6.1.13 Recognises ocular manifestations of systemic disease

What is high blood pressure?

Normal blood pressure reading = between 90/60mmHg and 120/80mmHg

Retinal signs of hypertension

• Arterial narrowing (changes in A/V ratio)

• Arteriovenous crossing changes

• Flame haemorrhages

• Copper/silver wiring

• Retinal oedema

If SEVERE: cotton wool spots, hard exudates/ macular star, optic nerve head swelling

What are the signs of malignant hypertension, and what are the symptoms?

Signs of malignant hypertension = over 180/120mmHg

Hypertensive retinopathy due to chronic hypertension is usually asymptomatic.

Malignant or accelerated hypertension are usually symptomatic:

• Intermittent blurring

• Visual field defects

• Headache

• Flushed and red appearance of face

• Nausea and vomiting

• Sudden painless loss of vision due to vessel occlusion

• Sings of end-organ damage

High blood pressure

Systemic risk factors:

• Poorly controlled BP

• Diabetes Mellitus

• Cardiovascular disease

• Obesity

• Smoking

• Alcohol consumption

• Poor diet

What is the Keith-Wagener-Barker classification?

• Grade 1: mild, generalised constriction of retinal arterioles

• Grade 2: definite focal narrowing of arterioles and AV nicking

• Grade 3: grd 2 with flame-shaped haemorrhages, cotton wool spots and hard exudates

• Grade 4: grd 3 with papilloedema and/or signs of retinal oedema

How is hypertension managed according to the Keith-Wagener-Barker classification?

• Grade 1 & 2 - refer if undiagnosed, hypertension control advice

• Grade 3 - routine refer for GP intervention for stricter hypertension control

• Grade 4 - Emergency referral to HES

What are the systemic risk factors for vein occlusions?

• Hypertension - arteriosclerosis compresses adjacent veins

• High cholesterol - promotes fatty deposits and vessel occlusion.

• Giant cell arteritis - arterial inflammation compressing venous outflow

In younger patients, investigate hypercoagulable (abnormality of blood coagulation that increases the risk of thrombosis) or inflammatory causes

What is a Central Retinal Vein Occlusion (CRVO),

• Signs

• Symptoms

Blockage of the main retinal vein, causing blood and fluid to leak into the retina.

Signs:

• “Blood and thunder” fundus,

• diffuse retinal haemorrhages,

• dilated tortuous veins,

• CWS,

• macular oedema,

• optic disc swelling,

• reduced VA

Symptoms:

• Sudden, painless vision loss

What are the actions required and clinical management for CRVO?

Actions required:

• OCT for macular oedema,

• Fundus photography

Clinical Management:

• Urgent referral to ophthalmology (same day if suspect ischaemia)

What is a Branch Retinal Vein Occlusion (BRVO), and what are its signs and symptoms?

Blockage of a smaller branch of the retinal vein resulting in localised retinal swelling and bleeding.

Signs:

• Localised flame/blot haemorrhages along one retinal quadrant,

• Venous dilation,

• CWS,

• possible macular oedema

Symptoms:

• Sudden, painless visual field defect, may be asymptomatic if peripheral

What are the actions required and clinical management for BRVO?

Actions required:

• OCT for macular oedema,

• fundus photography

Clinical Management:

• Non-urgent referral to ophthalmology (1-2 weeks unless macula)

What are the causes of artery occlusions in patients under and over 50 years?

<50 years - Cardiac emboli, hypercoagulable states, vasculitis, migraine, drug-induced vasospasm

>50 years - Atherosclerosis, carotid disease, cardiac emboli, hypertension, diabetes, giant cell arteritis

What is CRAO?

• Signs

• Symptoms

Sudden blockage of the central retinal artery, cutting off blood supply to the retina.

Signs:

• Pale retina,

• cherry red spot at macular,

• attenuated arterioles (white/yellow spots),

• “boxcarring” of blood columns (discontinuous columns of red blood cells)

Symptoms:

• Sudden, painless vision loss, often NLP or just hand movements

CRAO

• Actions required

• Clinical Management

Actions required:

• Ocular emergency! Ocular massage, IOP-lowering drops

Clinical Management:

• Immediately same-day referral to A&E or stroke unit

What is BRAO?

• Signs

• Symptoms

Blockage of a branch of the central retinal artery leading to sectoral lack of blood flow.

Signs:

• Localised retinal pallor,

• embolus may be visible,

• attenuated arterioles

Symptoms:

• Sudden painless sectoral vision loss

BRAO

• Actions required

• Clinical management

Actions required:

• Discuss stroke risk to patient

Clinical Management:

• Urgent referral to A&E or stroke unit

What conditions are associated with AAION?

• Giant Cell Arteritis - Results in luminal narrowing or occlusion → ischaemia of the optic nerve head.

• Behçet's disease - a rare, chronic condition causing inflammation in blood vessels (vasculitis) throughout the body.

What conditions are associated with NAION?

• Giant Cell Arteritis - Results in luminal narrowing or occlusion → ischaemia of the optic nerve head.

• Atherosclerosis

What is AAION?

• Signs

• Symptoms

Inflammation of the arteries (usually GCA) leading to reduced blood flow to the optic nerve.

Signs:

• Pale swollen optic disc, chalky white disc,

• RAPD,

• CWS,

• altitudinal defect - particularly lower half,

• thick and pulsating temporal artery

Symptoms:

• Sudden severe vision loss,

• headache,

• jaw claudication,

• scalp tenderness

AAION

• Actions Required

• Clinical Management

Actions required:

• Medical emergency! Stress importance of fast treatment

Clinical Management:

• Immediate same-day referral to hospital A&E

What is NAION?

• Signs

• Symptoms

Non-inflammatory condition where poor blood flow damages the optic nerve.

Signs:

• Optic disc swelling (often segmental),

• small cup-to-disc ratio,

• flame haemorrhages,

• altitudinal defect - particularly lower half

Symptoms:

• Sudden painless monocular vision loss,

• often upon waking

NAION

• Actions required

• Clinical Management

Actions required:

• Medical emergency! Stress importance of fast treatment

Clinical Management:

• Immediate same-day referral to hospital A&E