The ocular presentation of systemic diseases
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The document summarizes various ocular manifestations of systemic diseases. It discusses how conditions like diabetes, hypertension, sarcoidosis, thyroid disease, and infections can present with issues like uveitis, cataracts, retinal vessel abnormalities, proptosis, ptosis, and abnormal eye movements. It provides details on characteristic signs, potential etiologies, and implications for underlying systemic illnesses for each type of ocular presentation.
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The ocular presentation of systemic diseases
- 2. The ocular presentation of systemic diseases Data collected by : Ruwida Mohammed Saeed
- 3. The eyes are actually a part of the human body sharing functions with it , and affected by factors leading to its deterioration … It can be your mirror if you knew how to use
- 4. Here are some of the main complaints that are commonly faced
- 6. Amaurosis Fugax = is a painless transient monocular visual loss
- 9. Optic neuritis • Rapidly developing impairment of vision in 1 eye or, less commonly, both eyes • Dyschromatopsia ,may be more prominent than the decreased vision • Retro-orbital or ocular pain exacerbated by eye movement • Uhthoff phenomenon, in which vision loss is exacerbated by heat or exercise • Pulfrich phenomenon, in which objects moving in a straight line appear to have a curved trajectory: Presumably caused by asymmetrical conduction between the optic nerves
- 10. Multiple sclerosis is the most common manifestation (usually unilateral, but may be bilateral) and the presenting feature in about 25% of MS patients About 60% of patients in the 20- 40 years age group who present with ON will subsequently develop evidence of systemic demyelinisation !
- 12. Amaurosis Fugax Embolic Vasospastic/ Hemodynamic Neurologic Ocular Idiopathic Temporal Arteritis
- 13. Temporal arteritis • is a systemic inflammatory vasculitis of unknown etiology that affects medium- and large-sized arteries. The clinical criteria is : 1. New headache (localized temporal) 2. Abnormalities of the temporal arteries (tenderness or decreased temporal artery pulse) 3. (ESR) of 50 mm/h 4. Positive results of a temporal artery biopsy 5. visual impairment may occur in as many as 60% of patients
- 14. • The most common cause of vision loss is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head • optic neuropathy, central retinal artery occlusion, branch retinal artery occlusion • diplopia, ptosis,nystagmus, internuclear ophthalmoplegia (INO),and pupillary abnormalities. Branch retinal vein occlusion in a patient with giant cell arteritis
- 16. Proptosis • Infectious • Orbital cellulitis . Mucormycosis , Concurrent sinus disease • Inflammatory • Thyroidopathy • Vasculitis • Wegener granulomatosis • Churg-Strauss syndrome • Neoplastic • Lymphoma • Leukemia • Meningioma • Glioma • Ossifying fibroma • Metastatic (breast in women, lung and prostate in men, gastrointestinal, kidney
- 17. Dermatochalsis • Chronic dermatitis , as of the chronic inflammation leads to recurrent edema and redundancy of the eyelid skin. • Thyroid eye disease frequently associated with dermatochalsis and steatoblepharon ,infiltration of the orbital fat and extraocular muscles with immunoglobulin complexes. • Chronic renal insufficiency can be associated with periorbital edema. When chronic edema can result in stretching of the eyelid skin and redundancy of the eyelid
- 18. 1. Soft tissue involvement • Periorbital and lid swelling • Conjunctival hyperaemia • Chemosis • Superior limbic keratoconjunctivitis 2. Eyelid retraction 3. Proptosis 4. Optic neuropathy 5. Restrictive myopathy THYROID EYE DISEASE
- 19. Soft tissue involvement Periorbital and lid swelling Chemosis Conjunctival hyperaemia Superior limbic keratoconjunctivitis
- 20. Signs of eyelid retraction Occurs in about 50% Bilateral lid retraction Bilateral proptosis Lid lag in downgaze
- 21. Proptosis • Occurs in about 50% • Uninfluenced by treatment of hyperthyroidism Axial and permanent in about 70% May be associated with choroidal folds
- 22. • Occurs in about 40% • Due to fibrotic contracture Restrictive myopathy Elevation defect - most common Abduction defect - less common Depression defect - uncommon Adduction defect - rare
- 23. Ptosis • Any condition causing the upper eyelid to swell may cause ptosis • Reduced Sympathetic Activity (Horner’s syndrome ) • Partial Ptosis , Miosis , anhydrosis Brainstem stroke or tumor , 33% of patients with brainstem lesions demonstrated Horner syndrome Tumors (eg, Pancoast) or infection of the lung apex Dissecting carotid aneurysm Demyelinating disease (eg, multiple sclerosis) Central venous catheterization , Chest tubes Lymphadenopathy (eg, Hodgkin disease, leukemia, tuberculosis, or mediastinal tumors) Lesions of the middle ear (eg, acute otitis media
- 24. • Muscular , nerve , neuromuscular junction : myotonic dystrophy , polymyositis, dermatomyositis , myasthenia, Lambert–Eaton syndrome • Oculomotor nerve palsy giant cell arteritis, Infection, cavernous sinus thrombosis , diabetes mellitus Miller Fisher syndrome, associated with antibodies to ganglioside GQ1b In Miller Fisher syndrome, extraocular muscle involvement is the rule but there are reports of isolated ptosis.
- 26. Pupillary Abnormalities • Horner's syndrome • Third nerve palsy • Holmes-Adie syndrome • Argyl Robertson • Pontine stroke
- 27. Third nerve palsy • Infectious meningitis - Bacterial, fungal/parasitic, viral • Carcinomatous/lymphomatous/l eukemic infiltration, granulomatous inflammation (sarcoidosis, lymphomatoid granulomatosis, Wegener granulomatosis) • Pituitary adenoma, meningioma, craniopharyngioma, metastatic carcinoma
- 29. • is a neurological disorder characterized by dilated pupil that reacts slowly to light but shows a more definite response to accommodation • the classic signs of Argyll Robertson pupil, are rigidity to light and contraction to accommodation • it has been seen with herpes zoster, sarcoid, von Beonomo's encephalitis, diabetes, Lyme disease, Wernicke's encephalopathy. • Tertiary syphilis Holmes-Adie syndrome Argyl robertson pupil
- 31. The corneal changes and the systemic disease • Ulceration • Collagen vascular disease: rheumatoid arthritis, lupus erythematosus, polyarteritis, Sjögren's disease, Wegener's granulomatosis • Sjögren's disease (keratitis sicca, marginal melting) • Alterations in contour / keratoconus • Atopic diseases • Down's syndrome • Marfan's syndrome • DEPOSITS • Gout , myeloma • Wilson's disease (dark copper pigment in Descemet's membrane)
- 33. The lens changes are presented as cataracts
- 35. CATARACT Metabolic Other Systemic Diseases Drug Induced DM G6PD Muscular Dystrophy NF 2 Dermatitis Steroids
- 36. Two types of cataracts result from diabetes Earlier onset age-related • diabetic cataract ,more common type is which occurs in type I or II diabetics. • It is very similar to other age- related cataracts, and may present as a cortical, posterior subcapsular snowflake cataract • Rare, bilateral, occurs rapidly, and related to very high, uncontrolled DM in young type II diabetics
- 38. Uveitis Systemic Dis & Syndromes Infections Infestations TB Candida Herpes Zoster
- 39. Uveitis Systemic Dis & Syndromes Sarcoid BehcetsReiter's Ankylosing Spondylitis Crohn's Dis UC JCA
- 41. Ulcerative colitis is characterized severe diarrhea and cramps , Fever ,Leukocytosis , Abdominal distention UC is associated with various extracolonic manifestations, as follows: • Uveitis • Pyoderma gangrenosum • Pleuritis • Erythema nodosum • Ankylosing spondylitis • Spondyloarthropathies
- 42. Uveitis Systemic Dis & Syndromes Sarcoid BehcetsReiter's Ankylosing Spondylitis Crohn's Dis UC JCA
- 45. Uveitis Systemic Dis & Syndromes Sarcoid Behcets Reiter's Ankylosing Spondylitis Crohn's Dis UC JCA Sacroilitis 33% of pts of AS present with acute anterior uveitis …
- 48. Ocular involvement in Behçet disease • Ocular involvement is seen in about 70% of patients • In most cases, the ocular symptoms follow the oral and genital ulcers by 3-4 years, although ocular disease is the initial manifestation in about 20% of cases. • The classic finding of Behçet disease, iridocyclitis with hypopyon, is present in about one third of cases. • Gonioscopy may reveal an occult hypopyon characterised by hypopyon that it may change position with head movement, and it may form and disappear rapidly without sequelae. • Recurrent attacks may result in posterior synechiae, peripheral anterior synechiae, iris atrophy, and secondary glaucoma. A 19-year-old boy presenting with vitreous haze, and retinal infiltrates due to Behçet’s disease.
- 49. • The classic fundus finding is retinal vasculitis • retinal hemorrhages, yellow-white exudates deep in the retina, white focal retinal infiltrates, retinal edema, and optic disc edema with hyperemia. • Retinal neovascularization, secondary to either retinal vein occlusion or chronic inflammation, may result in retinal or vitreous hemorrhage. • Neovascular glaucoma • Vitreous cellular infiltration almost always is present during the acute phase. • Repeated episodes of posterior segment inflammation cause sheathing of retinal vessels, chorioretinal scars, and retinal and optic nerve atrophy.
- 50. Uveitis Systemic Dis & Syndromes Sarcoid BehcetsReiter's Ankylosing Spondylitis Crohn's Dis UC JCA Unknown Aetiology granuloma
- 51. SARCOIDOSIS Systemic Involvement • Lung lesions – 95% • Thoracic lymph nodes – 50% • Skin lesions – 30% • Eyes – 30%
- 52. SARCOIDOSIS Ocular Involvement • Conjunctival granuloma • Lacrimal gland involvement/dry eye • Acute or chronic uveitis • KPs described as ‘mutton fat’ because they are large and greasy • Chorioretinal granulonmas • Vasculitis including occlusive causing:- • Neovascularisation • Infiltrate in vitreous (vitritis) • Optic nerve head granuloma
- 54. The retina is affected by many diseases , but thecommonest are diabetes , hypertension ,
- 55. Capillary damage Pericyte necrosis (capillaries and veins) Endothelial damage Capillary non-perfusion Retinal ischaemia Vasoactive factors Hyperperfusion Abnormal autoregulation Hypertension New vesselsGrowth factors Hyperglycemia
- 57. Diabetic retinopathy • Diabetic retinopathy is the leading cause of new blindness in persons aged 25-74 years in the United States . And classified as : Background diabetic retinopathy Nonproliferative diabetic retinopathy proliferative diabetic retinopathy Maculopathy
- 59. Background Retinopathy Dot Haemorrhages Hard Exudates NORMAL eyesight -present in almost all who have had type 1 diabetes for 20 years -present in nearly 80 percent of those with type 2 disease for 20 years Micro- aneurysms
- 63. Pre-prolif Retionopathy REFER! 50% of patients progress to proliferative retinopathy within 1-2 years
- 68. ANTERIOR SEGMENT COMPLICATIONS OF DIABETES Recurrent, non-healing corneal epithelial defects Neovascular glaucoma Diabetes lowers the resistance of the patient to pyogenic infections and predisposes to recurrent styes
- 69. Transient Refractive Changes and diabetes Accommodation Disorders. Weakness of accommodation may result when the ciliary muscle becomes weakened by peripheral neuritis involving its nerve supply. Subjective Visual Disturbances. Amaurosis may occur in severe cases of diabetes. Disturbances of the visual cortex may lead to misty vision and to lashes of light which patients may experience after an overdose of insulin. .
- 70. Hypertension Grade I Grade II Grade III Grade IV Papill-oedema HaemorrhagesCotton Wool Spots A-V Nipping Silver Wiring
- 71. Abnormal eye movement Nystagmus • Seesaw nystagmus • Rostral midbrain lesions - Parasellar lesions (eg, pituitary tumors)
- 72. Downbeat nystagmus Lesions of the vestibulocerebellum and underlying medulla, including the following: • Demyelination (eg, multiple sclerosis) • Microvascular disease with vertebrobasilar insufficiency • Brain stem encephalitis • Tumors at the foramen magnum (eg, meningioma, cerebellar hemangioma) • Nutritional (eg, Wernicke encephalopathy, parenteral feeding, magnesium deficiency)
- 73. Restricted eye movement 1. Cranial Nerve Disease (palsy/paresis, congenital/developmental anomaly,tumor, vascular, inflammatory, trauma, immune, etc.) 2. Neuromuscular Junction (Myasthenia, etc) 3. Muscular Disease (congenital/developmental anomaly, tumor, vascular, inflammatory, trauma, immune, etc.) 4. Orbital Disease (pulley, congenital/developmental, tumor, vascular,inflammatory, trauma, immune, etc.)
- 74. Thank you