Ophtha 250

Dr.

amil Lisin!

Lecture 5: Ocular Manifestations of Systemic Diseases EXAM 1

4T5I13 I. II. Introduction Dommon Cystemic Donditions with .cular Manifestations -. Diabetes Mellitus E. Bypertension D. BIF<-IDC D. $hyroid anomalies G. $uberculosis III. .ther Donditions with .cular Manifestations
The content of the lecture is the same as that written in the SIM (pp 187-205). is mostly asymptomatic in patients less than 5 years into the disease. 6 3o data. Due to late diagnosis patients are prone to develop complications earlier7 hence the death of most of them. 3ote that $ype I "or IDDM' patients have a faster progression to D# after 1! 8 15 years than $ype II "or 3IDDM' patients

-lassification of #ia$etic %etinopath& I. 1on-proliferati+e (1*#%) 9no proliferation: 8 9no neovasculari;ation: A. Mild NPDR o 0resence mostly of "1' microaneur&sm which is the earliest clinically visible changes of D# o microaneurysms are presented as small<pinpoint red dots in clusters although they may be isolated o May also present with "2' hard e/udates "*' macular edema and "%' hemorrhages [although the SIM stated that for Mild NPDR, only icroaneurys can !e found"

INTRODUCTION
cular !un"us Important in the evaluation of systemic diseases being the only region in the body where one can directly visualize the manifestations of macrovascular and microvascular pathology.

SYSTEMIC CONDITIONS WITH OCULAR MANIFESTATIONS

#ia$etic %etinopath& (#%)

!i'ure 2. Mil" 1*#%. 3ote the presence of small red spots which can either be microaneursysms or hemorrhages. Dr. =ising said that microaneurysms are hard to see in D..

B.

!i'ure 1. () #ata on the *re+alence of #ia$etes an" the ,lo$al -auses of .lin"ness as a *roportion of Total .lin"ness/ 2002.

15 years after onset of DM: 2% become blind 1!% with severe vision loss "defined as loss of 6 lines in an ETDRS chart) 2! years after onset of DM 750 will have Diabetic #etinopathy $he piegraph shows Diabetic #etinopathy "%.&% or 1.& M' ran(ing )th among the global causes of blindness among *+ M cases of total blindness in 2!!2 "1st cataract 2nd others ",' *rd glaucoma %th -MD 5th corneal opacity' .ccurs in 25% of the total diabetic population which is appro/imately 1!% of the 0hilippines1 total population .ver 2!% of all diabetics will develop D#

Moderate NPDR 4 0resence of: o Microaneur&sm o )ar" e2u"ates or true e/udates "lipid transudates from blood vessels7 usually intra4retinal discrete with defined borders vs# soft e2u"ates which are paler and have indistinct borders and are actually infarcted nerve fibers in the neurosensory layer of the retina' 0resence of e/udates near macula indicates presence of macular e"ema o Macular e"ema " ost co on cause of decreased vision7 hard to control' o Intra-retinal hemorrha'e "bigger more conspicuous red dots compared to microaneurysms' >rom 2!12: -ccording to Dr -guila1s lecture Moderate 30D# may present with additional soft e2u"ates appearing as opa?ue cotton-wool spots which are actually swollen retinal cells @again, this is not consistent $ith the SIMA

Ta$le 1. *re+alence of #% in patients with T&pe 1 (I##M) an" T&pe 2 (1I##M) relate" to "uration of illness.

Duration "years' !45 1!415 1)42! *!6

IDDM "%' ! 2545! +5425 1!!

3IDDM "%' 5 2*4%* )! 6

53o data for this. 0atients are usually diagnosed greater than 5 years into the disease. $here is late diagnosis of 3IDDM since it

Ta$le 2. )ar" +s. Soft 32u"ates B-#D C.>$ -ppears as solitary or %otton $ool appearance confluent dots with fluffy borders $rue e/udate: fluid lea(ed 3ot truly an e/udate7 it is from vessels and the manifestation of containing lipids protein disrupted a/oplasmic flow cellular elements etc. of the nerve fi!er layer "top layer of retina' due to ische ia More yellow than white More white than yellow

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Ophtha 250

Dr.

amil Lisin!

Lecture 5: Ocular Manifestations of Systemic Diseases EXAM 1

!i'ure 9. Se+ere 1*#%.

II.

!i'ure 6. Mo"erate 1*#%. 1ote presence of hemorrha'es an" e2u"ates.

*roliferati+e (*#%) 0resence of new vessel growth either in the disc "3FD' or elsewhere "3FG' which is a response to the Fascular Gndothelial Irowth >actor released by ischemic areas "appearing as soft e/udates' in the retina. $hese new vessels will eventually bleed leading to blindness. Dlassified into high ris( and non4high ris( 4 predicts prognosis for blindness o Donsidered Bigh ris( if 3FD J K of disc -3D<.# 3FG J disc area

C.

Severe NPDR 40resence of: o Multiple microaneur&sm in all four ?uadrants o #iffuse intra-retinal hemorrha'e o Intra-retinal micro+ascular a$normalities (I%M7): telangiectatic<dilated capillaries appearing as thin vessels which do not brea( out beyond the outer limiting membrane "in contrast to new vessel growths'. o It is usually between a nearby arteriole and venule and is 3.$ a precursor to neovasculari;ation. -cc to Dr. =ising I#M- are difficult to identify esp from neovasculari;ations. >luorescein angiography may be used to identify these. o 8enous $ea"in': appearance of alternating dilated and constricted segments of the veins7 focal areas of constriction "li(e rosary beads or a string of sausages' o Soft e2u"ates

!i'ure 5. 1ew 8essel ,rowth in *#%.

Domplications include: o vitreous hemorrhage "often appearing as boat4shaped bleeds indicates a high ris( 0D#' o traction retinal detachment "$his occurs when the old blood due to hemorrhage fibrose and attach to two retinal points. Lhen the fibrosis contracts the retinal part to which it was attached tears down. $his appears as a boat4shaped hemorrhage.' o vision loss

-riteria for Se+ere 1*#% $o Diagnose Cevere 3D0# H%4241 ruleH is used. o Bemorrhages and Microaneurysms are present in 9 ?uadrants o .# venous beading is present in 2 ?uadrants o .# moderate intraretinal microvascular abnormalities "I#M-' are present in 1 ?uadrant In very severe NPDR two of these features are present

!i'ure :. %etinal #etachment as a complication of *#%.

IRMAs

Venous beading

Additional Notes from 2011: REFRACTION in DM PATIENTS Refraction of diabetics changes with their blood sugar level due to the presence of glucose in the tear film which makes it hypertonic. Thus, there are changes in the hydration of the cornea. Having multiple eyeglasses is not encouraged. The best treatment, therefore, is control of blood sugar. When EOR is assessed in a diabetic, it is correlated with the current blood sugar, so that if the blood sugar is too high the patient is advised to return for a proper refraction after a week of good control of blood glucose.

#ia$etic %etinopath& Mana'ement 3arl& "etection is important for prevention of vision loss ,ui"elines

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Ophtha 250

Dr.

amil Lisin!

Lecture 5: Ocular Manifestations of Systemic Diseases EXAM 1

Ty e !: J 5 years refer to ophthalmology "M prevalence of D# after 5 years' o Ty e ": ophthalmologic evaluation at time of diagnosis o "6' visual symptoms indicate prompt referral o 0regnancy: ophthalmologic monitoring because of the hormonal milieu NPDR# mild to moderate$ regular fundus e/am and fluorescein angiography 8 distinguishes between hemorrhage "blac(' and microaneurysms "white< hyperfluorescence' NPDR# severe$ =aser 0hotocoagulation 8 $his destroys parts of the retina with a green laser in order to reduce retinal o/ygen demand and prevent further neovasculari;ation. "3.$ an absolute indication' CSM% &Clinically Significant Macular %dema'$ Irid "encircles the fovea' or focal "select areas' laser treatment Proliferative DR$ 0anretinal 0hotocoagulation "0#0' all areas e/cept the macula7 peripheral and night vision are affected because the rods are destroyed. Fitreal anti4FGI> is now available to help regress neovasculari;ation. o o In the form of flame4shaped hemorrhages "unli(e dot hemorrhages of DM retinopathy this follows the nerve fiber layer' retinal edema hard e/udates Macular star "hard e/udates in Benle1s layer of fovea occur around the macula' .ptic disc edema "occurs in malignant hypertension' 8 loss of distinct disc borders

o o

!i'ure 8. Macular Star.

Arteriosclerosis o Dauses thic(ening of vessel wall due to intimal hyalini;ation medial hypertrophy endothelial hyperplasia o 78 crossin' chan'es "this is because arteries and veins in the retina share a common sheath at the points of their crossing7 thus a change in one affects the other' o %hanges secondary to arteriolar sclerosis' tapering "sheath becomes more fibrous'7 ban(ing "contraction of fibrous tissue' o %o on co &lications' central retinal vein occlusion "D#F. 9hotdog and (etchup: fundus with dilated and tortuous veins affecting the whole retina' and branch retinal vein occlusion "E#F. affects only one sector'

!i'ure 7. *anretinal *hotocoa'ulation.

(or Com lications$ Fitreoretinal surgery "retinal detachment' Ctrict blood glucose control may reverse beading microaneurysms e/udates but not I#M-s and hemorrhages >our parameters that diabetics -=L-NC need to monitor to maintain ?uality of life "5!% decrease in complications according to the DDD$ OP0DC LGCD# and G$D#C studies': o .loo" 'lucose "DDD$': intensive control group had 1+.1% rate of progression of D# compared to %2.2% in conventional group o .loo" pressure "DDD$ OP0DC': tight control of blood pressure "Q15!<&5 mm Bg' led to reduced ris( of retinopathy progression o -holesterol; Serum 5ipi"s "LGCD#': elevated levels of serum cholesterol associated with increased severity of hard e/udates associated with decreased visual acuity o )emo'lo$in levels "G$D#C': increased ris( of high4ris( 0D# with decreasing hematocrit

,ra"in' of )&pertensi+e %etinopath& 1. Eased on Dhanges due to Bypertension 8 =eith/ (a'ener/ .ar>er or =(. ,ra"in' Irade 1 2 * % 2. Ta,le -. ./B 0rading. Dhanges Clight generali;ed arteriolar attenuation "-F ratio 1:2' .bvious arteriolar narrowing with focal arteriolar attenuation "-F ration 1:*' "6' e/udates "6' hemorrhage "6' optic disc edema Eased on Dhanges due to -rteriosclerosis 8 Scheie ,ra"in' "old method' Ta,le 1. Scheie 0rading -rteriolar Dhange -F Drossing DhangesR Eroadening of the Minimal arteriolar light refle/5 .bvious broadening Moderate Dopper wire arterioles6 Mar(ed Cilver white arterioles Cevere

Irade 1 2 * %

)&pertensi+e %etinopath& ()%)

Most common referral to 0IB4.phtha esp from .E "in eclampsia' -ommon Manifestation of )*1< retino&athy choroidopathy neuropathy

%etinal Manifestations of )*1 )asoconstriction$ generali;ed<focal narrowing *ea+age o Due to abnormal vascular permeability

arteriolar

5arteriolar li'ht refle2< white column in the middle of the artery which is the reflection of light "a solid and more sclerosed vessel would have a broader light refle/'. Cince the light source "opththalmoscope' and viewer are in the same direction the tubular vessels naturally reflect more light from their middle parts "vessel wall perpendicular to line that bisects angle formed by light rays and viewer1s line of sight' than their edges "vessel wall less perpendicular'. =ight refle/ broadens when there is increase in opacity. 6 5!% white 5!% red R includes tapering and ban(ing "sudden turning of vessels'

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Ophtha 250

Dr.

amil Lisin!

Lecture 5: Ocular Manifestations of Systemic Diseases EXAM 1

Ctarts around blood vessels and later on involves the whole fundus

!i'ure ?. (5 to %) 1ormal 7rteriolar 5i'ht %efle2/ .roa" 5i'ht %efle2 (@-opper (ireA)/ an" @Sil+er (ireA 7rteriolar 5i'ht %efle2

!i'ure 12. -M8 %etinitis/ @piBBa pie fun"usA

!i'ure 10. (5 to %) 1ormal 78 -rossin'/ @Taperin'A/ an" @.an>in'A

$umors o

Paposi1s sarcoma of conTunctiva 3euro4ophthalmologic conditions

the

lids

or

-ommon -omplications of )*1 %etinopath& Dentral retinal vein occlusion 8 all % ?uadrants are affected Eranch retinal vein occlusion 8 142 ?uadrants only Mana'ement of )&pertensi+e %etinopath& Dontrol the blood pressure >or vascular occlusions "D#F.<E#F.': close follow4 up by an ophthalmologist laser treatment when indicated "e.g. 3FG 3FD vessels in the angle of the anterior chamber' 3ote: If patient has both DM and B03 with overlapping manifestations of both diagnose retinopathies separately.

#&sth&roi"

phthalmopath&

)I8;7I#S
cular Manifestations Dry eye #etinal microangiopathy 8 cotton wool spots o May be associated with retinal hemorrhage and microaneurysm o Osually asymptomatic S may disappear spontaneously o May be due to immune comple/ deposition or BIF infection of retinal vascular endothelium o G/udates correlate with immune status of individual "unli(e ischemia with &er anent cotton4wool spots'

!i'ure 11. -otton wool spots in 7I#S %etinopath&

.pportunistic infections o DMF retinitis 8 9pi;;a pie fundus: 3ecroti;ing condition7 (ills your retina yellow spots: necroti;ing area -ffects %!% of patients with -IDC Cignifies severe systemic involvement May occur in immunodeficient states

,ra+eCs "isease is an autoimmune disorder due to e/cess secretion of thyroid hormone Most common cause of unilateral or bilateral e/ophthalmos "proptosis' in adults 3ot always correlated with serum thyroid levels Dan progress even in euthyroid states Most common cause of unilateral or bilateral e/ophthalmos "proptosis' in adults Cymptoms: o 5i" retraction (#alr&mpleCs si'n) 8 9scleral show: at 12 o1cloc( and ) o1cloc( "superior and inferior limbus'7 even a show of the li !us in the 12 o1cloc( can indicate retraction o 5i" la' (+on ,raefeCs si'n) 8 patient loo(s down lids should go down with eyeball o 32ophthalmos (=ocherCs si'n) 8 9thyroid stare: Dlasses "1 S*3-S' "chec( your CIMs for the figures': o !: 1o signs and symptoms o 1: nly signs o 2: Soft tissue involvement "conTunctiva' o *: *roptosis o %: 3.M involvement o 5: -orneal damage o ): Sight loss 8 compression of optic nerve due to muscle enlargement =ess Cerious Domplications o G/posure (eratitis o $earing foreign body sensation o =id and conTunctival edema< chemosis More serious complications o Diplopia o .phthalmoplegia o =oss of vision Treatment of -on'esti+e *hase $ear substitutes Dorticosteroids .rbital irradiation or surgical decompression Treatment of -icatricial *hase =id surgery Muscle surgery .rbital surgery

Tu$erculosis
Daused by direct invasion or hypersensitivity .cular involvement in miliary $E

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Ophtha 250

Dr.

amil Lisin!

Lecture 5: Ocular Manifestations of Systemic Diseases EXAM 1

May occur even in patients with no pulmonary symptoms Most common manifestation: granulomatous uveitis "anterior<posterior' which is poorly responsive to corticosteroid treatment o Eussaca nodules: on the surface only o Poeppe nodules: occur on papillary borders "pupil' o Peratic precipitates "in corneal epithelium' .thers o 0hlyctenulosis 8 granulomatous inflammation of the conTunctiva esp in children o Fitritis o #etinal periphlebitis 8 concentrated .3=N beside veins "vs.DMF retinitis' o Dhoroidal tubercles o 0anuveitis $reatment: -nti4Poch1s

3tham$utol-relate" optic neuritis 0atients present with E.F and impaired color perception .n D. optic nerve loo(s white If severe unreactive to consensual 0=# Damage is irreversible

OTHER SYSTEMIC CONDITIONS WITH OCULAR MANIFESTATIONS

Sic>le-cell retinopath& -olla'en +ascular "iseases: rheumatoid arthritis "similar to uveitis' systemic lupus erythematosus "presents li(e DM and B03 retinopathies' polyarteritis nodosa "0-3' 4 similar to uveitis .loo" "&scrasias: leu(emia anemia hyperviscosity states .thers: sarcoidosis herpes ;oster leprosy

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