8. Eye in systemic disease

Question 1

Name the HIV associated eye disease

Answer 1

• Dry Eye
• Lid lesions
• Varicella Zoster Ophthalmicus
• HIV-related microvasculopathy
• CMV retinitis
• Squamous cell carcinoma of the conjunctiva

Question 2

What is the most common ocular manifestation of HIV?

Answer 2

Dry eye syndrome (keratoconjunctivitis sicca) is the most common ocular manifestation in HIV patients due to lacrimal gland infiltration and dysfunction.

Question 3

Why does dry eye occur in HIV patients?

Answer 3

It results from immune-mediated destruction of the lacrimal glands and reduced tear production.

Question 4

What types of lid lesions can be seen in HIV-positive patients?

Answer 4

Common lid lesions include molluscum contagiosum, herpes simplex virus lesions, and Kaposi’s sarcoma.

Question 5

How does molluscum contagiosum typically present in the eyelid of HIV patients?

Answer 5

As multiple small, umbilicated papules that are more widespread and resistant to treatment than in immunocompetent individuals.

Question 6

What is Varicella Zoster Ophthalmicus (VZO) and how is it associated with HIV?

Answer 6

VZO is reactivation of latent varicella-zoster virus in the ophthalmic division of the trigeminal nerve; it is more severe and prolonged in HIV patients.

Question 7

What are typical signs of Varicella Zoster Ophthalmicus in HIV patients?

Answer 7

Dermatomal vesicular rash, conjunctivitis, keratitis, uveitis, and possible cranial nerve palsies.

Question 8

What is HIV-related microvasculopathy and how does it present in the eye?

Answer 8

It’s a retinal vascular abnormality presenting as cotton wool spots, retinal hemorrhages, and microaneurysms due to HIV-induced endothelial damage.

Question 9

How do you differentiate HIV-related microvasculopathy from CMV retinitis?

Answer 9

HIV-related microvasculopathy is usually asymptomatic and non-progressive, while CMV retinitis causes vision loss and has a characteristic necrotizing retinitis appearance.

Question 10

What is the most common opportunistic ocular infection in HIV patients with CD4 counts <50 cells/μL?

Answer 10

Cytomegalovirus (CMV) retinitis.

Question 11

How does CMV retinitis present clinically?

Answer 11

Floaters, scotoma, blurred vision, and characteristic “pizza pie” or “cottage cheese and ketchup” fundus appearance (areas of retinal whitening with hemorrhages).

Question 12

What can happen if CMV retinitis is left untreated?

Answer 12

It can lead to full-thickness retinal necrosis and detachment, resulting in irreversible blindness.

Question 13

What is the treatment for CMV retinitis in HIV-positive individuals?

Answer 13

Antivirals like ganciclovir, foscarnet, or valganciclovir, along with HAART to improve immune status.

Question 14

hat malignancy of the eye is more common in HIV-positive patients, especially in sub-Saharan Africa?

Answer 14

Squamous cell carcinoma (SCC) of the conjunctiva.

Question 15

How does squamous cell carcinoma of the conjunctiva present?

Answer 15

As a fleshy, elevated, vascularized lesion on the conjunctiva, often at the limbus; it may be painless but progressively enlarging.

Question 16

What is the management of conjunctival SCC in HIV patients?

Answer 16

Surgical excision with cryotherapy to margins, possible adjunctive topical chemotherapy (e.g., mitomycin C), and HIV treatment optimization.

Question 17

What is the most common ocular complaint in HIV-positive individuals?

Answer 17

Dry eye syndrome.

Question 18

How should dry eye in HIV-positive patients be managed?

Answer 18

With long-term use of lubricating eye drops (artificial tears).

Question 19

What eyelid lesion in HIV patients can cause chronic conjunctivitis, and how is it treated?

Answer 19

Molluscum contagiosum can cause chronic conjunctivitis; it is treated by curetting the lesions off the eyelid.

Question 20

What is a characteristic vascular tumour that may appear on the eyelids or conjunctiva in HIV patients?

Answer 20

Kaposi’s sarcoma.

Question 21

How does Kaposi’s sarcoma of the eyelid or conjunctiva respond to treatment?

Answer 21

It responds well to radiotherapy.

Question 22

Is Varicella Zoster Ophthalmicus (VZO) seen only in HIV-positive individuals?

Answer 22

No, VZO can also occur in HIV-negative individuals, both young and old.

Question 23

What is the initial presentation of Varicella Zoster Ophthalmicus?

Answer 23

A painful, vesicular rash in the distribution of the ophthalmic branch of the trigeminal nerve.

Question 24

How does the rash of VZO progress over time?

Answer 24

The vesicles may form pustules (if secondarily infected), crust over, and eventually lead to scarring.

Question 25

Which nerve is affected in Herpes Zoster Ophthalmicus (HZO)?

Answer 25

The ophthalmic division (V1) of the 5th cranial nerve (trigeminal nerve).

Question 26

What is the pattern of the rash in Herpes Zoster Ophthalmicus?

Answer 26

A dermatomal distribution along the V1 (ophthalmic) branch of the trigeminal nerve.

Question 27

What is Hutchinson’s sign in HZO, and why is it clinically significant?

Answer 27

Hutchinson’s sign is the presence of lesions on the tip of the nose, indicating likely intraocular involvement because the cornea and nose are both innervated by the nasociliary branch of V1.

Question 28

Can HZO affect multiple parts of the eye?

Answer 28

Yes, HZO can affect almost every part of the eye.

Question 29

What anterior segment complications can HZO cause?

Answer 29

Keratitis, episcleritis, scleritis, and uveitis.

Question 30

What are possible posterior segment and neurologic complications of HZO?

Answer 30

Retinitis, optic neuritis, and cranial nerve palsies.

Question 31

What intraocular pressure complication can arise from HZO?

Answer 31

Secondary glaucoma due to uveitis or trabeculitis.

Question 32

Why is it essential to examine the eye in cases of HZO?

Answer 32

Because HZO can involve multiple ocular structures and lead to serious complications if untreated.

Question 33

How should the skin lesions of HZO be managed?

Answer 33

Use potassium permanganate soaks, Flamazine® ointment, and chloramphenicol ointment to eyelid lesions to help prevent disfiguring scarring.

Question 34

What antiviral treatment is used for HZO?

Answer 34

Oral acyclovir 800 mg five times daily for 7 days, ideally started within the first 72 hours of rash onset.

Question 35

What is the first-line treatment for post-herpetic neuralgia in HZO?

Answer 35

Amitriptyline 50–150 mg at night (nocté), which is the only proven effective drug for neuralgia. Paracetamol-codeine can be added for pain.

Question 36

When should a patient with HZO be referred to an ophthalmologist?

Answer 36

If Hutchinson’s sign is present, if there is decreased visual acuity (↓VA), a painful red eye (especially around day 10), or any suspected intraocular involvement.

Question 37

What is the most common fundus finding in HIV-related microvasculopathy?

Answer 37

Cotton wool spots.

Question 38

What do cotton wool spots look like on fundoscopy?

Answer 38

Pale lesions with blurred margins.

Question 39

What distinguishing features are absent in HIV microvasculopathy lesions?

Answer 39

There are no hard exudates or retinal haemorrhages.

Question 40

Do cotton wool spots in HIV microvasculopathy affect vision?

Answer 40

No, they do not reduce vision.

Question 41

What is the typical course of cotton wool spots in HIV microvasculopathy?

Answer 41

They come and go over a few weeks.

Question 42

What is the most common opportunistic eye infection in HIV patients with very low CD4 counts?

Answer 42

CMV retinitis.

Question 43

At what CD4 count does CMV retinitis typically occur?

Answer 43

Usually when CD4 < 50 cells/mm³.

Question 44

Is CMV retinitis typically unilateral or bilateral?

Answer 44

It may be unilateral or bilateral.

Question 45

What is the characteristic appearance of CMV retinitis on fundoscopy?

Answer 45

A "pizza pie" appearance.

Question 46

In CMV retinitis, what do the red and yellow areas on fundoscopy represent?

Answer 46

Red areas = hemorrhages; yellow areas = retinal necrosis.

Question 47

What is the systemic treatment for CMV retinitis in HIV patients?

Answer 47

Systemic ganciclovir or valganciclovir, prescribed by a physician.

Question 48

When should ophthalmology be involved in CMV retinitis management?

Answer 48

If the disease persists, refer for intravitreal ganciclovir injections.

Question 49

What clinical features raise suspicion for squamous cell carcinoma of the conjunctiva?

Answer 49

A conjunctival mass that is rapidly growing, unilateral, not located nasally, or looks like an atypical pterygium, especially in an HIV-positive patient.

Question 50

What should you do if you suspect squamous cell carcinoma of the conjunctiva?

Answer 50

Refer the patient to ophthalmology for a semi-urgent biopsy or excision.

Question 51

What are the two hallmark signs of thyroid-associated ophthalmopathy?

Answer 51

Lid retraction and exophthalmos.

Question 52

What are other clinical features of thyroid-associated ophthalmopathy?

Answer 52

Lid lag, red gritty eyes, lid and conjunctival swelling, and squint with diplopia.

Question 53

What serious complication can occur in severe thyroid-associated ophthalmopathy?

Answer 53

Vision loss due to optic nerve compression.

Question 54

What is the primary endocrine management in TAO?

Answer 54

Careful control of thyroid status.

Question 55

What lifestyle modification should be strongly encouraged in patients with TAO?

Answer 55

Stop smoking—it's a major risk factor for worsening TAO.

Question 56

How should dry eye symptoms in TAO be managed?

Answer 56

Treat symptomatically with lubricants.

Question 57

What precaution should be taken if giving radioactive iodine (I¹³¹) to a patient with hyperthyroidism?

Answer 57

Cover with oral prednisone for 2 weeks before and 2 months after treatment

Question 58

When should you refer a patient with TAO to ophthalmology?

Answer 58

If they have severe, active eye disease—refer for possible immunosuppression, radiotherapy, or orbital decompression surgery.

Question 59

What types of ocular manifestations can syphilis cause?

Answer 59

Almost any eye condition, including lid chancre, interstitial keratitis, uveitis, chorioretinitis, optic neuritis, and optic atrophy.

Question 60

What is a classic ocular finding in congenital syphilis?

Answer 60

Interstitial keratitis with Hutchinson’s peg teeth.

Question 61

What systemic diseases are commonly associated with scleritis?

Answer 61

Rheumatoid arthritis, SLE, Wegener’s granulomatosis, relapsing polychondritis, and other granulomatous or vasculitic diseases.

Question 62

What is the most common systemic association with scleritis?

Answer 62

Rheumatoid arthritis.

Question 63

What type of uveitis is typically associated with seronegative spondyloarthropathies?

Answer 63

Anterior uveitis.

Question 64

Which seronegative spondyloarthropathies are linked to anterior uveitis?

Answer 64

Ankylosing spondylitis (HLA-B27+), Reiter’s syndrome, psoriasis, inflammatory bowel disease, and Whipple’s disease.

Question 65

What types of systemic diseases are associated with granulomatous uveitis?

Answer 65

Tuberculosis, syphilis, sarcoidosis, leprosy, and brucellosis.

Question 66

What are examples of infectious causes of granulomatous uveitis?

Answer 66

Tuberculosis, syphilis, leprosy, and brucellosis.

Question 67

What is a key non-infectious granulomatous disease associated with uveitis?

Answer 67

Sarcoidosis

Question 68

What is the most common systemic disease associated with anterior uveitis in children?

Answer 68

Juvenile Idiopathic Arthritis (JIA).

Question 69

Which children with JIA are at higher risk for developing anterior uveitis?

Answer 69

Those with pauciarticular JIA and ANA-positive status.

Question 70

Why is uveitis in JIA particularly dangerous?

Answer 70

It can cause blindness without causing eye pain or redness.

Question 71

What is the recommended management for early detection of uveitis in JIA?

Answer 71

Refer for regular eye examinations to screen for uveitis.

Question 72

What are the ocular features of malignant hypertension?

Answer 72

Bilateral retinal haemorrhages, hard exudates, cotton wool spots (nerve fibre layer infarcts), and disc swelling.

Question 73

What is the immediate management step when malignant hypertension is suspected from eye findings?

Answer 73

Check blood pressure and admit the patient immediately for gradual BP control.

Question 74

What ocular side effects can steroids (especially eye drops) cause?

Answer 74

Cataracts, glaucoma, and severe worsening of herpes simplex keratitis.

Question 75

Why should only ophthalmologists prescribe topical steroids?

Answer 75

Because they can monitor for complications like cataracts, glaucoma, and worsening herpes keratitis.

Question 76

What is recommended for patients on chronic oral steroids regarding eye health?

Answer 76

They should be referred for regular ophthalmologic monitoring.

Question 77

What can any drug that dilates the pupil potentially precipitate?

Answer 77

Angle closure glaucoma.

Question 78

Which sympathomimetic drugs can cause angle closure glaucoma by dilating the pupil?

Answer 78

Vasoconstrictors such as pseudoephedrine (in cold remedies), cocaine (used in ENT), and "Eyegene" type drops.

Question 79

Which anti-cholinergic drugs can precipitate angle closure glaucoma?

Answer 79

Psychotropics (e.g. amitriptyline), Parkinson’s medications, antihistamines, antispasmodics, antiemetics (e.g. Stemetil), and atropine.

Question 80

What systemic contraindications exist for beta blockers used in glaucoma treatment?

Answer 80

They are contraindicated in asthma, heart block, and peripheral vascular disease.

Question 81

What are common systemic side effects of Diamox (Acetazolamide)?

Answer 81

Fatigue, paraesthesiae, and renal stones.

Question 82

What serious side effect can α2 agonists cause in children?

Answer 82

Respiratory arrest; also causes tiredness.

Question 83

What systemic risk is associated with Pilocarpine?

Answer 83

Scoline (succinylcholine) apnea.