Lecture 7: Ocular Manifestations of Systemic Disease
1. Presentation/History- acute hypertension, associated with: Intraretinal hemorrhages, branch/central retinal vein occlusion, branch/central retinal artery occlusion, retinal arterial macroaneurysms, non-arteritic ischemic optic neuropathy, worsening of diabetic retinopathy, cranial nerve palsy
2. Physical Findings/Specific Tests- changes in choroid, optic nerve. Visual field defect.
3. Treatments- control blood pressure!
4. Pathophysiological Changes- arterial narrowing (AV nicking, copper-wiring, silver wiring), retinopathy [hemorrhages, exudate (fatty deposits), cotton-wool spot (microstroke)], disc swelling/edema (with severe HTN)
What is this? What are the signs?
Central Retinal Artery Occlusion
signs: cherry red spot, lower pressure in eye
painless and sudden
pre-existing conditions: HTN, increased cholesterol
What is this?
What are important signs of this condition---
and what does it NOT show?
Non-proliferative Diabetic Retinopathy
Dot blot hemorrhages
Flame shaped hemorrhages
Hard exudates (in clumps/ring pattern)
Treatment for Non-proliferative Diabetic Retinopathy
Treatment - not required but watch for proliferative disease
control blood sugars, pressers, diet, renal function, lipids, quit smoking
Key finding in Proliferative Diabetic Retinopathy
- tiny recurrent microaneurysms cause sclerosis, requiring a need for new blood vessels= a lot of new, weak vessels that are prone to hemorrhaging
Treatment for Proliferative Diabetic Retinopathy
Laser Panretinal Photocoagulation
Gentle intensity burn (0.10-0.05 sec)
Initial treatment is 2000-3000 burns
to stop the growth of new neovascularization
Tight blood sugar and BP control. Intensive metabolic control and lipid levels. Blockage of VEGF (vascular endothelial growth factor).
Other Ocular Sequelae of Diabetes:
edema and hemorrhages
Presentation/History and Physical Findings for Non-proliferative and Proliferative Diabetic Retinopathy
Presentation/History- longer time with DM type I or II, leading cause of new blindness in US age 20-74, poor metabolic control, pregnancy, HTN, renal disease, obesity, hyperlipidemia, smoking, anemia
2. Physical Findings/Specific Tests-
A. Non-proliferative- macular edema, vitreous hemorrhage, cotton-wool spots, microaneurysms, venous beading, flame shaped hemorrhages, hard exudates, intraretinal microvascular abnormalities
B. Proliferative- neovascular glaucoma, thickening of central fovea, highly permeable vessels, tractional retinal detachment
Other Ocular Sequelae of Diabetes:
Neovascularization of the Iris and Angle
can lead to neovascular glaucoma
Presentation/History and Physical findings of of AGE-RELATED MACULAR DEGENERATION (ARMD)
1. Presentation/History- leading cause of visual impairment in patients older than 50 in developed countries (prevelance increases with age). Higher prevelance in females, Caucasians, smokers, HTN, light iris color, hyperopia.
2. Physical Findings/Specific Tests- Decreased central vision with intact peripheral vision, central scotoma, metamorphopsia. Hard drusen (small well-defined spots, innocuous) and soft drusen (larger, ill-defined sports, may enlarge and coalese)
B. Wet- pinkish-yellow subretinal lesion with fluid, subretinal blood or lipid
Nonexudative or Dry
Exudative, neovascular, or wet
Small well-defined spots
Larger, ill-defined spots
May enlarge and coalesce
Increased risk of ARMD
Treatment of Dry ARMD
Ocuvite(like a vitamin for your eye)
Follow ups (check progression with amsler grid)
Sunglasses (keep UV away)
signs of Wet Age-Related Macular Denegeration
Choroidal Neovascularization (CNV)
Metamorphopsia is initial symptom
Less common than atrophic ARMD but more serious
Pinkish-yellow subretinal lesion with fluid
Subretinal blood or lipid
Treatment of Exudative ARMD
Lucentis or Avastin- to stop growth signals
Definition and potential etiologeis of Amaurosis Fugax
1. Definition- temporary loss of vision
2. Potential Etiologies- may precede frank occlusion of retinal artery. Associated with profound loss of vision, afferent papillary defect, cherry-red spot in macula. An embolus/plaque may be visible. Tends to occur in older pts, congestion and elevation of optic disc.
Conditions: refractive errors, cataracts, age-related macular degeneration w/o hemorrhage or exudation