Lecture 3Lecture 3

EYE CHANGES IN SYSTEMIC EYE CHANGES IN SYSTEMIC DISEASESDISEASES

EMMERGENCY IN OPHTHALMOLOGYEMMERGENCY IN OPHTHALMOLOGY

Lecture is delivered byLecture is delivered byPh. D., associate professor Tetyana Ph. D., associate professor Tetyana Tabalyuk Tabalyuk

FUNDUS CHANGES IN ARTERY HYPERTENSIONFUNDUS CHANGES IN ARTERY HYPERTENSION(Krasnov M., 1948)(Krasnov M., 1948)

Hypertensive angiopathyHypertensive angiopathy – mild generalized arteriolar – mild generalized arteriolar narrowing, tortuosity and dilation of veins, Gvists’ symptom narrowing, tortuosity and dilation of veins, Gvists’ symptom (tortuosity of small venuls around macula).(tortuosity of small venuls around macula).

Hypertensive angiosclerosisHypertensive angiosclerosis – thickening of arteriolar walls, – thickening of arteriolar walls, ««cooper wiringcooper wiring»»,, « «silver wiringsilver wiring»», symptom of arteriovenous , symptom of arteriovenous crossingcrossing: :

Salus-Gun-Relman I - conic narrowing of vein in arteriovenous Salus-Gun-Relman I - conic narrowing of vein in arteriovenous crossingcrossing;;

Salus-Gun-Relman II - arc bending of vein in arteriovenous crossingSalus-Gun-Relman II - arc bending of vein in arteriovenous crossing;;Salus-Gun-Relman III - absence of vein picture in arteriovenous Salus-Gun-Relman III - absence of vein picture in arteriovenous

crossing.crossing.Hypertensive retinopathyHypertensive retinopathy – all above changes plus retinal – all above changes plus retinal

haemorrhages, haemorrhages, cotton wool spots and hard exudates.cotton wool spots and hard exudates.Hypertensive neuroretinopathyHypertensive neuroretinopathy – all above changes plus optic – all above changes plus optic

disc swelling.disc swelling. ManagementManagement: : control of blood pressure and treatment by control of blood pressure and treatment by general practitionergeneral practitioner;; regular review if treatment is not indicatedregular review if treatment is not indicated;; vitamvitamiinotherapy, tissue therapy and proteolitic ferments to notherapy, tissue therapy and proteolitic ferments to

dissolve retinal haemorrhages and dissolve retinal haemorrhages and exudates.exudates.

Salus-Gun-RelmanSalus-Gun-Relman I I

Salus-Gun-Relman IIISalus-Gun-Relman III

Hypertensive retinopathyHypertensive retinopathy(Kanski Jack)(Kanski Jack)

Grade 1 – mild generalized arteriolar Grade 1 – mild generalized arteriolar narrowingnarrowing

Grade 2 – focal as well as marked Grade 2 – focal as well as marked generalized arteriolar constrictiongeneralized arteriolar constriction

Grade 3 – as Grade 2 plus retinal Grade 3 – as Grade 2 plus retinal haemorrhages, cotton wool spots and hard haemorrhages, cotton wool spots and hard exudatesexudates

Grade 4 – as Grade 3 plus optic disc swellingGrade 4 – as Grade 3 plus optic disc swelling

Retinal artery occlusion Retinal artery occlusion (RAO)(RAO)

AetiologyAetiology:: embolization from a carotid or cardiac embolization from a carotid or cardiac source, or vazoobliteration by atheroma or arteritis.source, or vazoobliteration by atheroma or arteritis.

Clinical featuresClinical features:: acute loss of vision acute loss of vision; ; may be may be permanent or transient (amaurosis fugax). Retinal permanent or transient (amaurosis fugax). Retinal pallor corresponding to the involved area (central pallor corresponding to the involved area (central or branch) is seen, and in central RAO a or branch) is seen, and in central RAO a ««cherry red cherry red spotspot» at the fovea is typically present. » at the fovea is typically present. Segmentation of the arteriolar blood column Segmentation of the arteriolar blood column («cattle trucking») may be seen. Later the («cattle trucking») may be seen. Later the arterioles become attenuated and the optic disc arterioles become attenuated and the optic disc pale.pale.

EmmergencyEmmergency:: s/l nitroglicerini, validoli, euphyllini i/v, s/l nitroglicerini, validoli, euphyllini i/v, no-spa or acidi nicotinici i/m, diacarbi per os.no-spa or acidi nicotinici i/m, diacarbi per os.

Acute RAO may be relieved by lowering IOP by Acute RAO may be relieved by lowering IOP by nassage, intravenous acetaxolamide, anterior nassage, intravenous acetaxolamide, anterior chamber paracentesischamber paracentesis

Central retinal artery occlusion Central retinal artery occlusion with with ««cherry-red spotcherry-red spot»»

Retinal vein occlusion Retinal vein occlusion (RVO)(RVO)Predisposing factorsPredisposing factors include increasing age, include increasing age,

hypertension, hyperviscosity, trombophilic hypertension, hyperviscosity, trombophilic disorders, and raised IOP.disorders, and raised IOP.

PresentsPresents with sudden mild to severe loss of vision in with sudden mild to severe loss of vision in one eye. Acute signs include one eye. Acute signs include haemorrhages, haemorrhages, cotton cotton wool spots, venous tortuosity, optic dics and wool spots, venous tortuosity, optic dics and retinal oedema. Fundus picture in RVO is called retinal oedema. Fundus picture in RVO is called picture of picture of ««pressed tomatopressed tomato» or «red ischaemia».» or «red ischaemia».

Classification:Classification:Branch RVO – usually involves a retinal quatrantBranch RVO – usually involves a retinal quatrant;;Hemiretinal veib occlusion;Hemiretinal veib occlusion;Central RVO (ischaemic or non-ischaemic).Central RVO (ischaemic or non-ischaemic).EmmergencyEmmergency:: anticoagulants (heparini), trombolytics anticoagulants (heparini), trombolytics

(streptodekesa), and antiagregants (streptodekesa), and antiagregants (pentoxiphillini) systemically.(pentoxiphillini) systemically.

Central retinal vein Central retinal vein occlusionocclusion

Branch retinal vein Branch retinal vein occlusionocclusion

Peculiarities of Peculiarities of renal hypertensionrenal hypertension – exudative – exudative syndrome, syndrome, retinal oedema, retinal oedema, a lot of cotton wool spots on a lot of cotton wool spots on gray background, optic disc swelling, «star figure» in gray background, optic disc swelling, «star figure» in macula.macula.

Peculiarities of Peculiarities of atherosclerosisatherosclerosis - exudative syndrome - exudative syndrome is not typical, the primary are thickening of arteriolar is not typical, the primary are thickening of arteriolar walls, «cooper wiring» «silver wiring».walls, «cooper wiring» «silver wiring».

Fundus picture in Fundus picture in pregnancy toxicosispregnancy toxicosis is like changes is like changes in hypertensive angiopathy, retinopathy, in hypertensive angiopathy, retinopathy, neuroretinopathy (arteriolar narrowing, its tortuosity, neuroretinopathy (arteriolar narrowing, its tortuosity, haemorrhages, haemorrhages, cotton wool spots, cotton wool spots, optic disc swelling, optic disc swelling, «star figure» in macula). Despite artery hypertension in «star figure» in macula). Despite artery hypertension in arteriolararteriolar spasm caused by pregnancy toxicosis, spasm caused by pregnancy toxicosis, symptoms of arteriovenous crossing are not marked. In symptoms of arteriovenous crossing are not marked. In severe retinal swelling on background of pregnancy severe retinal swelling on background of pregnancy toxicosis transsudative retinal detachment or retinal toxicosis transsudative retinal detachment or retinal vein occlusion may happen.vein occlusion may happen.

Retinopathy inRetinopathy in renal hypertension renal hypertension..A color fundus photograph that shows optic disk A color fundus photograph that shows optic disk swelling, cotton-wool spots (blue arrow), swelling, cotton-wool spots (blue arrow), hemorrhages (white arrow), retinal exudation and a hemorrhages (white arrow), retinal exudation and a macular star (green arrow).macular star (green arrow).

Diabetic retinopathy (DR) Diabetic retinopathy (DR) is the most common cause of is the most common cause of blidness in the working-age population. The incidence of blidness in the working-age population. The incidence of severity of DR are strongly related to duration of diabetesseverity of DR are strongly related to duration of diabetes:: good control of blood glucose and hypertension are very good control of blood glucose and hypertension are very important. important.

Fundus picture in Fundus picture in diabetic angiopathydiabetic angiopathy - - tortuosity and dilation of veins, microaneurysmstortuosity and dilation of veins, microaneurysms;;nonproliferative DRnonproliferative DR – dot and blot haemorrhages – dot and blot haemorrhages and hard exudates in retinaand hard exudates in retina;;proliferative DRproliferative DR – new vessel formation at the optic – new vessel formation at the optic disk or elsewhere on the retina. Severe visual loss may disk or elsewhere on the retina. Severe visual loss may occur as a result of vitreous haemorrhage or tractional occur as a result of vitreous haemorrhage or tractional retinal detachment due to constriction of fibrovascular retinal detachment due to constriction of fibrovascular tissue.tissue.ddiabetic maculopathyiabetic maculopathy is the most common cause of is the most common cause of visual impairment in patients with diabetes. Loss of visual impairment in patients with diabetes. Loss of visual functions is usually caused by oedema, typically visual functions is usually caused by oedema, typically accompanied by exudates. Less commonly, the macula accompanied by exudates. Less commonly, the macula becomes ischemic, often with severe deterioration in becomes ischemic, often with severe deterioration in central visioncentral vision..

Nonproliferative diabetic retinopathyNonproliferative diabetic retinopathy

.

Management of DR:

Regular review if treatment is not indicated, frequency dependent on severity of DR;

Panretinal laser photocoagulation for proliferative DR;

Grid or focal laser photocoagulation for macular oedema fitting certain criteria (clinically significant macular oedema);

Vitrectomy for persistant vitreous haemorrhage or tractional retinal detachment involving the centre of the macula.

Fundus photo showing scatter Fundus photo showing scatter laser surgery for diabetic laser surgery for diabetic retinopathy. retinopathy.

The complex of hyperthyroidism (Graves’ disease) consists of the following eye signs:

Proptosis due to abnormal fluid infiltration of orbital contents;Retraction of the upper lid due to overaction of the levator muscle (Dalrimple’s symptom);Diplopia due to malfunction of the extrinsic ocular muscle;Visual loss due to the effects of corneal exposure or of pressure on the optic nerve;Infrequent blinking (Shtelfag’s sign);Convergence weakness (Mebius sign);Hyperpigmentation of upper eyelid (Ellinek’s sign);Graefe’s sign is lid lag; failure to follow the eyeball on down gaze;Joffroi’s sign is excessive retraction of the upper lid on looking upwards.

Thyroid orbitopathyThyroid orbitopathy

The ear diseases, i.e. purulent processes in it may be a source of purulent methastasis into the orbit and eyeball. As a result orbital cellulitis, choroiditis, panuveitis, panophthalmitis, optic neuritis may occur.

The nose diseases may cause conjunctivitis, blepharitis, chronic dacriocyctitis.

The stomatological diseases may result in orbital periostitis or cellulitis, keratitis or iridocyclitis.

The brain tumours are assosiated with papilloedema, hemianopsia, paralysis of oculomotor muscles, visual disturbances of cortical genesis.

In rheumatoid diseases usually uvea is involved. Iridocyclitis, choroiditis or panuveitis may occur.

Orbital cellulitisOrbital cellulitis

SignsSigns::eyelids oedemaeyelids oedemachemosischemosisproptosisproptosislimiting of eye movementslimiting of eye movementsdecreasing of visual acuitydecreasing of visual acuitygeneral intoxication (headacke, general intoxication (headacke,

increased temperature, brain increased temperature, brain signs).signs).

Optic neuritis, papilloedema, Optic neuritis, papilloedema, central vein occlusion may central vein occlusion may occur with outcome in optic occur with outcome in optic atrophy.atrophy.

OPTIC NEURITIS – inflammation of the optic nerve, with a range of causes, the most important being multiple sclerosis. Clinical features: presents with subacute, usually unilateral, impairment of central vision that may be associated with pain, especially on eye movement. The optic disc is usually normal (retrobulbar neuritis) and occasionally swollen and red (papillitis). Severe or recurrent attacks may lead to optic atrophy.PAPILLOEDEMA – disc swelling caused by raised intracranial pressure. Clinical features: symptoms of raised intracranial pressure including headaches and nausea. Transient visual obscuration lasting a few seconds are common but visual acuity is normal until late. Signs: early – hyperaemia with indistinct margins; established – obvious elevation, peripapillary haemorrhages and cotton wool spots; long-standing – markedly elevated «champagne cork» appearance;

Optic neuritisOptic neuritis

PapilloedemaPapilloedema