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Ophthalmology > 7. Ocular Manifestations of Systemic Disease > Flashcards

7. Ocular Manifestations of Systemic Disease Flashcards

1
Q

Which diseases of the thyroid may cause eye pathology?

A 
Thyroidtoxicosis (Excessive Thyroid secretion)
Graves Disease (AI, IgG binds to TSH receptors, T3/4 secretion).
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2
Q

What are the systemic presentations of hyperthyroidism?

A 
Diffuse thyroid enlargement
Fine hand tremor
Finger clubbing
Pretibial myxoedema
Tachycardia
Atrial fibrilation
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3
Q

Describe the pathophysiology of the ocular manifestations of Thyroid Eye Disease?

A

It is an organ-specific autoimmune reaction.

Inflammation of extraoccular muscles.
Enlargement. Up to 8x.

Then they degenerate and become fibrosed = Restrictive myopathy & diplopia

Inflammatory Cellular Infiltration = Increases volume of orbital contents = Elevated IOP

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4
Q

What are the clinical ocular manifestations of TED?

A 
Soft tissue involvement
Lid retraction
Proptosis
Optic neuropathy
Restrictive myopathy
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5
Q

What are the signs and symptoms of soft tissue involvement in TED?

A

SIGNS
Grittiness, lacrimation, retrobulbar discomfort

SYMPTOMS
Epibulbar hyperaemia (Red)
Periorbital swelling (Bags below/above eyes)
Chemosis (oedema of the conjunctiva)

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6
Q

What are the the signs of Lid Retraction?

A
  1. Dalrymple sign: lid retaraction in primary position
  2. Kocher sign: frightened appearance on attentive fixation
  3. Von Graefe sign: retarded descent of upper eye lid on downgaze-lid lag
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7
Q

How is proptosis categorised?

A

Axial
Unilateral or bilateral
Symmetrical or asymmetrical

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8
Q

What are the possible complications of proptosis?

A

Incomplete lid closure exposure keratitis or corneal ulceration

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9
Q

How is proptosis managed?

A

Systemic steroid used in rapidly, progressive & painful
Radiotherapy
Combined therapy
Surgical decompression

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10
Q

What is restrictive myopathy?

A

Ocular motility is restricted by inflammatory oedema & later by fibrosis

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11
Q

What is the Tx for restrictive myopathy?

A

Treatment is by surgery, if there is diplopia in primary or reading position

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12
Q

What is Optic Neuropathy?

A

Uncommon but serious complication

There is optic n. compression at the orbital apex by the enlarged recti

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13
Q

How does optic neuropathy present?

A

Impairment of central vision
Decreased VA, RAPD, colour vision desaturation Reduced light brightness appreciation
VF defect

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14
Q

What is the treatment for optic neuropathy?

A

Systemic steroid

Orbital decompression

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15
Q

What is Myasthenia Gravis?

A

Autoimmune disease

Antibodies mediates damage to acetylcholine receptors in striated muscle = impairment of neuromuscular conduction

There is weakness & fatigability of skeletal musculature

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16
Q

What are the systemic manifestations of Myasthenia Gravis?

A 
Usually in the third decade
Mostly with ptosis & diplopia
Painless fatigue by exercise
Worse towards the end of the day
Difficult swallowing
Difficult breathing is rare but serious
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17
Q

What are the ocular manifestations of Myasthenia Gravis?

A

OCULAR MYASTHENIA
Ptosis is insidious, bilateral & asymmetrical
Worse by the end of the day
Worse on prolong upgaze
Positive ice test: ptosis improves if an ice pack placed over the eye lids for 2 min.
Diplopia

18
Q

What tests should be positive in myasthenia gravis?

A

Edrophonium ( Tensilon) test

Ice Test

19
Q

Describe the Edrophoium Test

A

Edrophonium is a short acting anticholinesterase agent
It increases the acetylcholine available at the neuromuscular junction
In myasthenia there would be improvement of symptoms & signs
Uncommon complication: bradycardia

Method:

a. Objective baseline measurements are made for ptosis & diplopia
b. IV atropine to minimize the side effect
c. IV edrophonium 
d. Repeat ptosis & diplopia measurements
20
Q

What are the Tx options for myasthenia gravis?

A 
Anticholinesterase drugs (pyridostigmine, neostigmine)
Steroid
Immunosuppressive drugs
Plasma exchange
Intravenous immunoglobline
21
Q

Autoimmune inflammation & destruction of lacrimal & salivary glands?

A

Sjogren’s Syndrome

22
Q

Distinguish between primary and secondary sjogrens disease? Which is more common in females?

A

Classified as Primary when it exists in isolation

Secondary when associated with other disease e.g. Rh. arthritis, SLE, systemic sclerosis

The primary one is more common in females

23
Q

How does Sjogren Syndrome typically present?

A

Dryness, grittiness of the eyes
Posterior blepharitis (inflammation of the eyelids)
Reduced tear secretion

Ankylosing spondylitis = Rieter syndrome associated with anterior uveitis
Rheumatoid arthritis = Wegener granulomatosis with scleritis, peripheral corneal ulceration

24
Q

What is the hallmark of hypertensive retinopathy

A

Optic disc swelling is the hallmark of malignant hypertension.
Rare, may occur as the result of an acute hypertensive crisis (accelerated hypertension) in young adult.
Exudative retinal detachment, sometimes bilateral

25
Q

What is a migraine?

A

Unilateral headache associated with nausea, vomiting
Often a familial disorder
More prevalent in females

26
Q

What are the signs and symptoms of a migraine?

A 
The attack is heralded by a visual aura which lasts 20 min.
This consist of bright or dark spots
Zig-zags
Scintillating scotomas
hemianopia
Full recovery within 30 minutes
Sometimes visual aura without a headache
27
Q

What is Ddx for migraine symptoms?

A
  1. Acute posterior vitreous detachment photopsia, floaters.
  2. Transient ischaemic attacks due to retinal microembolization
  3. Disc oedema
28
Q

What is the most common site in uvea for metastasis?

A

The Choroid

29
Q

What is the most frequent primary sites for metastatic tumour?

A

Most frequent primary site is breast & bronchus.

Less frequently include the GIT, kidney & skin melanoma

30
Q

How does metastatic cancer present in the eye?

A

SYMPTOMS
Visual impairment although they could be asymptomatic

SIGNS
A fast-growing cream lesion with indistinct margins
They are multifocal
May have exudative RD

31
Q

How are metastatic lesions managed?

A

Observation if the patient is asymptomatic or receiving systemic chemotherapy
Radiotherapy
Systemic therapy of the primary tumour

32
Q

The most common primary intraocular malignancy in adults

A

Choroidal Melanoma

33
Q

In what decade doe incidence of choroidal melanoma peak?

A

60’s

34
Q

How does choroidal melanoma typically present?

A

a. asymptomatic tumour at the periphery of the eye

b. symptomatic tumour: decrease VA, blurring, metamorphopsia,, VF, loss, floaters or photopsia

35
Q

What are the signs of a choroidal tumour?

A

Solitary dome shaped mass

Exudative retinal detachment

36
Q

What investigations should be undertaken in suspected choroidal melanoma?

A
  1. US when the media is opaque, show extraocular extension.
  2. MRI demonstrates optic n. & orbital invasion
  3. Biopsy
  4. Systemic Investigations
    Excluding metastasis to the choroid: from the lung in both sexes or breast in females. Occasionally, the primary site is the kidney or GIT
    Detecting possible metastatic spread from the choroid:
    a. Liver US & LFT
    b. CXR
37
Q

What is the prevalence and charateristic of choroidal naevus?

A

Present in 5-10% of Caucasians
Majority are asymptomatic
Investigation is by photography, FFA, US

38
Q

What is a common ocular manifestation of HIV?

A

Uveitis
HIV targets CD4+ T cells, which are vital to the initiation of the immune response to pathogens
There is a steady decline in the number of CD4+ T

39
Q

What are the systemic features of HIV?

A

Progression of HIV infection

a. Acute seroconversion illness
b. An asymptomatic phase
c. Symptomatic HIV infection due to immunosuppression with opportunistic infections, neoplasms & tissue damage directly due to HIV infection.

40
Q

What are the ocular signs of HIV?

A
  1. Eyelid: Blepharitis, HZO, Molluscum contagiosum infection
  2. Orbital: Cellulitis, B- cell lymphoma
ANTERIOR SEGMENT
Conjunctival SSC
Keratitis HSV, H-Z
Keratoconjunctivitis sicca
Anterior uveitis

POSTERIOR SEGMENT
HIV retinitis
Cytomegalovirus
Toxoplasmosis

41
Q

What are the systemic and ocular features of Neurofibromatosis?

A

Café au lait macules
Neurofibroma
Axillary or inguinal freckling

Optic glioma
Lisch nodules (iris hamartomas)
Spheno-orbital encephalocele

Ophthalmology (10 decks)

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