Lecture 6 THE CHANGES OF VISUAL ORGAN IN SYSTEMIC DISEASES Lecture is delivered by Ph. D., assistant of professor Tabalyuk T.A.

FUNDUS CHANGES IN ARTERY HYPERTENSION (Krasnov M., 1948) Hypertensive angiopathy – mild generalized arteriolar narrowing, tortuosity and dilation of veins, Gvists’ symptom (tortuosity of small venuls around macula). Hypertensive angiosclerosis – thickening of arteriolar walls, «cooper wiring», «silver wiring», symptom of arteriovenous crossing: Salus-Gun-Relman I - conic narrowing of vein in arteriovenous crossing; Salus-Gun-Relman II - arc bending of vein in arteriovenous crossing; Salus-Gun-Relman III - absence of vein picture in arteriovenous crossing. Hypertensive retinopathy – all above changes plus retinal haemorrhages, cotton wool spots and hard exudates. Hypertensive neuroretinopathy – all above changes plus optic disc swelling. Management: control of blood pressure and treatment by general practitioner; regular review if treatment is not indicated; vitaminotherapy, tissue therapy and proteolitic ferments to dissolve retinal haemorrhages and exudates.

Salus-Gun-Relman I

Salus-Gun-Relman III

Hypertensive retinopathy (Kanski Jack) Grade 1 – mild generalized arteriolar narrowing Grade 2 – focal as well as marked generalized arteriolar constriction Grade 3 – as Grade 2 plus retinal haemorrhages, cotton wool spots and hard exudates Grade 4 – as Grade 3 plus optic disc swelling

Retinal artery occlusion (RAO) Aetiology: embolization from a carotid or cardiac source, or vazoobliteration by atheroma or arteritis. Clinical features: acute loss of vision; may be permanent or transient (amaurosis fugax). Retinal pallor corresponding to the involved area (central or branch) is seen, and in central RAO a «cherry red spot» at the fovea is typically present. Segmentation of the arteriolar blood column («cattle trucking») may be seen. Later the arterioles become attenuated and the optic disc pale. Emmergency: s/l nitroglicerini, validoli, euphyllini i/v, no-spa or acidi nicotinici i/m, diacarbi per os. Acute RAO may be relieved by lowering IOP by nassage, intravenous acetaxolamide, anterior chamber paracentesis

Central retinal artery occlusion with «cherry-red spot»

Retinal vein occlusion (RVO) Predisposing factors include increasing age, hypertension, hyperviscosity, trombophilic disorders, and raised IOP. Presents with sudden mild to severe loss of vision in one eye. Acute signs include haemorrhages, cotton wool spots, venous tortuosity, optic dics and retinal oedema. Fundus picture in RVO is called picture of «pressed tomato» or «red ischaemia». Classification: Branch RVO – usually involves a retinal quatrant; Hemiretinal veib occlusion; Central RVO (ischaemic or non-ischaemic). Emmergency: anticoagulants (heparini), trombolytics (streptodekesa), and antiagregants (pentoxiphillini) systemically.

Central retinal vein occlusion

Branch retinal vein occlusion

Peculiarities of renal hypertension – exudative syndrome, retinal oedema, a lot of cotton wool spots on gray background, optic disc swelling, «star figure» in macula. Peculiarities of atherosclerosis - exudative syndrome is not typical, the primary are thickening of arteriolar walls, «cooper wiring» «silver wiring». Fundus picture in pregnancy toxicosis is like changes in hypertensive angiopathy, retinopathy, neuroretinopathy (arteriolar narrowing, its tortuosity, haemorrhages, cotton wool spots, optic disc swelling, «star figure» in macula). Despite artery hypertension in arteriolar spasm caused by pregnancy toxicosis, symptoms of arteriovenous crossing are not marked. In severe retinal swelling on background of pregnancy toxicosis transsudative retinal detachment or retinal vein occlusion may happen.

Retinopathy in renal hypertension Retinopathy in renal hypertension. A color fundus photograph that shows optic disk swelling, cotton-wool spots (blue arrow), hemorrhages (white arrow), retinal exudation and a macular star (green arrow).

Diabetic retinopathy (DR) is the most common cause of blidness in the working-age population. The incidence of severity of DR are strongly related to duration of diabetes: good control of blood glucose and hypertension are very important. Fundus picture in diabetic angiopathy - tortuosity and dilation of veins, microaneurysms; nonproliferative DR – dot and blot haemorrhages and hard exudates in retina; proliferative DR – new vessel formation at the optic disk or elsewhere on the retina. Severe visual loss may occur as a result of vitreous haemorrhage or tractional retinal detachment due to constriction of fibrovascular tissue. diabetic maculopathy is the most common cause of visual impairment in patients with diabetes. Loss of visual functions is usually caused by oedema, typically accompanied by exudates. Less commonly, the macula becomes ischemic, often with severe deterioration in central vision.

Nonproliferative diabetic retinopathy

Management of DR: Regular review if treatment is not indicated, frequency dependent on severity of DR; Panretinal laser photocoagulation for proliferative DR; Grid or focal laser photocoagulation for macular oedema fitting certain criteria (clinically significant macular oedema); Vitrectomy for persistant vitreous haemorrhage or tractional retinal detachment involving the centre of the macula. .

Fundus photo showing scatter laser surgery for diabetic retinopathy.

The complex of hyperthyroidism (Graves’ disease) consists of the following eye signs: Proptosis due to abnormal fluid infiltration of orbital contents; Retraction of the upper lid due to overaction of the levator muscle (Dalrimple’s symptom); Diplopia due to malfunction of the extrinsic ocular muscle; Visual loss due to the effects of corneal exposure or of pressure on the optic nerve; Infrequent blinking (Shtelfag’s sign); Convergence weakness (Mebius sign); Hyperpigmentation of upper eyelid (Ellinek’s sign); Graefe’s sign is lid lag; failure to follow the eyeball on down gaze; Joffroi’s sign is excessive retraction of the upper lid on looking upwards.

Thyroid orbitopathy

The ear diseases, i.e. purulent processes in it may be a source of purulent methastasis into the orbit and eyeball. As a result orbital cellulitis, choroiditis, panuveitis, panophthalmitis, optic neuritis may occur. The nose diseases may cause conjunctivitis, blepharitis, chronic dacriocyctitis. The stomatological diseases may result in orbital periostitis or cellulitis, keratitis or iridocyclitis. The brain tumours are assosiated with papilloedema, hemianopsia, paralysis of oculomotor muscles, visual disturbances of cortical genesis. In rheumatoid diseases usually uvea is involved. Iridocyclitis, choroiditis or panuveitis may occur.

Orbital cellulitis Signs: eyelids oedema chemosis proptosis limiting of eye movements decreasing of visual acuity general intoxication (headacke, increased temperature, brain signs). Optic neuritis, papilloedema, central vein occlusion may occur with outcome in optic atrophy.

OPTIC NEURITIS – inflammation of the optic nerve, with a range of causes, the most important being multiple sclerosis. Clinical features: presents with subacute, usually unilateral, impairment of central vision that may be associated with pain, especially on eye movement. The optic disc is usually normal (retrobulbar neuritis) and occasionally swollen and red (papillitis). Severe or recurrent attacks may lead to optic atrophy. PAPILLOEDEMA – disc swelling caused by raised intracranial pressure. Clinical features: symptoms of raised intracranial pressure including headaches and nausea. Transient visual obscuration lasting a few seconds are common but visual acuity is normal until late. Signs: early – hyperaemia with indistinct margins; established – obvious elevation, peripapillary haemorrhages and cotton wool spots; long-standing – markedly elevated «champagne cork» appearance;

Optic neuritis

Papilloedema

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