Ophthalmology - General medical disorders and the eye

Question 1

What signs are associated with long term hypertension?

Answer 1

There are mild fundal changes associated with hypertension:

• “silver wiring” of the retinal arteries
• arteriovenous nipping
• arteriolar narrowing (most reliable sign)

Question 2

What findings are associated with accelerated hypertension?

Answer 2

Malignant hypertension is classically associated with swelling of the optic nerve head. Any patient with hard exudates, cottonwool spots, or haemorrhages as a result of hypertension has a grave prognosis. Patients with these fundal signs should have their BP checked and diabetes excluded.

Retinal vein occlusion is also more common in hypertensive patients.

Question 3

How common is thyroid eye disease?

Answer 3

It affects between 25-50% of patients with GRAVES disease.

Question 4

What is the pathophysiology of thyroid eye disease?

Answer 4

It is thought to be caused by an autoimmune response against an antigen, possibly the TSH receptor leading to retro orbital inflammation. Inflammation results in collagen and glycosaminoglycan deposition in extra occular muscles.

Question 5

How can thyroid eye disease be prevented?

Answer 5

Smoking is THE most important modifiable risk factor for the development of thyroid eye disease.

Radio-iodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. Prednisolone may help to reduce this risk.

Question 6

Outline the features of thyroid eye disease?

Answer 6

The patient may be eu, hypo, or hyperthyroid at the time of presentation.

Features include:

• exophthalmos
• conjunctival oedema
• optic disc swelling
• optic neuropathy (this is relatively rare, the fundal signs include vascular congestion and swelling or atrophy of the optic head. There may be “folds” in the choroid caused by pressure on the globe)
• ophthalmoplegia
• inability to close the eyelids may lead to sore, dry eyes.

If severe and untreated patients can be at risk of exposure keratopathy

Question 7

How should thyroid eye disease be managed?

Answer 7

Topical lubricants may be needed to help prevent corneal inflammation caused by exposure.
Steroids
Radiotherapy
Surgery

Question 8

How common are ocular manifestations of rheumatoid arthritis?

Answer 8

These are common, and occur in 25% of patients (they also occur in other collagen vascular diseases such as SLE, scleroderma, and dermatomyositis)

Manifestations include:

• keratoconjunctivitis sicca (most common)
• episcleritis
• scleritis (erythema and pain)
• corneal ulceration
• keratitis

Iatrogenic causes include steroid induced cataracts, and chloriquine retinopathy.

Patients normally complain of dry, gritty and sore eyes.

Question 9

How can rheumatoid arthritis ocular manifestations be treated?

Answer 9

Treatment consists of replacement artifical tear drops instilled as often as necessary. Simple ointment may also be helpful, but this will blur the vision if used during the day. If there is an aggregation of mucus, mucolytic eye drops (e.g. acetylcysteine) may help, but patients should be warned that these sting.

Question 10

What ocular complications occur in seronegative arthritides?

Answer 10

Seronegative arthritis includes ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, and arthritis associated with inflammatory bowel disease.

Acute anterior uveitis is much more common in these patients and can lead to secondary cataract. If a patient with any of these conditions has a red eye, anterior uveitis should be suspected.

Question 11

What are the risk factors for ocular involvement in childhood seronegative arthritis?

Answer 11

Seronegative childhood arthritis is a particularly important cause of chronic anterior uveitis. Risk factors include:

• female sex
• fewer than five joints affected
• antinuclear antibodies

The danger in these cases is that the eyes are often white and pain free, and the child may not complain of any visual problems. There may be secondary cataracts which cause irreversible ambylopia.

Question 12

How does rosacea affect the eyes?

Answer 12

Blepharitis is common in rosacea, and this can result in recurrent chalazia and stye. The abnormal lid and lipid secretion affect the tear film and “dry eye” syndrome occurs.

Question 13

How is eye involvement in rosacea treated?

Answer 13

Treatment is with:

• tear substitutes
• treatment of any co-existing blepharitis
• systemic tetracycline (250mg QDS) - avoid use in pregnant or lactating women

Question 14

How can sarcoidosis affect the eye?

Answer 14

Acute and chronic uveitis (can result in cataract)
Glaucoma
Band of calcium deposited in the cornea (band keratopathy)
Lacrimal gland infiltration resulting in “dry eye” syndrome
Granulomatous process may affect the posterior part of the eye as vasculitis and sometimes infiltration of the optic nerve.

Question 15

How does congenital rubella affect the eye?

Answer 15

Cataract
Glaucoma
Squint 
Refractive error
Retinopathy ("salt and pepper" appearance)

The child may also be deaf and have severe learning difficulties, so early recognition and treatment are important.

Question 16

Name some of the ocular complications of AIDS

Answer 16

Retinitis
Retinal detachment
Papillitis
Cystoid macula oedema

Manifestations of HIV include Kaposi’s sarcoma of the conjunctiva, HIV microvasculopathy (retinal haemorrhages and cottonwool spots) and vasculitis.

Question 17

How does ocular cytomegalovirus present?

Answer 17

Ocular CMV is a complication of HIV infection. It presents as a slowly progressive necrotising retinitis with areas of retinal opacification and haemorrhages and exudates along vascular arcades. About 20-30% of patients with CMV retinitis will develop retinal detachment.