ocular manifesations of systemic disease

Question 1

Hypertensive Retinopathy

Answer 1

Occurs in 15% of patients with just HTN
Rarely by itself causes significant vision loss
Hypertensive changes:
Mild:
Retinal artery narrowing (Due to vasospasm)
Arterial wall thickening or opacification
Arteriovenous nicking—referred to as “nipping”

Question 2

Hypertensive changes:

Answer 2

Moderate:
Hemorrhages—either flame or dot shaped
Cotton-wool spots (retinal nerve fiber layer microinfarcts)
Hard exudates (lipid residue from serous leakage from damaged capillaries)
Microaneurysms
Severe:
Some or all of the above
Plus optic disc edema
Presence of papilledema MANDATES lowering of the BP!!!

Question 3

Hypertensive Retinopathy

Answer 3

Generalized narrowing and nicking are related to current & previous BP levels

Focal narrowing, exudates and flame hemorrhages are related to CURRENT BP levels

Question 4

Hypertension

Answer 4

1. Early hypertensive retinal changes are flame-
   shaped hemorrhages
   2.Long standing hypertension can produce:
   arteriolar sclerotic changes, w/ arteriolar narrowing (copper wire)

Question 5

Hypertension Differential Diagnosis

Answer 5

DM 
Renal disease
Papilledema from another cause
Preeclampsia/eclampsia
SLE  (lupus)
Adrenal disease
Anemia

Question 6

Hypertension Treatment

Answer 6

Control HTN–can reverse some effects of hypertensive retinopathy

Manage renal disease associated w/ HTN

Patients w/ decrease in vision need to be seen by an ophthalmologist

Question 7

Intracranial Hypertension

Answer 7

Most common ocular manifestation of intracranial HTN is optic disc swelling—papilledema

Visual sxs are transient: can range from mild blurring to complete visual loss, usually lasting only a few seconds

Fundascopic exam typically reveals marked disc swelling and vascular engorgement

Question 8

Common causes of Intracranial Hypertension

Answer 8

brain tumor
venous sinus thrombosis
Meningitis
Hydrocephalus
pseudotumor cerebri (Pseudotumor cerebri may be associated with vitamin A or vitamin D intoxication)
Tetracycline therapy
Steroid withdrawal

Question 9

Grave’s Ophthalmopathy

Answer 9

Occurs in about 20% of patient’s with Grave’s disease (hyperthyroid condition)

Question 10

Grave’s Ophthalmopathy Pathogenesis:

Answer 10

activation of T lymphocytes result in inflammation and the accumulation of hydrophilic glycosaminoglycans (GAG)***
Most commonly affected muscle is inferior rectus:
restricts upward-gaze
results in vertical diplopia

Question 11

Grave’s Ophthalmopathy Signs:

Answer 11

Proptosis

Periorbital edema

Question 12

Grave’s Ophthalmopathy Visual Symptoms

Answer 12

Excessive tearing, eye or retroorbital pain

Blurred vision, diplopia and occasionally loss of vision

Question 13

Ocular Myasthenia Gravis

Answer 13

Autoimmune disorder characterized by weakness and fatigue of skeletal muscles

Due to dysfunction at the neuromuscular junction:
AChR-Ab (acetyl choline receptor-antibodies)
Usually only 45-60% positive in OMG

Ptosis fluctuation & oculomotor paresis:
Fatigability of the levator muscle
Ophthalmoparesis results in binocular diplopia

Question 14

Treatment for MG

Answer 14

Symptomatic—anticholinesterase meds
Chronic immunomodulating
Rapid immunomodulating
Surgical—remove thymus

Question 15

HIV

Answer 15

Most common finding cotton wool spots (nonspecific)
Infections:
CMV retinitis
Toxoplasmosis

Kaposi sarcoma

Question 16

AIDS Retinal Disease

Answer 16

CMV retinitis most common serious ocular complication of AIDS
25-40% have retinal detachment because of CMV
Usually unilateral without Tx often other eye becomes involved
Sx: floaters, decreased or blurred vision, scotoma, photopsia (“flashing lights”), NEW visual Sx require dilated fundoscopic exam
Diff: toxoplasmosis, HIV retinopathy (cotton wool spots & retinal hemorrhages)
Tx: anti-HIV meds, IV or intravitrial antivirals (such as ganciclovir) or implants of drug

Question 17

Toxoplasmosis Retinitis

Answer 17

Potentially blinding, necrotizing retinitis

Sx: wavy or distorted vision (metamorphopsia), floaters, pain-variable, decreased or blurred vision

Signs: may see old scars, vitreous debris, yellow-white areas on retina, optic nerve yellow-white & swollen, macular edema

Diff. Dx. sarcoidosis, acute retinal necrosis w/ HZI, syphillis

Tx: pyramethamine and folate, sulfisoxazole, clindamycen (“Triple therapy”) + prednisone

Question 18

Diabetes Mellitus (DM)

Answer 18

Diabetes commonly produces significant ocular complications that may lead to blindness if not recognized and treated
Diabetic retinopathy is now the leading cause of new blindness in adults in the United States!

Question 19

DM Pathogenesis

Answer 19

In chronic hyperglycemia—excess glucose binds with free amino acids forming irreversible advanced glycolsylation end products (AGEs)

High serum levels of AGEs in diabetic patients result in high tissue levels of AGEs which can then crosslink with collagen and initiate microvascular complications

Microthrombosis results in capillary thrombosis and leads to capillary leakage

Vascular endothelial growth factor (VEGF) is synthesized in the retina and can be excessively synthesized leading to the overgrowth of new blood vessels

Question 20

DM Retinopathy Symptoms:

Answer 20

some patients w/ severe disease can have 20/20 vision
blurring slowly or suddenly
visual distortion (things may appear crooked or wavy)
floaters which can be from vitreous hemorrhage—described as “shower”
scotomata

Question 21

Types of Diabetic Retinopathy (DR)

Answer 21

Early Nonproliferative Retinopathy:
Advanced Nonproliferative Retinopathy:
Proliferative Retinopathy:

Question 22

DM Retinopathy Treatment

Answer 22

Photocoagulation (Laser) for macular edema
Leaking MA are treated directly with the argon laser to seal them and prevent further vision loss, not necessarily to improve visual acuity
Growth factor inhibitors

Question 23

Herpes Zoster Infection

Answer 23

Rare to involve retina unless immunocompromised pt—such as HIV/AIDS pt or pregnant woman
Develop— acute retinal necrosis from varicella-zoster virus (also from HSV)
Sx: decreased vision
Dx: immediate fundoscopic exam and referral for treatment as potentially blinding

Question 24

Sjogrens Syndrome

Answer 24

Syndrome of systemic autoimmune exocrinopathy
Inflammatory infiltration of lacrimal glands:
Leads to cell death
Then tear hyposecretion
Causing keratoconjunctivitis sicca