Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 34 Ocular Manifestations of Systemic Diseases Lecture Notes
Ocular Manifestations of Systemic Diseases
1
Objectives of learning
? Why some systemic disorders can involve
eyes?
? What are commoner disorders you can
encounter during your clinical postings in
other specialities?
? Learn a multi-speciality , judicious cross
referral.
The eye is linked with rest of the body by-
? Development
? Blood supply
? Meninges & nerve
fibres of brain
3
Common Systemic Diseases affecting the Eye
? Autoimmune disorders
? Hematological abnormalities
? Infections
? Endocrine disorders
? Muscular disorders
? Inherited disorders
5
Auto-immune disorders
6
Rheumatoid Arthritis
a)Kerato Conjunctivitis Sicca
(Dry eye)- 25% patients
b) Ulcerative Keratitis
c) Scleritis
K C S
7
Scleritis
Systemic Lupus Erythematosus
a) Kerato Conjunctivitis Sicca
(Dry Eye)- 25% patients
b) Scleritis
Raynaud's phenomenon
c) Optic Neuropathy
Madarosis
Peripheral ulcerative Keratitis
Retinal Vasculitis
8
SARCOIDOSIS
?25-30% patients have ocular signs
Mutton fat kps
Iris nodule
Phlebitis
9
Sjogren's Syndrome
Dry Eye
in
30% Patients
Dry fissured tongue
Dental caries
Parotid enlargement
10
Bulbar conjunctiva
congestion
in Interpalpebral
area
Schirmer test
? 5mm end of 5 minutes
SIGNIFY DRY EYE
( less than 10 mm at the
end of 5 min is
suggestive of
abnormality)*
Corneal Staining
? Fluorescein Staining
? Punctate epithelial
staining present in
lower half of cornea
(interpalpebral region)
TEAR FILM BREAK UP TIME
? Less than 5 seconds ( SIGNIFY DRY EYES)
? ( less than 10 seconds is considered
abnormal)*
Ankylosing Spondylitis
?Acute anterior uveitis
(prevalence of 0.2?
1.2%) ,
? HLAB27 is +ve in
75% cases
?
?Bilateral sclerosis
Scleritis
?Erosion of s-i joint
?Bony fusion of
spine
15
Reiter Syndrome
Urethritis
Triad Arthritis
Conjunctivits
Eye Signs:
? Conjunctivitis
? Ac. anterior uveitis
? Numular Keratitis
? Episcleritis
? Scleritis
? Papillitis
? Retinal vasculitis
16
Behcet's Disease
Triad of oral aphthous ulcers, genital ulcers, and uveitis
Eye Signs:
a) Hypopyon
b) Uveitis / Iritis
17
Inflammatory Bowel Disease- Ulcerative Colitis
Crohn's Disease
Ophthalmic
manifestations:
a) Acute anterior uveitis
b) Episcleritis
c) Conjunctivitis
Acute anterior uveitis
d) Peripheral corneal infiltrates
e) Scleritis
f) Papillitis
g) Retinal Vasculitis
b) Peripheral corneal
18
infiltrates
Giant Cell Arteritis
Predilection for superficial temporal A, ophthalmic A, posterior
Ciliary & proximal vertebral A
a) AION (Arteritic)
b) TIA , Cilio-retinal Occlusion
c) Central retinal artery occlusion
Giant cells & small round cells
Superficial temporal arteritis
19
Vasculitis
?Wegener granulomatosis
?Relapsing Polyarteritis
nodosa
?Polychondritis
Dermal infarcts
Ocular features-
a) Necrotising scleritis
b) Peripheral ulcerative Keratitis
c) Occlusive retinal periarteritis
Peripheral ulcerative Keratitis
d) Peripheral ulcerative Keratitis
e) Dacryocystitis
f) Acute anterior uveitis
Dacryocystitis
Haematological diseases
Haematological diseases
1) Anaemia
2) Leukaemia
3) Lymphomas
4) Sickle cell Anaemia
Ocular Presentation:
Haemorrhagic Retinopathy
"ROTHS SPOT"
22
Hypertensive retinopathy
Infectious diseases
24
1) Tuberculosis
May involve all Structures of Eye except Lens
a) Uveitis: chronic granulomatous anterior uveitis,
multifocal choroiditis
b) Eyelids: lupus vulgaris
c) Orbit: dacryoadenitis,dacryocystitis,
osteomyelitis
d) Conjunctiva: phlyctenular conjunctivitis
e) Cornea: phlyctenular keratoconjunctivitis,
interstitial keratitis
f) Sclera: episcleritis, nodular scleritis
g) Retina: exudative retinitis, Vasculitis
h) Optic nerve:- papilloedema, ON
2) Leprosy
a) Facial palsy
b) Madarosis
c) Granulomatous iritis
d) Episleritis/scleritis
e) Secondary Glaucoma
f) Cataract
3) Syphilis
Congenital: Acute interstitial keratitis, Diffusely opaque cornea,
salt & pepper fundus
Secondary : Iritis, choroiditis, and/or exudates around
disc + vessels
Tertiary: Chorioretinitis and/or diffuse neuro-retinitis and
vascular sheathing
26
Viral Infections associated with Ocular Diseases
? Herpes zoster
? Herpes simplex
? CMV
? Rubella- cataract
? Measles
? AIDS
27
AIDS
Kaposi's sarcoma-
AIDS retinopathy- 50 to 70%
most common tumour
CMV retinitis-most common
Anterior Uveitis
opportunistic infection
28
? Fungal
Candidiasis- Fluffy white-yellow
superficial retinal infiltrate, vitritis
? Parasitic
? Toxoplasmosis : Macular scarring, retinochoriditis,
vitritis, VR Granuloma
? Toxocariasis
? Cysticercosis Cyst
29
Al India Institute of Medical Sciences,
Rishikesh
Ocular Manifestations of Systemic Diseases
[Lecture 2] Dated 10-10-2017
Dr Sanjeev Kumar Mittal
Professor & Head, Ophthalmology
30
Endocrine & Metabolic disorders
Endocrine & Metabolic disorders
? Diabetes Mellitus
? Muco-polysaccharidoses
? Wilson disease
? Homocystinuria
? Hyperthyroidism
? Hypothyroidism
32
Metabolic Cataract
Diabetes Mellitus-
? Pre-senile cataract
? Snowflake cataract
[Sorbitol accumulation in
lens due to aldose
reductase pathway
33
Metabolic Cataract
? Galactosemic Cataract
Deficiency of GPUT- Oil droplet cataract
Deficiency of Galactokinase-Lamellar Cataract
Metabolic Cataract
? Wilsons disease
Hepatolenticular degeneration
Sun flower Cataract
Kayser-Fleischer Ring
Metabolic Cataract
? Lowe's syndrome [oculo-cerebral-renal
syndrome]
inborn error of amini acid metabolism
Congenital cataract, microphakia
Posterior lenticonus, glaucoma
Metabolic Cataract
? Mannosidosis
Deficiency of alpha-mannosidase mannose rich
oligosaccharides in tissues spokes like
posterior capsular cataract
Metabolic Cataract
? Fabry's disease
Deficiency of alpha galactosidose spoke like
cataract & vortex keratopathy
? Hypocalcemia-
Decreased parathyroid activity leads to cataract
Diabetes Mellitus
? Diabetic Retinopathy
? Diabetic Maculopathy
? Corneal erosions
? Optic nerve Papillopathy
? Transient Myopia
FUNDUS
Retinopathy
Maculopathy
THYROID EYE DISEASE
Unilateral lid retraction & proptosis
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OCULAR MOVEMENTS
Restrictive myopathy
Dalrymple Sign
Lid Retraction
Normal
Naffziger test
Exophthalmos
MRI
? Thickening of Muscle bel y
? Tendon sparing
? Radiological y both eyes
are involved
Slight straightening
of optic nerve in Right
eye
Muscular disorders
Muscular disorders
? Myasthenia gravis
? Muscular dystrophy
Ocular Manifestations:
a) Ptosis,
b) diplopia,
c) exophthalmoplegia,
d) cataract(Christmas-
tree cataract)
51
Inherited disorders
52
Marfan Syndrome
a) Ectopia lentis BE
[superior Lenticular
subluxation]
b) Microspherophakia
c) Retinal Detachment
d) Myopia
e) Keratoconus
Ectopia lentis
53
Long spider like fingers
Tall thin stature with
disproportionately long limbs
compared to trunk
? High arch palate
Sticklers Syndrome
(Herditary artho-ophthalmopathy)
?Vitreous syneresis
?Retinal Detachment
Flat nasal bridge
55
3) Pseudoxanthoma elasticum
Prevalence 1/25000
Angiod streaks
Loose skin folds
56
Osteogenesis imperfecta
1/20000 live births
Blue sclera
Ehlers - Danlos Syndrome type 6 (Ocular sclerotic)
Keratoconus
Hyperelasticity of skin
High myopia
RD
Hypermobility of joints
PHACOMATOSES - Neurofibromatosus-Type I
(Von Recklinghausen disease)
?Most common phacomatosis
?Affects 1:4000 individuals
?Presents in childhood
?Gene localized to chromosome 17q11
Nodular
Facial hemiatrophy-
Skeletal defects
Caf?-au-lait spots
3/24/2022
59
? C/O mass over right eyelid
since birth
? Growing with age
? Painless
Iris-Lisch Nodules
? LISCH
NODULES/hamartoma
? Caf? au lait spot and
axil ary freckling were
also present
Intraocular lesions in NF-1
Lisch nodules
Choroidal naevi
62
Family history
Father has multiples neurfibromas al over chest and
arm ( 1st degree relative)
Orbital lesions in NF-1
?Spheno-orbital encephalocele showing
congenital absence of left greater wing
?Optic nerve glioma(in 15%)
of sphenoid bone
invading hypothalamus
? Pulsating proptosis without bruit!
64
Tuberous sclerosis (Bournevil e disease)
? Autosomal dominant
? Triad - mental handicap,
epilepsy,
adenoma sebaceum
Adenoma sebaceum
Shagreen patches
Ash leaf spots
Retinal astrocytomas
Innocuous tumour pre65
sent in
50% of patients
Von-Hippel-Lindau syndrome
?Tumours? renal carcinoma and phaeochromocytoma
?Cysts- kidneys, liver, pancreas, epididymis, ovary and lungs
?Polycythaemia
?Retinal capil ary haemangioma
Tiny lesion between
Associated dilatation and
arteriole and venuole
Round orange-red mass
tortuosity of feeder vessels
66
Sturge-Weber syndrome
Involves face, leptomeninges and the eyes
? Arteriovenous malformations of episclera
? Choroidal haemangioma
? Glaucoma (ipsilateral)
? Iris heterochromia
Albinism
Hypopigmented skin and hair with eyes
involvement
? Nystagmus
? Translucent iris giving rise to a "pink-eyed"
appearance.
? Large choroidal vessels are seen due to lack of
pigment in fundus.
? Foveal hypoplasia
Malignancy
Malignancy
? Metastasis
? From Breast, lung most common.
? Usually localize to choroid but Extra Ocular
Muscles,
? optic nerve and orbit can also be affected
? Lymphoma, leukemia
70
Summary
? Ocular examination plays a significant role in
diagnosing several systemic illnesses.
? At times, patient present for eye related
problem, which then comes out to be a part of
systemic disease, requiring inter-departmental
reference of the case to Physician/
Paediatrician/Neurologist/ Neurosurgeon/
Orthopaedician/Obstetrician.
71
Acknowledgement
Photgraphs from Kanski, Parson and Archives Dept of
Ophthalmology AI Ms Rishikesh
1] Snow-flake cataract is seen in
a)
Diabetes
b)
Galactosemia
c)
Trauma
d) Rubella
2] Cataract associated with atopic dermatitis
a) Sunflower cataract
b) Coronary cataract
c) Shields cataract
d) Coralliform cataract
3] Sunflower type cataract is seen in
(a)
Diabetes
(b)
Chalcosis
(c)
Argyrosis
(d)
Tay sach's disease
4. Most common ocular manifestation of AIDS is:
(a) Cottonwood spots
(b) Cytomegalovirus retinitis
(c) Kaposi's sarcoma of conjunctiva
(d) Pseudotumors
5. Which prominent ocular manifestation is
associated with
Marfan's syndrome? :
(a) Microcornea
(b) Microspherophakia
(c) Megalocornea
(d) Ectopia lentis
This post was last modified on 07 April 2022