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General Medicine for the Optometrist2
 

General Medicine for the Optometrist2

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    General Medicine for the Optometrist2 General Medicine for the Optometrist2 Presentation Transcript

    • General Medicine for the Optometrist Dr Russell Watkins
    • Vasculitis
      • The vasculitides, defined by inflammation of the vessel wall are a heterogeneous group of diseases, affecting blood vessels of all types
      • Abnormal immune responses may be involved
      • Vasculitis can be complicated by thrombosis and severe cases result in permanent vessel wall damage
      • In milder cases the damage is transient & may be marked only by cellular infiltration & vessel wall damage by leakage of RBCs
    • Vasculitis
      • Can be infective or non-infective
      • Non-infective vasculitis sub-classified according to size of BV involved
        • Large, medium and small BVs
        • Medium and small BVs
        • Small BVs
    • Vasculitis
      • Can also be classified according to aetiology
        • Hypersensitivity vasculitis (type III), e.g. drug-induced, bacteraemia
        • A component of a systemic autoimmune disease, e.g. RA, SLE, sarcoidosis
        • The systemic vasculitides, e.g. PAN, WG, GCA
    • Giant Cell Arteritis
      • Systemic disease
      • Patients rarely less than 60yrs
      • Affects ~1 in 1,500 per year of over-60s; F>M (2:1)
      • Large & medium muscular arteries (with elastic tissue) affected, mainly in head & neck
      • Type IV hypersensitivity
      • Patients will have temporal artery biopsy and ESR measured
    • Giant Cell Arteritis
      • Symptoms
        • Malaise
        • Fever
        • Anorexia
        • Weight loss
        • HEADACHE
        • Tender temporal arteries & scalp
        • May be jaw claudication or painful tongue
    • Giant Cell Arteritis
      • Complicated by
        • Aortitis
        • Bowel infarct
        • MI
        • CVA
      • Associated with polymyalgia rheumatica
        • Proximal muscle weakness & pain
    • Giant Cell Arteritis
      • Ocular features
        • Anterior ischaemic optic neuropathy
        • Less commonly, central retinal artery occlusion
        • Ocular palsies due to muscle or nerve ischaemia
        • Rarely, anterior segment ischaemia
      • Patients may complain of transient visual obscurations preceding AION
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    • Polyarteritis Nodosa
      • Necrotising inflammation affecting medium & small arteries, associated with thrombosis
      • Affects ~1 in 10,000 per year; M>F (2:1)
      • Type III hypersensitivity
        • ?Hepatitis B, CMV
      • Fatal unless treated with immunosuppression (90% remission)
    • Polyarteritis Nodosa
      • General features
        • Kidney damage producing hypertension (often malignant) & renal failure
        • MI & angina
        • Bowel & skin infarcts, including erythema nodosum
        • Arthritis
        • Peripheral neuropathies
    • Polyarteritis Nodosa
      • Ocular features
        • Necrotising scleritis/sclerokeratitis
        • “ Primary retinopathy” - vasculitis with occlusion
        • “ Secondary retinopathy” - due to hypertension
        • Ischaemic optic neuropathy
        • Transient focal detachments
        • Rarely, retinal vessel aneurysms
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    • Wegener’s Granulomatosis
      • Necrotising vasculitis involving
        • Upper respiratory tract (haemoptysis)
        • Kidneys (renal failure)
        • Skin lesions
        • Middle ear & sinuses
    • Wegener’s Granulomatosis
      • Affects ~1 in 10,000; peak incidence in adults 40-50 years of age; M>F (2:1)
      • The cause is presumed to be immune complex formation secondary to inhaled antigens
      • Necrotising, granulomatous arteritis with fibrinoid necrosis
      • Collagenolysis
    • Wegener’s Granulomatosis
      • General features
        • Fever
        • Weight loss
        • Haemoptysis
        • Runny nose and nasal mucosal ulceration
        • Nasal deformity
        • Peripheral neuropathy
        • Cerebral vasculitis
    • Wegener’s Granulomatosis
      • 40-50% of patients may have ocular involvement (mostly contiguous from the sinus or pharynx, but it may be isolated)
      • 18-22% of patients demonstrate orbital involvement, usually bilateral
      • Treatment consists of immunosuppression
      • Improvement with systemic therapy is usual, with up to 90% remission
    • Wegener’s Granulomatosis
      • Ocular features
        • Haemorrhagic conjunctivitis
        • Episcleritis & scleritis
        • Corneal infiltration & ulceration; guttering
        • Nasolacrimal duct obstruction
        • Orbital: proptosis & painful ophthalmoplegia, chemosis, retinal venous congestion
        • Retinopathy: arterial narrowing, venous tortuosity, cotton wool spots, cystoid macular oedema, chorioretinitis
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    • Sarcoidosis
      • A multisystem granulomatous disease of unknown aetiology; there is a deficiency of T-cells in blood but an excess in lung granulomas; ?Type IV hypersensitivity
      • Affects ~1 in 4,000; F>M (3:2); onset tends to be acute in younger adults and insidious in older adults
      • More common in New York African Americans and Ireland
      • Can spontaneously resolve, be progressive, or relapsing-remitting
    • Sarcoidosis
      • Organ involvement
        • Lungs 95%
        • Thoracic lymph nodes 50%
        • Skin 30%
        • Eyes 30%
          • 10% present with ocular problems
    • Sarcoidosis
      • General features include
        • No symptoms
        • Fever, night sweats, weight loss
        • Breathlessness
        • Rashes including lupus pernio and erythema nodosum
        • Arthralgia
        • Peripheral neuropathy
        • Parotid gland enlargement & facial palsies
    • Sarcoidosis
      • Ocular features
        • Eyelids - lupus pernio or nodules
        • Band keratopathy
        • Lacrimal gland enlargement
        • Conjunctival follicles
        • Nodular episcleritis & scleritis
        • Acute non-granulomatous & chronic granulomatous iridocyclitis
        • Secondary cataracts & glaucoma
    • Sarcoidosis
      • Ocular features (cont.)
        • Vitritis (classic sign)
        • Choroiditis with white or yellow nodules
        • Retinal periphlebitis with candle wax exudates
        • Retinal neovascularisation
        • Pars planitis
        • Choroidal & optic nerve granulomata
        • Disc oedema
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    • Rheumatoid Arthritis
      • Chronic inflammatory condition
      • Multi-system disorder characterised by peripheral, symmetrical polyarthritis
      • F>M
      • Vasculitis part of the disease process
    • Rheumatoid Arthritis
      • General features
        • Symmetrical arthritis
        • Rheumatoid nodules - skin and lung
        • Pericarditis
        • Myopathy & neuropathy
        • Vascular disease
          • Raynaud’s phenomenon
          • Necrotising arteritis
          • Skin ulceration
          • Rarely organ infarction
    • Rheumatoid Arthritis
      • Ocular features
        • Keratoconjunctivitis sicca
        • Keratitis
        • Peripheral corneal thinning - “contact lens cornea” - may perforate
        • Scleritis
        • Episcleritis
        • NB uveitis is NOT an association
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    • Systemic Lupus Erythematosus
      • Multisystem autoimmune disease
      • Autoantibodies to nuclear DNA
      • Type III hypersensitivity
      • Affects ~1 in 3,000; more common in Asians and Afro-Caribbeans; F>M (8:1)
      • Vasculitis part of the disease process
    • Systemic Lupus Erythematosus
      • General features
        • Migratory symmetrical polyarthritis
        • Renal failure & hypertension
        • Skin
          • Butterfly rash
          • Photosensitivity
          • Discoid rash
          • Raynaud’s phenomenon
        • Pleurisy & pericarditis
        • Peripheral neuropathy & psychosis
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    • SLE
      • Ocular features of SLE
        • Eyelid erythema (with butterfly rash)
        • Telangiectasia
        • KCS
        • Keratitis with peripheral corneal thinning
        • Scleritis
        • Retinopathy
          • Primary due to vasculitis - disc oedema + CWS
          • Secondary – hypertension
        • Cranial nerve palsies
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    • Sjögren’s Syndrome
      • Chronic inflammatory autoimmune disorder
      • Characterised by mixed cellular infiltration (plasma cells & lymphocytes with fibrosis) of lacrimal & salivary glands (amongst others)
      • Features
        • Dry eye (xerophthalmia)
        • Dry mouth (xerostomia)
        • Dyspareunia & chest infections
    • Sjögren’s Syndrome
      • Primary - the “sicca complex”
      • Secondary - associated with
        • RA
        • SLE
        • Polymyositis/dermatomyositis
        • Scleroderma
        • PAN
        • Et al
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    • Vasculitis and the Optometrist
      • Optometric management depends on ocular findings and systemic symptoms
      • If any systemic vasculitis is suspected, urgent ophthalmic referral is indicated
      • Have a high level of suspicion in elderly patients with a new or ‘different’ headache
      • Refer keratitis, scleritis, uveitis, orbitopathy, cranial neuropathy and retinal vasculitis urgently
      • If a disorder is suspected (but not diagnosed) for another reason, refer to GP for medical investigation
      • If patient is known to have a vasculitic disorder then be on the lookout for possible ocular problems