systemic eye diseases
DESCRIPTION
A lecture from Penang Medical College on systemic eye diseases.TRANSCRIPT
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EYEEYE window towindow to
Systemic Systemic DiseasesDiseases
DR. ANG EE LINGDR. ANG EE LINGPENANG GENERAL HOSPITAL PENANG GENERAL HOSPITAL
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PapilloedemaPapilloedema
Optic NeuritisOptic Neuritis
PhakomatosesPhakomatoses
Grave’s OphthalmopathyGrave’s Ophthalmopathy
SarcoidosisSarcoidosis
TuberculosisTuberculosis
Hypertensive retinopathyHypertensive retinopathy
Retinal emboliRetinal emboli
Giant cell arteritisGiant cell arteritis
Rheumatoid Rheumatoid arthritisarthritis
SLESLE
Juvenile arthritisJuvenile arthritis
PANPAN
Wilson’sWilson’s
LeukaemiaLeukaemia
Sickle cell anaemiaSickle cell anaemia
HIVHIV
SyphilisSyphilis
ToxoplasmosisToxoplasmosis
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HYPERTENSIVE RETINOPATHY
DYSTHYROID EYE DISEASE
UVEITIS DEFINATION CLASSIFICATION SIGNS N SYMPTOMS TOXOPLASMOSIS OCULAR MANIFESTATION OF HIV
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HYPERTENSIVE RETINOPATHYHYPERTENSIVE RETINOPATHY
• WHO definition:WHO definition:• Systolic blood pressure >140 mm Hg • Diastolic blood pressure > 90 mm Hg
• HTN can affect the choroid, retina, and optic nerve
• HTN may cause cranial nerve palsies that affect extraocular motility, and strokes that result in visual field defects
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Keith-Wagener-Barker Hypertensive Keith-Wagener-Barker Hypertensive Retinopathy ClassificationsRetinopathy Classifications
Grade Description
1Mild retinal vascular changes (generalized arteriolar narrowing).
2Moderate to severe retinal vascular changes Moderate to severe retinal vascular changes (arteriovenous crossing and nicking changes).(arteriovenous crossing and nicking changes).
3Stage 1 and 2 findings, plus cotton-wool spots, retinal hemorrhages and exudates.
4Stage 3 findings, plus associated optic nerve head swelling and macular star formation.
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DYSTHYROID EYE DISEASEDYSTHYROID EYE DISEASE(TED)(TED)
associated with disease of the thyroid gland
Commonly occurs with an overactive thyroid (Thyrotoxicosis):
Grave’s disease
Toxic Nodular Goitre
It also occurs in hypothyroidism: eg: Hashimoto’s disease
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Eye signs of TEDEye signs of TED
EXTRAOCULAREXTRAOCULAR INTRAOCULARINTRAOCULAR
ANTERIORANTERIOR
SEGMENTSEGMENT
POSTERIORPOSTERIOR
SEGMENTSEGMENT
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EXTRAOCULAREXTRAOCULAR
PROPTOSIS
LID SIGNS
RESTRICTIVE MYOPATHY
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ProptosisProptosis• Occurs in about 50%
• Axial and permanent in about 70%
• Unilateral or bilateral
• due to inflammation of the extraocular muscles
and orbital fat
• May be associated with choroidal folds.
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• Average readings are 15 to 17 mm for adults with range of 12 to 22 mm Difference between the two eyes of greater than 2 mm is significant for this test
HERTELHERTEL exopthalmometerexopthalmometer
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Attentive gaze (Kocher’s sign )
Lid retraction (Dalrymple’s sign)
Lid lag (Von Graefe’s sign)
Lid fullness ( Enoth’s Sign)
Infrequent blinking (Stellwag’s sign)
Lid signs
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RESTRICTIVE MYOPATHYRESTRICTIVE MYOPATHY
Occurs in about 40%
Due to fibrotic contracture
“I M SLOW”
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INTRAOCULARINTRAOCULAR
ANTERIOR SEGMENT
• Conjunctival injection and chemosis
• Superior limbic keratitis
• Dry eyes
• Exposure keratopathy
• Episcleritis/Scleritis
• Glaucoma
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INTRAOCULARINTRAOCULAR
POSTERIOR SEGMENT
• Choroidal folds
• Macula oedema
• Optic disc swelling
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Axial CT scan markedly enlarged recti muscles compressing the optic nerve
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Management• Monitor all patients closely during their inflammatory
phase to ensure they do not develop optic nerve compression or corneal exposure
• Patients with severe orbitopathy may require orbital bony decompression, external beam radiation of the orbit, steroids, or a combination of all three modalities
• In general strabismus and eyelid procedures are not performed until the phase of active inflammation has subsided, (and following orbital decompression if decompression is required)
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UVEITISUVEITIS
Inflammation of the
uveal tract
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CLASSIFICATIONCLASSIFICATION
ANATOMICAL
PATHOLOGICAL
CLINICAL
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ANTERIOR
INTERMEDIATEINTERMEDIATE
POSTERIORPOSTERIOR
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Pathological Pathological
GRANULOMATOUSGRANULOMATOUS NON-NON-GRANULOMATOUSGRANULOMATOUS
INFECTIVE NON INFECTIVE
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ClinicalClinical ACUTE
sudden
symptomatic onset
May persist for upto 3 months
CHRONIC insidious onset
maybe asymptomatic
Persists for longer than 3 months
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Symptoms
• Pain
• Redness (circumcorneal imjection)
• Blurring of vision
• Photophobia
• Dull headache
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Ocular Examination
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Anterior uveitis
• Circumcorneal injection
• AC cells an flare
• Keratitic precipitates
• Iris nodules
• Posterior synechiae
• Posterior anterior synchiae (PAS)
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KOEPPE’S
BUSSACA
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Intermediate uveitisIntermediate uveitis
• Snow flakes an snow banks
• vitritis
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Posterior uveitis
• Cystoid macular oedema
• Choroiditis
• Retinitis
• Vasculitis
• Optic neuritis
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ToxoplasmosisToxoplasmosis
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• Congenital
• Acute acquired
• Recurrent
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Clinical manifestationsClinical manifestations
• mild flu-like symptoms, prolonged glandular – fever type illness
• If the infection occurs early in the pregnancy, the baby may be miscarried or stillborn.
• If infected between the third and sixth month of pregnancy, the baby may develop some or all of the following severe symptoms: - – Hydrocephalus
(An excess of fluid on the brain) – Brain Lesions
(Scarring of the brain tissue) – Eye damage
(Retinochoroditis)
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Fundus findings
• Solitary
• Round
• Pigmented punched out retinal scar
• Location: temporal to the macula
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• Clinical examination and fundus appearance
• Serum Ig G and Ig M antibodies
• PCR of aqueous humour
Diagnostic evaluationDiagnostic evaluation
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Treatment• Clindamycin
• Sulphur drugs– Sulphadiazine
– Cotrimoxazole
• Pyrimethamine
• Azithromycin
• Systemic steroids
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Ocular manifestationsOcular manifestationsof of
HIVHIV
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EXTERNALEXTERNALANTERIORANTERIOR
SEGMENTSEGMENT
POSTERIORPOSTERIOR
SEGMENTSEGMENT
NEURO-OPHTHALMICNEURO-OPHTHALMIC
• Molluscum Contagiosum
•Herpes Zoster Ophthalmicus
•Kaposis’s Sarcoma
•Conjunctival Squamous Cell Carcinoma
• Dry eye
• Anterior uveitis
• Retinal Microvasculopathy
• CMV Retinitis
• Acute Retinal Necrosis
• Progressive Outer Retinal Necrosis
• Toxoplasmosis Retinochoroiditis
• Syphilis Retinitis
• Candida albicans endophthalmitis
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Molluscum contagiosumMolluscum contagiosum• viral infection of the
skin.• painless, small,
umbilicated nodules, which produce a waxy discharge
• Treatment – excision – curettage – cryotherapy
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Kaposi’s sarcomaKaposi’s sarcoma• vascular neoplasm which
is almost exclusively seen in patients with HIV.
• The mainstay of treatment is radiotherapy.
• Other options include cryotherapy or chemotherapy.
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HIV retinopathy HIV retinopathy
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CMV retinitisCMV retinitis
• most common opportunistic infection in HIV, usually seen when CD4 <50
• CMV retinitis was easily recognized as a “tomato ketchup in mozzarella cheese appearance” . ie Retinal haemorrhages along edge or within the areas of necrosis.
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TREATMENTTREATMENT• GANCICLOVIRGANCICLOVIR
– reverse transcriptase inhibitors– Analog of guanosine – Virostatic
– Mode:• Intravenous• Oral• Intravitreal• Implant
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TREATMENTTREATMENT• HAART (Highly active antiretroviral HAART (Highly active antiretroviral
therapy)therapy)– a combination of protease inhibitors taken with
reverse transcriptase inhibitors
Protease inhibitor :– indinavir
• Nucleotides reverse transcriptase inhibitors:– Combivir (zidovudine / lamivudine) – Retrovir (Zidovudine, AZT)
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PrognosisPrognosis• 80-95% will respond, with resolution of
intraretinal hemorrhages and white infiltrates.
• If treatment is discontinued and the individual is still immunocompromised (ie, CD4 <50) – retinitis will recur in 100%.
• Prior to the advent of HAART,– 50% of patients would experience recurrence within 6
months despite maintenance therapy. – This rate is reduced if the CD4 count is elevated.
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PrognosisPrognosis
• Untreated retinitis will progress to blindness from
– retinal necrosis,– optic nerve involvement, or– retinal detachment.
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Eye: help in diagnosisEye: help in diagnosis
KF RingKF Ring
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Marfan’s SyndromeMarfan’s Syndrome
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Thank you