Medical Ophthalmology - An Exciting and Emerging Interdisciplinary Speciality
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Transcript of Medical Ophthalmology - An Exciting and Emerging Interdisciplinary Speciality
Medical Ophthalmology
Medical ophthalmologists (or ophthalmic physicians) investigate, diagnose and manage eye disorders relating to systemic disease. The physician's approach and knowledge of internal medicine is crucial in managing both the systemic problem and the eye. Therefore, the training encompasses both ophthalmology
and medicine.
An Exciting and Emerging Interdisciplinary Specialty
Currently there is a training programme in the United Kingdom which is undertaken after basic physician training. In Australia and Ireland, medical ophthalmology training can be undertaken after basic or advanced ophthalmology training.
Nima Ghadiri, MA MB BChir MRCP(UK), Medical Ophthalmology Trainee, Addenbrooke’s Hospital, Cambridge, UK
This poster spotlights the role of the medical ophthalmologist as an interdisciplinarian who has expertise in both the eye itself, and the various physician specialties which affect the eye.
CHEST
Sarcoid (Chest and Multi-system granulomatous inflammation - ? Infectious)
Eyes: conjunctiva uveitis, choroiditis, retinal vasculitis, optic neuropathy)
2 Months before referral At referral
Pleural effusions (rarely, if ever, arise in sarcoid)
Note neuroretinitis and arterial sheathing. Characteristics of tuberculosis, not found in sarcoid
25yr old Caucasian student referred from a London teaching hospital “Pneumonia with pleural effusion”, followed by “ocular sarcoidosis, uncontrollable by immunosuppression”. Bilateral visual loss (HM, 6/36).
Good response to anti-tuberculous treatment with steroids, visual recovery to 6/60, 6/5.
Tuberculosis (Multi-system granulomatous infection, Latency/reactivation)
Eyes : conjunctiva uveitis, choroiditis, retinal vasculitis, (arterial and venous sheathing retinitis, neuroretinitis
NEUROLOGICAL
Retinal vasculitis and multiple sclerosis
Visual pathways: Inflammation (autoimmune, infection), tumors, vascular *(anomalies, disease), drug toxicity
50yr old Indian woman with unresponsive scleritisRight visual obscuration and afferent pupil defect, headache, tinnitus, jaw claudication, weight loss, ANCA positive. Wegeners’ Meningitis suspected.Meningeal enhancement on MRIS.Diagnosis by meningeal biopsy.Treatment: Rituximab
CARDIOVASCULAR
Emboli to retinal and posterior ciliary artery territories: occlusive/bacterial
Cardiac arrhythmias, valvular heart disease, aortic and carotid atheroma, right-to-left shunting (atrial septal defects and patent foramen ovale), bacterial endocarditis
Anterior segment vascular imaging: ocular ischaemic syndromes/systemic vasculitis
Optic disc of 29yr old man with visual loss due to chronic severe hypertension
AUTOIMMUNE
Temporal arteritis, ANCA positive vasculitis systematic lupus erythematosus, Behcet’s syndrome
MRI scan of orbital Wegener’s Granulomatosis.
An inflammatory mass wraps the right optic nerve
Acute retinitis in patient with Behcet’ssyndrome
JOINTS
Rheumatoid disease: scleritis and keratitis
HLA-B27: uveitis +/- reactive arthritis
67yr old woman: rheumatoid disease, uncontrollable necrotizing sclerokeratitis
[Prosthetic R shoulder joint had been removed due to Staph aureus infection]
Search for infectious drives by indium leucocyte scan: Collection in the Right humerus.
• Surgical removal of cement restrictor (iv antibiotic and steroid cover)
• Systemic immunosuppression (prednisolone + cyclophosphamide)
+4yrs: immunosuppression withdrawn
+5yrs: scleritis complicating Staph aureus orbital cellulitis (responded to antibiotics, then immunomodulation)
INFECTIONS
Bacterial:
Surface: upper respiratory tract and conjunctiva share organisms.
Intraocular: latent (reactivation) / endogenous endophthalmitis / SBE
Viral: adenovirus, herpesviruses (simplex, zoster, cytomegalovirus)
Parasitic: toxoplasma, toxocara
60yr old: Polymyalgia rheumatic for 6yrs: methotrexate, azathioprine
Episodic R visual loss: prednisolone 120mg/day
+3 months: L stroke
+5 months: L granulomatous uveitis + retinal arteritis
+8 months: Prednisolone 20mg, azathioprine 175mg
Cytomegalovirus retinitis
Azathioprine stopped, Prednisolone reduced (17.5mg>)
Ganciclovir, then valganciclovir
Eye inflammation and systemic symptoms resolved
HAEMATOLOGICAL
Thrombophilia (retinal arterial and venous occlusions)
Lymphoma (orbital, conjunctival, intraocular)
69yr old woman with uveitis
Left-sided facial sensory loss
Progression despite steroids
Features of lymphoma: cords of vitreous cells
Brain biopsy: High-grade B-cell lymphoma
expanding before Rx contracting before Rx
Months
0 CF, CF → Methylprednisolone x3, cyclosporine A 200ug/1, nifedipine
1 6/60, 6/24 → Methylprednisolone x3
10 6/12, 6/9
11 colour vision full, driving
4yr 6/12, 6/9 → Block/replace withdrawn no immunosuppression
ENDOCRINE
Medical treatments for thyroid eye disease
At presentation 4 years later
49yr old diabetic woman with treated thyrotoxicosis
Reduced right vision 6/36, 6/9
R surgical orbital decompression: awoke with bilateral visual loss (CF, CF)
Orbits hard vision (no colour vision on R)
OTHERS
Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) - Uveitis
Gastrointestinal
Urinary Tract
Skin and Mucus Membranes
Interstitial nephritis – uveitis
Systemic vasculitis – scleritis, keratitis
Stevens-Johnson Syndrome, ocular cicatricialpemphigoid
OCULAR
Ocular and orbital inflammatory disease
Management of macular oedema
Perioperative management in ocular inflammatory disease
Post-operative eye infections (exogenous endopthhalmitis)
Ocular vascular disease
New techniques for imaging microcirculations
Adhesions between iris and lens in uveitis
Bacterial deposits in lens capsule after cataract surgery
Haemoglobin video imaging study of normal human
conjunctival microcirculation
AN INTERDISCIPLINARY SPECIALTY
This interdisciplinary speciality has an important role in managing complex patient groups throughout the world and in bridging the gap between hospital ophthalmic services, inpatient medical care and community care.
Therapeutic options can be very effective, in many cases circumventing the need for potentially risky surgery. The continued development of new treatments mean that the speciality has an exciting future.