systemic ophthalmology
TRANSCRIPT
Systemic Systemic OphthalmolOphthalmol
ogyogy
Eye Eye manifestations manifestations
of of systemic diseasessystemic diseases
The eye is a unique The eye is a unique organorgan
In DevelopmentIn Development
In PositionIn Position
In Structure In Structure
Systemic diseases affect eyes in various Systemic diseases affect eyes in various waysways
BUT ALSOBUT ALSO
Many of the systemic diseases may be first Many of the systemic diseases may be first diagnosed by ophthalmologistdiagnosed by ophthalmologist
Endocrine DisordersEndocrine Disorders Diabetes MellitusDiabetes Mellitus Thyroid glandThyroid gland Pituitary glandPituitary gland
Cardiovascular & blood disordersCardiovascular & blood disorders Anemia Anemia leukemialeukemia AstherosclerosisAstherosclerosis HypertensionHypertension
Collagen vascular diseasesCollagen vascular diseases Congenital Congenital Acquired: Rheumatoid arthritisAcquired: Rheumatoid arthritis
Neurological DisordersNeurological Disorders Migraine.Migraine. Papilloedema.Papilloedema. Optic neuritis.Optic neuritis. Pseudotumour cerebri.Pseudotumour cerebri. phakomatosisphakomatosis
Vitamin deficiencyVitamin deficiency Vitamin A, B, C, DVitamin A, B, C, D
Infectious diseasesInfectious diseases HIVHIV
Malignancy Malignancy
Eye manifestations of Eye manifestations of diabetesdiabetes
Eye lidsEye lids
Recurrent styesRecurrent styes Xanthelasmas Xanthelasmas
Conjunctiva & CorneaConjunctiva & Cornea
Conjunctivitis Conjunctivitis Cornea: Cornea: recurrent erosions, ulcers..recurrent erosions, ulcers..
Iris Iris
Rubiosis iridesRubiosis irides Edema & vesiculation of Edema & vesiculation of
pigment epithelium: easy pigment epithelium: easy scattering of iris pigment scattering of iris pigment by mild trauma. by mild trauma.
Neovascular Neovascular glaucomaglaucoma
CataractCataract Senile catarct in diabetic Senile catarct in diabetic
patient, density accelerates patient, density accelerates more.more.
True diabetic cataractTrue diabetic cataract Develops quickly & rapidly Develops quickly & rapidly
progressive.progressive. Starts flocculent, snow flake, milky Starts flocculent, snow flake, milky
white cortical opacities.white cortical opacities.
VireousVireous Intraocular hgeIntraocular hge
HyphemaHyphema Vitreous hgeVitreous hge Retinal hgeRetinal hge
Lipemia retinalisLipemia retinalis Milky retinal Milky retinal
vesselsvessels..
RetinaRetina
rdiabetica_06(ingles).swf
Optic nerveOptic nerve
Retrobulbar neuritis:Retrobulbar neuritis: (diabetic optic neuropathy)(diabetic optic neuropathy)
Usually bilateralUsually bilateral Rapid onsetRapid onset Often painless.Often painless.
Extraocular musclesExtraocular muscles
Extraocular muscle palsy:Extraocular muscle palsy: Diabetic third nerve palsy:Diabetic third nerve palsy:
most common cause of isolated 3most common cause of isolated 3rdrd n. n. palsy..micro infarctionspalsy..micro infarctions
Sixth nerve palsySixth nerve palsy
Visual DisturbancesVisual Disturbances
Transient refractive changes:Transient refractive changes: Changes in the state of lens hydration & Changes in the state of lens hydration &
alteration of the refractive index of the alteration of the refractive index of the lens due to osmotic changes.lens due to osmotic changes.
Hypermetropia: in hypoglycemiaHypermetropia: in hypoglycemia Myopia: hyperglycemia.Myopia: hyperglycemia.
NO GLASSES PRESCRIPTION IN UNCONTROLLED DM NO GLASSES PRESCRIPTION IN UNCONTROLLED DM
Visual DisturbancesVisual Disturbances
Accomodative disorders:Accomodative disorders: Weakness of accomodation due to weak Weakness of accomodation due to weak
ciliary muscles due to peripheral neuritis ciliary muscles due to peripheral neuritis involving its nerve supply.involving its nerve supply.
Subjective visual disturbances:Subjective visual disturbances: Amaurosis in severe casesAmaurosis in severe cases Flshes due to visual cortex disturbances in Flshes due to visual cortex disturbances in
insulin overdose.insulin overdose.
Vitreous Haemorrhage from PDRVitreous Haemorrhage from PDR Tractional Retinal Detachment involving Tractional Retinal Detachment involving
the maculathe macula Maculopathy, exudative and ischaemicMaculopathy, exudative and ischaemic Neovascular GlaucomaNeovascular Glaucoma
In addition: In addition: higher cataract prevalencehigher cataract prevalence
GoutGout Charecterized by excess of uric acid in blood, urate deposits of cartilages of small joints. Starts in big toe,,,then polyarticular.
GoutGout
ConjunctivitisConjunctivitis Marginal corneal ulcerMarginal corneal ulcer EpiscleritisEpiscleritis TenonitisTenonitis Iridocyclitis Iridocyclitis
Vitamin DeficiencyVitamin Deficiency
Vitamin AVitamin A
Vitamin A deficiencyVitamin A deficiency
Night blindness: defective or Night blindness: defective or degenerative night vision.degenerative night vision.
Dry eye (Xerophthalmia)Dry eye (Xerophthalmia) BitotBitot’’s spotss spots Corneal thinningCorneal thinning keratomalaciakeratomalacia BlepharitisBlepharitis Recurrent styes & chalazia.Recurrent styes & chalazia.
Vitamin A deficiencyVitamin A deficiency
Vitamin B deficiencyVitamin B deficiency
Vitamin B1Vitamin B1
Vitamin B1Vitamin B1
Vitamin B1 deficiencyVitamin B1 deficiency
(Thiamine deficiency: Beri Beri: (Thiamine deficiency: Beri Beri: (cardiac, muscular weakness, neuritis)(cardiac, muscular weakness, neuritis)
ConjunctivitisConjunctivitis NystagmusNystagmus PapilloedemaPapilloedema Retinal hgeRetinal hge Extra ocular muscle paralysisExtra ocular muscle paralysis
Vitamin B2Vitamin B2(Riboflavin)(Riboflavin)
Vitamin B2 deficiencyVitamin B2 deficiencyRiboflavin deficiencyRiboflavin deficiency
Conjunctivitis: typical Conjunctivitis: typical manifestationmanifestation
Peripheral corneal Peripheral corneal vascularizationvascularization
CataractCataract Fundus changes:Fundus changes:
Papilledema.Papilledema. Pigmentary changes of macula.Pigmentary changes of macula. Partial optic atrophy.Partial optic atrophy.
Vitamin CVitamin C
Vitamin C deficiencyVitamin C deficiency
Vitamin C deficiencyVitamin C deficiency
HemorrhageHemorrhage SubconjunctivalSubconjunctival Palpebral Palpebral Orbital Orbital RetinalRetinal
KeratoconjunctivitisKeratoconjunctivitis CataractCataract
Eye Manifestations
Vitamin DVitamin D
Vitamin DVitamin D
Vitamin D deficiencyVitamin D deficiency
Lamellar cataractLamellar cataract AssociationsAssociations
High myopiaHigh myopia Phlyctenular conjunctivitisPhlyctenular conjunctivitis keratoconuskeratoconus
Daily therapeutic dose 2500 IU
Endocrinal DisordersEndocrinal Disorders
Thyroid DisordersThyroid Disorders
Thyroid Eye DiseaseThyroid Eye Disease
1.1. Soft tissue involvementSoft tissue involvement1.1. Periorbital and lid swellingPeriorbital and lid swelling
2.2. Conjunctival hyperaemiaConjunctival hyperaemia
3.3. Conjunctival chemosis.Conjunctival chemosis.
2.2. Eye lid retractionEye lid retraction
3.3. ProptosisProptosis
4.4. Optic neuropathyOptic neuropathy
5.5. Restrictive myopathyRestrictive myopathy
Patient may be: Hyper thyroid, euthyroid, Hypothyroid
Soft tissue involvementPeriorbital and lid swelling
Chemosis
Conjunctival hyperaemia
Superior limbic keratoconjunctivitis
Eyelid Retraction Occurs in about 50%
• Bilateral lid retraction • No associated proptosis
• Bilateral lid retraction • Bilateral proptosis
• Lid lag in downgaze • Unilateral lid retraction • Unilateral proptosis
Proptosis Occurs in about
50%
TED is the commonest cause of proptosis (unilateral or bilateral )in adults
Axial and permanent in about 70%
May be associated with choroidal folds
Optic Neuropathy Occurs in about
5% Early defective colour vision Usually normal disc
appearance
Caused by optic nerve compression at
orbital apex by enlarged recti
Often occurs in absence of significant proptosis
• Occurs in about 40% Due to fibrotic contracture
Restrictive Myopathy
Elevation defect - most common Abduction defect - less common
Depression defect - uncommon Adduction defect - rare
HypothyroidismHypothyroidism
HypothyroidismHypothyroidism
Puffiness of eyelids.Puffiness of eyelids. Loss of hair from outer third of the eye Loss of hair from outer third of the eye
brow.brow. Madarosis.Madarosis. Discrete spots in the central cornea.Discrete spots in the central cornea. Whitish opacities of the lens periphery.Whitish opacities of the lens periphery. Bilateral retrobulabar neuritis.Bilateral retrobulabar neuritis. Optic atrophy.Optic atrophy.
Parathyroid glandParathyroid gland
HypoparathyroidismHypoparathyroidism
PhotophobiaPhotophobia Cortical lens opacityCortical lens opacity Lid twitches.Lid twitches. Conjunctivitis & keratitisConjunctivitis & keratitis
HyperparathyroidismHyperparathyroidism
Calcium crystal deposition in the Calcium crystal deposition in the conjunctivaconjunctiva
Band shaped keratopathy.Band shaped keratopathy.
Anemia Anemia
Subconjunctival hemorrhages.Subconjunctival hemorrhages. Dilated tortous retinal veins.Dilated tortous retinal veins. Edema, exudates.Edema, exudates. Optic neuritisOptic neuritis
LeukemiaLeukemia
Ocular effectsOcular effects
Orbital infiltrationOrbital infiltration Proptosis.Proptosis. Exophthalmos.Exophthalmos. Iritis with hypopionIritis with hypopion Spontaneous hyphema Spontaneous hyphema
& subconj. hge.& subconj. hge.
Posterior SegmentPosterior Segment
Retinal edema, Retinal edema, hemorrhages, tortous hemorrhages, tortous vessels, Rothvessels, Roth’’s spots.s spots.
Papillitis.Papillitis.
Astherosclerosis Astherosclerosis
Grading of arteriolosclerosis
Ocular effectsOcular effects Arcus senilisArcus senilis Lipid keratopathyLipid keratopathy Arteriolar narrowing, focal or diffuse Arteriolar colour changes AV crossing changes, e.g. nicking ±
flame hges, vessel sclerosis, threading
Hypertension Hypertension
Hypertensive retinopathy
Cotton-wool spots and
macular star
Disc oedem
a
Focal Generalized
Arteriolar constriction
Extravascular signs
Flame-shaped retinal haemorrhages
Arteriolosclerosis (A-V changes)
Ocular associations of hypertension
Retinal vein occlusion Retinal artery macroaneurysm
Ocular motor nerve palsies Anterior ischaemic optic neuropathy
rHipertensiva_02(ingles).swf
Connective Tissue DisordersConnective Tissue Disorders
Connective tissue disordersConnective tissue disorders
Inherited:Inherited: Marfan’s syndrome:Marfan’s syndrome: Ectopia lentis, Ectopia lentis,
22ryry glaucoma, retinal detachment. glaucoma, retinal detachment.
Ehlers-Danlos syndrome:Ehlers-Danlos syndrome: Blue sclera, Blue sclera, keratoconus, ectopia lentis, angioid streakskeratoconus, ectopia lentis, angioid streaks
Marfan’s syndromeMarfan’s syndrome
Ectopia lentis, Ectopia lentis, 22ryry glaucoma, glaucoma, retinal detachment.retinal detachment.
Ehlers-Danlos syndromeEhlers-Danlos syndrome
Blue scleraBlue sclera keratoconus,keratoconus, ectopia lentis,ectopia lentis, angioid streaksangioid streaks
Acquired connective tissue disorders:Acquired connective tissue disorders: Rheumatoid arthritisRheumatoid arthritis
Peripheral corneal Peripheral corneal thinning (CL Cornea).thinning (CL Cornea).
Iritis & its complicationsIritis & its complications episcleritisepiscleritis ScleritisScleritis Scleromalacia perforansScleromalacia perforans
Infectious Diseases
Infectious diseases
TuberculosisTuberculosis PhlyctenPhlycten UveitisUveitis Choroidal depositsChoroidal deposits
SyphilisSyphilis Interstitial keratitisInterstitial keratitis UveitisUveitis ChorioretinopathyChorioretinopathy BSKBSK
Infectious diseases
RubellaRubella MicrophthalmiaMicrophthalmia CataractCataract GlaucomaGlaucoma UveitisUveitis Salt & pepper retinopathySalt & pepper retinopathy
Others:Others: Viral infections: Viral infections: Varicella-Varicella-
ZosterZoster Parasitic: Parasitic: ToxoplasmosisToxoplasmosis Granulomatous:Granulomatous: Sarcoid Sarcoid FungalFungal
Ocular regions related to systemic diseases
Cornea
The corneal epithelium is of ectodermal embryologic origin so it is affected by diseases of the
skin and mucous membranes. The rest of the cornea is of
mesodermal embryologic origin: so it is affected by disorders of
collagen metabolism
Cornea
Much of the cornea is made of collagen and mucopolysaccharide ground substance, so systemic diseases affecting
collagen may indirectly affect the cornea by way of auto antibodies in the circulation leading to limbal and marginal ulcerations.
The cornea stores materials made in excess by the body, so damage to the cornea may occur indirectly by accumulation of metabolic products.
Systemic metabolic diseases that produce elevated levels of certain precursors and that may opacify the cornea.
The cornea is the most anterior part of the eye, exposed to environmental harm.
Cataract Cataract
Lens fibers opacify as a response to alterations of the physical and chemical medium within the semipermeable lens capsule. Chromosomal disordersChromosomal disorders Diseases of skin & mucous membraneDiseases of skin & mucous membrane Metabolic disorders & infectionsMetabolic disorders & infections Toxic substances produced systemicallyToxic substances produced systemically
Glaucoma Glaucoma
Secondary glaucomas may arise as complications of the systemic disease
itself or from its therapy.
Uveitis Uveitis
Inlftammation of the iris, ciliary body, and choroid may be caused by a wide variety of diseases.
Systemic allergic diseases. Cardiovascular diseases: endocarditis
(subacute bacterial). Collagen diseases Diseases of skin and mucous membranes Metabolic diseases Gastrointestinal and nutritional diseases Neoplastic disease Infectious diseases
Retina Retina
Retinal veasels, choroid: (Microaneurys, Hemorrhages, Exudates, Hemangiomas, Choroiditis).
Neural tissue (Retinitis, Rxudative retinal detachment, Selective rod and cone destruction).
Retinal pigment epithelium (Loss of pigment, Accumulation of toxic substances).
Retina Retina Is vulnerable to these systemic
diseases:
Cardiovascular diseases Collagen diseases Chromosomal disorders Endocrine diseases Diseases of skin and mucous membranes Gastrointestinal and ntritional diseases Hematologic disease Inlectious diseases Phacomatoses: most affect the retina. Pulmonary diseases Renal diseases Metabolic diseases