RELATION TO SLEEP APNEA

Individuals with FES are a

subset of all OSA patients

>90% of patients with FES

have OSA

5-15% of patients with

OSA have FES

OSA tends to be more

severe in patients with FES

Page 73: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

FLOPPY EYELID SYNDROME

• Obese middle-aged men

• Excessive sleepiness

• Witnessed apneas

• Disruptive snoring

• Regular AM headaches

Page 74: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

FLOPPY EYELID SYNDROME

CHARACTERISTICS

• Eyelid hyperlaxity

• Papillary conjunctivitis

worse upon awakening

rubbing on pillowcase

• SPK/ mucoid discharge

• Suspect in any obese

patient with chronic red

eye

Page 75: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

FLOPPY EYELID SYNDROME

POTENTIAL EYE ASSOCIATIONS

• NAION

• NTGlaucoma

• Papilledema

• CPAP associated red eye

Page 76: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HIV/AIDS:

OCULAR MANIFESTATIONS

• Dry eye

• Herpes Zoster ophthalmicus

• Retinitis

• Kaposi’s sarcoma of eyelid or conjunctiva

• Optic atrophy

• Disc edema

• Cranial nerve palsy

Page 77: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HIV INFECTION

•Cotton-wool spots -

common ocular

finding

•No prognostic

significance

Page 78: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HIV INFECTION

AIDS

•Herpes Zoster

ophthalmicus

Page 79: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HIV INFECTION

AIDS

•Herpes Zoster

ophthalmicus

Page 80: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

HIV INFECTION

AIDS

•Infectious

retinitis

•Usually

secondary to

cytomegalovirus

•Begins in retinal

periphery

Page 81: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN

DIABETES

DIABETIC RETINOPATHY

•Microangiopathy

•Hemorrhages

•Exudates

•Edema

•Neovascularization -

vitreous hemorrhage

•Leading cause of new

blindness in adults aged

20-40

Page 82: Thom S. Thomassen, M.D. · SYSTEMIC LUPUS ERYTHEMATOSIS: OCULAR MANIFESTATIONS •Dry eyes •Scleritis •Peripheral corneal ulcers •Retinopathy •Optic neuropatthy . COLLAGEN