ocular manifesations of systemic disease Flashcards
Hypertensive Retinopathy
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”
Hypertensive changes:
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!!!
Hypertensive Retinopathy
Generalized narrowing and nicking are related to current & previous BP levels
Focal narrowing, exudates and flame hemorrhages are related to CURRENT BP levels
Hypertension
- Early hypertensive retinal changes are flame-
shaped hemorrhages
2.Long standing hypertension can produce:
arteriolar sclerotic changes, w/ arteriolar narrowing (copper wire)
Hypertension Differential Diagnosis
DM Renal disease Papilledema from another cause Preeclampsia/eclampsia SLE (lupus) Adrenal disease Anemia
Hypertension Treatment
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
Intracranial Hypertension
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
Common causes of Intracranial Hypertension
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
Grave’s Ophthalmopathy
Occurs in about 20% of patient’s with Grave’s disease (hyperthyroid condition)
Grave’s Ophthalmopathy Pathogenesis:
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
Grave’s Ophthalmopathy Signs:
Proptosis
Periorbital edema
Grave’s Ophthalmopathy Visual Symptoms
Excessive tearing, eye or retroorbital pain
Blurred vision, diplopia and occasionally loss of vision
Ocular Myasthenia Gravis
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
Treatment for MG
Symptomatic—anticholinesterase meds
Chronic immunomodulating
Rapid immunomodulating
Surgical—remove thymus
HIV
Most common finding cotton wool spots (nonspecific)
Infections:
CMV retinitis
Toxoplasmosis
Kaposi sarcoma
AIDS Retinal Disease
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
Toxoplasmosis Retinitis
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
Diabetes Mellitus (DM)
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!
DM Pathogenesis
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
DM Retinopathy Symptoms:
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
Types of Diabetic Retinopathy (DR)
Early Nonproliferative Retinopathy:
Advanced Nonproliferative Retinopathy:
Proliferative Retinopathy:
DM Retinopathy Treatment
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
Herpes Zoster Infection
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
Sjogrens Syndrome
Syndrome of systemic autoimmune exocrinopathy
Inflammatory infiltration of lacrimal glands:
Leads to cell death
Then tear hyposecretion
Causing keratoconjunctivitis sicca
