Ocular Manifestations of Systemic Disease

Question 1

What is this?`

Answer 1

• Nonproliferative diabetic retinopathy/pre-proliferative retinopathy: First ocular manifestation of T2DM is microaneurysm formation
• Capillary leak and later become occluded

(This also shows maculopathy)

Question 2

T2DM 2/circinate retinopathy (aka nonproliferative diabetic retinopathy (NPDR) or pre-proliferative: what are the typical signs and symptoms (4)?

Answer 2

1. Dot and blot hemorrhages
2. Hard exudates
3. Cotton wool spots (infarct of optic nerve fiber)
4. Macular edema

(circinate = circular shape)

Question 3

What is this?

(hint: it is the leading cause of blindness in diabetic patients)

Answer 3

Proliferative Diabetic Retinopathy (PDR): neovascularization over the optic disc (NVD) or elsewhere (NVE) on the retinal surface

(this photo is NVE, may also happen on iris → glaucoma)

Question 4

Where in the photo is the neovascularization? Treatment?

Answer 4

• The superior aspect of the right optic nerve
• Panretinal photocoagulation

Question 5

What is this? What stage (pathogenesis?)

Answer 5

• proliferative diabetic retinopathy
• New vascularization to the point that vessels bleed into the vitreous

(proteins are also formed in neovascularization, they may contract and detach the retina)

Question 6

What is the surgical treatment of proliferative diabetic retinopathy (shown) with tractional retinal detachment (not in photo)?

Answer 6

vitrectomy (laser surgery)

Question 7

What is this? How does it work?

Other treatment options?

Answer 7

• panretinal photocoagulation trmt of proliferative diabetic retinopathy: 1k-2k laser burns on retina, outside of vascular arcades → reduces metabolic O₂ requirement needed of retina or destroys VEGF-secreting cells → regression of neovascular tissue
• Intravitreal local ranibizumab (Lucentis) injections

Question 8

Answer 8

Question 9

T2DM standard of care (ophthalmologically)

Answer 9

dilated exam of fundus once per year minimum

Question 10

What is this?

Lower arrows?

Upper arrows?

Answer 10

• Hypertensive retinopathy (long-standing hypertension)
• copper wiring (vessels clogged w/plaque) & silver wiring (completely obstructed)
• A/V crossing changes

Question 11

What is this? What causes this?

Answer 11

Hypersensitive retinopathy with cotton wool spots

severe A/V nicking (vein is pinched as it crosses the artery) → branch retinal vein occlusion (BRVO)→ appears as cotton wool spots or hemorrhage in the sector that is drained by the affected vein

Question 12

Unlike Branch retinal vein occlusion (BRVO), Branch retinal artery occlusion (BRAO) and Central retinal artery occlusion (CRAO) are usually the result of ______.

Answer 12

systemic embolism from the Carotid system of the heart

Question 13

Older patients with Central retinal artery occlusion (CRAO) should be screened for signs and symptoms of ______. What lab work is ordered (3)?

Answer 13

• giant cell arteritis

1. emergent sed rate (ESR)
2. C-reactive protein (CRP)
3. temporal artery biopsy

Question 14

What is this?

What can be seen on fundoscopic exam?

Answer 14

• Severe Hypertensive retinopathy
• Fibrinoid necrosis of the vessel wall → exudates, cotton-wool spots, flame-shaped hemorrhages, subretinal fluid

Question 15

Ophthalmic findings in hypertension (4)

Answer 15

1. Arteriolar Sclerosis
2. A-V nicking/crossing changes
3. Copper-wiring of arterioles
4. Silver-wiring of arterioles

(May lead to branch retinal vein occlusion (BRVO))

Question 16

What is this? What can be visualized on fundoscopic exam?

Answer 16

• Malignant hypertension retinopathy
• Optic disc swelling (similar to papilledema), exudates that may assume a stellate configuration in the outer plexiform layer of Henley (“macular star”)

Question 17

Answer 17

Question 18

Sickle-cell retinopathy: 3 causes

Answer 18

1. HbSC disease (most common form)
2. HbSS disease
3. Sickle thalassemia

Question 19

Of the three Sickle Cell retinopathies, which one(s) is(are) more likely to be involved with ocular manifestations?

Answer 19

1. Sickle Cell Hemoglobin C
2. Sickle Cell thalassemia

(as with diabetes, inadequate perfusion of the retina can stimulate neovascularization)

Question 20

Thyroid eye disease: characteristics seen upon examination (2)

Answer 20

1. Eyelid retraction of the upper or lower eyelids
2. Fibrosis and restriction of extraocular muscles

Question 21

Fibrosis and restriction of extraocular muscles: 2 most common muscles involved?

Answer 21

1. Inferior rectus (can’t look down)
2. Medial rectus

(patient presents w/head extended to correct)

Question 22

Sarcoidosis most commonly affects which population

Answer 22

African-Americans and Hispanics

(ocular involvement in about 25% of patients)

Question 23

What is this? Caused by?

Answer 23

• Mutton-fats keratic precipitates in sarcoidosis
• sarcoidosis: chronic autoimmune disease

(may cause anterior or posterior uveitis)

Question 24

CD4 counts below_____ cells/mL puts patients at risk for _____.

Answer 24

• 100 cells/mL
• CMV retinitis

(cell counts above 100 cells per milliliter leave a patient susceptible to other infections such as syphilis)

refer to ophthalmologist

Question 25

What is this? It is due to ________ of the pre capillary retinal arterioles that result in \_\_\_\_\_\_.

Answer 25

* retinal cotton-wool spots * axoplasmic stasis of the retinal nerve fiber axons (these are usually the sole ocular finding in patients with AIDS. Occlusions are thought to be from micro thrombi from antigen-antibody complexes and fibrin) ***_refer to ophthalmologist_***

Question 26

What is the leading cause a visual loss in patients with AIDS? Characterization?

Answer 26

* CMV retinitis * Sectional sectoral hemorrhagic necrosis of the retina (along vessels), distinct borders abruptly abut normal areas of retina ## Footnote ***_refer to ophthalmologist_***

Question 27

Herpes zoster ophthalmicus: treatment regimen

Answer 27

* Acyclovir 800 mg five times per day for 7 to 10 days * 48 hours from onset of symptoms preferable (look for lesion of the tip of the nose which indicates nasociliary nerve involvement)

Question 28

Any patient with an autoimmune disease or systemic infection who presents with a ________ (4) should be referred to an ophthalmologist for a slit-lamp examination to look for subtle but ***vision-threatening*** intraocular inflammation. ***_(TQ!!)_***

Answer 28

1. decreased vision 2. floaters 3. red eye 4. photophobia

Question 29

\_\_\_\_\_\_\_\_ is the first ocular manifestation of T2DM

Answer 29

* Non proliferative diabetic retinopathy microaneurysm formation

Question 30

Rheumatoid Arthritis (RA) ocular manifestations (5)

Answer 30

1. Corneal ulcer 2. Dry eyes 3. Episcleritis 4. Scleritis 5. Uveitis