6.1.13 Recognises ocular manifestations of systemic disease Flashcards
What is hypertensive retinopathy?
Ocular manifestation of systemic hypertension
What are the stages of hypertension - BP level values?
- Normal - <120mmHg/80 mmHg
- Prehypertension - 120-139mmHg /80-89mmHg
- Stage 1 hypertension–140-159mmHg/90-99 mmHg
- Stage 2 hypertension- >160mmHg/>100 mmHg
- Stage 3 hypertension- >180mmHg/>110mmHg
What are the features and severe features of hypertensive retinopathy?
Features
* Tortuous Vessels
* Venous compression at A/V crossing
* Focal arteriolar narrowing
* Arteriosclerotic changes
* Nerve fibre haemorrhages (Flame-Shaped)
* Accelerated hypertension: Cotton wool spots, Disc Oedema, Macular star of
exudates
Severe Hypertensive Retinopathy Features
* Swollen Disc
* Macular Star
* Cotton wool spots
* Dilated retinal veins
* Tortuous vessels
Macular oedema
What is the grading of hypertensive retinopathy?
- Grade 1– Mild arteriolar attenuation (narrowing)
- Grade 2
o Focal arteriorlar attenuation
o venous compression at arterio-venous crossings (Nipping)
o exaggerated light reflex (copper wiring) - Grade 3 (>110mmHg DBP)
o Haemorrhages
o Cotton Wool Spots
o Exudates - Grade 4 (>200mmHg/>130mmHg. Malignant Hypertension)
o All of above plus Disc Oedema and Macular Star formation (accumulation
of exudate in NFL)
§ Headaches, Diplopia, Decreased Vision, Scotomas, Photopsia
What are the levels of arteriosclerotic changes that occurs with hypertensive retinopathy?
Grade 1
o Broadening of Arteriolar light reflex
Grade 2
o Deflection of the veins when crossing the arteries (Salus’ sign)
Grade 3
o Copper Wiring of the retinal arterioles
o Banking of veins distal to the crossings (Bonnet’s sign)
o Tapering of veins on either sides of crossings (Gunn’s sign)
o Right angled deflection of veins
Grade 4
o Silver wiring of retinal arterioles
What is the pathogenesis of hypertensive retinopathy?
- Vasoconstriction of Retinal Arterioles (Grade 1)
- Acceleration of atherosclerotic changes in retinal vessels (Grade 2)
- Retinal Vessel alterations impede blood flow, through retinal arterioles and
capillaries – retinal perfusion is reduced as a result - Ischaemia and hypoxia lead to damage of the blood vessel walls
* Blood Retinal barrier is disrupted
* There’s increased vascular permeability - Blood and plasma leak out of blood vessels and into the surrounding retina (G3
and 4)
Differentiate hypertensive and diabetic retinopathy?
- Hypertensive Retinopathy
o few haemorrhages
o rare oedema
o rare exudates
o multiple CWS
o flame shape haemorrhages
o visibly abnormal retinal arteries - Diabetic Retinopathy
o Multiple haemorrhages
o Extensive oedema
o Few CWS
o Dot and Blot Haemorrhages
o Visibly abnormal retinal veins and capillaries
What is the management of hypertensive retinopathy?
o Grade 1/2 - Non-urgent referral – inform GP
o Grade 3 – Urgent Referral
o Grade 4 – Emergency Referral
- if lots of haems may need to go to GP same day
- if mac affected and VA reduced then HES referral
Describe the ocular blood supply?
- Common Carotid Artery
- Internal Carotid Artery
- Ophthalmic Artery
- A. Central Retinal Artery
* Inner Retinal Layers (NFL – INL)
B. Posterior Cillary Arteries
* Outer Retinal Layers (OPL – RPE Via choriocapillaris)
* Optic Nerve
What are the signs of retinal vessel leakage?
- Haemorrhages: Dot/blot, Flame, Microaneurysms
- Oedema
- Hard Exudates
What are the signs of retinal vessel occlusion?
Occlusion causes ischaemia, leading to:
* CWS
* Neovascularisation
What is a CRVO and what are the RFs?
Occlusion of the central retinal vein at the level of the lamina cribosa due to thrombosis.
Risk Factors
* Hypertension
* Hyperlipidaemia
* Diabetes
* Hyper-viscosity of blood
* Smoking
* Contraceptives
* Raised IOP (>30mmHg)
What is the pathogenesis and appearance of CRVO?
- Occlusion of CRV
- Hypoxia
- Leakage
- Capillary Occlusion
- Retinal ischaemia
Appearance
* Tortuous dilated veins in all 4 quadrants of the retina
* Round/Blot and flame haemorrhages
* CWS
* Possible macula and disc oedema
What investigation is required in CRVO/BRVO?
– Investigate underlying cause and blood work up. Assess whether ischaemic or non-ischaemic
Describe non-ischaemic CRVO and sxs and signs?
- Where the outer retinal layers are still perfused as choroidal circulation remains
intact - 30% will progress onto ischaemic
Sx
Sudden onset, unilateral blurred vision (6/36-6/60). Main concern: conversion to
ischaemic
Signs - Tortuous dilated veins in all 4 quadrants of the retina
- Round/Blot and flame haemorrhages - less dark
- Occasional CWS
- Mild Possible macula and disc oedema
- Mild/absent RAPD
Describe ischaemic CRVO and sxs and signs?
Complete retinal ischaemia
Sx
Sudden onset, unilateral, severe vision loss (6/60 - HM). Main concern: development of
neovascularisation.
Signs
* Tortuous dilated veins in all 4 quadrants of the retina
* Extensive Round/Blot and flame haemorrhages - darker
* Multiple CWS
* Macula Oedema and disc oedema
* Marked RAPD
important to detect because neovascularisation may occur and leading to rubeosis iridis and
neovas glaucoma.
What are the complications of BRVO and CRVO?
- Macular Oedema
- NVD (New vessels disc) & NVE (New vessels elsewhere) could possibly cause
vitreous haemorrhage - Rubeosis Iridis
- Neovascular glaucoma (Very High IOP)
What referral, investigations and treatment is required for CRVO/BRVO?
If IOP is normal and signs/sx suggest non-ischaemic:
* Routine to Ophthalmology and GP OR urgent if macula involved
If IOP is elevated and signs and sx suggest ischaemia:
* urgent to GP and Ophthalmology
Investigation – Investigate underlying cause and blood work up. Assess whether
ischaemic or non-ischaemic.
Treatment – Laser PRP for neovascularisation, Intravitreal Anti-VEGF and steroids for
neovascularisation and macula oedema
Describe BRVO and the treatment?
o Appearance depends on which vessels occluded usually in quadrant of retina affected commonly located 1-2
DD from OD however tertiary branches and macular branches can be affected
o Features of haemorrhages and CWS plus exudates
o Occlusion occurs at A/V crossing where arteriole anterior to vein
o Visual prognosis will depend on macular involvement
o Treatment – Investigate and treat systemic cause, Laser PRP for neovascularisation and Intravitreal Anti-VEGF
for oedema and neovascularisation
What is CRAO/BRAO?
Obstruction of artery due to atherosclerosis, a thrombus or embolus (Carotid Embolism)
(usually BRVO If embolus) blocking the artery or inflammation of the artery
What would you expect from H&S of CRAO/BRAO? and what are the sxs?
- Aged 70-80yrs
- Carotid artery occlusive disease
- systemic hypertension
- high cholesterol
- smoking
- diabetes
- history of stroke or TIA
- Amaurosis Fugax attack (sudden blanking of vision lasting a few seconds)
Symptoms – Sudden, painless loss of vision, sometimes preceded by Amaurosis Fugax
attacks
What are the signs of CRAO? and the later developments of CRAO?
- VA – No LP (although LP and HM may be preserved in some parts of vision)
- Marked RAPD
- Central vision may be preserved if the patient has a cilioretinal artery supplying
the macula (<30% of population) - Retinal Signs:
o red foveal ‘cherry red spot’ due to the fovea being the most transparent
part of the retina
o Extensive whitening of Retina due to retinal oedema
o Attenuation of arteries and vein
Later developments of CRAO - Atrophy of inner retinal layers and optic nerve
- Neovascularisation at the disc and iris
- Vessels remain attenuated and cherry red spot reduces over weeks
What are the signs of BRAO?
- Sudden painless altitudinal or sectorial visual field loss
- Central vision may vary accordingly to the involvement of the macula (VA 6/6 –
CF) - Possible RAPD
- Retinal Signs:
o Extensive whitening of Retina due to retinal oedema in one quadrant
o Attenuation of arteries and veins in one quadrant
What is the management of RAOs?
- Massage the globe with px laying down
- Nd-YAG laser of embolus if visible
- Acetazolamide (Carbonic Anhydrase inhibitors): Decreases IOP by decreasing
Aqueous Humour production - Sublingual Isosorbide dinitrate: Causes vasodilation, can help move a clot
- Anti-coagulants (e.g. Warfarin) as risk of stroke/ischaemic heart disease is high.
Management Guidelines - EMERGENCY Referral if caught within <48hrs
- Routine >48hrs due to neovascularisation and need for blood work up to
determine systemic cause.
FV guidance: phone triage line - likely urgent referral
Describe TIA - sxs and what to do?
Temporary obstruction of blood supply to brain or eye lasting a few seconds to minutes
à high risk of impending stroke
sx:
* Weakness
* Numbness down one side of body
* Vertigo
* Diplopia
* Slurred speech and loss of balance/co-ordination
* Transient vision loss (amaurosis fugax):
o Curtain coming down on vision, can be total or sectorial, resolves
completely (centrally first)
o Most common cause: embolism
o High risk of impending CRAO or vision loss through AION.
Urgent referral to GP and Ophthalmology for MRI and bloods.
What is AION?
Infarction of the optic nerve head secondary to occlusion of the Posterior Cerebral Arteries (PCAs)
What is AAION and what is needed to be done? What can AAION lead to?
Due to GCA (an inflammation of medium and large artery walls, e.g: Superficial temporal
artery, Ophthalmic artery, PCA).
Emergency referral for temporal artery biopsy, blood
test for ESR levels, and prompt oral/intravenous steroid administration.
AAION can also lead to:
* CRAO
* 3rd and 4th nerve palsy
What are the symptoms of AAION?
- Sudden unilateral vision loss
- Preceeding amaurosis fugax
- Possible periocular pain
- Headache, neck or temple pain
- Scalp tenderness
- Jaw claudication
- Weight loss
- Fatigue
- Muscle pain/stiffness
- Protruding temporal artery – pulseless, tender, doesn’t compress
What are the signs of AAION?
- VA <6/60
- RAPD
- Swollen optic disc
- Possible CWS
- Possible flame haemorrhages
- Arcuate VF defect
What is NAION and what is it due to?
Infarction of the optic nerve head due to PCA occlusion as a result of atherosclerosis. No
preceding amaurosis fugax.
Can be due to:
* hypertension
* diabetes
* heart disease
* carotid artery diseaseW
What are the signs of NAION and what do you do?
Signs:
* Normal – severe reduction in VA
* RAPD
* Dyschromatopsia
* Altitudinal VF defect
* ONH signs:
o Diffuse or sectorial oedema
o Pale or mild hyperaemia
o Possible flame haemorrhages
Emergency referral
What is thyroid eye disease and what does it cause?
Due to Graves’ disease
* Soft Tissue involvement: Inflammation
* Proptosis
* EOM involvement causing diplopia
* Corneal Involvement
* Sight Loss due to optic nerve involvement
What are some autoimmune conditions and what can they cause?
- Ankylosing Spondylitis
- IBD
- SLE
- Arthritis
- Myasthenia Gravis
- MS
Can cause - Ant Uveitis
- Episcleritis
- Scleritis
- Dry Eye
- Optic Neuritis
