Ocular Manifestations of Systemic Disease Flashcards
What is the leading cause of new blindness in adults age 20-65 in the US?
diabetic retinopathy
After 20 yrs of being a diabetic, what percent of individuals with Type 1 & Type 2 will develop some form of retinopahy?
DM type I - 99%
DM type II - 60%
What are the strategies to reduce development & progression of diabetic retinopathy?
Intensive glycemic control - reduced risk newly diagnosed & reduced progression
Hypertension control- reduce progression & vision loss
What would you expect to see in a physical exam on a patient with nonproliferative diabetic retinopathy?
Treatment?
- Findings
- microaneurysms
- capillary non-perfusion
- nerve fiber layer infarcts (cotton wool spots)
- dot-blot heme
- intraretinal microvascular abnormalities (IRMA)
- retinal edema
- hard exudates
- venous beading
- Treatment
- control blood sugars & blood pressure
- for significant macular edema : anti VEGF or laser
What are the two ways that we trate macular edema with laser therapy?
cauterizing retinal vessels
1) look for individula leaky areas
2) do a pattern w/ big area of leakage (may make this area permanently blurry)
What would you expect to see in a physical exam on a patient with proliferative diabetic retinopathy?
Treatment?
- Findings
- extraretinal fibrovascular proliferation with neovascularization of the disc (NVD)
- neovascularization
- neovascularization of the retina (NVE)
- neovascularization of the iris/anterior angle (rubeosis)
- vitreous hemorrhage
- tractional retinal detachments
- Treatment
- control blood sugars & blood pressure
- anti-VEGF or pain retinal laser
- vitrectomy for non-clearing hemorrhage or traction detachment
Why do you see the peripheral lasered areas?
may see dimmer / lose some peripheral vision but want to preserve the more (central) important areas for vision so that patients can still read and drive
What is the most important eye screening for indiciduals with diabetes?
yearly dilated eye exam
What is the pathophysiology of hypertensive retinopathy?
focal or generalized vasoconstriction, breakdown of blood-retinal barrier
What would you expect to see on a physical exam of a patient with hypertensive retinopathy?
Treatment?
- Findings
- AV nicking
- copper wire of arteries
- hemorrhages
- exudates
- cotton wool spots
- retinal venous occlusions
- florid disc edema
- exudative retinal detachment
- Treatment
- goal blood pressure <140/90
- no treatment for atherosclerotic changes of chronic HTN
What is the pathophysiology seen thyroid eye disease?
antibodies directed against receptors present in the thyroid cells and extraocular muscles and soft tissues of the orbit (MC associated with Graves)
Autoimmune inflammation of the periocular tissue and orbit
What are the physical exam findings seen in patients with thyroid eye disease?
- proptosis (MCC in adults)
- eyelid reaction
- extraocular muscle movement limitations
- severe: decreased bision from optic nerve compression
What is the workup for a patient with thyroid eye disease?
Treatment?
- Work-up
- CT Face Orbit - enlarged extraocular muscles
- thyroid function studies
- anti-thyroid antibody screening
- TSH-R, TBII, TSI
- Treatment
- achieve euthyroid state
- ocular lubricants
- smoking cessation
- optic nerve compromise (severe): steoird or orbital decompression
- frequent follow up with ophthalmology
What is uveitis?
MCC?
inflammation of the uveal tissue
(anterior/intermediate/posterior)
inflammatory/autoimmune, infectious, neoplastic
the “uvea” refers to what structures?
iris, ciliary body, choroid
What is the clinical presentation of a patient with anterior uveitis?
MCC?
- Presentation
- pain
- photophobia
- rednes & decreased vision
- MCC
- idiopathic or HLA-B27 associated
What would you expect to see in a physical exam of a patient with anterior non-infectious uveitis?
Management?
- Exam
- conjunctival injection, prominent around cornea, “ciliary flush”
- anterior chamber cell (WBC) anad flare (inflammatory debris)
- keratic precipitates (WBC on back of cornea)
- hypopyon
- Management
- referral to ophthalmology
What is the clinical presentation of a patient with scleritis?
What would you expect to see upon physical exam?
- Presentation
- “deep boring pain”
- redness
- photophobia
- Findings
- diffuse or sectoral deep injection of hte oscular surface
- scleral nodule, scleral thinning, chorioretinal folds
What is the workup & management of a patient with scleritis?
- work up
- rule out autoimmune disease
- rhematroid arthritis (CBC, ESR, CCP, ANA)
- vasculitis (C-ANCA, P-ANCA)
- rule out autoimmune disease
- Management
- refer to ophthalmology & rheumatology
- oral NSAIDs, oral steroids, immune modulators
- topical steroids usually to NOT help
What is optic neuritis?
Common causes?
inflammation of the optic nerve
can be idiopathic or associated with multiple sclerosis
Whta physical exam findings are seen with optic neuritis?
Management?
- Findings
- acute unilateral vision loss
- pain with eye movements
- decreased color vision
- positive RAPD
- visual field defects
- normal appearing optic nerve (2/3)
- swollen appearing nerve (1/3)
- Management
- MRI to rule out demyelination
- ophthalmology/neurology referral
- IV steroids speed visual recovery & may reduce risk of MS
What is the most common intraocular malignancy in children?
retinoblastoma
Whta is the clinical presentation of a patient with a retinoblastoma?
It is associated with what genetic cause?
Management?
- Presentation
- leukocoria (white pupil)
- strabismus
- decreased vision
- 30% bilatera
- 30% multifocal
- Genetics
- chromosome 13
- siblings should be examined
- Management
- fatal 2-4 yrs if untreated
- enucleation, laser, chemo, monitor for other systemic tumors
What is the most common primary intraocular tumor in caucasian adults?
choroidal melanoma
What are the risk factors for developing a choroidal melanoma?
sunlight exposure, smoking, neurofibromatosis, white
What is the clinical presentation of a patient with choroidal melanoma?
What would you see during a physical exam?
Management?
- Presentation
- blurred vision
- visual field loss
- flashes & floaters
- Exam
- brown dome or mushroom shaped tumor in choroid
- subretinal fluid
- Management (via ocular oncology / oncology)
- rule out metastatic disease, (MC liver)
- radiation plaque therapy or enucleation
