Eye Problems in Systemic Disease
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Eye Problems in Systemic Disease

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What is the primary cause of proptosis in adults according to the content?

Thyroid Eye Disease (TED)

Which thyroid condition affects 40% of patients with Graves disease in relation to ocular symptoms?

Hyperthyroidism

List two ocular manifestations associated with Cushing's disease.

Cataract and exophthalmos

What are the symptoms associated with Grade 2/3 hypertensive retinopathy?

<p>Blurring of vision, headache, and diplopia.</p> Signup and view all the answers

Name one management strategy for Thyroid Eye Disease (TED).

<p>Orbital decompression surgery</p> Signup and view all the answers

What is the relationship between hypertensive retinopathy and diabetes?

<p>Diabetes increases the risk of developing hypertensive retinopathy.</p> Signup and view all the answers

Identify two ocular symptoms of suprasellar tumors affecting the hypothalamus.

<p>Optic atrophy and papilloedema.</p> Signup and view all the answers

What does AV nicking indicate in the context of hypertensive retinopathy?

<p>Arteriolar narrowing at the crossing of arteries and veins.</p> Signup and view all the answers

What role can ophthalmologists play in the diagnosis of systemic diseases?

<p>Ophthalmologists can often identify signs of systemic diseases through eye examinations, which may lead to the diagnosis of such conditions before other symptoms emerge.</p> Signup and view all the answers

Identify two endocrine disorders that significantly affect eye health.

<p>Diabetes mellitus and thyroid dysfunction are two significant endocrine disorders that can affect eye health.</p> Signup and view all the answers

What is the primary systemic disease associated with blindness in working-age individuals?

<p>Diabetes mellitus is the primary systemic disease associated with blindness among individuals aged 20 to 65 years.</p> Signup and view all the answers

List two types of systemic diseases that can lead to eye problems.

<p>Infectious diseases and neurological disorders are two types of systemic diseases that can lead to eye problems.</p> Signup and view all the answers

How can eye problems serve as indicators of systemic diseases?

<p>Eye problems can serve as early warning signs, indicating the presence of underlying systemic diseases that require further investigation.</p> Signup and view all the answers

What is the normal blood pressure target for treating hypertensive retinopathy?

<p>Below 140/90 mmHg.</p> Signup and view all the answers

List two conditions associated with malignant hypertension.

<p>Eclampsia of pregnancy and pheochromocytoma.</p> Signup and view all the answers

What causes retinal vein occlusion primarily?

<p>Thrombus formation and external compression of the vein.</p> Signup and view all the answers

What role does age play in the incidence of retinal vein occlusion?

<p>Over 50% of cases occur in individuals over 65 years old.</p> Signup and view all the answers

Identify two cardiovascular diseases that can lead to eye problems.

<p>Atrial fibrillation and aortic stenosis.</p> Signup and view all the answers

What is the 4-2-1 rule in the context of severe diabetic retinopathy?

<p>The 4-2-1 rule indicates severe diabetic retinopathy when there are hemorrhages and microaneurysms in 4 quadrants, venous beading in at least 2 quadrants, or intraretinal microvascular abnormalities in at least 1 quadrant.</p> Signup and view all the answers

What are the late complications of proliferative diabetic retinopathy?

<p>The late complications include tractional retinal detachment and diabetic maculopathy.</p> Signup and view all the answers

How does fluorescein angiography assist in diagnosing proliferative diabetic retinopathy?

<p>Fluorescein angiography reveals wide areas of capillary dropout and ischemia in the retina.</p> Signup and view all the answers

What is the role of blood sugar and blood pressure control in diabetic retinopathy?

<p>Blood sugar and blood pressure control are as important as laser treatment in reducing the risk of retinopathy progression and vision loss.</p> Signup and view all the answers

What is the significance of Rubeosis Iridis in diabetic patients?

<p>Rubeosis Iridis indicates neovascularization on the iris, which can lead to neovascular glaucoma.</p> Signup and view all the answers

Describe the typical visual field defect associated with pituitary tumors.

<p>The typical visual field defect is bitemporal hemianopia, where the outer parts of the visual field are lost.</p> Signup and view all the answers

In the context of diabetic maculopathy, how does hyperlipidaemia treatment impact patient outcomes?

<p>Active treatment of hyperlipidaemia is shown to benefit diabetics suffering from exudative maculopathy with extensive lipid exudates.</p> Signup and view all the answers

What distinguishes ischaemic maculopathy from exudative maculopathy in diabetic patients?

<p>Ischaemic maculopathy is not treatable, while exudative maculopathy can be managed with focal laser treatments.</p> Signup and view all the answers

What is the estimated prevalence of blindness due to diabetic retinopathy in Western communities?

<p>Between 1.6 and 1.9 per 100,000.</p> Signup and view all the answers

List at least two visual problems that may occur due to diabetes.

<p>Diabetic retinopathy and cataract.</p> Signup and view all the answers

What pathological changes occur in the retina due to hyperglycemia?

<p>Basement membrane thickening and increased free radical activity.</p> Signup and view all the answers

Describe the process that leads to the release of VEGF in diabetic retinopathy.

<p>Ischaemia in the retina directly affects rods and cones, causing VEGF release for new blood vessel formation.</p> Signup and view all the answers

Differentiate between the stages of diabetic retinopathy.

<p>The stages include Background, Preproliferative, Proliferative, and Maculopathy.</p> Signup and view all the answers

What characterizes mild non-proliferative diabetic retinopathy?

<p>The presence of at least one microaneurysm without severe hemorrhages.</p> Signup and view all the answers

What are Cotton Wool Spots and what do they indicate in relation to diabetic retinopathy?

<p>Cotton Wool Spots are microinfarcts of the nerve fiber layer, often associated with other preproliferative signs.</p> Signup and view all the answers

How can proliferative diabetic retinopathy evolve over time?

<p>It can evolve very quickly, sometimes within a span of six weeks.</p> Signup and view all the answers

Name one systemic disease that can lead to eye problems.

<p>Diabetes Mellitus</p> Signup and view all the answers

How might eye problems indicate the presence of a systemic disease?

<p>Eye problems may serve as early signs of systemic diseases, prompting ophthalmologists to diagnose conditions based on ocular symptoms.</p> Signup and view all the answers

What is the most significant cause of blindness in individuals aged 20-65 years?

<p>Diabetes Mellitus</p> Signup and view all the answers

Identify one endocrine disorder that significantly affects eye health.

<p>Thyroid dysfunction</p> Signup and view all the answers

Explain how systemic diseases can be diagnosed first by ophthalmologists.

<p>Ophthalmologists can detect signs of systemic diseases through eye examinations, which may reveal symptoms unnoticed by other medical professionals.</p> Signup and view all the answers

What is a common review timeline for patients with severe diabetic retinopathy?

<p>Patients typically require a review in 4 months.</p> Signup and view all the answers

What is neovascularization in the context of proliferative diabetic retinopathy?

<p>Neovascularization refers to the growth of new blood vessels, which can bleed and lead to vision complications.</p> Signup and view all the answers

What are two systemic risk factors that can worsen diabetic retinopathy?

<p>Uncontrolled blood sugar levels and hypertension are two significant risk factors.</p> Signup and view all the answers

How does focal laser therapy assist in managing exudative maculopathy?

<p>Focal laser therapy targets and seals leaks from abnormal retinal capillaries, reducing fluid accumulation.</p> Signup and view all the answers

How does diabetic maculopathy affect vision?

<p>Diabetic maculopathy can distort vision due to fluid leakage and lipid exudate accumulation.</p> Signup and view all the answers

What can occur as a late complication of proliferative diabetic retinopathy?

<p>Tractional retinal detachment can occur as a late complication.</p> Signup and view all the answers

What imaging technique is used to assess capillary dropout in diabetic retinopathy?

<p>Fluorescein angiography is used to examine capillary dropout.</p> Signup and view all the answers

What is Rubeosis Iridis and why is it significant?

<p>Rubeosis Iridis is the abnormal growth of new vessels on the iris, indicating severe ischemic changes.</p> Signup and view all the answers

How can Thyroid Eye Disease (TED) impact a patient's vision?

<p>TED can lead to vision loss in 4-8% of patients due to complications such as dysthyroid myopathy and optic neuropathy.</p> Signup and view all the answers

What is a common ocular manifestation seen in patients with Addison's disease?

<p>A common ocular manifestation in Addison's disease is hyperpigmentation.</p> Signup and view all the answers

Describe the ophthalmic signs associated with hypertensive retinopathy.

<p>Signs include Cotton Wool Spots, flame-shaped hemorrhages, and AV nicking.</p> Signup and view all the answers

What role do lubricants play in the management of Thyroid Eye Disease?

<p>Lubricants help alleviate symptoms of dry eyes and conjunctival hyperemia associated with TED.</p> Signup and view all the answers

What is the primary ocular consequence of malignant hypertension?

<p>The primary ocular consequence is optic disc swelling, leading to blurred vision and field loss.</p> Signup and view all the answers

How can diabetes exacerbate the effects of hypertensive retinopathy?

<p>Diabetes increases the risk of severe retinal damage in hypertensive retinopathy.</p> Signup and view all the answers

What are some surgical options available for managing Thyroid Eye Disease?

<p>Surgical options include orbital decompression surgery and muscle surgery.</p> Signup and view all the answers

What ocular symptom is commonly associated with keratoconjunctivitis sicca in TED patients?

<p>Common symptoms include dryness and irritation of the eyes.</p> Signup and view all the answers

What is the target blood pressure for treating hypertensive retinopathy?

<p>Below 140/90 mmHg.</p> Signup and view all the answers

What can cause disc edema in hypertensive retinopathy?

<p>Severe hypertension, potentially reaching 250/150 mmHg.</p> Signup and view all the answers

What is a common etiology for retinal vein occlusion?

<p>Hypertension is a common cause, affecting 64% of patients.</p> Signup and view all the answers

What are two potential complications of severe hypertensive retinopathy?

<p>Retinal/macular edema and disc edema.</p> Signup and view all the answers

Identify one systemic condition that can lead to malignant hypertension.

<p>Eclampsia of pregnancy.</p> Signup and view all the answers

What is indicated by the presence of at least one microaneurysm in non-proliferative diabetic retinopathy?

<p>It indicates mild non-proliferative diabetic retinopathy.</p> Signup and view all the answers

What are the three stages of diabetic retinopathy?

<p>The stages are non-proliferative, preproliferative, and proliferative diabetic retinopathy.</p> Signup and view all the answers

What does VEGF stand for and what is its role in diabetic retinopathy?

<p>VEGF stands for Vascular Endothelial Growth Factor, and it promotes new blood vessel formation.</p> Signup and view all the answers

What characterizes preproliferative diabetic retinopathy?

<p>It is characterized by venous beading, intraretinal microvascular abnormalities, and severe hemorrhages.</p> Signup and view all the answers

What are Cotton Wool Spots and what do they indicate?

<p>Cotton Wool Spots are soft exudates indicating microinfarcts of the nerve fiber layer.</p> Signup and view all the answers

What is the estimated prevalence of blindness due to diabetic retinopathy in Western communities?

<p>The prevalence is estimated to be between 1.6-1.9 per 100,000.</p> Signup and view all the answers

What are two visual problems that may occur due to diabetes?

<p>Diabetic retinopathy and cataracts are two visual problems.</p> Signup and view all the answers

What processes contribute to the pathology of diabetic retinopathy due to hyperglycemia?

<p>Key processes include basement membrane thickening and increased free radical activity.</p> Signup and view all the answers

Study Notes

Eye Problems in Systemic Disease

  • Systemic diseases can affect the eye in many ways, but ophthalmologists are often the first to diagnose these issues.
  • Diabetes mellitus is the most common cause of blindness in working-age individuals (20-65 years old), with a prevalence of 1.6-1.9/100,000
  • Vision issues in diabetes can occur due to diabetic retinopathy, cataracts, glaucoma, ischemic optic neuropathy, retinal vein and artery occlusions, and IIIrd, IVth, and VIth nerve palsies.

Diabetic Retinopathy

  • Hyperglycemia causes basement membrane thickening, non-enzymatic glycosylation, increased free radical activity, increased flux through the polyol pathway, and osmotic damage.
  • Diabetic retinopathy develops in stages: background (mild non-proliferative), preproliferative, proliferative, and maculopathy.
  • Background diabetic retinopathy is characterized by mild hemorrhages and microaneurysms (MAs), with no more severe changes.
  • Preproliferative diabetic retinopathy includes venous beading, intraretinal microvascular abnormalities (IRMAs), and severe hemorrhages.
  • Proliferative diabetic retinopathy has new vessels growing on the disc (DNV) and elsewhere on the retina (NVE).

Key Signs of Diabetic Retinopathy

  • Cotton-wool spots (CWS) are soft exudates that are microinfarcts of the nerve fiber layer. They are often associated with preproliferative diabetic retinopathy signs; however, isolated CWS may be caused by hypertension or recent stricter blood sugar control.

Classifying Diabetic Retinopathy

  • Non-proliferative Diabetic Retinopathy:

    • Mild: presence of at least 1 microaneurysm.
    • Moderate: presence of hemorrhages, microaneurysms, hard exudates, and cotton wool spots.
    • Severe: The 4-2-1 rule: hemorrhages and microaneurysms in 4 quadrants, venous beading in at least 2 quadrants, intraretinal microvascular abnormalities in at least 1 quadrant.

  • Proliferative Diabetic Retinopathy

    • Mild-moderate: neovascularization, vitreous/preretinal hemorrhage.
    • Severe: advanced neovascularization, vitreous/preretinal hemorrhage.

Treatment of Diabetic Retinopathy

  • Scattered laser pan-retinal photocoagulation (PRP) for proliferative diabetic retinopathy.
  • Focal laser/laser grid for exudative maculopathy.
  • Ischemic maculopathy is not treatable.
  • Anti-VEGF used for treatment.

Systemic Risk Factors and Diabetic Retinopathy

  • Blood sugar and blood pressure control are as beneficial as laser treatment in reducing the risk of retinopathy progression and vision loss.
  • Nephropathy is a risk factor for diabetic retinopathy.
  • Diabetics with exudative maculopathy and extensive lipid exudates benefit from active treatment of hyperlipidemia.

Endocrine Disorders and the Eye

  • Thyroid, pituitary, hypothalamus, parathyroids, and adrenals can all cause eye problems.

Pituitary Tumours

  • Headache, visual field defect (bitemporal hemianopia), optic nerve dysfunction, color deficit, visual deterioration, and optic atrophy are possible symptoms.
  • MRI scan and neuro referral are recommended for diagnosis and management.

Thyroid Eye Disease (TED)

  • TED is a manifestation of Grave's disease and is the most common cause of proptosis (unilateral or bilateral) in adults.
  • It can occur in patients with euthyroidism, hypothyroidism, or hyperthyroidism.
  • 40% of patients with Grave’s disease have eye signs, and 4-8% experience vision loss.

Other Endocrine Disorders Affecting the Eyes

  • Gland - Disorder - Ocular Manifestations:
    • Hypothalamus - Suprasellar tumors - Optic atrophy, papilledema
    • Parathyroids - Hyper/Hypoparathyroidism - Conjunctival & corneal calcification, cataract
    • Adrenals - Pheochromocytoma -Hypertensive retinopathy
    • Adrenals - Addison’s disease - Hyperpigmentation
    • Adrenals - Cushing’s disease - Cataract, exophthalmos

Hypertensive Retinopathy

  • Damage to the retina from high blood pressure, and the risk increases with duration.
  • Worse with diabetes, high cholesterol, smoking, and malignant hypertension.

Symptoms of Hypertensive Retinopathy

  • Grade 1: no symptoms.
  • Grade 2/3: blurring of vision, headache, diplopia.
  • Grade 4: optic disc swelling, which causes blurred vision and field loss.

Signs of Hypertensive Retinopathy

  • Cotton-wool spots (CWS) are common, especially with a diastolic blood pressure greater than 100 mmHg.
  • Flame-shaped hemorrhages, CWS, A-V nicking, arteriolar narrowing, arteriolar color changes, vessel sclerosis, threading can all be present.

Treatment of Hypertensive Retinopathy

  • Lower blood pressure to below 140/90 mmHg.

Malignant Hypertension

  • This can be caused by collagen vascular diseases, renal problems, eclampsia of pregnancy, and pheochromocytoma.

Cardiovascular Diseases that Cause Eye Problems

  • Atrial fibrillation, aortic stenosis, hyperlipidemia (arcus, xanthoma), hypercholesterolemia, and thromboembolism (retinal arteriolar occlusion).

Retinal Vein Occlusion

  • The second most common vascular disease causing loss of vision.

Retinal Vein Occlusion Pathophysiology

  • Thrombus formation, disease of the vein wall, external compression of the vein, can all contribute.
  • Thickening of the arteriole can compress the vein and cause occlusion.

Types of Retinal Vein Occlusion

  • Branch Retinal Vein Occlusion (BRVO)
  • Central Retinal Vein Occlusion (CRVO)

Retinal Vein Occlusion Etiology

  • Advancing age is a risk factor, especially over 65 years old.
  • Other risk factors include hypertension, hyperlipidemia, diabetes, smoking, obesity, raised intraocular pressure, inflammatory diseases (sarcoidosis, Behçet's syndrome), hyperviscosity states (myeloma), and thrombophilic disorders.

Eye Problems and Systemic Diseases

  • The eye is a unique organ often the first place to signal systemic diseases.

  • Endocrine disorders are a common cause of eye problems, especially diabetes mellitus, thyroid dysfunction, and pituitary tumors.

  • Diabetes mellitus is a leading cause of blindness in working-age individuals (20-65 years old).

    • The prevalence of blindness due to diabetic retinopathy in Western communities is estimated at 1.6-1.9 per 100,000 people.
    • Visual problems can occur due to diabetic retinopathy, cataracts, glaucoma, ischemic optic neuropathy, retinal vein and artery occlusions, and cranial nerve palsies.

  • Diabetic retinopathy (DR) is caused by high blood sugar (hyperglycemia).

    • Hyperglycemia leads to changes in blood vessels, including thickening of the basement membrane, non-enzymatic glycosylation, increased free radical activity, increased flux through the polyol pathway, and osmotic damage.
    • Ischemia results from the damage to the retinal blood vessels.
    • Ischemia damages photoreceptors (rods and cones), and leads to release of vascular endothelial growth factor (VEGF), which promotes new blood vessel formation (neovascularization).
    • Neovascularization bleeds and scars contributing to vision impairment.
    • DR stages include background diabetic retinopathy, preproliferative diabetic retinopathy, and proliferative diabetic retinopathy.
    • Background diabetic retinopathy is characterized by mild hemorrhages and microaneurysms.
    • Preproliferative diabetic retinopathy includes venous beading, intraretinal microvascular abnormalities (IRMA), and severe hemorrhages.
    • Proliferative diabetic retinopathy involves new vessel growth on the optic nerve (disc neovascularization) or on other retinal surface areas (neovascularization elsewhere).
    • In the latter stages of DR, new vessels tend to bleed, leading to vitreous hemorrhages and tractional retinal detachment.

Diabetes and Retinopathy

  • The 4-2-1 rule: one or more hemorrhages and microaneurysms in four quadrants, venous beading in at least two quadrants, and intraretinal microvascular abnormalities in at least one quadrant characterize severe non-proliferative diabetic retinopathy.

  • Proliferative DR is characterized by neovascularization (new blood vessel growth), vitreous hemorrhages, and preretinal hemorrhages.

  • Diabetic maculopathy involves exudates, fluid leakage, and retinal ischemia.

    • There are three types of diabetic maculopathy: exudative, ischemic, and mixed exudative/ischemic.

  • New vessel growth on the iris (rubeosis iridis) can lead to neovascular glaucoma.

    • Rubeosis iridis is caused by ischemia of the iris.
    • Neovascular glaucoma is a type of glaucoma that is caused by new blood vessels growing on the iris.

Treating Diabetic Retinopathy

  • Diabetic retinopathy often progresses with elevated blood sugar and blood pressure.
    • Control of both is as effective as laser treatment in reducing the risk of disease progression and vision loss.
  • Treatment options for DR include pan-retinal photocoagulation (PRP), focal laser, laser grid for exudative maculopathy, and anti-VEGF therapy
    • PRP is used to treat proliferative DR
    • Focal laser and laser grid are used to treat exudative maculopathy.
    • There is no treatment for ischemic maculopathy.
    • Anti-VEGF therapy is a newer treatment option for DR.
  • Hyperlipidemia (high blood cholesterol) in the setting of diabetic maculopathy may benefit from treatment.

Pituitary Tumors

  • Pituitary tumors can affect the optic nerve, and cause a variety of visual problems, including optic atrophy, color deficit, visual deterioration, and bitemporal hemianopia.
  • MRI imaging and neurological referral should be performed.

Thyroid Eye Disease (TED)

  • TED is a manifestation of Grave’s disease.
    • TED can occur in patients with euthyroidism, hypothyroidism, and hyperthyroidism.
      • TED may occur before the onset of hyperthyroidism or after treatment of hyperthyroidism.
    • TED may worsen in patients who are hypothyroid due to hyperthyroidism overtreatment.
    • TED can be seen in 40% of patients with Graves disease.
    • TED can cause vision loss in 4 to 8% of patients.
  • TED is the most common cause of proptosis (bulging eyes) in adults.
    • TED may be unilateral or bilateral.
  • TED can also cause a number of other symptoms, including lid lag, lid retraction, conjunctival hyperemia and chemosis, dry eye, dysthyroid myopathy, and optic neuropathy.

Treating Thyroid Eye Disease

  • Treatment includes controlling thyroid status (medication or surgery), lubricants, orbital decompression surgery, muscle surgery (with prisms in eyeglasses to correct misalignment), and lid surgery.

Other Endocrine Disorders:

  • Hypothalamus: Suprasellar tumors can lead to papilledema and optic atrophy.
  • Parathyroid: Hyperparathyroidism and hypoparathyroidism can cause conjunctival and corneal calcification, and cataracts.
  • Adrenals: Pheochromocytoma causes hypertensive retinopathy.
  • Adrenals: Addison’s disease can cause hyperpigmentation of the skin.
  • Adrenals: Cushing’s disease is associated with cataracts and exophthalmos.

Hypertensive Retinopathy

  • Hypertensive retinopathy occurs when high blood pressure damages the retina.
  • The longer the high blood pressure, the greater the risk of hypertensive retinopathy.
  • Hypertension is a significant risk factor for retinal vein occlusion.
  • Other risk factors for hypertensive retinopathy include diabetes, high cholesterol, and smoking.
  • Malignant hypertension is a severe form of hypertensive retinopathy accompanied by headache and diplopia.
    • Malignant hypertension is associated with papilledema and macular edema.
    • Malignant hypertension usually occurs with other medical conditions such as collagen vascular diseases, scleroderma, renal problems, eclampsia of pregnancy, and pheochromocytoma.
    • Malignant hypertension is a medical emergency.

Signs and Symptoms of Hypertensive Retinopathy

  • The symptoms of hypertensive retinopathy vary depending on the severity of the condition.
    • Grade 1 hypertensive retinopathy has no symptoms.
    • Grade 2 and 3 hypertensive retinopathy may cause blurred vision, headache, and diplopia.
    • Grade 4 hypertensive retinopathy is rare but serious.
      • Grade 4 is associated with papilledema.
        • Papilledema is a swelling of the optic disc that occurs when there is increased pressure in the brain.
  • Ophthalmoscopic findings of hypertensive retinopathy include flame-shaped hemorrhages, cotton wool spots, arteriolar narrowing (focal or diffuse), arteriolar color changes, AV nicking, and vessel sclerosis.

Treating Hypertensive Retinopathy

  • Blood pressure should be lowered to below 140/90 mmHg.

Cardiovascular Diseases

  • Aortic stenosis, atrial fibrillation, hyperlipidemia, hypercholesterolemia, and thromboembolism can cause eye problems.
    • Aortic stenosis can cause retinal artery occlusion and choroidal ischemia.
    • Atrial fibrillation increases risk of retinal artery occlusion and ischemic stroke.
    • Hyperlipidemia can cause arcus (a ring around the cornea), xanthalasma, and corneal neovascularization.
    • Hypercholesterolemia can cause retinal artery occlusion.
    • Thromboembolism causes retinal artery occlusion.

Retinal Vein Occlusion

  • Retinal Vein Occlusion (RVO) is the second most common vascular disease causing loss of vision.
  • There are two types of RVO: central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).

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