Graves’ disease - endocrine (NB)
Pathogenesis
Visual system abnormalities
PATHOGENESIS
- Autoimmune disorder in which an antibody to the thyroid stimulating hormone receptor causes hyperthyroidism
- postulated that the same antibody binds to receptors in orbital tissues to produce the associated orbital abnormalities.
- Orbital complications can present before, concurrent with, or after the endocrine abnormalities.
VISUAL SYSTEM ABNORMALITIES
- Eyelid swelling.
- Eyelid retraction resulting in a staring expression.
- Lid lag.
- Conjunctival chemosis and erythema.
- Proptosis = exophthalmos
- Limitation of eye movements which may lead to diplopia.
- Exposure keratopathy.
- Optic neuropathy due to pressure from swollen eye muscles and other intraorbital soft tissues.
Diabetes mellitus - metabolic disease
General
Visual system abnormalities
Visual system abnormalities
GENERAL
- ocular complications only after the disease has been present for many years, but may also occur without the pt being aware of being diabetic.
- ocular manifestations that can lead to blindness if the disease is not recognised and treated in good time.
- should undergo a thorough eye examination at least once a year.
VISUAL SYSTEM ABNORMALITIES
GENERAL
- Increased incidence of superficial and deep infections: blepharitis, conjunctivitis, preseptal cellulitis, orbital cellulitis.
LENS
- Sudden refractive changes as a result of poor metabolic control.
- Cataract.
UVEA
- Increased incidence of anterior uveitis.
RETINA
- Diabetic retinopathy
GLAUCOMA
- Neovascular glaucoma: a fibrovascular membrane grows over the iris and angle structures.
NEUROOPHTHALMOLOGY
- Extraocular muscle paralysis usually presenting with diplopia.
- clears spontaneously within a few months.
- paralysis of III it is characteristic that the pupil is spared
Examples of cardiovascular system diseases
Hypertension & Arteriosclerosis
- Retinal vasculopathies
Vascular occlusions
- Retinal arterial and venous occlusions
- Ciliary arterial occlusions
Rheumatoid Arthritis - Collagen diseases
- Dry eyes (keratoconjuctivitis sicca) ➡️ irritation and decreased surface immunity ➡️ an increased incidence of corneal infections by bacteria and fungi.
- Peripheral corneal thinning that may lead to corneal perforation.
- Scleritis:
➡️ very poor prognostic sign
➡️ usually indicative of a flare-up of the systemic disease.
➡️Patients with this complication have a greater tendency to die of the systemic complications.
Juvenile chronic arthritis (JCA) - Collagen diseases
- Chronic anterior uveitis = most common ocular complication.
- usually asymptomatic, but leads to the development of posterior synechiae, dense cataracts and glaucoma that are very difficult to treat if not detected early.
- Eye complications more common in pt with monoarthritis than in those with severe systemic disease.
- must be examined early and regularly (every three months for those with monoarthritis) by an ophthalmologist, even if they do not complain of eye problems
Ankylosing spondylitis - collagen diseases
- affects mainly young men.
- Recurrent attacks of acute painful anterior uveitis are the most common ocular complication
- uveitis may present before the spondylitis
- All patients with acute anterior uveitis of unknown cause must have X-rays of the sacroiliac joint and be referred to a physician.
SLE - Collagen diseases
Visual system abnormalities
CNS complications may lead to
VISUAL SYSTEM ABNORMALITIES
- Dry eyes.
- Peripheral corneal thinning.
- Anterior uveitis.
- Retinopathy is the most important eye complication of this disease and may present with retinal haemorrhage, cotton wool spots and optic disc swelling.
CNS COMPLICATIONS MAY LEAD TO THE FOLLOWING
- homonymous hemianopia.
- Optic atrophy
- III and VI paresis.
Reiter’s syndrome - collagen diseases
- Classical triad of nonspecific (nongonococcal) urethritis, arthritis and conjunctivitis.
- Uveitis and keratitis may also occur.
Behcet’s syndrome - collagen diseases
Classical triad of oral and genital ulceration, arthritis and anterior uveitis.
NB for test
Giant cell arteritis (Temporal arteritis) - collagen diseases
- Arteritis of medium and large arteries usually presents in people older than 60 years with headache, weight loss and tender temporal arteries.
- may suddenly lose their vision due to:
(a) Anterior Ischaemic Optic Neuropathy (AION)
(b) Central Retinal Arterial Occlusion (CRAO) - emergency, because, without treatment, the second eye can be affected within days.
- They may present with cranial nerve fallout e.g. III, VI.
AIDS - NB
Visual system manifestations
AIDS virus retinal vascular involvement
- Cotton wool spots: areas of nerve fibre layer ischaemia, usually transient in nature with no prognostic value.
- Microaneurysms.
- Retinal haemorrhages.
Opportunistic infections
- Herpes zoster ophthalmicus may be the first manifestation of the disease.
- Cytomegalovirus retinitis is associated with a reduced life expectancy.
- Toxoplasma retinochoroiditis.
- Cryptococcus neoformans retinochoroiditis.
Neoplasms
- Kaposi’s sarcoma of the eyelids, conjunctiva and orbit.
- Squamous carcinoma of the eyelids and conjunctiva.
- Burkitt’s lymphoma of the orbit.
Neuroophthalmic signs of intracranial disease
- Cranial nerve paresis.
- Field defects.
- Disc swelling.
- Optic atrophy.
- Pupillary abnormalities.
Define phacomatoses
Group of diseases in which neurological abnormalities are associated with congenital defects of the skin, eye and other organs.
Sturge-weber syndrome - Phacomatoses
Visual system abnormalities
Other systemic abnormalities
VISUAL SYSTEM ABNORMALITIES
- Conjunctival haemangioma.
- Choroidal haemangioma.
- Open angle glaucoma probably due to a combination of a developmental angle anomaly and haemangioma induced raised venous pressure.
OTHER SYSTEMIC ABNORMALITIES
- Facial haemangioma: port wine stain.
- Meningeal haemangioma: seizures.
For test
- visual system abnormalities
- why high risk for open angle glaucoma
Neurofibromatosis - Phacomatoses
Visual system abnormalities
Other systemic abnormalities
VISUAL SYSTEM ABNORMALITIES
- Eyelid neuroma.
- Iris nodules (Lisch nodules)
- Open angle glaucoma.
- Choroidal naevus.
- Optic nerve glioma.
OTHER SYSTEMIC ABNORMALITIES
- Skin neurofibromas.
- CNS tumours.
- Endocrine tumours.
Main visual system problems produced by collagen diseases
- dry eyes
- peripheral corneal thinning
- scleritis
- anterior uveitis
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11.1 The Orbit15
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11.2 Eyelids & Lacrimal System25
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11.3.1 Conjuctiva13
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11.4.1 Uvea6
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11.4.2 Lens7
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11.5.1 Retinal Vasculopathies And Systemic Diseases24
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11.5.2 Degenerative Conditions Of Retina, Retinal Cancer & Detachments7
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11.6 Strabismus11
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11.7.1 Eye Revision Overview27
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11.7.2 Glaucoma10
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11.7.3 Neuro-opthalmology And Optic Nerve27
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11.7.4 Systemic Diseases15
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11.3.2 Cornea19
