Systemic Ophthalmology

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Systemic Ophthalmology

Eye manifestations of systemic diseases

The eye is a unique organ

In Development In Position In Structure

Systemic diseases affect eyes in various ways BUT ALSO Many of the systemic diseases may be first diagnosed by ophthalmologist

Endocrine Disorders

Diabetes Mellitus

Thyroid gland Pituitary gland Anemia leukemia Astherosclerosis Hypertension

Cardiovascular & blood disorders

Most i

orta t relations are:

Collagen vascular diseases

Congenital Acquired: Rheu atoid arthritis Migraine. Pa illoede a. O tic neuritis. Pseudotu our cerebri. hakomatosis Vitamin A, B, C, D HIV

Neurological Disorders

Vitamin deficiency

Infectious diseases


Eye manifestations of diabetes

Eye lids

Recurrent styes Xanthelasmas

Conjunctiva & Cornea

Conjunctivitis Cornea: recurrent erosions, ulcers..


Rubiosis irides Edema & vesiculation of pigment epithelium: easy scattering of iris pigment by mild trauma.

Neovascular glaucoma


Senile catarct in diabetic patient, density accelerates more. True diabetic cataract

Develops quickly & rapidly progressive. Starts flocculent, snow flake, milky white cortical opacities.


Intraocular hgeHyphema Vitreous hge Retinal hge

Lipemia retinalis

Milky retinal vessels. vessels.



Optic nerve

Retrobulbar neuritis:

(diabetic optic neuropathy)Usually bilateral Rapid onset Often painless. painless.

Extraocular muscles

Extraocular muscle palsy:

Diabetic third nerve palsy: palsy:

most common cause of isolated 3rd n. palsy..micro infarctions

Sixth nerve palsy

Visual Disturbances

Transient refractive changes: Changes in the state of lens hydration & alteration of the refractive index of the lens due to osmotic changes. Hypermetropia: in hypoglycemia Hypermetropia: Myopia: hyperglycemia. hyperglycemia.


Visual Disturbances

Accomodative disorders:

Weakness of accomodation due to weak ciliary muscles due to peripheral neuritis involving its nerve supply. supply.

Subjective visual disturbances:

Amaurosis in severe cases Flshes due to visual cortex disturbances in insulin overdose.

Causes of Visual Loss & Blindness in DRVitreous Haemorrhage from PDR Tractional Retinal Detachment involving the macula Maculopathy, Maculopathy, exudative and ischaemic Neovascular Glaucoma In addition: higher cataract prevalence

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


Conjunctivitis Marginal corneal ulcer Episcleritis Tenonitis Iridocyclitis

Vitamin Deficiency

Vitamin A

Vitamin A deficiency

Night blindness: defective or degenerative night vision. Dry eye (Xerophthalmia) Bitot Bitots spots Corneal thinning keratomalaciaBlepharitis Recurrent styes & chalazia.

Vitamin A deficiency

Vitamin B deficiency

Vitamin B1 B1

Vitamin B1 B1

Vitamin B1 deficiency(Thiamine deficiency: Beri Beri: eri: (cardiac, (cardiac, muscular weakness, neuritis) neuritis)

Conjunctivitis Nystagmus Papilloedema Retinal hge Extra ocular muscle paralysis

Vitamin B2 (Riboflavin)

Vitamin B2 deficiency Riboflavin deficiencyConjunctivitis: Conjunctivitis: typical manifestation Peripheral corneal vascularization Cataract Fundus changes: changes:

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

Vitamin C

Vitamin C deficiency

Vitamin C deficiencyEye Manifestations

HemorrhageSubconjunctival Palpebral Orbital Retinal

Keratoconjunctivitis Cataract

Vitamin D

Vitamin D

Vitamin D deficiencyDaily therapeutic dose 2500 IU

Lamellar cataract AssociationsHigh myopia Phlyctenular conjunctivitis keratoconus

Endocrinal Disorders

Thyroid Disorders

Thyroid Eye DiseasePatient may be: Hyper thyroid, euthyroid, Hypothyroid


Soft tissue involvement1. 2. 3.

Periorbital and lid swelling Conjunctival hyperaemia Conjunctival chemosis. chemosis.

2. 3. 4. 5.

Eye lid retraction Proptosis Optic neuropathy Restrictive myopathy

Soft tissue involvementPeriorbital and lid swelling Conjunctival hyperaemia


Superior limbic keratoconjunctivitis

Eyelid RetractionOccurs in about 50%

Bilateral lid retraction No associated proptosis

Bilateral lid retraction Bilateral proptosis

Unilateral lid retraction Unilateral proptosis

Lid lag in downgaze

ProptosisOccurs 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 NeuropathyOccurs 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

Restrictive MyopathyOccurs in about 40% Due to fibrotic contracture

Elevation defect - most common

Abduction defect - less common

Depression defect - uncommon

Adduction defect - rare



Puffiness of eyelids. Loss of hair from outer third of the eye brow. Madarosis. Madarosis. Discrete spots in the central cornea. Whitish opacities of the lens periphery. Bilateral retrobulabar neuritis. Optic atrophy.

Parathyroid gland

HypoparathyroidismPhotophobia Cortical lens opacity Lid twitches. Conjunctivitis & keratitis


Calcium crystal deposition in the conjunctiva Band shaped keratopathy. keratopathy.


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


Ocular effects

Orbital infiltration Proptosis. Exophthalmos. Iritis with hypopion Spontaneous hyphema & subconj. hge.

Posterior Segment

Retinal edema, hemorrhages, tortous vessels, Roths spots. Roth Papillitis. Papillitis.


Grading of arteriolosclerosis

Ocular effects

Arcus senilis Lipid keratopathy Arteriolar narrowing, focal or diffuse Arteriolar colour changes AV crossing changes, e.g. nicking flame hges, vessel sclerosis, threading


Hypertensive retinopathyArteriolar constriction


Generalized Extravascular signs

Arteriolosclerosis (A-V changes)

Flame-shaped retinal haemorrhages

Cotton-wool spots and macular star

Disc oedema

Ocular associations of hypertension

Retinal vein occlusion

Retinal artery macroaneurysm

Anterior ischaemic optic neuropathy

Ocular motor nerve palsies


Connective Tissue Disorders

Connective tissue disorders


Marfans syndrome: Ectopia lentis, lentis, 2ry glaucoma, retinal detachment. EhlersEhlers-Danlos syndrome: Blue sclera, keratoconus, keratoconus, ectopia lentis, angioid streaks lentis,

Marfans syndromeEctopia lentis, lentis, 2ry glaucoma, retinal detachment.

EhlersEhlers-Danlos syndrome

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

Acquired connective tissue disorders: Rheumatoid arthritis

Peripheral corneal thinning (CL Cornea). Iritis & its complications episcleritis Scleritis Scleromalacia perforans

Infectious Diseases

Infectious diseases



Phlycten Uveitis Choroidal deposits

Interstitial keratitis Uveitis Chorioretinopathy BSK

Infectious diseases



Microphthalmia Cataract Glaucoma Uveitis Salt & pepper retinopathy

Viral infections: VaricellaVaricellaZoster

Parasitic: Toxoplasmosis Granulomatous: Sarcoid Fungal

Ocular regions related to systemic diseases


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


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.


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


Secondary glaucomas may ariseas complications of the systemic disease itself or from its therapy.

UveitisInlftammation of the iris