Systemic Ophthalmology

Systemic Ophthalmology

OCULAR MANIFESTATIONS OF NUTRITIONAL DEFICIENCIES

Vitamin-A deficiency
Xerophthalmia is the term now reserved to cover all the ocular manifestations of vitamin A deficiency which has been classified by WHO (1982).

Night blindness is the earliest symptom of xerophthalmia is children.

A revised schedule of vitamin ‘A’ supplements being followed in India since August 1992 under the programme, named as ‘child survival and safe motherhood (CSSM) is as follows:
• First dose (1 lac. I.U.) – at 9 months of age along with measles.
• Second dose (2 lac. T.U.) – at V/i years of age along with booster dose of DPT/OPV.
• Third dose (2 lac. I.U.) – at the age of 2 years

Deficiency of vitamin B1 (thiamine)
It can cause corneal anaesthesia, conjunctival and corneal dystrophy, acute retrobulbar neuritis and external ophthalmoplegia.

Deficiency of vitamin B2 (Riboflavin)
It can produce photophobia and burning sensation in the eyes due to conjunctival irritation and vascularisation of the cornea.

Deficiency of vitamin C
It may be associated with haemorrhages in the conjunctiva, lids, anterior chamber, retina and orbit. It also delays wound healing.

Deficiency of vitamin D
It may be associated with zonuiar cataract, papilloedema and increased lacrimation.

Systemic OphthalmologyOCULAR MANIFESTATIONS OF VIRAL INFECTIONS

1. Measles: Ocular lesions may be catarrhal conjunctivitis, Koplik’s spots on conjunctiva, corneal ulceration, optic neuritis and retinitis.

2. Mumps: Ocular lesions seen are; conjunctivitis, acute dacryoadenitis, keratitis and uveitis.

3. Rubella: Ocular lesions seen are; congenital microphthalmos, congenital cataract, congenital glaucoma, chorioretinitis and optic atrophy.

4. Whooping cough: There may occur subconjunctival haemorrhage and rarely orbital haemorrhage leading to proptosis.

5. Acquired immune deficiency syndrome
Retinal microvasculopathy: It is characterised by multiple cotton wool patches, superficial and deep haemorrhages. Micro-aneurysms and telengiectasia occur rarely.
Usual ocular infections which occur with greater frequency and produce more severe infections in patients with AIDS include: herpes zoster ophthalmicus, herpes simplex infections, toxoplasmosis, syphilis and fungal corneal ulcers.
Opportunistic infections of the eye: cytomegalovirus (CMV) retinitis, Candida endophthalmitis, cryptococcal infections and pneumocystis carinii choroiditis.
Unusual neoplasms are Kaposis secroma of the lids or conjunctiva and Burkitt’s lymphoma of the orbit.
Neurophthalmic lesions include isolated or multiple cranial nerve palsies.

OCULAR ABNORMALITIES IN TRISOMIES

Trisomy 13 (D Trisomy or Patau Syndrome)
• Microphthalmos
• Colobomas (almost 100%)
• Retinal dysplasia
• Cataract
• Corneal opacities
• Optic nerve hypoplasia
• Cyclopia
• Intra-ocular cartilage

Trisomy 18 (E trisomy or Edwards syndrome)
• Blepharophimosis
• Ptosis
• Epicanthal fold
• Hypertelorism
• Microphthalmos
• Uveal coloboma
• Congenital glaucoma
• Corneal opacities

Trisomy 21 (G Trisomy or Down’s syndrome)
• Upward slanting palpebral fissure (Mongoloid slant)
• Almond-shaped palpebral fissure
• Epicanthus
• Telecanthus
• Narrowed interpupillary distance
• Esotropia (35% cases)
• High refractive errors
• Cataract
• Iris hypoplasia
• Keratoconus

Ocular abnormalities in chromosomal deletion syndromes

Cri-du-Chat syndrome (5p.)
• Hypertelorism
• Epicanthus
• Antimongoloid slant
• Strabisums

Cri-du-Chat syndrome (11 p.)
• Aniridia
• Glaucoma
• Foveal hypoplasia
• Nystagmus
• Ptosis

Cri-du-Chat syndrome (13 q.)
• Retinoblastoma
• Hypertelorism
• Microphthalmos
• Epicanthus
• Ptosis
• Coloboma
• Cataract

De Grouchy syndrome (18q.)

• Hypertelorism
• Epicanthus
• Ptosis
• Strabismus
• Myopia
• Glaucoma
• Microphthalmos (with or without cyst)
• Coloboma
• Optic atrophy
• Corneal opacity

Turner syndrome (XO)
• Antimongoloid slant
• Epicanthus
• Ptosis
• Strabismus
• Blue sclera
• Eccentric pupils
• Cataract
• Colourblindness
• Pigmentary disturbances of fundus

ADVERSE OCULAR EFFECTS OF COMMON SYSTEMIC DRUGS

C.V.S. drugs
Digitalis: Disturbance of colour vision, scotomas
Quinidine: Optic neuritis (rare)
Thiazides: Xanthopsia (yellow vision), Myopia
Carbonic anhydrase inhibitors: Ocular hypotony, Transient myopia
Amiodarone: Comeal deposits
Oxprenolol: Photophobia, Ocular irritation

G.I.T. drugs
• Anticholinergic agents: Risk of angle-closure glaucoma due to mydriasis, Blurring of vision due to cycloplegia (Occasional).

C.N.S. drugs
Barbiturates: Extraocular muscle palsies with diplopia. Ptosis, Cortical blindness
Chloral hydrate: Diplopia, Ptosis, Miosis
Phenothiazines: Deposits of pigment in conjunctiva, cornea, lens and retina. Oculogyric crisis
Amphetamines: Widening of palpebral fissure, Dilatation of pupil. Paralysis of ciliary muscle with loss of accommodation
Monoamine oxidase inhibitors: Nystagmus, Extraocular muscle palsies, Optic atrophy
• Tricyclic agents: Pupillary dilatation (glaucoma risk), Cycloplegia
Phenytoin: Nystagmus, Diplopia, Ptosis, Slight- blurring of vision (rare)
• Neostigmine: Nystagmus, Miosis
• Morphine: Miosis
• Haloperidol: Capsular cataract
• Lithium carbonate: Exophthalmos, Oculogyric crisis
• Diazepam: Nystagmus.

Hormones

Female sex hormones
• Retinal artery thrombosis
• Retinal vein thrombosis
• Papilloedema
• Ocular palsies with diplopia
• Nystagmus
• Optic neuritis and atrophy
• Retinal vasculitis
• Scotomas
• Migraine
• Mydriasis
• Cyloplegia
• Macular oedema

Corticosteroids
• Cataract (posterior subcapsular)
• Local immune suppression causing susceptibility to viral (herpes simplex), bacterial and fungal infections
• Steroid-induccd glaucoma

Antibiotics
• Chloramphenicol: Optic neuritis and optic atrophy
• Streptomycin: Optic neuritis
• Tetracycline: Pseudotumour cerebri,Transient myopia

Antimalarial

Chloroquine
• Macular changes (Bull’s eye maculopathy)
• Central scotomas
• Pigmentary degeneration of the retina
• Chloroquine keratopathy
• Ocular palsies
• Ptosis
• Electroretinographic depression

Amoebicides
Diiodohydroxy quinoline: Subacute myelo optic neuropathy (SMON), optic atrophy

Chemotherapeutic agents
Sulfonamides: Stevens-Johnson syndrome
Ethambutol: Optic neuritis and atrophy
Isoniazid: Optic neuritis and optic atrophy

Heavy metals
Gold sails: Deposits in the cornea and conjunctiva
Lead: Optic atrophy, Papilloedema, Ocular palsies

Chelating agents
Penicillamine: Ocular pemphigoid. Ocular neuritis. Ocular myasthenia

Oral hypoglycemic agents
Chloropropamide: Transient change in refractive error. Diplopia, Stevens-Johnson syndrome

Vitamins

Vitamin A
• Papilloedema
• Retinal haemorrhages
• Loss of eyebrows and eyelashes
• Nystagmus
• Diplopia and blurring of vision

Vitamin D
• Band-shaped keratopathy

Antirheumatic agents
• Salicylates: Nystagmus, Retinal haemorrhages. Cortical blindness (rare)
• lndomethacin: Corneal deposits
• Phenylbutazone: Retinal haemorrhages

MISCELLANEOUS POINTS

• Most common ocular involvement in sarcoidosis is iritis.
• The most common ocular finding in AIDS patients is iritis and the most common fundus finding is cotton wool spots.
• The commonest ocular finding in anaemia is pallor of conjunctiva.
• Diabetes is the most common cause of cotton wool spots.
• Toxoplasmosis is the most common cause of posterior uveitis.
• The major cause of blindness in leprosy is iritis
• The most common ocular manifestation of multiple sclerosis is retrobulbar neuritis.
• Ocular signs in SLE are marginal corneal degeneration, episcleritis, scleritis, retinal haemorrhages and cottonwool retinal exudates.
• Pupillary abnormalities in tabes dorsalis include spinal miosis, anisocoria and ArgyE Robertson Pupil.
• Most commonly involved cranial nerve in fracture base of the skull is facial nerve.
• The commonest ocular sign of hypothyroidism is cataract.
• Dalrymple’s sign is the commonest lid sign of Graves’ ophthalmopathy.
• The commonest feature of Waardenburg’s syndrome is lateral displacement of both medial canthi and lacrimal puncta.
• The commonest ocular infection associated with AIDS is CMV retinitis.
• Ocular complications associated with pregnancy are worsening of diabetic retinopathy, ptosis, central serous retinopathy, ophthalmoplegia.