ocular manifestations - uva...giant cell arteritis: management • begin treatment immediately with...
TRANSCRIPT
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Introduction
OCULAR MANIFESTATIONS
SYSTEMIC DISEASES
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CATEGORIES OF SYSTEMIC DISEASE
• Congenital • Traumatic • Vascular • Neoplastic • Autoimmune • Idiopathic • Infectious • Metabolic/Endocrine • Drugs/Toxins
Introduction
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EYE EXAMINATION
• Vision • External • Pupils
– Relative afferent pupillary defect
• Motility • Anterior segment exam • Dilated ophthalmoscopy • Visual fields
Introduction
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CONGENITAL DISORDERS
• Down syndrome • Marfan syndrome • Myotonic dystrophy • Tuberous sclerosis • Neurofibromatosis • Congenital metabolic disorders
– Lysosomal storage – Carbohydrate metabolism
Congenital Disorders
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Café-au-lait spots Iris Lisch nodules
Congenital Disorders
NEUROFIBROMATOSIS NF1
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Traumatic Disorders
Shaken baby syndrome: multiple retinal hemorrhages
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SYSTEMIC HYPERTENSION: FACTORS AFFECTING RETINAL
ARTERIOLES • Severity • Duration
Vascular Disorders
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Vascular Disorders
Malignant hypertension
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Sites of emboli to the ophthalmic circulation
Cholesterol embolus (Hollenhurst plaque)
Embolic Disease
Vascular Disorders
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Vascular Disorders
Left eye with superotemporal branch retinal artery occlusion
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“Cherry red spot” in CRAO Normal fundus
CRAO
Vascular Disorders
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AMAUROSIS FUGAX "Fleeting Blindness"
• Monocular dimming of vision • Temporary arterial obstruction • Sudden, transient, painless visual loss
Vascular Disorders
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AMAUROSIS FUGAX: A MULTIDISCIPLINARY
EVALUATION • Cardiovascular • Cerebrovascular • Ophthalmologic
Vascular Disorders
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Vascular Disorders
Talc embol in IV drug abuser
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Vascular Disorders
Central retinal vein occlusion (CRVO)
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Left eye Right eye
Transient homonymous hemianopia • Scintillations • Transient
obscuration of vision
• Transient homonymous hemifield loss
Vascular Disorders
MIGRAINE: VISUAL SYMPTOMS
Scintillations
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MIGRAINE: TYPES
• With headache – Classic – Common – Complicated
• Without headache – Acephalgic
Vascular Disorders
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MIGRAINE: TREATMENT
• Prevent frequent attacks • Examine for visual loss • Consider discontinuing oral contraceptives
Vascular Disorders
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BLOOD DYSCRASIAS WITH OCULAR
MANIFESTATIONS
• Hyperviscosity syndromes • Thrombocytopenia • Anemia, including sickle cell anemia
Vascular Disorders
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HYPERVISCOSITY SYNDROMES:
OCULAR SYMPTOMS
• Amaurosis fugax • Permanent visual loss
Vascular Disorders
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Vascular Disorders
Hyperviscosity dilated retinal veins, retinal hemorrhages, and disc edema
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Vascular Disorders
Leukemia
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Vascular Disorders
Leukemic infiltration of the optic nerve
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SICKLE CELL RETINOPATHY
• HbSC disease (most common form) • HbSS disease • Sickle thalassemia
Vascular Disorders
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Retinal arterial occlusions “Sea fan” neovascularization
Vascular Disorders
SICKLE CELL ANEMIA
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MALIGNANT NEOPLASMS INVOLVING THE EYE
• Primary ocular melanoma • Large cell lymphoma • Metastatic carcinoma
Neoplastic Disorders
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METASTATIC CARCINOMA
• Most common intraocular malignancy in adults
• May be asymptomatic • May produce decreased or distorted vision
Neoplastic Disorders
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Neoplastic Disorders
Iris metastasis from lung carcinoma
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Neoplastic Disorders
Choroidal metastasis from breast cancer
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Ophthalmologists should monitor ocular metastases
at regular intervals.
Neoplastic Disorders
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AUTOIMMUNE DISORDERS
• Connective tissue diseases • Thyroid eye disease • Myasthenia gravis
Autoimmune Disorders
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CONNECTIVE TISSUE DISORDERS
• Dry eyes are the most common manifestation (keratoconjunctivitis sicca)
• Symptoms – Burning – Foreign-body sensation – Photophobia
Autoimmune Disorders
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SJÖGREN’S SYNDROME
• Dry eyes • Dry mouth • ± Connective tissue disorder • Specific antibodies
Autoimmune Disorders
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DRY EYES: TREATMENT
• Artificial tears • Lubricating ointment at night • Punctual occlusion • Environmental modification • Topical anti-inflammatory agents
Autoimmune Disorders
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Autoimmune Disorders
Severe tear deficiency: corneal ulceration and perforation
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If iritis, refer for evaluation and treatment.
Autoimmune Disorders
ANKYLOSING SPONDYLITIS: OCULAR SYMPTOMS
• Photophobia • Redness • Decreased vision
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Topical corticosteroids may lead to serious ocular
complications.
Autoimmune Disorders
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RHEUMATOID ARTHRITIS: OCULAR MANIFESTATIONS
• Dry eyes • Episcleritis • Scleritis • Corneal ulcers • Uveitis
Autoimmune Disorders
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Autoimmune Disorders
Episcleritis
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Autoimmune Disorders
Scleritis
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Autoimmune Disorders
Scleritis Necrotizing scleritis
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Autoimmune Disorders
Scleromalacia perforans
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Autoimmune Disorders
Peripheral corneal ulceration
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Autoimmune Disorders
Juvenile rheumatoid arthritis: band keratopathy
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IRITIS IN JUVENILE RHEUMATOID ARTHRITIS
• Few symptoms or signs • Usually chronic • Secondary cataract and glaucoma Refer for periodic ophthalmic screening.
Autoimmune Disorders
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SYSTEMIC LUPUS ERYTHEMATOSUS: OCULAR
MANIFESTATIONS • Dry eyes • Scleritis • Peripheral corneal ulcers • Retinopathy and optic neuropathy
Autoimmune Disorders
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Autoimmune Disorders
Systemic lupus erythematosis: Cotton wool spots and hypertensive retinopathy
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Autoimmune Disorders
Systemic lupus erythematosis: optic nerve involvement
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POLYARTERITIS NODOSA: OCULAR MANIFESTATIONS
• Dry eyes • Corneal ulcers • Scleritis • Hypertensive retinopathy • Retinal vasculitis
Autoimmune Disorders
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SARCOIDOSIS
• More commonly affects African-Americans and Hispanics
• Ocular involvement in about 25% of patients
Autoimmune Disorders
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Keratic precipitates in granulomatous uveitis
“Candlewax drippings” in choroiditis
SARCOIDOSIS Autoimmune Disorders
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Refer patients with sarcoidosis if ocular involvement is
suspected. Treatment may include
corticosteroids.
Autoimmune Disorders
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GIANT CELL ARTERITIS: SYMPTOMS
• Jaw claudication • Headache • Scalp tenderness • Fever • Weight loss • Fatigue • Myalgias • Acute visual loss
Autoimmune Disorders
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Autoimmune Disorders
Giant cell arteritis: ischemic optic neuropathy
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Autoimmune Disorders
Giant cell arteritis: third cranial nerve involvement
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GIANT CELL ARTERITIS: DIAGNOSIS
• Clinical history • STAT ESR and CRP • Temporal artery biopsy • Fluorescein angiogram
Autoimmune Disorders
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GIANT CELL ARTERITIS: MANAGEMENT
• Begin treatment immediately with high-dose corticosteroids daily
• Do not wait for results of temporal artery biopsy
• Ophthalmologist, PCP, and rheumatologist manage jointly
Autoimmune Disorders
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THYROID OPHTHALMOPATHY
• Not always correlated with serum thyroid levels
• Can progress after thyroid function is normal
Autoimmune Disorders
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SPECTRUM OF THYROID OPHTHALMOPATHY
• Eyelid retraction • Exophthalmos (proptosis) • Extraocular muscle dysfunction • Corneal exposure • Conjunctival erythema • Optic nerve dysfunction
Autoimmune Disorders
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Widened palpebral fissure Soft tissue involvement
Autoimmune Disorders
THYROID OPHTHALMOPATHY: OCULAR INVOLVEMENT
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Proptosis Inferior rectus muscle
restriction
THYROID OPHTHALMOPATHY: ADVANCED
Autoimmune Disorders
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Corneal damage Swollen optic disc
THYROID OPHTHALMOPATHY: SEVERE
Autoimmune Disorders
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Proptosis Enlarged extraocular muscles
THYROID OPHTHALMOPATHY: COMPUTED TOMOGRAPHY OF THE
ORBIT
Autoimmune Disorders
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THYROID OPHTHALMOPATHY: TREATMENT OF CONGESTIVE
PHASE
• Tear substitutes • Corticosteroids • Orbital irradiation or
surgical decompression
Autoimmune Disorders
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THYROID OPHTHALMOPATHY: TREATMENT OF CICATRICIAL
PHASE
• Lid surgery • Muscle surgery • Orbital surgery
Autoimmune Disorders
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Refer suspects for neurologic evaluation.
Autoimmune Disorders
MYASTHENIA GRAVIS: SYSTEMIC INVOLVEMENT
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Papilledema
Idiopathic Disorders
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• Brain tumor • Meningitis • Venous sinus
thrombosis • Hydrocephalus • Idiopathic
intracranial hypertension (pseudotumor cerebri)
Idiopathic Disorders
INTRACRANIAL HYPERTENSION: CAUSES
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OPTIC NEURITIS
• May be initial manifestation of MS • Acute, painful vision loss in one or both
eyes • Treat initial episode with intravenous
methylprednisolone • Interferon beta-1a may be of benefit
Idiopathic Disorders
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AIDS: OCULAR MANIFESTATIONS
• Dry eye • Retinal cotton-wool spots • CMV retinitis • Kaposi’s sarcoma
(eyelid or conjunctiva)
Infectious Disorders
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Infectious Disorders
AIDS: Cotton wool patches
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Infectious Disorders
AIDS: cytomegalovirus (CMV) retinitis
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CMV RETINITIS: THERAPY
• HAART (Highly Active Anti-Retroviral) Therapy
• IV ganciclovir • IV foscarnet • Intravitreal ganciclovir • Implantable pellets of sustained-release
ganciclovir into the vitreous
Infectious Disorders
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CD4 COUNTS
• < 100 cells/ml: Opportunistic infections (eg, CMV retinitis)
• > 100 cells/ml: Other ocular infections (eg, syphilis)
Infectious Disorders
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Metabolic/Endocrine Disorders
Diabetic retinopathy
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SYSTEMIC MEDICATIONS WITH SIGNIFICANT OCULAR
EFFECTS • Toxic Retinopathy – Thioridazine – Chloroquine – Hydroxychloroquine – Tamoxifen
• Toxic Optic Neuropathy – Ethambutol – Isoniazid – Fluoroquinolones
Drugs/Toxins
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Conclusion
OCULAR MANIFESTATIONS
SYSTEMIC DISEASES