Medical Ophthalmology - An Exciting and Emerging Interdisciplinary Speciality
1. Medical Ophthalmology
Medical ophthalmologists (or
ophthalmic physicians) investigate,
diagnose and manage eye disorders
relating to systemic disease. The
physician's approach and knowledge
of internal medicine is crucial in
managing both the systemic problem
and the eye. Therefore, the training
encompasses both ophthalmology
and medicine.
An Exciting and Emerging Interdisciplinary Specialty
Currently there is a training programme
in the United Kingdom which is
undertaken after basic physician training.
In Australia and Ireland, medical
ophthalmology training can be
undertaken after basic or advanced
ophthalmology training.
Nima Ghadiri, MA MB BChir MRCP(UK), Medical Ophthalmology Trainee, Addenbrooke’s Hospital, Cambridge, UK
This poster spotlights the role of the
medical ophthalmologist as an
interdisciplinarian who has expertise in
both the eye itself, and the various
physician specialties which affect the eye.
2. CHEST
Sarcoid (Chest and Multi-system granulomatous
inflammation - ? Infectious)
Eyes: conjunctiva uveitis, choroiditis, retinal
vasculitis, optic neuropathy)
2 Months before referral At referral
Pleural effusions (rarely, if ever, arise in sarcoid)
Note neuroretinitis and arterial sheathing. Characteristics of tuberculosis,
not found in sarcoid
25yr old Caucasian student referred from a London
teaching hospital
“Pneumonia with pleural effusion”, followed by “ocular
sarcoidosis, uncontrollable by immunosuppression”.
Bilateral visual loss (HM, 6/36).
Good response to anti-tuberculous treatment with
steroids, visual recovery to 6/60, 6/5.
Tuberculosis (Multi-system granulomatous infection,
Latency/reactivation)
Eyes : conjunctiva uveitis, choroiditis, retinal
vasculitis, (arterial and venous sheathing retinitis,
neuroretinitis
3. NEUROLOGICAL
Retinal vasculitis and multiple sclerosis
Visual pathways: Inflammation (autoimmune,
infection), tumors, vascular *(anomalies, disease), drug
toxicity
50yr old Indian woman with unresponsive scleritis
Right visual obscuration and afferent pupil defect,
headache, tinnitus, jaw claudication, weight loss, ANCA
positive. Wegeners’ Meningitis suspected.
Meningeal enhancement on MRIS.
Diagnosis by meningeal biopsy.
Treatment: Rituximab
4. CARDIOVASCULAR
Emboli to retinal and posterior ciliary artery
territories: occlusive/bacterial
Cardiac arrhythmias, valvular heart disease, aortic
and carotid atheroma, right-to-left shunting
(atrial septal defects and patent foramen ovale),
bacterial endocarditis
Anterior segment vascular imaging: ocular
ischaemic syndromes/systemic vasculitis
Optic disc of 29yr old man with visual loss due to
chronic severe hypertension
5. AUTOIMMUNE
Temporal arteritis, ANCA positive vasculitis systematic lupus erythematosus, Behcet’s syndrome
MRI scan of orbital Wegener’s Granulomatosis.
An inflammatory mass wraps the right optic nerve
Acute retinitis in patient with Behcet’s
syndrome
6. JOINTS
Rheumatoid disease: scleritis and keratitis
HLA-B27: uveitis +/- reactive arthritis
67yr old woman: rheumatoid disease, uncontrollable
necrotizing sclerokeratitis
[Prosthetic R shoulder joint had been removed due to
Staph aureus infection]
Search for infectious drives by indium leucocyte scan:
Collection in the Right humerus.
• Surgical removal of cement restrictor (iv antibiotic
and steroid cover)
• Systemic immunosuppression (prednisolone +
cyclophosphamide)
+4yrs: immunosuppression withdrawn
+5yrs: scleritis complicating Staph aureus orbital
cellulitis (responded to antibiotics, then
immunomodulation)
8. HAEMATOLOGICAL
Thrombophilia (retinal arterial and venous occlusions)
Lymphoma (orbital, conjunctival, intraocular)
69yr old woman with uveitis
Left-sided facial sensory loss
Progression despite steroids
Features of lymphoma: cords of vitreous cells
Brain biopsy: High-grade B-cell lymphoma
expanding before Rx contracting before Rx
9. Months
0 CF, CF → Methylprednisolone x3, cyclosporine A 200ug/1, nifedipine
1 6/60, 6/24 → Methylprednisolone x3
10 6/12, 6/9
11 colour vision full, driving
4yr 6/12, 6/9 → Block/replace withdrawn no immunosuppression
ENDOCRINE
Medical treatments for thyroid eye disease
At presentation 4 years later
49yr old diabetic woman with treated thyrotoxicosis
Reduced right vision 6/36, 6/9
R surgical orbital decompression: awoke with bilateral visual
loss (CF, CF)
Orbits hard vision (no colour vision on R)
11. OCULAR
Ocular and orbital inflammatory
disease
Management of macular
oedema
Perioperative management in
ocular inflammatory disease
Post-operative eye infections
(exogenous endopthhalmitis)
Ocular vascular disease
New techniques for imaging
microcirculations
Adhesions between iris
and lens in uveitis
Bacterial deposits in lens capsule after
cataract surgery
Haemoglobin video imaging
study of normal human
conjunctival microcirculation
12. AN INTERDISCIPLINARY
SPECIALTY
This interdisciplinary speciality has an important role in managing complex patient groups throughout
the world and in bridging the gap between hospital ophthalmic services, inpatient medical care and
community care.
Therapeutic options can be very effective, in many cases circumventing the need for potentially risky
surgery. The continued development of new treatments mean that the speciality has an exciting future.
