Systemic disease

Question 1

GRAVES’ DISEASE

Answer 1

VISUAL SYSTEM ABNORMALITIES

1. Eyelid swelling.
2. Eyelid retraction resulting in a staring expression.
3. Lid lag.
4. Conjunctival chemosis and erythema.
5. Proptosis = exophthalmos.
6. Limitation of eye movements which may lead to diplopia.
7. Exposure keratopathy.
8. Optic neuropathy due to pressure from swollen eye muscles and other intraorbital soft tissues.

Because the optic neuropathy may progress suddenly, all patients with orbital involvement must be followed regularly by an ophthalmologist.

Path: AI disorder: AB to TSH receptor causes–> hyperthyroidism
Same AB binds to receptors in orbital tissues–> orbital abnormalities.

Question 2

DIABETES MELLITUS

Answer 2

VISUAL SYSTEM ABNORMALITIES

1. Superficial and deep infections: blepharitis, conjunctivitis, preseptal cellulitis, orbital cellulitis. (general)
2. Sudden refractive changes as a result of poor metabolic control. (Lens)
3. Cataract. (Lens)
4. Increased incidence of anterior uveitis. (Uvea)
5. Diabetic retinopathy (Retina)
6. Neovascular glaucoma: a fibrovascular membrane grows over the iris and angle structures.
7. Extraocular muscle paralysis usually presenting with diplopia. (Neuro Opthalmology)
8. It usually clears spontaneously within a few months. (Neuro Opthalmology)
9. In paralysis of III it is characteristic that the pupil is spared. (Neuro Opthalmology)

Question 3

HYPERTENSION & ARTERIOSCLEROSIS

Answer 3

Retinal vasculopathies

Question 4

VASCULAR OCCLUSIONS

Answer 4

1. Retinal arterial and venous occlusions: Retinal vasculopathies
2. Ciliary arterial occlusions: AION–> Optic nerve abnormalities

Question 5

RHEUMATOID ARTHRITIS (RA)

Answer 5

1. Dry eyes (keratoconjuctivitis sicca) –> irritation and decreased surface immunity –> corneal bacterial and fungal infections
2. Peripheral corneal thinning –> corneal perforation.
3. Scleritis: flare-up of the systemic disease–> > tendency to die of the systemic cx.

Question 6

JUVENILE CHRONIC ARTHRITIS (JCA)

Answer 6

1. Chronic anterior uveitis: asymptomatic, but leads to the development of posterior synechiae, dense cataracts and glaucoma that are very difficult to treat if not detected early.
2. Eye complications are more common in monoarthritis than in those with severe systemic disease.
3. Consequently every child with Juvenile Chronic Arthritis 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.

Question 7

ANKYLOSING SPONDYLITIS

Answer 7

1. young men.
2. Recurrent attacks of acute painful anterior uveitis
3. The uveitis may present before the spondylitis.
4. All patients with acute anterior uveitis of unknown cause must have X-rays of the sacroiliac joint and be referred to a physician.

Question 8

SYSTEMIC LUPUS ERYTHEMATOSIS

Answer 8

VISUAL SYSTEM ABNORMALITIES

1. Dry eyes.
2. Peripheral corneal thinning.
3. Anterior uveitis.
4. 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

1. A homonymous hemianopia.
2. Optic atrophy.
3. III and VI paresis.

Question 9

REITER’S SYNDROME

Answer 9

Classical triad of nonspecific (nongonococcal) 
1. urethritis
2. arthritis
3. conjunctivitis. 
with Uveitis and keratitis

Question 10

BEHÇET’S SYNDROME

Answer 10

Classical triad of:

1. oral and genital ulceration
2. arthritis
3. anterior uveitis.

Question 11

GIANT CELL ARTERITIS (TEMPORAL ARTERITIS)

Answer 11

1. Arteritis of medium and large arteries usually presents in people older than 60 years with headache, weight loss and tender temporal arteries.
2. They may suddenly lose their vision due to:
   (a) Anterior Ischaemic Optic Neuropathy (AION)
   (b) Central Retinal Arterial Occlusion (CRAO)
3. This is an emergency, because, without treatment, the second eye can be affected within days.
4. Cranial nerve fallout e.g. III, VI.

Question 12

AIDS.

Answer 12

1. AIDS virus retinal vascular involvement.
   (a) Cotton wool spots: areas of nerve fibre layer ischaemia, transient no prognostic value.
   (b) Microaneurysms.
   (c) Retinal haemorrhages.
2. Opportunistic infections.
   (a) Herpes zoster ophthalmicus may be the first manifestation of the disease.
   (b) Cytomegalovirus retinitis is associated with a reduced life expectancy.
   (c) Toxoplasma retinochoroiditis.
   (d) Cryptococcus neoformans retinochoroiditis.
3. Neoplasms
   (a) Kaposi’s sarcoma of the eyelids, conjunctiva and orbit.
   (b) Squamous carcinoma of the eyelids and conjunctiva.
   (c) Burkitt’s lymphoma of the orbit.
4. Neuroophthalmic signs of intracranial disease.
   (a) Cranial nerve paresis.
   (b) Field defects.
   (c) Disc swelling.
   (d) Optic atrophy.
   (e) Pupillary abnormalities.

Question 13

STURGE-WEBER SYNDROME

Answer 13

VISUAL SYSTEM ABNORMALITIES
1. Conjunctival haemangioma.
2. Choroidal haemangioma.
3. Open angle glaucoma: due to a combination of a developmental angle anomaly and
haemangioma induced raised venous pressure.

OTHER SYSTEMIC ABNORMALITIES

1. Facial haemangioma: port wine stain.
2. Meningeal haemangioma: seizures.

Question 14

NEUROFIBROMA TOSIS

Answer 14

VISUAL SYSTEM ABNORMALITIES

1. Eyelid neuroma.
2. Iris nodules (Lisch nodules)
3. Open angle glaucoma.
4. Choroidal naevus.
5. Optic nerve glioma.

OTHER SYSTEMIC ABNORMALITIES

1. Skin neurofibromas.
2. CNS tumours.
3. Endocrine tumours.