OCULAR MANIFESTATIONS

OF
SYSTEMIC DISEASE

Clint Gregg, M.D.

TTUHSC
Department of Ophthalmology
 Categories of
Systemic Disease
 Congenital  Idiopathic
 Traumatic  Infectious
 Vascular  Metabolic/Endocrine
 Neoplastic  Drugs/Toxins
 Autoimmune
 EYE EXAMINATION
 Vision  Motility
 External  Exam of anterior
 Pupils segment
• Relative afferent  Dilated
pupillary defect ophthalmoscopy
 Visual Fields
CONGENITAL DISORDERS
 Down syndrome
 Marfan syndrome
 Myotonic dystrophy
 Tuberous sclerosis
 Congenital metabolic disorders
• Lysosomal storage
• Carbohydrate metabolism
 Neurofibromatosis
 HYPERTENSION: FACTORS
AFFECTING RETINAL ARTERIOLES
 Severity
 Duration
INTRACRANIAL HYPERTENSION:
CAUSES

 Brain tumor
 Meningitis
 Venous sinus thrombosis
 Hydrocephalus
 Idiopathic intracranial
hypertension
CENTRAL RETINAL ARTERY
OCCLUSION: MANAGEMENT

 Rebreathing CO2
 Topical beta blockers
 Intravenous acetazolamide 500mg
 Massaging of globe with lids closed
 Anterior chamber paracentesis
 Hyperbaric O2
AMAUROSIS FUGAX

 Monocular dimming of
vision
 Temporary arterial
obstruction
 Sudden, transient, painless
visual loss
AMAUROSIS FUGAX:
EVALUATION
 Cardiovascular
 Cerebrovascular
 Ophthalmologic
 MIGRAINE:
VISUAL SYMPTOMS
 Scintillations
 Amaurosis fugax
 Transient homonymous
hemifield loss
 Transient cortical blindness
BLOOD DYSCRASIAS WITH
OCULAR MANIFESTATIONS
 Hyperviscosity
syndromes
 Thrombocytopenia
 Anemia, including
sickle cell anemia
HYPERVISCOSITY SYNDROMES:
OCULAR SYMPTOMS
 Amaurosis fugax
 Permanent visual loss
SICKLE CELL RETINOPATHY

 HbSC disease (most common form)

 HbSS disease
 Sickle thalassemia
MALIGNANT NEOPLASMS
INVOLVING THE EYE
 Primary ocular melanoma
 Large cell lymphoma
 Metastatic carcinoma
METASTATIC CARCINOMA
 Most common intraocular
malignancy in adults
 May be asymptomatic
 May produce decreased or
distorted vision
OCULAR METASTASIS:
TREATMENT
 Local radiation
 Chemotherapy
 Eye wall resection
 Enucleation if blind,
painful eye
AUTOIMMUNE DISORDERS

 Connective tissue diseases

 Thyroid eye disease
 Myasthenia gravis
CONNECTIVE TISSUE DISORDERS

 Dry eyes are the most common

manifestation
 Symptoms:
• Burning
• Foreign body sensation
• Photophobia
SJÖGREN’S SYNDROME
 Dry eyes
 Dry mouth
 + Connective tissue disorder
 Specific antibodies
 DRY EYES:
TREATMENT
 Artificial tears
 Lubricating ointment at night
 Punctal occlusion
 Environmental modification
ANKYLOSING SPONDYLITIS:
OCULAR SYMPTOMS
 Photophobia
 Redness
 Decreased vision

Refer for evaluation and treatment

Topical corticosteroids may lead to
serious ocular complications.
RHEUMATOID ARTHRITIS:
OCULAR MANIFESTATIONS
 Dry eyes
 Episcleritis
 Scleritis
 Corneal ulcers
 Uveitis
 IRITIS IN JUVENILE
RHEUMATOID ARTHRITIS

 Few symptoms or signs

 Usually chronic
 Secondary cataract and glaucoma

Refer for periodic ophthalmic screening.

 SYSTEMIC LUPUS
ERYTHEMATOSUS:
OCULAR MANIFESTATIONS

 Dry eyes
 Scleritis
 Peripheral corneal ulcers
 Retinopathy and optic neuropathy
POLYARTERITIS NODOSA:
OCULAR MANIFESTATIONS
 Dry eyes
 Corneal ulcers
 Scleritis
 Hypertensive retinopathy
 Retinal vasculitis
GIANT CELL ARTERITIS:
SYMPTOMS
 Headache
 Scalp tenderness
 Jaw claudication
 Polymyalgia rheumatica
 Acute visual loss
GIANT CELL ARTERITIS:
DIAGNOSIS
 Clinical history
 Stat ESR
 Fluorescein angiogram
 Temporal artery biopsy
If GCA is suspected,
begin treatment immediately
with high dose corticosteroids daily.

Do not wait for results of

temporal artery biopsy.
THYROID OPHTHALMOPATHY

 Not always correlated with

serum thyroid levels
 Can progress after thyroid
function is normal
THYROID OPHTHALMOPATHY:
CLASSES

0 No signs or symptoms
• Only signs
• Soft tissue involvement
• Proptosis
• Extraocular muscle involvement
• Corneal damage
6 Sight loss
 THYROID OPHTHALMOPATHY:
TREATMENT OF CONGESTIVE PHASE

 Tear substitutes
 Corticosteroids
 Orbital irradiation or
surgical decompression
 THYROID OHPTHALMOPATHY:
TREATMENT OF CICATRICIAL PHASE
 Lid surgery
 Muscle surgery
 Orbital surgery
 MYASTHENIA GRAVIS:
SYSTEMIC INVOLVEMENT

Refer suspects for neurologic evaluation.

SARCOIDOSIS
 More commonly affects
African-Americans and
Hispanics
 Ocular involvement in +
25% of patients
 OPTIC NEURITIS
 May be initial manifestation of
MS
 Acute, painful vision loss in one
or both eyes
 Treat initial episode with
intravenous methylprednisolone
 AIDS:
OCULAR MANIFESTATIONS
 Dry eye
 Cotton-wool spots
 CMV retinitis
 Kaposi’s sarcoma
(eyelid or conjunctiva)
 CMV RETINITIS:
THERAPY
 IV ganciclovir
 IV foscarnet
 Intravitreal ganciclovir
 Implantable pellets of
sustained-release ganciclovir
into the vitreous
 CD4 COUNTS
 < 100 cells/ml: Opportunistic infections
(e.g., CMV retinitis)
 > 100 cells/ml: Other ocular infections
(e.g., syphilis)
SYSTEMIC MEDICATIONS

 Toxic Retinopathies
• Thioridazine
• Chloroquine
• Hydroxychloroquine
• Tamoxifen
 Toxic Optic Neuropathies
• Ethambutol
• Isoniazid
• Fluoroquinolones