General Medicine for the Optometrist Dr Russell Watkins
Vasculitis <ul><li>The vasculitides, defined by inflammation of the vessel wall are a heterogeneous group of diseases, aff...
Vasculitis <ul><li>Can be infective or non-infective </li></ul><ul><li>Non-infective vasculitis sub-classified according t...
Vasculitis <ul><li>Can also be classified according to aetiology </li></ul><ul><ul><li>Hypersensitivity vasculitis (type I...
Giant Cell Arteritis <ul><li>Systemic disease </li></ul><ul><li>Patients rarely less than 60yrs </li></ul><ul><li>Affects ...
Giant Cell Arteritis <ul><li>Symptoms </li></ul><ul><ul><li>Malaise </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><u...
Giant Cell Arteritis <ul><li>Complicated by </li></ul><ul><ul><li>Aortitis </li></ul></ul><ul><ul><li>Bowel infarct </li><...
Giant Cell Arteritis <ul><li>Ocular features </li></ul><ul><ul><li>Anterior ischaemic optic neuropathy </li></ul></ul><ul>...
 
 
 
Polyarteritis Nodosa <ul><li>Necrotising inflammation affecting medium & small arteries, associated with thrombosis </li><...
Polyarteritis Nodosa <ul><li>General features </li></ul><ul><ul><li>Kidney damage producing hypertension (often malignant)...
Polyarteritis Nodosa <ul><li>Ocular features </li></ul><ul><ul><li>Necrotising scleritis/sclerokeratitis </li></ul></ul><u...
 
 
 
Wegener’s Granulomatosis <ul><li>Necrotising vasculitis involving </li></ul><ul><ul><li>Upper respiratory tract (haemoptys...
Wegener’s Granulomatosis <ul><li>Affects ~1 in 10,000; peak incidence in adults 40-50 years of age; M>F (2:1) </li></ul><u...
Wegener’s Granulomatosis <ul><li>General features </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Weight loss </li>...
Wegener’s Granulomatosis <ul><li>40-50% of patients may have ocular involvement (mostly contiguous from the sinus or phary...
Wegener’s Granulomatosis <ul><li>Ocular features </li></ul><ul><ul><li>Haemorrhagic conjunctivitis </li></ul></ul><ul><ul>...
 
 
 
 
 
 
 
 
 
Sarcoidosis <ul><li>A multisystem granulomatous disease of unknown aetiology; there is a deficiency of T-cells in blood bu...
Sarcoidosis <ul><li>Organ involvement </li></ul><ul><ul><li>Lungs 95% </li></ul></ul><ul><ul><li>Thoracic lymph nodes 50% ...
Sarcoidosis <ul><li>General features include </li></ul><ul><ul><li>No symptoms </li></ul></ul><ul><ul><li>Fever, night swe...
Sarcoidosis <ul><li>Ocular features </li></ul><ul><ul><li>Eyelids - lupus pernio or nodules </li></ul></ul><ul><ul><li>Ban...
Sarcoidosis <ul><li>Ocular features (cont.) </li></ul><ul><ul><li>Vitritis (classic sign) </li></ul></ul><ul><ul><li>Choro...
 
 
 
 
 
 
 
 
 
 
 
 
 
Rheumatoid Arthritis <ul><li>Chronic inflammatory condition </li></ul><ul><li>Multi-system disorder characterised by perip...
Rheumatoid Arthritis <ul><li>General features </li></ul><ul><ul><li>Symmetrical arthritis </li></ul></ul><ul><ul><li>Rheum...
Rheumatoid Arthritis <ul><li>Ocular features </li></ul><ul><ul><li>Keratoconjunctivitis sicca </li></ul></ul><ul><ul><li>K...
 
 
 
 
 
 
 
 
Systemic Lupus Erythematosus <ul><li>Multisystem autoimmune disease </li></ul><ul><li>Autoantibodies to nuclear DNA </li><...
Systemic Lupus Erythematosus <ul><li>General features </li></ul><ul><ul><li>Migratory symmetrical polyarthritis </li></ul>...
 
SLE <ul><li>Ocular features of SLE </li></ul><ul><ul><li>Eyelid erythema (with butterfly rash) </li></ul></ul><ul><ul><li>...
 
 
 
 
 
 
 
Sjögren’s Syndrome <ul><li>Chronic inflammatory autoimmune disorder </li></ul><ul><li>Characterised by mixed cellular infi...
Sjögren’s Syndrome <ul><li>Primary - the “sicca complex” </li></ul><ul><li>Secondary - associated with </li></ul><ul><ul><...
 
 
 
 
Vasculitis and the Optometrist <ul><li>Optometric management depends on ocular findings and systemic symptoms </li></ul><u...
Upcoming SlideShare
Loading in...5
×

General Medicine for the Optometrist2

1,107

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,107
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
64
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

General Medicine for the Optometrist2

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

    Clipping is a handy way to collect important slides you want to go back to later.

×