THE EYE & THE BODY Ocular Manifestations of Systemic Diseases Dr.Turki AL-Turki Consultant Ophthalmlogist

NORMAL FUNDUS

Cardiovascular diseases

Flame shaped hemorrhages Cotton wool spots Hard exudates Flame shaped hemorrhages

Grade IV Hypertensive Retinopathy Central retinal vein occlusion Branch retinal vein occlusion Second most common cause of vascular-related visual loss. Risk factors Hypertension Coagulopathy Vasculitis (Behcets,sarcoidosis,AIDS,SLE)

Cardiovascular diseases Diagnostic workup BP measurement Lipid profile ECG Echocardiography Carotid Doppler Consider risk factors Hypertension Carotid artery diseases Cardiac Arrhythmias Coagulopathy Central retinal artery occlusion OCULAR EMERGENCY

Diabetes Mellitus A cause of 4000 new case of blindness/year. Risk factors Family history Duration of disease Type of DM Use of insulin Poor metabolic control Presence of Co-morbid conditions Hypertension Hyperlipidemia Renal disease Smoking Alcohol consumption Anemia Obesity Pregnancy

Mild non-prolifrative diabetic retinopathy Moderate non-prolifrative diabetic retinopathy Sever non-prolifrative diabetic retinopathy

Proliferative diabetic retinopathy

Tractional retinal detachment

Argon laser pan-retinal photocoagulation (PRP). Focal laser treatment for macular edema. Intravitreal injection of steroids Intravitreal injections of anti-vascular endothelial growth factor (Anti-VEGF)

Diabetes Mellitus Third (Oculomotor) cranial nerve palsy. MAKE SURE THAT THE PUPIL IS NORMALLY REACTING IN 3RD NERVE PALSY Complete 3rd nerve palsy

Unilateral lid retraction Bilateral lid retraction Thyroid eye disease Unilateral lid retraction Unilateral proptosis Bilateral lid retraction Bilateral proptosis In 50% of cases

Thyroid eye disease 1. Soft tissue involvement 2. Eyelid retraction Periorbital and lid swelling Conjunctival hyperemia Chemosis Superior limbic keratoconjunctivitis 2. Eyelid retraction 3. Proptosis 4. Optic neuropathy 5. Restrictive myopathy

Lid lag on down gaze movement

Proptosis Occurs in about 50% not influenced by treatment of hyperthyroidism Axial and permanent in about 70% May be associated with choroidal folds Treatment options Systemic steroids Radiotherapy Surgical decompression

keratoconjunctivitis Soft tissue involvement Periorbital and lid swelling Conjunctival hyperaemia Superior limbic keratoconjunctivitis Chemosis

Optic neuropathy Occurs in about 5% Early defective colour vision Usually normal disc appearance Caused by optic nerve compression at orbital apex by enlarged recti muscles Often occurs in absence of significant proptosis

Restrictive myopathy Occurs in about 40% Due to fibrotic contracture Elevation defect - most common Abduction defect - less common Depression defect -uncommon Adduction defect - rare

Inflammatory conditions (Sarcoidosis) Idiopathic multisystem disorder Characterised by non-caseating granuloma More common in women 20-50 yrs More common in blacks and Asians Eyes – 30%

Inflammatory conditions (Sarcoidosis) Anterior segment lesions (30%) Conjunctival granuloma Acute or chronic uveitis Lacrimal gland involvement& dry eye Posterior segment lesions (20%) Patchy venous sheathing Cellular infiltrate around vessels Chorioretinal granulonmas Vasculitis Neovascularisation Infiltrate in vitreous (vitritis)

Sickle cell retinopathy Hyphema New vessel formation Sea fan neovascularization

White centered hemorrhage (Roth’s spot) Leukemia Sterile hypopyon White centered hemorrhage (Roth’s spot)

Metastatic lung cancer Metastasis Metastatic lung cancer Metastatic renal cell carcinoma Metastatic lymphoma

Increase in size and number throughout Neurofibromatosis type-1 (NF-1) Café-au-lait spots Most common phacomatosis Affects 1:4000 individuals Presents in childhood Appear during first year of life Increase in size and number throughout childhood

Eyelid neurofibromas in NF-1 Nodular Plexiform May cause mechanical ptosis May be associated with glaucoma

Intraocular lesions in NF-1 Lisch nodules Congenital ectropion uveae Very common - eventually present in 95% of cases Uncommon - may be associated with glaucoma Choroidal naevi Retinal astrocytomas Rare - identical to those seen in tuberous sclerosis Common - may be multifocal and bilateral

Common - combined hamartomas of RPE Ocular features of NF-2 Very common - presenile cataract Common - combined hamartomas of RPE and retina

Peripheral corneal involvement in Rheumatoid arthritis,Wegener granulomatosis, polyarteritis nodosa Without inflammation With inflammation Chronic and asymptomatic Circumferential thinning with intact epithelium (‘contact lens cornea’) Acute and painful Circumferential ulceration and infiltration Treatment - systemic steroids and/or cytotoxic drugs

GIANT CELL ARTERITIS Systemic signs & symptoms Headache Scalp tenderness Thickened temporal arteries Jaw claudication Acute visual loss Weight loss, anorexia, fever, night sweats, malaise & depression Ocular Complications Transient monocular visual loss (amaurosis fugax) Visual loss due to Central retinal artery occlusion (CRAO) or Anterior ischaemic optic neuropathy (AION) Visual field defects

Systemic infections Can affect any part of the eye Tuberculosis Lids optic nerve. Can be limited to the eye only Difficult Dx Requires systemic antimicrobial therapy PLUS Steroids Can cause severe visual loss secondary to inflammation and infection. Tuberculosis Syphilis HIV Toxoplasmosis Brucellosis Herpes zoster Candida infection

Retinitis with vasculitis Endogenous endophthalmitis Systemic infections Retinitis with vasculitis Endogenous endophthalmitis

Systemic infections Anterior Uveitis Herpes Zoster Ophthalmicus