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Ocular Manifestations of Systemic Diseases

Ocular Manifestations of Systemic Diseases. Dalman. Dysthyroid Orbitopathy. autoimmune disorder usually associated with Graves' disease 10-25% euthyroid extra-ocular muscles are the target of the autoimmune attack  restrictive ophthalmoplegia and proptosis Cardinal Signs

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Ocular Manifestations of Systemic Diseases

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  1. Ocular Manifestations of Systemic Diseases Dalman

  2. DysthyroidOrbitopathy • autoimmune disorder usually associated with Graves' disease • 10-25% euthyroid • extra-ocular muscles are the target of the autoimmune attack  restrictive ophthalmoplegia and proptosis • Cardinal Signs • upper eyelid retraction and lag, conjunctival injection and chemosis, and periorbital edema.

  3. DysthyroidOrbitopathy • Pathophysiology • antibody-mediated reaction against the TSH receptor with orbital fibroblast modulation of T-cell lymphocytes

  4. DysthyroidOrbitopathy • Pathophysiology T- cells inflammation Thyroid cells Hyperosmotic shift Orbital fibroblast EOM edema cytokines mucopolysaccharides

  5. DysthyroidOrbitopathy • Pathophysiology Preadipocyte fibroblasts adipocytes Inc. orbital volume Inc. fat proptosis lagophthalmos edema Tissue damage and fibrosis EO motility restriction

  6. DysthyroidOrbitopathy

  7. DysthyroidOrbitopathy

  8. DysthyroidOrbitopathy

  9. DysthyroidOrbitopathy • Management • self-limited (over 1 year) • No immediate cure available

  10. DysthyroidOrbitopathy • Management • Orbital radiation • moderate-to-severe inflammatory symptoms, diplopia, and visual loss in patients with TAO • Optic nerve compression • High-dose steroids (proceed to surgery if unresponsive) • Surgical • Orbital decompression • Strabismus surgery • Lid lengthening • Blepharoplasty

  11. Occular Changes in Hypertension • Damage to the retina caused by high blood pressure • 3 manifestations • Hypertensive retinopathy • Hypertensive optic neuropathy • Hypertensive choroidopathy

  12. Occular Changes in Hypertension • Pathophysiology • Retinal microvasculature Inc BP Hyperoxic & hypercapneic stress Bifurcation angles and retinal arteriolar diameters show Dec vascular reactivity Disadvantageous branching geometry in retinal vasculature

  13. Occular Changes in Hypertension • Pathophysiology • Dynamics of ocular blood flow Hypertensive arterial changes Inc resistance to optic nerve head blood flow Inc BP Breakdown of autoregulation

  14. Occular Changes in Hypertension • Pathophysiology • Different manifestations because • Acute HTN disrupts blood-retinal barriers • Retinal and optic nerve head vascular beds have autoregulation (choroidal has none) • Choroidal vessels has no blood-ocular barrier • Retinal vessels (no autonomic nerve supply) • Choroidal vessels (richly supplied by both sympathetic and parasympathetic nerves)

  15. Hypertensive Retinopathy • Represents target-organ damage

  16. Grade II

  17. Grade III

  18. Grade IV

  19. Hypertensive Retinopathy • Clinical features • Vasoconstriction • Fundus • focal and generalised arteriolar narrowing, microaneurysms, intraretinal hemorrhages, cotton-wool spots, hard exudates, optic disc swelling • 2o to arteriolosclerosis  arteriovenous nipping • Flame-shaped hemorrhages (abnormal vascular permeability) • Macular star (lipid deposition around the fovea) • Disc swelling (minimal microvascular change)

  20. Cotton-wool spots

  21. Hypertensive Retinopathy • Clinical features • Vasoconstriction • Fundus • Untreated hypertension  hemorrhagic detachment of retina and vitreous hemorrhage

  22. Hypertensive Retinopathy • Clinical features • Vasoconstriction • Fundus • Secondary arteriosclerosis • Bonnet’s sign - banking of the venule distal to the crossing • Gunn’s sign - nipping of the blood column • Salus’ sign - displacement of the venule at right angles to the arteriole

  23. Hypertensive Retinopathy • Gunn’s sign and Bonnet’s sign

  24. Hypertensive Retinopathy • Focal arterial narrowing of the retina

  25. Hypertensive Optic Neuropathy • Papilloedema or bilateral disc swelling • Grade IV hypertensive retinopathy • Poor prognostic sign • Other causes like space-occupying lesions and benign intracranial HTN should be excluded • Theories on the pathophysiology • Ischemia and raised ICP as a part of hypertensive retinopathy/enchephalopathy

  26. Hypertensive Optic Neuropathy • Usually resolve following control of BP, but some might develop disc pallor • Longstanding uncontrolled HTN  retinal nerve fiber loss

  27. Hypertensive Choroidopathy • Less well recognized than retinopathy • Commonly described features: • Choroidal vascular sclerosis • Elschnig spots – focal areas of degenerative retinal pigment epithelium • Siegrist’s streaks – linear pigment epithelial changes • poor prognosis

  28. Hypertensive Choroidopathy • Elschnig spots

  29. Management • Control hypertension • Grade I and II • Non-urgent referral • Grade III • More urgent referral to the GP • Grade IV • Patient is in medical crisis. Patient needs immediate referral to a hospital eye casualty department

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