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Systemic Systemic DiseasesDiseases

DR. ANG EE LINGDR. ANG EE LINGPENANG GENERAL HOSPITAL PENANG GENERAL HOSPITAL

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

HYPERTENSIVE RETINOPATHY

DYSTHYROID EYE DISEASE

UVEITIS DEFINATION CLASSIFICATION SIGNS N SYMPTOMS TOXOPLASMOSIS OCULAR MANIFESTATION OF HIV

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

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.

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

Eye signs of TEDEye signs of TED

EXTRAOCULAREXTRAOCULAR INTRAOCULARINTRAOCULAR

ANTERIORANTERIOR

SEGMENTSEGMENT

POSTERIORPOSTERIOR

SEGMENTSEGMENT

EXTRAOCULAREXTRAOCULAR

PROPTOSIS

LID SIGNS

RESTRICTIVE MYOPATHY

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.

• 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

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

RESTRICTIVE MYOPATHYRESTRICTIVE MYOPATHY

Occurs in about 40%

Due to fibrotic contracture

“I M SLOW”

INTRAOCULARINTRAOCULAR

ANTERIOR SEGMENT

• Conjunctival injection and chemosis

• Superior limbic keratitis

• Dry eyes

• Exposure keratopathy

• Episcleritis/Scleritis

• Glaucoma

INTRAOCULARINTRAOCULAR

POSTERIOR SEGMENT

• Choroidal folds

• Macula oedema

• Optic disc swelling

Axial CT scan markedly enlarged recti muscles compressing the optic nerve

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)

UVEITISUVEITIS

Inflammation of the

uveal tract

CLASSIFICATIONCLASSIFICATION

ANATOMICAL

PATHOLOGICAL

CLINICAL

ANTERIOR

INTERMEDIATEINTERMEDIATE

POSTERIORPOSTERIOR

Pathological Pathological

GRANULOMATOUSGRANULOMATOUS NON-NON-GRANULOMATOUSGRANULOMATOUS

INFECTIVE NON INFECTIVE

ClinicalClinical ACUTE

sudden

symptomatic onset

May persist for upto 3 months

CHRONIC insidious onset

maybe asymptomatic

Persists for longer than 3 months

Symptoms

• Pain

• Redness (circumcorneal imjection)

• Blurring of vision

• Photophobia

• Dull headache

Ocular Examination

Anterior uveitis

• Circumcorneal injection

• AC cells an flare

• Keratitic precipitates

• Iris nodules

• Posterior synechiae

• Posterior anterior synchiae (PAS)

KOEPPE’S

BUSSACA

Intermediate uveitisIntermediate uveitis

• Snow flakes an snow banks

• vitritis

Posterior uveitis

• Cystoid macular oedema

• Choroiditis

• Retinitis

• Vasculitis

• Optic neuritis

ToxoplasmosisToxoplasmosis

• Congenital

• Acute acquired

• Recurrent

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)

Fundus findings

• Solitary

• Round

• Pigmented punched out retinal scar

• Location: temporal to the macula

• Clinical examination and fundus appearance

• Serum Ig G and Ig M antibodies

• PCR of aqueous humour

Diagnostic evaluationDiagnostic evaluation

Treatment• Clindamycin

• Sulphur drugs– Sulphadiazine

– Cotrimoxazole

• Pyrimethamine

• Azithromycin

• Systemic steroids

Ocular manifestationsOcular manifestationsof of

HIVHIV

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

Molluscum contagiosumMolluscum contagiosum• viral infection of the

skin.• painless, small,

umbilicated nodules, which produce a waxy discharge

• Treatment – excision – curettage – cryotherapy

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.

HIV retinopathy HIV retinopathy

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.

TREATMENTTREATMENT• GANCICLOVIRGANCICLOVIR

– reverse transcriptase inhibitors– Analog of guanosine – Virostatic

– Mode:• Intravenous• Oral• Intravitreal• Implant

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)

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.

PrognosisPrognosis

• Untreated retinitis will progress to blindness from

– retinal necrosis,– optic nerve involvement, or– retinal detachment.

Eye: help in diagnosisEye: help in diagnosis

KF RingKF Ring

Marfan’s SyndromeMarfan’s Syndrome

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