6.1.13 Recognises ocular manifestations of systemic disease.

Question 1

Ocular manifestations of Hypertension

Pathogenesis

Answer 1

Vasoconstrictive phase - autoregulation breaks down due to higher luminal pressure causing arteriolar narrowing; AV ratio affected

Sclerotic phase - persistent HBP leads to hyalinized walls & loss of muscle cells, causing arteriosclerosis. AV nipping & copper wiring result. Macro & micro aneurysms, CRA, CRV & ERM can form

Exudative phase - blood retinal barrier (barrier between retina & blood regulating movement of waste, protein, ions, water flux etc in & out of retina) disrupted due to loss of smooth muscles and endothelial cells. Haems, Oedema, CWS & exudates result. Macular star can result

Question 2

Ocular manifestations of Hypertension

Signs & Grading

Answer 2

Grade 1 - Arteriolar narrowing

Grade 2 - Arteriolar narrowing, AV nipping, Copper wiring

Grade 3 - Grade 2 + Retinal haems (dot, blot, flame), Exudates (chronic oedema = macula star), CWSs, IRMA

Grade 4 - Grade 3 + ONH swelling i.e. malignant hypertension

Classification is not closely related to severity of hypertension!!

Question 3

Ocular manifestations of Hypertension

Vessel Changes

Answer 3

In reality, just says there’s nipping

Gunn’s sign:

Bonnet sign:

Question 4

Ocular manifestations of Hypertension

Hypertensive choroidopathy

Answer 4

Severe hypertension - younger people

Associated with renal disease, pregnancy or collagen vascular diseases

Signs - Elschnig’s spots (RPE lesions), Siegrists streaks, Serous detachments

Question 5

Ocular manifestations of Hypertension

Management

Answer 5

Hypertensive Retinopathy Severity and Management

Mild
- Signs:
- General arteriolar narrowing.
- Arteriolar wall opacification.
- Arteriovenous nipping.
- Management:
- Routine referral to GP if the cause is undiagnosed.

Moderate
- Signs:
- Flame-shaped or blot-shaped hemorrhages.
- Microaneurysms.
- Cotton-wool spots.
- Hard exudates.
- Management:
- Referral to GP.
- Consider hospital eye service (HES) if diabetic or visual symptoms are present, or if vascular complications arise.

Severe / Malignant
- Signs:
- All of the above signs plus swelling of the optic disc.
- Management:
- Same-day referral to HES or emergency care (A&E).
- Immediate attention if BP >180/120.
- Chronic hypertensive damage may reflect past BP levels, not necessarily current control.

Question 6

Uveitis

Classifications:

Answer 6

Anterior uveitis – iris & anterior ciliary body. Anterior has ended up being iritis in many cases

Intermediate uveitis - posterior ciliary body & peripheral retina

Posterior uveitis – uveal tract behind the posterior border of the vitreous base

Panuveitis – entire uveal tract

Question 7

Causes of uveitis:

Answer 7

1. Infections (Bacterial, parasitic, fungal and viral) like herpes zoster
2. Trauma – IOFB, perforating injury
3. Systemic diseases - syphilis, TB, sarcoidosis, toxocariasis, toxoplasmosis. Majority of people have ocular first, THEN systemic condition may be found after you refer them
4. Idiopathic

Question 8

Anterior uveitis symptoms and signs:

Answer 8

• Symptoms - rapid onset of unilateral pain, blurred vision (depends on severity), photophobia, redness & watery discharge
• Signs - Ciliary Injection, Miosis, Cells & flare, KPs, Hypopyon, Iris nodules (Busacca - iris stroma, Koeppe - pupillary margin), PS causing pigment on the lens, Lowered IOP (function of ciliary body not as good) (can sometimes be raised if TM blocked by cells & flare)
• Management - Emergency, same day referral. Make sure to look at fundus to exclude posterior uveitis & if clear view not obtained, must make HES aware

Question 9

Intermediate symptoms and signs:

Answer 9

• Onset - Idiopathic or systemic linked. Age 15-40 so young! Bilateral but assymetric
• Symptoms - painless floaters, blurred vision, anterior uveitis sxs are rare
• Signs - vitreous cells more anteriorly (vitritis), vitreous haze, snowballs (inflammatory cells & exudate), snowbanking (inferior & after gravity makes snowballs go downward), periphlebitis (perivascular inflammation)
• Management - same as anterior??

Question 10

Posterior uveitis signs and symptoms:

Answer 10

• Onset
  
  • Sarcoidosis, Tuberculosis, Toxoplasmosis, Toxocariasis, Acquired syphilis, Presumed Ocular Histoplasmosis syndrome (as examples)
• Symptoms - Painless Floaters, Blurred vision, Scotomas (patchy), Distortion (if macula affected), Photopsia
• Signs - cells & flare, possible PVD, choroidal & vasculature changes
  
  • Retinitis - whitish retinal opacities
  • Choroiditis - round, yellow nodule
  • Vasculitis - periarteritis (artery) or periphlebitis (vein). Grey-white/yellowish perivascular patchy cuffing (inflammation of the outer coat of a vein/artery or of tissues around a vein/artery.) Candle-wax drippings
• Management - same as anterior??

Question 11

Sarcoidosis…

Answer 11

• Growth of tiny collections of inflammatory cells (granulomas) in any part of your body
• Results in all types of uveitis
• Common signs:
  
  • Mutton fat KPs, Small KPs
  • Iris nodules
  • PAS
  • Vitritis, snowballs
  • Chorioretinal lesions
  • Periphlebitis
  • Optic disc nodules/granulomas - granulomas can be on retina (creamy patches - check elevation on OCT) & even outside the eye on adnexa

Question 12

Ankylosing spondylitis

Answer 12

• 3rd-4th decade, limitation of spinal movements
• AAU, Scleritis, Episcleritis, Keratitis, Mechanical ptosis

Question 13

Toxoplasmosis

Answer 13

• Infected by ingesting undercooked meats, cat faeces or congenital.
  Often asymptomatic and self resolving
• Focal necrotising retinitis

Question 14

Tuberculosis

Answer 14

• Rare to see as people vaccinated
• Granulomatous inflammation of anterior & posterior segment

Question 15

The manifestations of uveitis

Answer 15

Manifestations of Uveitis

• Visual Symptoms:
  
  • Reduced visual acuity.
  • Intraocular pressure (IOP) may be increased or reduced.
• Signs:
  
  • Lid Oedema: Swelling of the eyelids.
  • Ciliary Injection: Redness around the cornea due to inflammation.
  • Chemosis: Swelling of the conjunctiva.
  • Keratic Precipitates (KPs): Deposits on the corneal endothelium composed of inflammatory cells (lymphocytes, plasma cells, macrophages).
  • Anterior Chamber:
    
    • Cells: Presence of inflammatory cells in the anterior chamber.
    • Hypopyon: Whitish purulent exudate in the inferior part of the anterior chamber.
    • Aqueous Flare: Haziness in the anterior chamber due to proteins from breakdown of the blood-aqueous barrier.
    • Fibrinous Exudates: Clots of fibrin in the anterior chamber.
• Iris:
  
  • Iris Nodules:
    
    • Koeppe Nodules: Site of posterior synechiae.
    • Bussaca Nodules: Feature of granulomatous uveitis.
    • Yellowish Nodules: Seen in syphilitic uveitis.
  • Iris Pearls: Seen in lepromatous uveitis.
  • Iris Crystals: Crystals within the iris.
  • Posterior Synechiae: Adhesion of the iris to the lens.
  • Iris Atrophy: Seen in herpetic uveitis.
  • Heterochromia Iridis: Difference in iris color.
  • Iris Neovascularization: Formation of new blood vessels on the iris.
• Other Ocular Changes:
  
  • Cataract: Opacification of the lens.
  • Secondary Glaucoma: Increased intraocular pressure due to inflammation.
  • Vitritis: Inflammation of the vitreous body.
  • Vitreous Hemorrhage: Blood in the vitreous body.
  • White Snowball-Like Exudates: Seen near the ora serrata in the peripheral retina.
  • Papillitis or Disc Edema: Swelling of the optic disc.
  • Peripheral Phlebitis: Inflammation of peripheral retinal veins.
  • Macular Edema: Fluid accumulation in the macula.
  • Exudates in the Choroid and Retina: Leakage of fluid from blood vessels into the retina and choroid.
  • Retinal Hemorrhages: Bleeding within the retina.
  • Choroidal Neovascularization: Growth of new blood vessels in the choroid.
  • Retinal Detachment: Separation of the retina from the underlying tissue.

Question 16

Thyroid

Answer 16

• Description - the thyroid produces T3 & T4 which are hormones that regulate…
• Bilateral but assymetrical condition
• TED can occur in hyper or hypo active thyroid conditions

Question 17

Thyroid eye disease

Signs: (wet phase - myogenic)

Answer 17

• Early Signs:
  
  • Lid Lag: The upper lid does not follow the downward gaze fully, remaining retracted.
  • Lid Retraction: The patient appears to have a startled or wide-eyed look due to proptosis (forward displacement of the eye).
    
    • Scleral Show: In primary gaze, the upper limbus should not show above the iris; if it does, it suggests lid retraction or proptosis, which is a bad sign.
• Soft Tissue Involvement:
  
  • Periorbital Oedema: Swelling around the eyes.
  • Swollen and Red Lids: Inflammation and redness of the eyelids.
  • Gritty Sensation: Feels like there is sand or foreign material in the eyes.
  • Dryness: Due to reduced blinking and exposure of the cornea.
  • Bulbar Hyperaemia: Redness of the white part of the eye (sclera), often associated with inflammation.
• Later Signs:
  
  • Corneal Exposure: The eyes may not fully close, leading to dryness and potential damage to the cornea, possibly resulting in reduced vision.
  • Severe Oedema & Inflammation of the Orbit & Muscles: Painful eye movements as the muscles and tissues around the eyes become inflamed.
  • Enlarged Recti Muscles & Increased Orbital Contents: The muscles of the eye become swollen, contributing to increased proptosis. This can make it difficult for the patient to fully close their eyes.
    
    • Optic Nerve Compression: Prolonged proptosis or muscle enlargement may start to compress the optic nerve, leading to optic neuropathy, which can cause vision loss.

Question 18

Thyroid eye disease

Dry phase - mechanical

Answer 18

• Inflammation subsides, muscles become fibrotic
• Normally IR affected most commonly. Next most common is MR, then…
  
  • E.g. if IR affected then it is essentially more stiff & hardened, causing it to stay down but not letting it more up to elevate the eye as he fibrosis is on top of the muscle
• This might cause diplopia and possibily a unilateral limitation in eye movement

Question 19

Stroke

Answer 19

• This is when blood supply to the brain is stopped
• Manifestations - Visual pathway defect like a hemianopia, Visual neglect, Eye movement problems
  
  • Eye movement - nystagmus, gaze palsy, trouble doing saccades or pursuit. May be diplopia
  • Visual neglect - unaware of objects to one side
• Management - fresnel prism until stable, occlusion, scanning techniques, vertical text, typoscope

Question 20

Sjogren’s syndrome

Answer 20

• Description - a chronic inflammatory disorder (autoimmune - mistakenly attacking the body) causing lymphocitic infiltration of the lacrimal & salivary glands, causing their dysfunction & hence dry eye, dry mouth etc
  
  • Severe aqueous tear deficiency
• Signs & Sxs
  
  • Burning, Stinging, Gritiness, FB sensation, Itchiness, Soreness, Redness, Photophobia, Watering
  • Reduced TBUT, Reduced schirmer (<5mm), Reduced phenol red (<10mm)
  • NaFl staining, reduced tear volume (<0.18mm)
  • Rarely anterior uveitis, episcleritis
• Management
  
  • Refer to college guidelines on dry eye