Ocular Manifestations of Systemic Disease and Ocular injury

Describe Diabetes

• Clinical Imp

• List the Non-proliferative changes (NPDR)

  • Mild/Mod

  • Severe

• List the Proliferative (PDR) changes

  • Clinical Imp

  • MOA

  • Untreated →?

• Describe Macula Edema

• Management

  • Freq. of exams

  • Treatment

Diabetes

Clinical Importance:

• Leading cause of vision loss (18-64 yrs)

• Risk of developing retinopathy ↑ with duration of disease 

  • (type 1 23% @ 5 yrs, 80% @ 15 yrs, rates lower for type 2)

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Non-proliferative changes (NPDR)

• Mild - Moderate

  • Microaneurysms

  • Dot-blot hemorrhages

  • Hard exudates

  • Venous beading

  • Intraretinal microvascular abnormalities (IRMA)

• Severe

  • 4 quads of hemorrhages, 2 quads of beading or 1 quad of IRMA

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Proliferative (PDR)

• Clinical Importance:

  • Responsible for most of profound visual loss

• MOA:

  • Neovascularization in response to ischemia

    • Disc, retina, iris

• If untreated 

  • → vitreous hemorrhage, tractional retinal detachment

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Macular Edema

• Most common cause of mild-mod VA loss

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Management

• Frequency of exams

  • Type 1 – initial exam when post-pubertal and within 5 yrs of Dx

  • Type 2 – exam @ time of Dx

  • All:

    • generally examine q1yr unless poor glycemic control, HTN, anemia, proteinuria,

    • mod- severe NPDR or PDR which require more freq F/U

    • Pregnant + type I – first trimester + q3months

• Treatment

  • Focal laser

  • Panretinal photocoagulation

  • Vitrectomy with laser

Dot Hemorrhages

Microaneuysms

• NVE = Neovascularization Elsewhere

• NVD = Neovascularization of the Disc

Panretinal photocoagulation

Describe Arteriolar Sclerosis

• Severity of Eye disease?\

• Eye symptoms?

  • Associated w/ Thickening and sclerosis of arterioles

  • Associated w/ BP Elevation

• Classifications?

• Management?

Arteriolar Sclerosis

Severity of Eye disease 

• Extent relates to duration + severity of HTN

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Eye Symptoms:

• Thickening and sclerosis of arterioles

  • ↑ light reflex width (copper → silver wire)

    • Changes in the color of blood vessels

  •  A-V nicking

    • ***hardened, thickened artery (arteriole) crosses over and compresses a vein (venule), making the vein look pinched or bulging on both sides ***

    • May predispose to BRVO if severe

• Acute BP elevation

  • Fibrinoid necrosis → 

    • exudates, 

    • CWS (cotton wool)

    •  flame hemorrhages, 

    • optic disc swelling

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Classification

• Grade 0 – no changes

• Grade 1 – barely detectable arterial narrowing

• Grade 2 – obvious arterial narrowing with focal irregularities

• Grade 3 – gr 2 + retinal hemorrhages or exudate

• Grade 4 – gr 3 + disc swelling

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Management

• Control BP

• Avoid nocturnal hypotension

  • ischemic optic neuropathy, glaucomatous field loss

Describe Pregnancy and the eye

• List the Physiologic Δs

• List the Pathologic Δs

Physiologic Δs

• ↓ IOP, 

• ↓ corneal sensitivity, 

• ↓ accommodation, 

• dry eye, 

• Δ in refraction

• ***Avoid changing glasses, contacts, refractive surgery***

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Pathologic Δs

• ↑ risk of CSR, uveal melanoma

• Pre-eclampsia/eclampsia

  • Scotoma, diplopia, dimness

  • Vascular Δs

  • Hemorrhages, exudates, retinal edema, disc swelling

  • Serous exudative RD in 10% of eclampsia

• Diabetes – exacerbated retinopathy

Cooper wiring + Nicking

Hypertensive Retinopathy with cotton-wool spots

Severe Hypertensive Retinopathy

Malignant Hypertension Retinopathy

Malignant Hypertension with Papilledema

Describe Sickle Cell Anemia

• Patho

• Treatment

Sickle Cell Anemia

• Patho:

  • Arteriolar occlusion

    •  intravasc sickling → hemolysis → hemostasis → thrombosis → capillary non-perfusion

      • -> poor perfusion = retinal ischemia → neovascularization

        • Similar to Diabetes

• Treatment:

  • Laser Tx – can prevent vision loss

• NOTE:

  • SC and S Thal more likely to have eye involved

Seafan in SS Sickle cell retinopathy

Describe autoimmune influences on the eye:

• Dry eyes

  • Causes

  • Symptoms

  • Tx

• Anterior uveitis

  • Causes

  • Treatment

List RA Ocular Manifestations

Dry eyes:

• Causes: Sarcoidosis, SLE, Rheumatoid arthritis, Thyroid

  • Healthy pts > 40yrs

• Symptoms

  • Burning, grittiness esp in PM

  • crusting in AM

  • Tearing

• Treatment:

  • lubrication

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Anterior uveitis

• Causes: 

  • Ankylosing spondylitis, Reiter, Behcet

  • Juvenile RA – esp pauciarticular (asymptomatic)

• Treatment: 

  • Close F/U

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RHEUMATOID ARTHRITIS: OCULAR MANIFESTATIONS

• Dry eyes

• Episcleritis

• Scleritis

• Corneal ulcers

• Uveitis

Episcleritis

Episcleritis w/ ulcers forming

sclera so thin from inflammation→ see choroid underneath

Corneal Ulcer

Describe Grave’s effect on the eyes

• Signs

• Treatment

Graves

• Signs

  • Retraction of upper + lower lids

  • Upper lid lag in ↓ gaze

  • Eyelid swelling,

  • conj vascular congestion

• Treatment

  • Surgery for 

    • severe proptosis, 

    • diplopia 2° EOM involvement, 

    • optic nerve decompression

  • Radiation/Steroids/Tepezza (Teprotumumab) for inflammatory TED

Thyroid Eye Disease Eyelid Retraction

Thyroid Eye Disease Fibrosis of Inferior Rectus

Describe Sarcoidosis

• What is it

• Epidemiology

• Abnormal Labs

• Ocular Involvement

• Tx

Sarcoidosis

• What is it?

  • Focal non-caseating granulomas

• Epidemiology:

  • MC African-American females 20 – 40 yrs

• Abnormal Labs

  • ↑ Ca++, ↑ACE, abnormal CXR

• Ocular involvement

  • Conj, lacrimal gland → dry eye

  • Ant/post uveitis

  • Retinal perivasculitis, 

  • Hemorrhages,

  • neovascularization

  • CNS involvement (if retina affected)

• Treatment:

  • Early topical or systemic steroids may prevent complications

    • Cataract, glaucoma, iris to lens adhesion

Mutton-Fat Keratic Precipitates in Sarcoidosis

Describe AIDS

• List the common complications and describe them

• Less common complications?

AIDS

• Common Complications

  • AIDS retinopathy

    • Cotton wool spots

  • CMV retinitis

    • Leading cause of visual loss in AIDS

    • Hemorrhagic necrosis of retina

    • More common if CD4<100

  • Kaposi’s sarcoma

• Less common Complications

  • Herpes zoster, simplex, toxoplasmosis

  • Oculomotor dysfcn 2° CNS involvement

HIV Retinopathy with Roth Spots and Cotton-Wool Spots

CMV Retinitis in AIDS

Describe Syphilis

• Clinical Imp

• Primary Complication?

  • Epi

  • Manifestations

• Secondary Symptoms

• Tertiarty?

Syphilis

Clinical Imp:

• permanent visual loss if dx and tx are delayed

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• Primary Complication : Acute interstitial keratitis

  • Epi:

    • Age 5 – 25 yrs

  • Manifestations: Bilateral vs unilateral

    • Pain + photophobia

    • Diffusely opaque cornea with ↓ VA

    • Late – ghost vessels + opacities

• Secondary Symptoms:

  • Pain, redness, photophobia, blurred vision, floaters

  • Iritis, choroiditis, and/or exudates around disc + vessels

• Tertiary Symptoms:

  • Chorioretinitis 

  • diffuse neuroretinitis and vascular sheathing

Describe Malignancy and the eye:

• Primary?

• Describe metastasis

  • MC?

  • Localization?

  • Other?

• List the Radiation complications

  • Cornea, Lens, Optic nerve, Retina

• List the chemo complication

Malignancy

• Primary ocular malignancy 

  • rare

• Metastasis

  • MC: Breast; lung 

  • Usually Localize to choroid 

    • but EOMs, optic nerve can be affected

  • Lymphoma, leukemia

• Radiation complications

  • Cornea 

    • keratitis / dryness

  • Lens 

    • cataract

  • Optic nerve 

    • neuropathy

  • Retina

    •  vasculopathy

• Chemo

  • Carmustine

1. In which disease is an early diagnosis crucial in?

2. What symptoms warrent an immidiantly referral to an eye doc? for him to do what?

3. What should be considered in any ocular dif. diagnosis

Early diagnosis of diabetic retinopathy is crucial to the ultimate success of treatment, which is effective for both nonproliferative and proliferative retinopathy.

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Any patient with an autoimmune disease or systemic infection who presents with a red eye, decreased vision, photophobia, or floaters should be referred to an ophthalmologist for a slit-lamp examination to look for subtle but vision-threatening intraocular inflammation.

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TB, Scarcoid and Syphilis should be considered in any ocular differential diagnosis

1. What can fracture near optic canal cause?

2. What is a blowout fracture?

3. What can an ethmoid fracture cause?

Fracture near optic canal → traumatic optic neuropathy

• 4% to 11% of pts → globe injury

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Blowout fracture:

• Orbital floor fracture into maxillary sinus

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Ethmoid Fracture:

• Very Thin

• → subcutaneous emphysema of the eyelids

Ruptured Globe

Subconjunctival hemorrhage

Dislocated lens

Peaked Pupil (ruptured globe until proven otherwise)

Iris coming out of eyeball

Blood coming from iris; hyphema; ant. chamber

Corneal Abrasion

Retinal sclopataria

Object in eye

Foreign body under the tarsus

Full thickness eyelid laceration

Morgan Lens

Pressure Patch

eye shield

subperiosteal abcess

Compartment Syndrome

How treat compartment syndrome in orbit

lateral canthotomy canthelis,

Dog bite eyelid lacerations

Eyelid laceration involving canaliculi

Post-traumatic inability to supraduct or elevate the eye

Forced duction tes

Repair of orbital floor with implant

1. Which is worst? Acid or Akali Chemical burn; why?

2. What should you do?

Chemical burn

• Alkali worsen than Acid

  • more rapid penetration 

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OPHTHALMIC EMERGENCY

• ALL chemical burns require immediate and perfuse irrigation to achieve pH of 7,

• Then, ophtho referral

List the Urgen and Semi-urgent optho situations

Urgent Situation

• Penetrating injuries of the globe

• Conjunctival or corneal foreign bodies

• Hyphema

• Lid laceration 

  • (sutured if not deep and neither the lid margin nor the canaliculi are involved)

• Traumatic optic neuropathy

• Radiant energy burns 

  • (snow blindness or welder’s burn)

• Corneal Abrasion

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Semi-urgent Situation

• Orbital fracture

• Subconjuctival hemorrhage in blunt trauma

• Refer patient within 1-2 days

1. What does a teardrop-shaped pupil and a flat anterior chamber signify?

2. What do you avoid in a pt w/ suspected perforating injury?

3. What do you do immediately in a chem injury

A teardrop-shaped pupil and a flat anterior chamber

• = perforating ocular injury;

• look for uveal tissue where the teardrop pupil is pointing.

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Avoid any pressure on the globe in a patient with a suspected perforating injury.

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In a chemical injury, irrigate immediately with water