Amun Sachdev Ophthalmology ST1

Amun Sachdev Ophthalmology ST1

- Understand which systems may have eye-related problems - How the eye problems may herald systemic disease - Understand some of the mechanisms of systemic disease and the eye.

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

- Endocrine disorders - Gastrointestinal disorders - Disorders of connective tissues - Skin diseases - Cardiovascular & Pulmonary diseases - Neurological and muscular disorders

- Most important ones are: Diabetes Thyroid dysfunction Pituitary Tumours

- Visual loss may occur through: Diabetic retinopathy Cataract Glaucoma Ischaemic Optic Neuropathy Retinal vein and artery occlusions IIIrd, IVth and VIth nerve palsies

- Stages: Background (R1) Pre-proliferative (R2) Proliferative (R3) Maculopathy (M1)

Retinal blot haemorrhages Microaneurysms

On fundoscopy: - Multiple number of background DR features in all quadrants - Particularly features suggesting ischaemia (e.g. cotton wool spots, venous beading/looping) Normal Cotton wool spots Venous beading Saccular bulges in vein walls Venous Loops

Normal NVD NVE Along superior arcade Vitreous haemorrhage Retinal detachment Rubeosis Iridis

On fundoscopy: - Focal / diffuse macular oedema - Clinically significant macular oedema (CSMO) o Retinal thickening + Exudates near fovea - Ischaemic maculopathy o Loss of capillaries at macula (particularly seen on FFA) Normal A) Color fundus photograph ; B) FFA Diffuse macular oedema (difficult to visualize on colour photo) Exudates

On fundoscopy: - Focal / diffuse macular oedema - Clinically significant macular oedema (CSMO) o Retinal thickening + Exudates near fovea - Ischaemic maculopathy o Loss of capillaries at macula (particularly seen on FFA) Normal Ischaemia Normal capillary bed

Panretinal Laser Photocoagulation Fresh laser burns Panretinal Laser Photocoagulation Atrophic old laser scars - Blood sugar and BP control are as good as laser treatment for reducing the risk of retinopathy progression and loss of vision

- Headache - Visual field defect - Optic nerve dysfunction Colour deficit Visual deterioration - MRI scan & Neuro referral

Patient may be: - Euthyroid - Hypothyroid - Hyperthyroid 40% patients with Grave s disease get eye signs 4-8% will lose vision

Most common cause of proptosis (unilateral or bilateral) in adults

Symptoms / Signs: - Pain on eye movements - Pain (pressure-like behind the eye) - Impaired vision - Impaired eye movements (diplopia) - Increasing proptosis - Red lids - Red conjunctiva - Swelling of lids - Swelling of conjunctiva (chemosis) - Swelling of caruncle

- Damage to the retina from high blood pressure - Duration increases risk - Worse with - Diabetes - High cholesterol - Smoking - Malignant hypertension

- Grade 1 - No symptoms - Grade 2 / 3 - Blurred vision / Headache / Diplopia - Grade 4 - Optic disc swelling Blurred vision; Field loss - Often associated with: - Poor renal function - Risk of stroke / encephalopathy

Focal closure of retinal microvasculature Microinfarcts - Cotton wool spots - Flame shaped haemorrhages

- Arteriolar narrowing - Arteriolar colour changes - AV crossing changes - Nicking, Flame haemorrhages AV Nicking

- Often when BP ~ 250/150 mmhg - Retinal / Macular oedema - Macular star in extreme cases - Disc oedema Macular star develops in weeks; resolves in months Disc oedema develops in days; resolves in weeks or months

- Lower blood pressure to below 140/90mmHg

Second most common vascular disease causing loss of vision Pathophysiology - Thrombus formation - Disease of the vein wall - External compression of the vein Retinal arteries and arterioles and their corresponding veins share a common adventitial sheath. Atherosclerosis and thickening of the arteriole compresses the vein, eventually causing occlusion.

- Papilloedema - Flame haemorrhages - Vein dilation / tortuosity - Cotton wool spots (esp if ischaemic) BRVO CRVO

- Advancing age Usually age > 65 - Cardiovascular risk factors Hypertension (64% cases) Hyperlipidaemia Diabetes Smoking Obesity - Raised intraocular pressure - Hyperviscosity states - myeloma - Thrombophilic disorders (considered if age <45)

- Tall stature - Large eyes - Myopia - Ectopia lentis - Secondary glaucoma - Retina detachment

- Blue sclera - Keratoconus - Ectopia lentis - Angioid streaks

Episcleritis - Inflammation of episclera (between sclera and conjunctiva) - Idiopathic or Autoimmunity - Symptoms: - Discomfort/Gritty - Red - Watering - Signs: - Engorged episcleral vessels - Translucent white nodule within inflamed area - Treatment: - Self-limiting - Lubricants - Topical NSAIDs/steroids

Scleritis - Full-thickness inflammation of sclera - Associated with Rheumatoid Arthritis - Symptoms: - Boring pain (wakes patient at night, on eye movement) - Red - Watering - Photophobia - VA - Treatment: - Refer to Ophthalmology - Topical NSAIDs/steroids - Manage underlying disease

Atopic conditions: Allergic Eye Disease *Conjunctivitis *Dry skin around eyes Acne rosacea: Blepharitis Chalazion Stye

- Crohn s Disease - Ulcerative Colitis - Inflammatory Bowel Disease Episcleritis Anterior uveitis - Vitamin A Deficiency Night Blindness Retinitis Pigmentosa

- Inflammation of uvea (iris, ciliary body, choroid) - Symptoms: - Pain - Red - Photophobia - Blurred - Signs: - Reduced VA - Raised IOP - Red conjunctiva - Cells in anterior chamber - Irregular pupil (posterior synychiae) - Pupil reaction sluggish to light - Treatment: - Refer to Ophthalmology - Topical steroids - Cycloplegic (i.e. dilating drops)

Myasthenia Gravis - Bilateral, Asymmetrical - Ptosis - Diplopia - Fatiguability Worsens throughout the day - Positive ice test - Positive edrophonium test

Multiple Sclerosis & Optic Neuritis - Inflammation of optic nerve ; Common in young women - Symptoms - colour vision - visual acuity - Central scotoma - Signs - Optic disc swelling - RAPD - Management - Usually self-limiting - Systemic steroids - Speed recovery ; No improvement in outcome