The Eye in Systemic Disease

Question 1

What are the systemic causes of the swollen optic nerve?

Answer 1

• Raised intracranial pressure
  
  • Brain tumour
  • IIH
• Optic neuritis
  
  • Multiple sclerosis
• Pseudo-papilloedema
  
  • Drusen
  • Small ‘crowded’ disc

Question 2

What are the eye changes associated with multiple sclerosis?

Answer 2

• Optic neuritis
  
  • ​Loss of vision, painful eye movements, afferent pupil defect, swollen optic nerve head (not always), later onset optic atrophy.
• Eye movement abnormalities with diplopia and / or oscillopsia
  
  • ​Any cranial nerve palsy (3rd, 4th, 6th) or an inter-nuclear ophthalmoplegia (INO) or cerebellar / brain stem lesions.
• Intermediate uveitis
  
  • ​Floaters and blurred vision, sometimes red eye and photophobia.

Question 3

Describe anterior ischaemic optic neuropathy.

Answer 3

• Occlusion of the blood vessels of the anterior optic nerve head.
• Sudden profound loss of vision.
• 2 main types:
  
  • Arteritic - Giant Cell Arteritis (aka temporal arteritis) - EMERGENCY.
  • Non-arteritic - usual risk factors for CV disease (such as retinal vein and artery occlusions).

Question 4

Describe a patient who presents with giant cell arteritis and state how you would manage.

Answer 4

• History is important:
  
  • Jaw pain
  • Tongue pain
  • Scalp pain
  • Weight loss
  • Decreased appetite
  • Shoulder pain
  • Night sweats
  • Profound loss of vision
  • Grossly swollen optic nerve head
• TREAT, then investigate (try to prevent loss of vision in remaining fellow eye).
• High dose steroids (oral or IV), then investigate with inflammatory markers (CRP, ESR, PV) and USS of temporal arteries +/- temporal artery biopsy (giant cells).

Question 5

Describe the presentation of retinal artery and vein occlusions.

Answer 5

• Typically sudden onset and painless unless associated with GCA.
• Associated risk factors:
  
  • Increasing age
  • Hypertension
  • Dyslipidaemia
  • Obesity
  • Smoking
  • Poor diet
  • No exercise
• Arterial occlusions due to embolic disease. Source:
  
  • Carotids
  • Valves
  • Chambers in arrhythmias
• Venous occlusions usually due to ‘nipping’ by overlying ‘hardening’ arterioles, therefore much the same risk factors.

Question 6

What are the risk factors for retinal vein occlusion?

Answer 6

• Systemic risk factors
  
  • Hypertension
  • DM
  • Hyperlipidaemia
  • Atherosclerotic associated diseases: IHD, obesity, cigarette smoking
  • Systemic vasculitis
  • Haematologic neoplasia
  • Hypercoagulability
  • Drug therapy - OCP, diuretics and hypotensives
• Ocular risk factors
  
  • Glaucoma
  • Decreased ocular perfusion pressure
  • External retrobulbar compression-orbital neoplasma and endocrine orbitopathy
  • Retinal arteriolar signs - focal arteriolar narrowing and arteriovenous nicking

Question 7

Describe diabetic retinopathy.

What are the 4 ways to go blind from diabetic retinopathy?

Answer 7

• Damage to microvasculature​
• Blindness due to:
  
  • Growth of new vessels
    
    1. Vitreous haemorrhage
    2. Tractional retinal detachment
    3. Rubeotic glaucoma
  • Leakage of fluid from damaged vessels

4. Macular oedema

.

Question 8

What are the pathological steps of diabetic eye disease?

Answer 8

• Chronic hyperglycaemia
• Glycosylation of protein/basement membrane
• Loss of pericytes
• Reduced O₂ transport = tissue hypoxia
• Vaso-proliferative factors produced (VEGF)
• Neo-vascularisation and leakage
• Macular oedema, vitreous haemorrhage, retinal detachment and rubeotic glaucoma

Question 9

How does myasthenia gravis affect the eyes?

Answer 9

• In more than half of people who develop myasthenia gravis, their first signs and symptoms involve eye problems, such as:
  
  • Drooping of one or both eyelids (ptosis).
  • Double vision (diplopia), which may be horizontal or vertical, and improves or resolves when one eye is closed.

Question 10

Describe thyroid eye disease.

Answer 10

• Caused by antibodies to orbital contents.
• Often associated with hyperthyroidism.
• Much more common in females and in smokers.
• Risk of sight loss due to optic nerve compression.
• Cosmetic issues.
• Immunosuppression often needed then surgery on the orbits, then on the eye lids.