Ocular manifestations of Systemic Disease Flashcards
Hypertensive Retinopathy
- mild changes
- moderate
- severe
Mild
- retinal artery narrowing
- arterial wall thickening or opacification
- arteriovenous nicking- “nipping” (vein and artery cross, pressure in artery causes vein to bulge out & cause damage)
Moderate:
- hemorrhage (flame or dot shaped)
- cotton-wool spots (retinal nerve fiber layer microinfarction)
- 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 BP.
What are silver and copper wire and when do they occur?
they occur with long standing hypertension:
*only occur in HTN Retinopathy (?)
Copper wire= arteriolar sclerotic (hard from constant pressure) changes w/
arteriolar narrowing. Moderate vascular wall changes.
Silver Wire=with halogen light source see sclerosis of vessel, white retinal vessel. More severe vascular hyperplasia and thickening.
Signs and symptoms of HTN Retinopathy
Sx: vision normal, blurred or sudden decreas; scotoma(waves in the air, spotty visual changes, usually unilateral and transient), diplopia
Signs:
- arteriolar narrowing in chronic HTN
- focal spasm in acute HTN
- retinal edema
- microaneurysm may rupture producing sudden vision loss from hemorrhage
Tx of HTN Retinopathy
CONTROL HTN, may be able to reverse some effects of HTN retinopathy
-refer to ophthalmologist
When looking at retina, what are the white and red punctate dots?
What are cotton wool spots caused from? How about yellow spots?
white= ischemia
red-hemorrhage
caused from ischemia
yellow spots are exudate- lipid residues of serous leakage from damaged capillaries
What are ghost vessels?
-new blood vessels formed to increase o2 and nutrient transport to retina, the old vessels become white b/c they are no longer being used.
What is the hallmark sign of malignant HTN?
What disease are these pts most likely to develop secondarily?
swelling of the optic disc- PAPILLEDEMA
-heart and renal failure, stroke, hypertensive encephalopathy
Why must BP be carefully controlled & reduced in malignant HTN pts?
BP must be controlled carefully immediately;
-a sudden drop in tissue perfusion can result in infraction of the optic disc (acute ischemic optic neuropathy) and subsequent blindness.
What is the most common ocular manifestation of intracranial HTN?
What are some the signs associated with this?
optic disc swelling- papilledema
-signs are transient; can range from mild blurring to complete visual loss usually lasting a few seconds. Fundoscopic exam reveals marked disc swilling and vascular engorgement.
Common causes of Intracranial HTN
- brain tumor
- venous sinus thrombosis
- meningitis
- hydrocephalus
- pseudotumor cerebri
- tetracycline therapy (not common)
- steroid withdrawal
Pathogenesis of Diabtic Retinopathy
- over time sugar causes damage to blood vessels. body wants to heal by increasing Vascular Endothelial Growth Factor (VEGF) leading to neovascularization.
- this is key in Diabetic Retinopathy (DR) (?)p
Sx of DR
- blurring suddenly or slowly
- visual distortion (crooked/wavy)
- floaters from vitreous hemorrhage (shower)
- scotoma
How often is eye exam performed in diabetic patients?
EVERY. SINGLE. YEAR.
Types of Diabetic Retinopathy & signs associated with each.
Early Nonproliferative:
- microaneruysm and intraretinal hemorrhages
- cotton wool spots
- visual acuity is usually unaffected
- graded: mild, moderate, severe
- sounds like HTN
- Advanced Nonproliferative:
- cotton wool spots
- extensive retinal hemorrhages
Proliferative:
- vitreous hemorrhage and tractional retinal detachment
- NEOVASCULARIZATION; not always confined to the retina
- new vessels may grown on the surface of the iris and the trabecular meshwork, blocking aqueous outflow causing a very dangerous form of GLAUCOMA.
Tx of DR
- photocoagulation (Laser) for macular edema (ophthomologist does this)
- leaking vessels are treated directly with the laser to seal them and prevent further vision loss, not to improve visual acuity.
- Intraocular injection of Growth Factor inhibitors.
-Treat Blood sugar as you can and refer to Ophtho.
surgery:
- used to remove nonclearing vitreous hemorrhage and to treat/prevent retinal detachment
- vitreous removed and destroy new retinal vessels. O
Graves Ophthalmopathy Pathogensis
-what muscles are most commonly affected?
- activation of T lymphocytes result in inflamm and infiltration of orbital connective tissue. Inflamm results in a deposition of collogen and glycoaminoglycans in the muscles, leading to enlargement and fibrosis of eye muscles.
- most commonly affected muscles: inferior rectus
Signs & Symptoms of Graves Ophtho.
Signs
- proptosis (bug eyes)
- periorbital edema
Visual symptoms
- excessive tearing, conjunctivitis, eye or retroorbital pain
- blurred vision, diplopia (usually vertical), occasional loss of vision.
Physical Exam pts w/ Graves Ophtho.
- see lid lage and stare
- determine extent to which upper/lower lids close.
- assess EOM range of motion
- evaluate visual acuity, color vision, and visual fields.
Complications of Graves
- proptosis: dry eyes & corneal ulceration
- extraocular muscle impairment: diplopia (side by side image), inability to achieve upward vision or to maintain convergence.
Tx of Graves Ophtho.
-treat underlying hyperthyroidism - surgery or meds
Mild symptoms:
- dark glasses
- artificial tears
- raise head of bed
Severe:
- glucocorticosteroids - IV or oral (only thing that treats severe exopthalmos)
- if vision threatened–radiation then surgery.
Ocular Myasthenia Gravis Pathogensis
- autoimmune disorder characterized by weakness and fatigue of skeletal muscles (works head down, eyes usually first affected)
- due to dysfunction of NMJ (Ach related)
- ptosis d/t levator palpebrae superioris
- binocular diplopia d/t opthalmoparesis (weakeness of the extraocular muscles)
Tx of Myasthenia Gravis
- smyptomatic- anticholinesterase meds (increase Ach)
- chronic immunomodulatiing
- rapid immunomodulating
- surgical (remove thymus)
What is the most common ophtho. finding in HIV patients?
Cotton wool spots
What is the most common serious complication of AIDS? Describe this disease.
CMV retinitis- Cytomegalovirus retinitis
-it is from the Herpes family
Symptoms of CMV retinitis
25-40% have retinal detachment
- usually unilateral but move to both eyes if not treated
- floaters, decreased or blurred vision, scotoma, photopsia (flashing lights)
- *frosted branch appearance is classic of CMV
***New visual symptoms in an HIV patient require a dilated fundoscope exam by ophtho.
CMV retinitis treatment
- anti-HIV meds
- IV or intravitrial antivirals
- implants of drug
What is Toxoplasmosis Retinitis?
Potentially blinding, necrotizing retinitis caused by parasite, carried by a cat. Most people can fight off but immunosuppressed ppl cannot.
Toxoplasmosis Retinitis signs and symptoms
-symptoms: 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 and swollen, macular edema. Headlight in the fog (where infection is) blurry white spot =infection of vitreous. O
Toxoplasmosis Retinitis treatment
pyrimethamone, sulfadiazine with folate, corticosteroids
*an infectious disease specialist will treat this, not us.
Herpes Zoster Infection
- who gets this?
- Sx
- Dx
- rare to involve retina unless immunocompromised such as HIV/AIDS or pregnant
- Symptoms: develop acute retinal necrosis from varicella zoster virus, decreased vision
Dx- immediate fundoscopic exam and refer to ophtho.
Traumatic Disorder: Shaken baby syndrome
- see dark hemorrhage on retina/vitreous
Further rheumatological differential of Ocular Disease
- Sjogrens syndrome
- Systemic Lupus Erythematosus
- Inflammatory bowel disaes
- Sarcoidosis ( granulomas= collection of inflamm cells)
