Ocular manifestations of systemic diseases Dr mahmood fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE

Objectives To review the normal features of the human eye and the ocular fundus. To record the common systemic diseases affecting the eye. To describe the ocular signs and symptoms associated with selected systemic diseases and their serious ocular squeal. To compare and contrast the important features of diabetic retinopathy types and the current screening guidelines. To review the important ocular features of hypertension, thyroid disease, sarcoidosis and inflammatory conditions, malignancy and acquired immunodeficiency syndrome.

Hollenhorst Plaque A Hollenhorst plaque appears as a bright, glistening, refractile plaque, usually at the bifurcation of a retinal arteriole. These have the propensity to break up and move, and may not be present at subsequent visits. Patient previously experiencing amaurosis fugax will not exhibit retinal emboli, but may have arteriolar narrowing and sheathing. PATHOPHYSIOLOGY The Hollenhorst plaque is an embolus composed of cholesterol that forms from an ulcerated ipsilateral carotid artery plaque. The patient frequently has concurrent hypertension and elevated cholesterol levels. The stress on the arteries induced by hypertension leads to reduced elasticity of the vessels.

Ocular manifestations of HIV infection

Retinal Manifestations of HIV Infection BACK OF THE EYE Retinal Microvasculopathy CMV Retinitis Acute Retinal Necrosis Progressive Outer Retinal Necrosis Toxoplasmosis Retinochoroiditis Syphilis Retinitis Candida Albicans Endophthalmitis

CMV Retinitis Most common intraocular infection with AIDS Retinal necrosis, exudation, & hemorrhage Treatment: IV ganciclovir/foscarnet Intravitreal ganciclovir/foscarnet; Ganciclovir intravitreal implant

Toxoplasmosis Retinitis CD4<100

Syphilis Tertiary Syphilis Need LP Rx with IV PenicilinG

Tuberculosis Uveitis Choroidal granulomas Periphlebitis Granulomas = Choroidal Tubercules An Ocular clue for Diagnosis of Tuberculosis Cilio-retinal granuloma in TB

Fundus photography of a 40-year-old male with positive Mantoux test with choroidal tuberculoma.

Acute central retinal artery occlusion in Adamantiades-Behçet disease Fundus photography and fluorescein angiography. Note grossly impaired perfusion, retinal whitening and relative cilioretinal sparing.

Multiple Sclerosis: Optic Neuritis 50% of patients with MS will develop Optic Neuritis 20-30% of time will be presenting sign for MS

Metastatic Disease Most common intraocular malignancy in adults May be asymptomatic May produce decreased or distorted vision Most common primary: Lung, Breast 10% have unknown primary No prior history of Cancer in 25% Metastatic Lung Cancer.

Sturge-Weber Syndrome: Choroidal Hemangioma Nevus flammeus (Port Wine Stain)

Systemic Medications Benign ocular conditions Amiodarone – whorl keratopathy Toxic Retinopathies Thioridazine, chloroquine, hydroxychloroquine, tamoxifen Toxic Optic Neuropathies Ethambutol, isoniazid

Hydroxychloroquine: Ophthalmic Screening  caused by the drugs chloroquineor hydroxychloroquine, Used for rheumatoid arthritis, SLE, etc This eye toxicity limits long-term use of the drugs. Both agents bind to melanin pigment in the RPE, and this may serve to concentrate the drugs or to prolong their adverse effects. Bulls Eye Maculopathy

salt and pepper fundus is found in congenital syphilis, choroideremia, Leber's congenital amaurosis, rubeola, poliomyelitis, cmv retinitis. combination of RPE loss and migration produces the "salt and pepper" fundus. The pepper may be clumpy ("bone spicular"), Damaged RPE migrate into superficial retina. The black pigment flecks are particularly evident in the retinal mid-periphery.

A myopic crescent is white or grayish white moon-shaped atrophic changes of choroid develop at the temporal border of disc of myopic eyes.  In myopia that is no longer progressing, the crescent may be asymptomatic except for its presence on ocular examination. However, in high-degree myopia, it may extend to the upper and lower borders, or form a complete ring around the optic disc and form a central scotoma.

Resources http://www.aao.org/theeyeshaveit/acquired/ http://www.aafp.org/afp/2002/0915/p991.html http://www.ncbi.nlm.nih.gov/pubmed/11926152

Quiz …… http://ocularmanifestofsystemicdisease.weebly.com/quiz.html http://www.easynotecards.com/quiz/6222