Systemic Ophthalmology

Systemic Systemic OphthalmolOphthalmol

ogyogy

Eye Eye manifestations manifestations

of of systemic diseasessystemic diseases

The eye is a unique The eye is a unique organorgan

In DevelopmentIn Development

In PositionIn Position

In Structure In Structure

Systemic diseases affect eyes in various Systemic diseases affect eyes in various waysways

BUT ALSOBUT ALSO

Many of the systemic diseases may be first Many of the systemic diseases may be first diagnosed by ophthalmologistdiagnosed by ophthalmologist

Endocrine DisordersEndocrine Disorders Diabetes MellitusDiabetes Mellitus Thyroid glandThyroid gland Pituitary glandPituitary gland

Cardiovascular & blood disordersCardiovascular & blood disorders Anemia Anemia leukemialeukemia AstherosclerosisAstherosclerosis HypertensionHypertension

Collagen vascular diseasesCollagen vascular diseases Congenital Congenital Acquired: Rheumatoid arthritisAcquired: Rheumatoid arthritis

Neurological DisordersNeurological Disorders Migraine.Migraine. Papilloedema.Papilloedema. Optic neuritis.Optic neuritis. Pseudotumour cerebri.Pseudotumour cerebri. phakomatosisphakomatosis

Vitamin deficiencyVitamin deficiency Vitamin A, B, C, DVitamin A, B, C, D

Infectious diseasesInfectious diseases HIVHIV

Malignancy Malignancy

Eye manifestations of Eye manifestations of diabetesdiabetes

Eye lidsEye lids

Recurrent styesRecurrent styes Xanthelasmas Xanthelasmas

Conjunctiva & CorneaConjunctiva & Cornea

Conjunctivitis Conjunctivitis Cornea: Cornea: recurrent erosions, ulcers..recurrent erosions, ulcers..

Iris Iris

Rubiosis iridesRubiosis irides Edema & vesiculation of Edema & vesiculation of

pigment epithelium: easy pigment epithelium: easy scattering of iris pigment scattering of iris pigment by mild trauma. by mild trauma.

Neovascular Neovascular glaucomaglaucoma

CataractCataract Senile catarct in diabetic Senile catarct in diabetic

patient, density accelerates patient, density accelerates more.more.

True diabetic cataractTrue diabetic cataract Develops quickly & rapidly Develops quickly & rapidly

progressive.progressive. Starts flocculent, snow flake, milky Starts flocculent, snow flake, milky

white cortical opacities.white cortical opacities.

VireousVireous Intraocular hgeIntraocular hge

HyphemaHyphema Vitreous hgeVitreous hge Retinal hgeRetinal hge

Lipemia retinalisLipemia retinalis Milky retinal Milky retinal

vesselsvessels..

RetinaRetina

rdiabetica_06(ingles).swf

Optic nerveOptic nerve

Retrobulbar neuritis:Retrobulbar neuritis: (diabetic optic neuropathy)(diabetic optic neuropathy)

Usually bilateralUsually bilateral Rapid onsetRapid onset Often painless.Often painless.

Extraocular musclesExtraocular muscles

Extraocular muscle palsy:Extraocular muscle palsy: Diabetic third nerve palsy:Diabetic third nerve palsy:

most common cause of isolated 3most common cause of isolated 3rdrd n. n. palsy..micro infarctionspalsy..micro infarctions

Sixth nerve palsySixth nerve palsy

Visual DisturbancesVisual Disturbances

Transient refractive changes:Transient refractive changes: Changes in the state of lens hydration & Changes in the state of lens hydration &

alteration of the refractive index of the alteration of the refractive index of the lens due to osmotic changes.lens due to osmotic changes.

Hypermetropia: in hypoglycemiaHypermetropia: in hypoglycemia Myopia: hyperglycemia.Myopia: hyperglycemia.

NO GLASSES PRESCRIPTION IN UNCONTROLLED DM NO GLASSES PRESCRIPTION IN UNCONTROLLED DM

Visual DisturbancesVisual Disturbances

Accomodative disorders:Accomodative disorders: Weakness of accomodation due to weak Weakness of accomodation due to weak

ciliary muscles due to peripheral neuritis ciliary muscles due to peripheral neuritis involving its nerve supply.involving its nerve supply.

Subjective visual disturbances:Subjective visual disturbances: Amaurosis in severe casesAmaurosis in severe cases Flshes due to visual cortex disturbances in Flshes due to visual cortex disturbances in

insulin overdose.insulin overdose.

Vitreous Haemorrhage from PDRVitreous Haemorrhage from PDR Tractional Retinal Detachment involving Tractional Retinal Detachment involving

the maculathe macula Maculopathy, exudative and ischaemicMaculopathy, exudative and ischaemic Neovascular GlaucomaNeovascular Glaucoma

In addition: In addition: higher cataract prevalencehigher cataract prevalence

GoutGout Charecterized by excess of uric acid in blood, urate deposits of cartilages of small joints. Starts in big toe,,,then polyarticular.

GoutGout

ConjunctivitisConjunctivitis Marginal corneal ulcerMarginal corneal ulcer EpiscleritisEpiscleritis TenonitisTenonitis Iridocyclitis Iridocyclitis

Vitamin DeficiencyVitamin Deficiency

Vitamin AVitamin A

Vitamin A deficiencyVitamin A deficiency

Night blindness: defective or Night blindness: defective or degenerative night vision.degenerative night vision.

Dry eye (Xerophthalmia)Dry eye (Xerophthalmia) BitotBitot’’s spotss spots Corneal thinningCorneal thinning keratomalaciakeratomalacia BlepharitisBlepharitis Recurrent styes & chalazia.Recurrent styes & chalazia.

Vitamin A deficiencyVitamin A deficiency

Vitamin B deficiencyVitamin B deficiency

Vitamin B1Vitamin B1

Vitamin B1Vitamin B1

Vitamin B1 deficiencyVitamin B1 deficiency

(Thiamine deficiency: Beri Beri: (Thiamine deficiency: Beri Beri: (cardiac, muscular weakness, neuritis)(cardiac, muscular weakness, neuritis)

ConjunctivitisConjunctivitis NystagmusNystagmus PapilloedemaPapilloedema Retinal hgeRetinal hge Extra ocular muscle paralysisExtra ocular muscle paralysis

Vitamin B2Vitamin B2(Riboflavin)(Riboflavin)

Vitamin B2 deficiencyVitamin B2 deficiencyRiboflavin deficiencyRiboflavin deficiency

Conjunctivitis: typical Conjunctivitis: typical manifestationmanifestation

Peripheral corneal Peripheral corneal vascularizationvascularization

CataractCataract Fundus changes:Fundus changes:

Papilledema.Papilledema. Pigmentary changes of macula.Pigmentary changes of macula. Partial optic atrophy.Partial optic atrophy.

Vitamin CVitamin C

Vitamin C deficiencyVitamin C deficiency

Vitamin C deficiencyVitamin C deficiency

HemorrhageHemorrhage SubconjunctivalSubconjunctival Palpebral Palpebral Orbital Orbital RetinalRetinal

KeratoconjunctivitisKeratoconjunctivitis CataractCataract

Eye Manifestations

Vitamin DVitamin D

Vitamin DVitamin D

Vitamin D deficiencyVitamin D deficiency

Lamellar cataractLamellar cataract AssociationsAssociations

High myopiaHigh myopia Phlyctenular conjunctivitisPhlyctenular conjunctivitis keratoconuskeratoconus

Daily therapeutic dose 2500 IU

Endocrinal DisordersEndocrinal Disorders

Thyroid DisordersThyroid Disorders

Thyroid Eye DiseaseThyroid Eye Disease

1.1. Soft tissue involvementSoft tissue involvement1.1. Periorbital and lid swellingPeriorbital and lid swelling

2.2. Conjunctival hyperaemiaConjunctival hyperaemia

3.3. Conjunctival chemosis.Conjunctival chemosis.

2.2. Eye lid retractionEye lid retraction

3.3. ProptosisProptosis

4.4. Optic neuropathyOptic neuropathy

5.5. Restrictive myopathyRestrictive myopathy

Patient may be: Hyper thyroid, euthyroid, Hypothyroid

Soft tissue involvementPeriorbital and lid swelling

Chemosis

Conjunctival hyperaemia

Superior limbic keratoconjunctivitis

Eyelid Retraction Occurs in about 50%

• Bilateral lid retraction • No associated proptosis

• Bilateral lid retraction • Bilateral proptosis

• Lid lag in downgaze • Unilateral lid retraction • Unilateral proptosis

Proptosis Occurs in about

50%

TED is the commonest cause of proptosis (unilateral or bilateral )in adults

Axial and permanent in about 70%

May be associated with choroidal folds

Optic Neuropathy Occurs in about

5% Early defective colour vision Usually normal disc

appearance

Caused by optic nerve compression at

orbital apex by enlarged recti

Often occurs in absence of significant proptosis

• Occurs in about 40% Due to fibrotic contracture

Restrictive Myopathy

Elevation defect - most common Abduction defect - less common

Depression defect - uncommon Adduction defect - rare

HypothyroidismHypothyroidism

HypothyroidismHypothyroidism

Puffiness of eyelids.Puffiness of eyelids. Loss of hair from outer third of the eye Loss of hair from outer third of the eye

brow.brow. Madarosis.Madarosis. Discrete spots in the central cornea.Discrete spots in the central cornea. Whitish opacities of the lens periphery.Whitish opacities of the lens periphery. Bilateral retrobulabar neuritis.Bilateral retrobulabar neuritis. Optic atrophy.Optic atrophy.

Parathyroid glandParathyroid gland

HypoparathyroidismHypoparathyroidism

PhotophobiaPhotophobia Cortical lens opacityCortical lens opacity Lid twitches.Lid twitches. Conjunctivitis & keratitisConjunctivitis & keratitis

HyperparathyroidismHyperparathyroidism

Calcium crystal deposition in the Calcium crystal deposition in the conjunctivaconjunctiva

Band shaped keratopathy.Band shaped keratopathy.

Anemia Anemia

Subconjunctival hemorrhages.Subconjunctival hemorrhages. Dilated tortous retinal veins.Dilated tortous retinal veins. Edema, exudates.Edema, exudates. Optic neuritisOptic neuritis

LeukemiaLeukemia

Ocular effectsOcular effects

Orbital infiltrationOrbital infiltration Proptosis.Proptosis. Exophthalmos.Exophthalmos. Iritis with hypopionIritis with hypopion Spontaneous hyphema Spontaneous hyphema

& subconj. hge.& subconj. hge.

Posterior SegmentPosterior Segment

Retinal edema, Retinal edema, hemorrhages, tortous hemorrhages, tortous vessels, Rothvessels, Roth’’s spots.s spots.

Papillitis.Papillitis.

Astherosclerosis Astherosclerosis

Grading of arteriolosclerosis

Ocular effectsOcular effects Arcus senilisArcus senilis Lipid keratopathyLipid keratopathy Arteriolar narrowing, focal or diffuse Arteriolar colour changes AV crossing changes, e.g. nicking ±

flame hges, vessel sclerosis, threading

Hypertension Hypertension

Hypertensive retinopathy

Cotton-wool spots and

macular star

Disc oedem

a

Focal Generalized

Arteriolar constriction

Extravascular signs

Flame-shaped retinal haemorrhages

Arteriolosclerosis (A-V changes)

Ocular associations of hypertension

Retinal vein occlusion Retinal artery macroaneurysm

Ocular motor nerve palsies Anterior ischaemic optic neuropathy

rHipertensiva_02(ingles).swf

Connective Tissue DisordersConnective Tissue Disorders

Connective tissue disordersConnective tissue disorders

Inherited:Inherited: Marfan’s syndrome:Marfan’s syndrome: Ectopia lentis, Ectopia lentis,

22ryry glaucoma, retinal detachment. glaucoma, retinal detachment.

Ehlers-Danlos syndrome:Ehlers-Danlos syndrome: Blue sclera, Blue sclera, keratoconus, ectopia lentis, angioid streakskeratoconus, ectopia lentis, angioid streaks

Marfan’s syndromeMarfan’s syndrome

Ectopia lentis, Ectopia lentis, 22ryry glaucoma, glaucoma, retinal detachment.retinal detachment.

Ehlers-Danlos syndromeEhlers-Danlos syndrome

Blue scleraBlue sclera keratoconus,keratoconus, ectopia lentis,ectopia lentis, angioid streaksangioid streaks

Acquired connective tissue disorders:Acquired connective tissue disorders: Rheumatoid arthritisRheumatoid arthritis

Peripheral corneal Peripheral corneal thinning (CL Cornea).thinning (CL Cornea).

Iritis & its complicationsIritis & its complications episcleritisepiscleritis ScleritisScleritis Scleromalacia perforansScleromalacia perforans

Infectious Diseases

Infectious diseases

TuberculosisTuberculosis PhlyctenPhlycten UveitisUveitis Choroidal depositsChoroidal deposits

SyphilisSyphilis Interstitial keratitisInterstitial keratitis UveitisUveitis ChorioretinopathyChorioretinopathy BSKBSK

Infectious diseases

RubellaRubella MicrophthalmiaMicrophthalmia CataractCataract GlaucomaGlaucoma UveitisUveitis Salt & pepper retinopathySalt & pepper retinopathy

Others:Others: Viral infections: Viral infections: Varicella-Varicella-

ZosterZoster Parasitic: Parasitic: ToxoplasmosisToxoplasmosis Granulomatous:Granulomatous: Sarcoid Sarcoid FungalFungal

Ocular regions related to systemic diseases

Cornea

The corneal epithelium is of ectodermal embryologic origin so it is affected by diseases of the

skin and mucous membranes. The rest of the cornea is of

mesodermal embryologic origin: so it is affected by disorders of

collagen metabolism

Cornea

Much of the cornea is made of collagen and mucopolysaccharide ground substance, so systemic diseases affecting

collagen may indirectly affect the cornea by way of auto antibodies in the circulation leading to limbal and marginal ulcerations.

The cornea stores materials made in excess by the body, so damage to the cornea may occur indirectly by accumulation of metabolic products.

Systemic metabolic diseases that produce elevated levels of certain precursors and that may opacify the cornea.

The cornea is the most anterior part of the eye, exposed to environmental harm.

Cataract Cataract

Lens fibers opacify as a response to alterations of the physical and chemical medium within the semipermeable lens capsule. Chromosomal disordersChromosomal disorders Diseases of skin & mucous membraneDiseases of skin & mucous membrane Metabolic disorders & infectionsMetabolic disorders & infections Toxic substances produced systemicallyToxic substances produced systemically

Glaucoma Glaucoma

Secondary glaucomas may arise as complications of the systemic disease

itself or from its therapy.

Uveitis Uveitis

Inlftammation of the iris, ciliary body, and choroid may be caused by a wide variety of diseases.

Systemic allergic diseases. Cardiovascular diseases: endocarditis

(subacute bacterial). Collagen diseases Diseases of skin and mucous membranes Metabolic diseases Gastrointestinal and nutritional diseases Neoplastic disease Infectious diseases

Retina Retina

Retinal veasels, choroid: (Microaneurys, Hemorrhages, Exudates, Hemangiomas, Choroiditis).

Neural tissue (Retinitis, Rxudative retinal detachment, Selective rod and cone destruction).

Retinal pigment epithelium (Loss of pigment, Accumulation of toxic substances).

Retina Retina Is vulnerable to these systemic

diseases:

Cardiovascular diseases Collagen diseases Chromosomal disorders Endocrine diseases Diseases of skin and mucous membranes Gastrointestinal and ntritional diseases Hematologic disease Inlectious diseases Phacomatoses: most affect the retina. Pulmonary diseases Renal diseases Metabolic diseases