Fundoscopic Findings in Fundoscopic Findings in Common Systemic Common Systemic

DiseasesDiseases

Jocelyn Kuryan, MDJocelyn Kuryan, MD

Chief ResidentChief ResidentDepartment of OphthalmologyDepartment of Ophthalmology

Albert Einstein College of MedicineAlbert Einstein College of MedicineMontefiore Medical Center/Jacobi Medical CenterMontefiore Medical Center/Jacobi Medical Center

OutlineOutline Retinal findings:Retinal findings:

Diabetes MellitusDiabetes Mellitus HypertensionHypertension HIV/AIDSHIV/AIDS

Overview of Some Common Eye Diseases:Overview of Some Common Eye Diseases: GlaucomaGlaucoma Macular DegenerationMacular Degeneration CataractCataract

Screening Recommendations for AdultsScreening Recommendations for Adults

Normal RetinaNormal Retina

Diabetic RetinopathyDiabetic Retinopathy Leading cause of new cases Leading cause of new cases

of legal blindness among of legal blindness among working-age Americans working-age Americans

Duration of DM is a major Duration of DM is a major risk factor for the risk factor for the development of retinopathy development of retinopathy

The severity of The severity of hyperglycemia is the key hyperglycemia is the key alterable risk factoralterable risk factor

Intensive management of Intensive management of HTN has been show to slow HTN has been show to slow DR progressionDR progression

DuratioDuration (yrs)n (yrs)

% Type I % Type I with DRwith DR

% Type II % Type II with DRwith DR

Up to 5Up to 5 2525 40 (on insulin)40 (on insulin)

24 (no insulin)24 (no insulin)

> 15 > 15 8080 84 (on insulin)84 (on insulin)

53 (no insulin)53 (no insulin)

Natural History of Natural History of Diabetic RetinopathyDiabetic Retinopathy

Early stages (NPDR=non proliferative DR) Early stages (NPDR=non proliferative DR) retinal vascular abnormalities increased retinal retinal vascular abnormalities increased retinal

vascular permeability can lead to macular vascular permeability can lead to macular edemaedema

Gradual closure of retinal vessels, Gradual closure of retinal vessels, impaired perfusion & retinal ischemia impaired perfusion & retinal ischemia

Proliferative disease (PDR)Proliferative disease (PDR) onset of neovascularization induced by retinal onset of neovascularization induced by retinal

ischemiaischemia new vessels can undergo fibrosis & contractionnew vessels can undergo fibrosis & contraction

Severity of Diabetic Severity of Diabetic RetinopathyRetinopathy

International Clinical Diabetic Retinopathy Severity ScaleInternational Clinical Diabetic Retinopathy Severity Scale

Proposed Disease Proposed Disease Severity LevelSeverity Level

Findings Observable upon DFEFindings Observable upon DFE

No apparent retinopathyNo apparent retinopathy No abnormalitiesNo abnormalities

Mild NPDRMild NPDR Microaneurysms onlyMicroaneurysms only

Moderate NPDRModerate NPDR More than just MAs but less severe More than just MAs but less severe than severe NPDRthan severe NPDR

Severe NPDRSevere NPDR Any one of the following:Any one of the following: 20 intraretinal hemorrhages in 20 intraretinal hemorrhages in

each of 4 quadrantseach of 4 quadrants definite venous beading in ≥ 2 definite venous beading in ≥ 2

quadrantsquadrants prominent IRMA in ≥ 1 quadrantsprominent IRMA in ≥ 1 quadrants

PDRPDR One or both of the following:One or both of the following: NeovascularizationNeovascularization Vitreous/Preretinal hemorrhageVitreous/Preretinal hemorrhage

Recommended Eye Examination Recommended Eye Examination Schedule for Patients with Diabetes Schedule for Patients with Diabetes

MellitusMellitus

Diabetes Diabetes TypeType

Recommended Recommended Time Time of 1of 1stst

ExaminationExamination

Recommended Follow-upRecommended Follow-up

Type 1Type 1 5 yrs after onset5 yrs after onset YearlyYearly

Type 2Type 2 At time of At time of diagnosisdiagnosis

YearlyYearly

Prior to Prior to pregnancy pregnancy (type 1 or (type 1 or 2)2)

Prior to conception Prior to conception or early in 1or early in 1stst trimestertrimester

No retinopathy to mild/mod NPDR: No retinopathy to mild/mod NPDR: every 3-12 months every 3-12 months Severe NPDR or worse: every 1-3 Severe NPDR or worse: every 1-3 monthsmonths

Nonproliferative Diabetic Nonproliferative Diabetic RetinopathyRetinopathy

http://depts.washington.edu/ophthweb/images/J02diabetic.jpg

Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy

http://blog.visivite.com/wp-content/uploads/2009/08/proliferative-diabetic-retinopathy.jpg

Fibrovascular ProliferationFibrovascular Proliferation

http://emedicine.medscape.com/article/1225210-media

Tractional Retinal Tractional Retinal DetachmentDetachment

Fluorescein Angiogram Fluorescein Angiogram showing Neovascularizationshowing Neovascularization

http://emedicine.medscape.com/article/1225210-media

Treatment OptionsTreatment Options Severe NPDR with evidence of areas of retinal Severe NPDR with evidence of areas of retinal

nonperfusion – panretinal photocoagulation (PRP)nonperfusion – panretinal photocoagulation (PRP) Goal: lower levels of VEGF which is thought to promote Goal: lower levels of VEGF which is thought to promote

and propagate neovascularizationand propagate neovascularization PDR - panretinal photocoagulationPDR - panretinal photocoagulation Clinically Significant Macular Edema – focal laser Clinically Significant Macular Edema – focal laser

photocoagulation directly to leaking photocoagulation directly to leaking microaneurysms (as seen on fluorescein microaneurysms (as seen on fluorescein angiogram) angiogram)

Vitreous Hemorrhage and/or Tractional Retinal Vitreous Hemorrhage and/or Tractional Retinal Detachment – VitrectomyDetachment – Vitrectomy

Anti-VEGF intravitreal injections (i.e. Lucentis, Anti-VEGF intravitreal injections (i.e. Lucentis, Avastin) initially used for macular degeneration are Avastin) initially used for macular degeneration are increasingly being used to treat neovascularization increasingly being used to treat neovascularization associated with DRassociated with DR

Panretinal PhotocoagulationPanretinal Photocoagulation

Hypertensive RetinopathyHypertensive Retinopathy Increased incidence in patients with uncontrolled Increased incidence in patients with uncontrolled

hypertensionhypertension44

Associated with increased risk for cardiovascular disease Associated with increased risk for cardiovascular disease and strokeand stroke77

Some studies have linked renal dysfunction with retinal Some studies have linked renal dysfunction with retinal vascular changesvascular changes66

HTN risk factor for retinal vascular occlusions, macular HTN risk factor for retinal vascular occlusions, macular degeneration, ischemic optic neuropathydegeneration, ischemic optic neuropathy55

Classification (modified Scheie classification): Classification (modified Scheie classification): Grade 0 - No changes Grade 0 - No changes Grade 1 - Barely detectable arterial narrowing Grade 1 - Barely detectable arterial narrowing Grade 2 - Obvious arterial narrowing with focal irregularities Grade 2 - Obvious arterial narrowing with focal irregularities Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates Grade 4 - Grade 3 plus disc swellingGrade 4 - Grade 3 plus disc swelling

Treatment – BP controlTreatment – BP control

Arteriolar Narrowing & Arteriolar Narrowing & SclerosisSclerosis

http://usa.nidek.com/wp-content/uploads/2008/10/6.jpg

A-V nickingA-V nicking

http://eyephoto.ophth.wisc.edu/LightBoxImages/A8.jpg

Retinal Hemorrhages, CWSRetinal Hemorrhages, CWS

http://www.otm1.com/page/services_otm

Grosso A et al. Br J Ophthalmol 2005;89:1646-1654©2005 by BMJ Publishing Group Ltd.

Malignant Hypertensive Malignant Hypertensive RetinopathyRetinopathy

Disc Edema & Malignant Disc Edema & Malignant HypertensionHypertension

http://www.opt.indiana.edu/ce/retvasdz/graphics/img030.jpg

HIV RetinopathyHIV Retinopathy

DefinitionDefinition: noninfectious microvascular disorder : noninfectious microvascular disorder characterised by cotton-wool spots (CWS), characterised by cotton-wool spots (CWS), microaneurysms, retinal hemorrhages, microaneurysms, retinal hemorrhages, telangiectatic vascular changes, and areas of telangiectatic vascular changes, and areas of capillary nonperfusioncapillary nonperfusion99

CWS in 25 to 50% of patients and are the earliest CWS in 25 to 50% of patients and are the earliest and most consistent finding; mimic diabetic & and most consistent finding; mimic diabetic & hypertensive retinopathyhypertensive retinopathy

More prevalent in the pre-HAART eraMore prevalent in the pre-HAART era1010

Ocular lesions in AIDS are varied and affect Ocular lesions in AIDS are varied and affect almost all structures of the eye & occur in 40 to almost all structures of the eye & occur in 40 to 70% of AIDS patients70% of AIDS patients88

HIV RetinopathyHIV Retinopathy

CMV RetinitisCMV Retinitis

It usually occurs when the CD4 cell count is less It usually occurs when the CD4 cell count is less than 100 cells/mmthan 100 cells/mm3 113 11

Leads to viral invasion of retinal cells and retinal Leads to viral invasion of retinal cells and retinal necrosis necrosis

““Pizza pie retinopathy” scattered yellow-white Pizza pie retinopathy” scattered yellow-white areas of necrotizing retinitis with variable degree areas of necrotizing retinitis with variable degree of hemorrhage and mild vitreous inflammation of hemorrhage and mild vitreous inflammation

Can result in retinal detachmentCan result in retinal detachment Treatment: systemic and/or local Treatment: systemic and/or local

IV and oral ganciclovir, IV foscarnet, IV cidofovir, the IV and oral ganciclovir, IV foscarnet, IV cidofovir, the ganciclovir implant and fomivirsen ganciclovir implant and fomivirsen

““Pizza Pie”Pizza Pie”

http://upload.wikimedia.org/wikipedia/commons/9/90/Fundus_photograph-CMV_retinitis_EDA07.JPG

CMV retinitisCMV retinitis

Early necrosis at periphery

http://emedicine.medscape.com/article/1227228-media

Progressive Outer Retinal Progressive Outer Retinal Necrosis (PORN)Necrosis (PORN)

Caused by Herpes simplex virus (HSV) or Varicella Caused by Herpes simplex virus (HSV) or Varicella zosterzoster

Can present with anterior uveitis, blurred vision Can present with anterior uveitis, blurred vision and severe eye painand severe eye pain

Peripheral retinitis progresses centrally. Peripheral retinitis progresses centrally. Regresses over 2-3 weeks & can cause retinal Regresses over 2-3 weeks & can cause retinal traction & tears leading to retinal detachmenttraction & tears leading to retinal detachment

Treatment: IV and PO acyclovirTreatment: IV and PO acyclovir Can result in retinal detachmentCan result in retinal detachment Prophylactic laser photocoagulation is considered Prophylactic laser photocoagulation is considered

beneficial following resolution of retinitis.beneficial following resolution of retinitis.

Outer Retinal NecrosisOuter Retinal Necrosis

Cream-colored areas of retinal necrosis with atrophic holes

http://www.retinalphysician.com/archive%5C2008%5CNovember%5Cimages/RP_November_A04_Fig02.jpg

Other Common Other Common Ophthalmologic DiagnosesOphthalmologic Diagnoses

GlaucomaGlaucoma Macular DegenerationMacular Degeneration CataractCataract

GlaucomaGlaucoma

Main types: primary open angle glaucoma, Main types: primary open angle glaucoma, angle closure glaucoma (ACG)angle closure glaucoma (ACG) POAG – chronic progressive optic neuropathy that POAG – chronic progressive optic neuropathy that

leads to peripheral vision loss and blindnessleads to peripheral vision loss and blindness Treatment – IOP lowering drops, close monitoring of Treatment – IOP lowering drops, close monitoring of

visual fields; surgery in those who fail medical visual fields; surgery in those who fail medical managementmanagement

Often runs in families; higher prevalence among BlacksOften runs in families; higher prevalence among Blacks1212

ACG – acute closure of aqueous drainage ACG – acute closure of aqueous drainage channels that leads to elevated eye pressure, channels that leads to elevated eye pressure, pain, nausea, vomiting and vision losspain, nausea, vomiting and vision loss

Treatment – IOP lowering drops, peripheral iridectomyTreatment – IOP lowering drops, peripheral iridectomy

Optic NerveOptic Nerve

Normal Glaucoma

http://www.besteyesurgery.co.uk/images/glaucoma/glaucoma_optic_nerve.jpg

Humphrey Visual FieldHumphrey Visual Field

Normal

Advanced Glaucoma with Sparing of Central Vision

Superior Visual Field Deficit

Age Related Macular Age Related Macular DegenerationDegeneration22

A leading cause of severe, irreversible vision A leading cause of severe, irreversible vision impairment in developed countries impairment in developed countries

The prevalence, incidence, and progression of The prevalence, incidence, and progression of AMD increase with age AMD increase with age

Late stages of AMD are more common among Late stages of AMD are more common among whites than blackswhites than blacks

Smoking doubles the risk of AMD Smoking doubles the risk of AMD Additional risk factors may include low levels of Additional risk factors may include low levels of

antioxidants, which led to the development of antioxidants, which led to the development of AREDS vitaminsAREDS vitamins beneficial effect of high doses of antioxidant beneficial effect of high doses of antioxidant

vitamins (vitamins C, E, beta-carotene) and zinc vitamins (vitamins C, E, beta-carotene) and zinc supplementation in reducing progressionsupplementation in reducing progression

““Dry” = drusen and “Wet” = neovascularizationDry” = drusen and “Wet” = neovascularization Screening – abnormalities on Amsler gridScreening – abnormalities on Amsler grid Treatment – anti-VEGF intravitreal injections, Treatment – anti-VEGF intravitreal injections,

photodynamic therapy, laser photocoagulationphotodynamic therapy, laser photocoagulation

Amsler GridAmsler Grid

Normal Scotoma & Metamorphopsia

http://www.vrmny.com/images/amsler_lg.jpg

Dry AMDDry AMD

http://www.blackwelleyesight.com/wp-content/uploads/2008/05/mac-deg-1.jpg

Wet AMDWet AMD

http://www.clevelandsightcenter.org/resources/conditions/images/wet_macular_fundus.jpg

CataractCataract33

A cataract is a degradation of the optical quality A cataract is a degradation of the optical quality of the crystalline lens. of the crystalline lens.

Cataracts are the leading cause of blindness Cataracts are the leading cause of blindness worldwide worldwide

Early development and/or more rapid progression Early development and/or more rapid progression in diabetics and with corticosteroid usein diabetics and with corticosteroid use

Indications for SurgeryIndications for Surgery Primary: visual function that no longer meets the Primary: visual function that no longer meets the

patient’s needs and for which cataract surgery provides patient’s needs and for which cataract surgery provides a reasonable likelihood of improved visiona reasonable likelihood of improved vision

Secondary: anisometropia, interference with optimal Secondary: anisometropia, interference with optimal diagnosis or management of posterior segment diagnosis or management of posterior segment conditions, causing inflammation, inducing angle closureconditions, causing inflammation, inducing angle closure

CataractCataract

Screening Recommendations Screening Recommendations for Adultsfor Adults1414

Age 20-29: a complete eye exam at least once Age 20-29: a complete eye exam at least once Age 30-39: a complete eye exam at least twiceAge 30-39: a complete eye exam at least twice Age 40-64: baseline exam at 40, then follow-up Age 40-64: baseline exam at 40, then follow-up

as per ophthalmologist as per ophthalmologist Age > 65: every 1-2 yearsAge > 65: every 1-2 years Patients with risk factors for eye disease – family Patients with risk factors for eye disease – family

history, history of eye injury, diabetes, history, history of eye injury, diabetes, hypertension, etc. should be seen regularlyhypertension, etc. should be seen regularly

Patients with symptoms – i.e. flashes, floaters, Patients with symptoms – i.e. flashes, floaters, visual changes or distorted vision, etc. should be visual changes or distorted vision, etc. should be seen as soon as possibleseen as soon as possible

QUESTIONS?QUESTIONS?

REFERENCESREFERENCES

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diagnosis and management of ocular lesions in human immunodeficiency virus positive patients. Indian J diagnosis and management of ocular lesions in human immunodeficiency virus positive patients. Indian J Ophthalmol. 2002 Jun;50(2):83-96. Ophthalmol. 2002 Jun;50(2):83-96.

10.10. Whitley RJ, Jacobson MA, Friedberg DN, Holland GN, Jabs DA, Dieterich DT et al. Guidelines for the treatment of Whitley RJ, Jacobson MA, Friedberg DN, Holland GN, Jabs DA, Dieterich DT et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy. cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy. Arch Intern MedArch Intern Med 1998;158:957-59.  1998;158:957-59. 

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13.13. http://www.herzig-eye.com/assets/images/cataract.jpghttp://www.herzig-eye.com/assets/images/cataract.jpg14.14. http://www.eyecareamerica.org/eyecare/treatment/eye-exams.cfmhttp://www.eyecareamerica.org/eyecare/treatment/eye-exams.cfm