1. Eye Manifestation in systemic disease
พญ. พัชรินทร์ แซ่ลิ่ว

2. Common systemic disease
Systemic hypertension
Diabetic retinopathy
AIDS
Thyroid
SJS
Ocular toxicity from systemic drug
Systemic steriod
Antimalarial ; chloroquine
Antituberculosis druds

3. Common systemic diseases affecting the eye
Infectious
Toxoplasmosis
Toxocariasis TB
Syphilis
Leprosy
HIV
CMV
Non-infectious
Endocrine – diabetes, HT, thyroid
Connective tissue disease – RA/ SLE
Vasculitides (GCA)
Sarcoidosis
Behcet’s Disease
Vogt Koyanagi Harada syndrome

19. Hypertensive retinopathy

20. Hypertensive Retinopathy
Elevation of systemic BP -> focal and generalized constriction of retinal arterioles.
Chronic effect of HT -> arteriolosclerotic changes; vascular thickening, arteriolar narrowing (reduction of A/V ratio).

21. Prolonged duration of high BP -> breakdown of inner blood-retinal barrier ; retinal hemorrhage, CWS, exudate.
Acute/accelerate HT -> choriocapillaris infarction -> breakdown of outer blood-retinal barrier.
Severe HT -> optic nerve involvemet.

22. Modified Scheie Classification of Hypertensive Retinopathy
Stage 0 ; no visible retinal vascular abnormality.
Stage 1 ; diffuse arteriolar narrowing, no focal constriction.
Stage 2 ; obvious arteriolar narrowing with focal irregularity.
Stage 3 ; arteriolar narrowing with retinal hemorrhage/exudate.
Stage 4 ; previous abnormality with retinal edema, optic disc edema.

23. Grading of arteriolosclerotic changes
Grade 1 ; broadening of light reflex from arteriole, minimal/no arteriovenous compression.
Grade 2 ; broadening of light reflex and deflection of vein at arteriovenous crossing.
Grade 3 ; copper wire appearance of arterioles, more arteriovenous compression.
Grade 4 ; silver wire appearance of arterioles, severe arteriovenous crossing.

29. THYROID EYE DISEASE 1. Soft tissue involvement 2. Eyelid retraction
Periorbital and lid swelling
Conjunctival hyperaemia
Chemosis
Superior limbic keratoconjunctivitis
2. Eyelid retraction
3. Proptosis
4. Optic neuropathy
5. Restrictive myopathy

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

31. Signs of eyelid retraction
Occurs in about 50%
Bilateral lid retraction
Bilateral lid retraction
No associated proptosis
Bilateral proptosis
Unilateral lid retraction
Lid lag in downgaze
Unilateral proptosis

32. Proptosis Occurs in about 50%
Uninfluenced by treatment of hyperthyroidism
Axial and permanent in about 70%
May be associated with choroidal folds
Treatment options
Systemic steroids
Radiotherapy
Surgical decompression

35. 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
Often occurs in absence of significant
proptosis

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

41. Vit A deficiency

44. Connective tissue disease

46. Peripheral corneal involvement in
rheumatoid arthritis
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

48. Ocular manifestations of HIV infection

49. Ophthalmic Manifestations of HIV Infection
AROUND THE EYE
Molluscum Contagiosum
Herpes Zoster Ophthalmicus
Kaposi’s Sarcoma
Conjunctival Squamous Cell Carcinoma
Trichomegaly
FRONT OF THE EYE
Dry Eye
Anterior Uveitis
BACK OF THE EYE
Retinal Microvasculopathy
CMV Retinitis
Acute Retinal Necrosis
Progressive Outer Retinal Necrosis
Toxoplasmosis Retinochoroiditis
Syphilis Retinitis
Candida albicans endophthalmitis
NEURO-OPHTHALMIC

50. Ophthalmic manifestation in AIDS
70–80% of adult AIDS patients experienced an ocular complication
Ophthalmic complications is lower in the pediatric age group
All patients with HIV disease should undergo routine ophthalmologic examinations
CD4+T Lymphocyte proved to be a reliable predictor of ocular complications

51. HIV retinopathy

52. CMV RETINITIS
CMV is the most common cause of retinitis in those with AIDS
Generally is a late manifestation, small percentage of patients, it may be the manifesting sign of AIDS.
CD4 is reliable risk factor , almost cases CD4 < 50 cells/mm3

53. CMV Retinitis
Introduction
CMV Retinitis is the commonest intraocular ocular opportunistic infection seen in patients with AIDS
Antibodies are found in almost 95% of adults, causing a trivial illness in immunocompetent adults, however severe immunosuppression causes viral reactivation and tissue invasive disease
Pathogenesis
Reactivation from extraocular sites leads to seeding in other sites such as the retina
Epidemiology
The number of newly diagnosed cases of CMVR has decreased since the introduction of the HAART
Highly Active Antiretroviral Therapy

54. CMV Retinitis Clinical manifestations
Patients may complain of minor visual symptoms such as floaters, flashing lights or mild blurred vision, or be totally asymptomatic.
It presents with a wide range of clinical appearances. From cotton wool spots which may look like HIV Retinopathy to confluent areas of full thickness retinal necrosis and vasculitis. CMVR can progress in a “brushfire” pattern from the active edge of an active lesion. The retinal vessels in an affected area show attenuation, becoming ghost vessels eventually.
Treatment
The treatment of CMVR in patients with AIDS requires the use of specific antiviral agents, ganciclovir, foscarnet or cidovir in conjunction with HAART.
These treatments can be administered orally, intravenously or intravitreally. Systemic treatment has the advantage of treating infection elsewhere in the body as well as the other eye but has the disadvantages of systemic side effects.
Intravitreal implants release the drug over a six-month period, achieving prolonged high intravitreal drug.

55. CMV RETINITIS three patterns of CMV retinitis
hemorrhagic
brush fire
granular
All of these may simultaneously occur in the same eye.

59. FIGURE 6  CMV retinitis exhibiting a brush-fire pattern in a patient with AIDS

60. Herpesvirus Common affect AIDS patients
Ophthalmic finding include keratitis, panuveitis, vitritis, retinal arteritis, disc edema, necrotizing retinitis (ARN or PORN)
Neuro-ophthalmic findings are uncommon
Encephalitis is most common in CNS involvement

61. Acute retinal necrosis Progressive outer retinal necrosis
viruses of the herpes family may also cause retinal infections in the patient with HIV,
ARN
consisting of severe vitreitis and a necrotizing retinitis
seen in patients with or without immunosuppression.
caused by both VZV and herpes simplex
PORN
limited to immunosuppressed patients
more rapidly progressive retinitis
minimal to no anterior chamber or vitreous reaction.
causative agent  VZV

63. ARN/PORN

64. Drugs toxicity

65. Chloroquine toxicity
Use for Tx of collagen-vas dis, malaria prophylaxis
Toxic relate to duration, total dose, pt age
Symptom: blurr vision, color vision loss, dark-adaptation deficit
Macular change most typically: bull’s eye, paracentral scotoma
Toxic occur: total accu dose > 300g (safe maintain < 250 mg daily)
Early detection: important but difficult

66. Chloroquine toxicity
Pt should: baseline ophthalmoscopy, fundus photo, VA, color, central VF (red)
F/U q 6-12mo
Recommend: cessation of drug at first sign of toxic
Sometimes progress despite discont

67. CQ maculopathy
Risk factors
Dose
Obesity
Old age>60 yrs
Retinal dz

68. 2) Hydroxychloroquine(HCQ)
-also used for Rx RA &SLE
-can produce retinopathy identical to CQ but rare
-VA ,paracentral scotoma &bull’s eye maculopathy
-received above recommended daily dosage of 400 mg/d (or 6.5 MKD)