Objectives of learning
? Why some systemic disorders can involve
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eyes?
? What are commoner disorders you can
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encounter during your clinical postings inother specialities?
? Learn a multi-speciality , judicious cross
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referral.
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The eye is linked with rest of the body by-
? Development
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? Blood supply? Meninges & nerve
fibres of brain
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3Common Systemic Diseases affecting the Eye
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? Autoimmune disorders? Hematological abnormalities
? Infections
? Endocrine disorders
? Muscular disorders
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? Inherited disorders5
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Auto-immune disorders
6
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Rheumatoid Arthritis
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a)Kerato Conjunctivitis Sicca
(Dry eye)- 25% patients
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b) Ulcerative Keratitisc) Scleritis
K C S
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7
Scleritis
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Systemic Lupus Erythematosusa) Kerato Conjunctivitis Sicca
(Dry Eye)- 25% patients
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b) Scleritis
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Raynaud's phenomenonc) Optic Neuropathy
Madarosis
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Peripheral ulcerative Keratitis
Retinal Vasculitis
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SARCOIDOSIS
?25-30% patients have ocular signs
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Mutton fat kpsIris nodule
Phlebitis
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9
Sjogren's Syndrome
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Dry Eyein
30% Patients
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Dry fissured tongue
Dental caries
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Parotid enlargement10
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Bulbar conjunctivacongestion
in Interpalpebral
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area
Schirmer test
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? 5mm end of 5 minutesSIGNIFY DRY EYE
( less than 10 mm at the
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end of 5 min issuggestive of
abnormality)*
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Corneal Staining
? Fluorescein Staining
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? Punctate epithelialstaining present in
lower half of cornea
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(interpalpebral region)
TEAR FILM BREAK UP TIME
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? Less than 5 seconds ( SIGNIFY DRY EYES)? ( less than 10 seconds is considered
abnormal)*
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Ankylosing Spondylitis
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?Acute anterior uveitis(prevalence of 0.2?
1.2%) ,
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? HLAB27 is +ve in
75% cases
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??Bilateral sclerosis
Scleritis
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?Erosion of s-i joint
?Bony fusion of
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spine15
Reiter Syndrome
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Urethritis
Triad Arthritis
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ConjunctivitsEye Signs:
? Conjunctivitis
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? Ac. anterior uveitis
? Numular Keratitis
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? Episcleritis? Scleritis
? Papillitis
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? Retinal vasculitis
16
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Behcet's Disease
Triad of oral aphthous ulcers, genital ulcers, and uveitis
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Eye Signs:
a) Hypopyon
b) Uveitis / Iritis
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17Inflammatory Bowel Disease- Ulcerative Colitis
Crohn's Disease
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Ophthalmic
manifestations:
a) Acute anterior uveitis
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b) Episcleritisc) Conjunctivitis
Acute anterior uveitis
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d) Peripheral corneal infiltratese) Scleritis
f) Papillitis
g) Retinal Vasculitis
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b) Peripheral corneal18
infiltrates
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Giant Cell Arteritis
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Predilection for superficial temporal A, ophthalmic A, posteriorCiliary & proximal vertebral A
a) AION (Arteritic)
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b) TIA , Cilio-retinal Occlusion
c) Central retinal artery occlusion
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Giant cells & small round cells
Superficial temporal arteritis
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19
Vasculitis
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?Wegener granulomatosis?Relapsing Polyarteritis
nodosa
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?Polychondritis
Dermal infarcts
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Ocular features-a) Necrotising scleritis
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b) Peripheral ulcerative Keratitis
c) Occlusive retinal periarteritis
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Peripheral ulcerative Keratitisd) Peripheral ulcerative Keratitis
e) Dacryocystitis
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f) Acute anterior uveitis
Dacryocystitis
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Haematological diseases
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Haematological diseases1) Anaemia
2) Leukaemia
3) Lymphomas
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4) Sickle cell AnaemiaOcular Presentation:
Haemorrhagic Retinopathy
"ROTHS SPOT"
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22
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Hypertensive retinopathy
Infectious diseases
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24
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1) Tuberculosis
May involve all Structures of Eye except Lens
a) Uveitis: chronic granulomatous anterior uveitis,
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multifocal choroiditis
b) Eyelids: lupus vulgaris
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c) Orbit: dacryoadenitis,dacryocystitis,osteomyelitis
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d) Conjunctiva: phlyctenular conjunctivitise) Cornea: phlyctenular keratoconjunctivitis,
interstitial keratitis
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f) Sclera: episcleritis, nodular scleritisg) Retina: exudative retinitis, Vasculitis
h) Optic nerve:- papilloedema, ON
2) Leprosy
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a) Facial palsyb) Madarosis
c) Granulomatous iritis
d) Episleritis/scleritis
e) Secondary Glaucoma
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f) Cataract3) Syphilis
Congenital: Acute interstitial keratitis, Diffusely opaque cornea,
salt & pepper fundus
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Secondary : Iritis, choroiditis, and/or exudates arounddisc + vessels
Tertiary: Chorioretinitis and/or diffuse neuro-retinitis and
vascular sheathing
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Viral Infections associated with Ocular Diseases? Herpes zoster
? Herpes simplex
? CMV
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? Rubella- cataract? Measles
? AIDS
27
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AIDS
Kaposi's sarcoma-
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AIDS retinopathy- 50 to 70%most common tumour
CMV retinitis-most common
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Anterior Uveitis
opportunistic infection
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? FungalCandidiasis- Fluffy white-yellow
superficial retinal infiltrate, vitritis
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? Parasitic
? Toxoplasmosis : Macular scarring, retinochoriditis,
vitritis, VR Granuloma
? Toxocariasis
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? Cysticercosis Cyst29
Al India Institute of Medical Sciences,
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Rishikesh
Ocular Manifestations of Systemic Diseases
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[Lecture 2] Dated 10-10-2017Dr Sanjeev Kumar Mittal
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Professor & Head, Ophthalmology
30
Endocrine & Metabolic disorders
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Endocrine & Metabolic disorders
? Diabetes Mellitus
? Muco-polysaccharidoses
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? Wilson disease? Homocystinuria
? Hyperthyroidism
? Hypothyroidism
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32Metabolic Cataract
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Diabetes Mellitus-? Pre-senile cataract
? Snowflake cataract
[Sorbitol accumulation in
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lens due to aldosereductase pathway
33
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Metabolic Cataract? Galactosemic Cataract
Deficiency of GPUT- Oil droplet cataract
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Deficiency of Galactokinase-Lamellar CataractMetabolic Cataract
? Wilsons disease
Hepatolenticular degeneration
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Sun flower CataractKayser-Fleischer Ring
Metabolic Cataract
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? Lowe's syndrome [oculo-cerebral-renalsyndrome]
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inborn error of amini acid metabolismCongenital cataract, microphakia
Posterior lenticonus, glaucoma
Metabolic Cataract
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? MannosidosisDeficiency of alpha-mannosidase mannose rich
oligosaccharides in tissues spokes like
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posterior capsular cataractMetabolic Cataract
? Fabry's disease
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Deficiency of alpha galactosidose spoke likecataract & vortex keratopathy
? Hypocalcemia-
Decreased parathyroid activity leads to cataract
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Diabetes Mellitus
? Diabetic Retinopathy
? Diabetic Maculopathy
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? Corneal erosions? Optic nerve Papillopathy
? Transient Myopia
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FUNDUS
Retinopathy
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Maculopathy
THYROID EYE DISEASE
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Unilateral lid retraction & proptosis42
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OCULAR MOVEMENTS
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Restrictive myopathy
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Dalrymple Sign
Lid Retraction
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NormalNaffziger test
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ExophthalmosMRI
? Thickening of Muscle bel y
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? Tendon sparing
? Radiological y both eyes
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are involvedSlight straightening
of optic nerve in Right
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eyeMuscular disorders
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Muscular disorders
? Myasthenia gravis
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? Muscular dystrophyOcular Manifestations:
a) Ptosis,
b) diplopia,
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c) exophthalmoplegia,d) cataract(Christmas-
tree cataract)
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51Inherited disorders
52
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Marfan Syndrome
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a) Ectopia lentis BE
[superior Lenticular
subluxation]
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b) Microspherophakia
c) Retinal Detachment
d) Myopia
e) Keratoconus
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Ectopia lentis
53
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Long spider like fingersTall thin stature with
disproportionately long limbs
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compared to trunk
? High arch palate
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Sticklers Syndrome
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(Herditary artho-ophthalmopathy)?Vitreous syneresis
?Retinal Detachment
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Flat nasal bridge
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553) Pseudoxanthoma elasticum
Prevalence 1/25000
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Angiod streaks
Loose skin folds
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Osteogenesis imperfecta
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1/20000 live births
Blue sclera
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Ehlers - Danlos Syndrome type 6 (Ocular sclerotic)Keratoconus
Hyperelasticity of skin
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High myopia
RD
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PHACOMATOSES - Neurofibromatosus-Type I(Von Recklinghausen disease)
?Most common phacomatosis
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?Affects 1:4000 individuals
?Presents in childhood
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?Gene localized to chromosome 17q11Nodular
Facial hemiatrophy-
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Skeletal defects
Caf?-au-lait spots
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3/24/202259
? C/O mass over right eyelid
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since birth
? Growing with age
? Painless
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Iris-Lisch Nodules
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? LISCH
NODULES/hamartoma
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? Caf? au lait spot andaxil ary freckling were
also present
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Intraocular lesions in NF-1
Lisch nodules
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Choroidal naevi62
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Family history
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Father has multiples neurfibromas al over chest and
arm ( 1st degree relative)
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Orbital lesions in NF-1?Spheno-orbital encephalocele showing
congenital absence of left greater wing
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?Optic nerve glioma(in 15%)
of sphenoid bone
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invading hypothalamus? Pulsating proptosis without bruit!
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64
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Tuberous sclerosis (Bournevil e disease)
? Autosomal dominant
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? Triad - mental handicap,epilepsy,
adenoma sebaceum
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Adenoma sebaceum
Shagreen patches
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Ash leaf spotsRetinal astrocytomas
Innocuous tumour pre65
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sent in
50% of patients
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Von-Hippel-Lindau syndrome?Tumours? renal carcinoma and phaeochromocytoma
?Cysts- kidneys, liver, pancreas, epididymis, ovary and lungs
?Polycythaemia
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?Retinal capil ary haemangiomaTiny lesion between
Associated dilatation and
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arteriole and venuole
Round orange-red mass
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tortuosity of feeder vessels66
Sturge-Weber syndrome
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Involves face, leptomeninges and the eyes? Arteriovenous malformations of episclera
? Choroidal haemangioma
? Glaucoma (ipsilateral)
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? Iris heterochromiaAlbinism
Hypopigmented skin and hair with eyes
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involvement
? Nystagmus
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? Translucent iris giving rise to a "pink-eyed"appearance.
? Large choroidal vessels are seen due to lack of
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pigment in fundus.
? Foveal hypoplasia
Malignancy
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Malignancy
? Metastasis
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? From Breast, lung most common.? Usually localize to choroid but Extra Ocular
Muscles,
? optic nerve and orbit can also be affected
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? Lymphoma, leukemia
70
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Summary
? Ocular examination plays a significant role in
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diagnosing several systemic illnesses.? At times, patient present for eye related
problem, which then comes out to be a part of
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systemic disease, requiring inter-departmental
reference of the case to Physician/
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Paediatrician/Neurologist/ Neurosurgeon/Orthopaedician/Obstetrician.
71
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Acknowledgement
Photgraphs from Kanski, Parson and Archives Dept of
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Ophthalmology AI Ms Rishikesh1] Snow-flake cataract is seen in
a)
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Diabetesb)
Galactosemia
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c)
Trauma
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d) Rubella2] Cataract associated with atopic dermatitis
a) Sunflower cataract
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b) Coronary cataract
c) Shields cataract
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d) Coralliform cataract3] Sunflower type cataract is seen in
(a)
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Diabetes
(b)
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Chalcosis(c)
Argyrosis
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(d)
Tay sach's disease
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4. Most common ocular manifestation of AIDS is:(a) Cottonwood spots
(b) Cytomegalovirus retinitis
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(c) Kaposi's sarcoma of conjunctiva
(d) Pseudotumors
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5. Which prominent ocular manifestation isassociated with
Marfan's syndrome? :
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(a) Microcornea
(b) Microspherophakia
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(c) Megalocornea(d) Ectopia lentis
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