Retinoscopic Findings in Common Systemic Diseases

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Fundoscopic Findings in
Common Systemic Diseases
Jocelyn Kuryan, MD
Chief Resident
Department of Ophthalmology
Albert Einstein College of Medicine
Montefiore Medical Center/Jacobi Medical Center
Outline
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Retinal findings:
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Overview of Some Common Eye Diseases:
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Diabetes Mellitus
Hypertension
HIV/AIDS
Glaucoma
Macular Degeneration
Cataract
Screening Recommendations for Adults
Normal Retina
Diabetic Retinopathy
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Leading cause of new
cases of legal blindness
among working-age
Americans
Duration of DM is a major
risk factor for the
development of
retinopathy
The severity of
hyperglycemia is the key
alterable risk factor
Intensive management of
HTN has been show to
slow DR progression
Duration
(yrs)
% Type I
with DR
% Type II
with DR
Up to 5
25
40 (on insulin)
24 (no insulin)
> 15
80
84 (on insulin)
53 (no insulin)
Natural History of
Diabetic Retinopathy

Early stages (NPDR=non proliferative DR)
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retinal vascular abnormalities increased retinal
vascular permeability can lead to macular edema
Gradual closure of retinal vessels, impaired
perfusion & retinal ischemia
Proliferative disease (PDR)

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onset of neovascularization induced by retinal
ischemia
new vessels can undergo fibrosis & contraction
Severity of Diabetic Retinopathy
International Clinical Diabetic Retinopathy Severity Scale
Proposed Disease Severity
Level
Findings Observable upon DFE
No apparent retinopathy
No abnormalities
Mild NPDR
Microaneurysms only
Moderate NPDR
More than just MAs but less severe than
severe NPDR
Severe NPDR
Any one of the following:

20 intraretinal hemorrhages in each of 4
quadrants

definite venous beading in ≥ 2
quadrants

prominent IRMA in ≥ 1 quadrants
PDR
One or both of the following:

Neovascularization

Vitreous/Preretinal hemorrhage
Recommended Eye Examination Schedule
for Patients with Diabetes Mellitus
Diabetes
Type
Recommended
Time
of 1st Examination
Recommended Follow-up
Type 1
5 yrs after onset
Yearly
Type 2
At time of diagnosis
Yearly
Prior to
pregnancy
(type 1 or
2)
Prior to conception or
early in 1st trimester
No retinopathy to mild/mod NPDR: every
3-12 months
Severe NPDR or worse: every 1-3
months
Nonproliferative Diabetic Retinopathy
http://depts.washington.edu/ophthweb/images/J02diabetic.jpg
Proliferative Diabetic Retinopathy
http://blog.visivite.com/wp-content/uploads/2009/08/proliferative-diabeticretinopathy.jpg
Fibrovascular Proliferation
http://emedicine.medscape.com/article/1225210-media
Tractional Retinal Detachment
Fluorescein Angiogram showing
Neovascularization
http://emedicine.medscape.com/article/1225210-media
Treatment Options

Severe NPDR with evidence of areas of retinal
nonperfusion – panretinal photocoagulation (PRP)
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Goal: lower levels of VEGF which is thought to promote and
propagate neovascularization
PDR - panretinal photocoagulation
Clinically Significant Macular Edema – focal laser
photocoagulation directly to leaking microaneurysms (as
seen on fluorescein angiogram)
Vitreous Hemorrhage and/or Tractional Retinal
Detachment – Vitrectomy
Anti-VEGF intravitreal injections (i.e. Lucentis, Avastin)
initially used for macular degeneration are increasingly
being used to treat neovascularization associated with
DR
Panretinal Photocoagulation
Hypertensive Retinopathy
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Increased incidence in patients with uncontrolled
hypertension4
Associated with increased risk for cardiovascular disease
and stroke7
Some studies have linked renal dysfunction with retinal
vascular changes6
HTN risk factor for retinal vascular occlusions, macular
degeneration, ischemic optic neuropathy5
Classification (modified Scheie classification):
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Grade
Grade
Grade
Grade
Grade
0
1
2
3
4
-
No changes
Barely detectable arterial narrowing
Obvious arterial narrowing with focal irregularities
Grade 2 plus retinal hemorrhages and/or exudates
Grade 3 plus disc swelling
Treatment – BP control
Arteriolar Narrowing & Sclerosis
http://usa.nidek.com/wp-content/uploads/2008/10/6.jpg
A-V nicking
http://eyephoto.ophth.wisc.edu/LightBoxImages/A8.jpg
Retinal Hemorrhages, CWS
http://www.otm1.com/page/services_otm
Malignant Hypertensive
Retinopathy
©2005 by BMJ Publishing Group Ltd.
Grosso A et al. Br J Ophthalmol 2005;89:1646-1654
Disc Edema & Malignant
Hypertension
http://www.opt.indiana.edu/ce/retvasdz/graphics/img030.jpg
HIV Retinopathy
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Definition: noninfectious microvascular disorder
characterised by cotton-wool spots (CWS),
microaneurysms, retinal hemorrhages, telangiectatic
vascular changes, and areas of capillary nonperfusion9
CWS in 25 to 50% of patients and are the earliest and
most consistent finding; mimic diabetic & hypertensive
retinopathy
More prevalent in the pre-HAART era10
Ocular lesions in AIDS are varied and affect almost all
structures of the eye & occur in 40 to 70% of AIDS
patients8
HIV Retinopathy
CMV Retinitis
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It usually occurs when the CD4 cell count is less than
100 cells/mm3 11
Leads to viral invasion of retinal cells and retinal
necrosis
“Pizza pie retinopathy” scattered yellow-white areas of
necrotizing retinitis with variable degree of hemorrhage
and mild vitreous inflammation
Can result in retinal detachment
Treatment: systemic and/or local
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IV and oral ganciclovir, IV foscarnet, IV cidofovir, the ganciclovir
implant and fomivirsen
“Pizza Pie”
http://upload.wikimedia.org/wikipedia/commons/9/90/Fundus_photographCMV_retinitis_EDA07.JPG
CMV retinitis
Early necrosis at periphery
http://emedicine.medscape.com/article/1227228-media
Progressive Outer Retinal Necrosis
(PORN)
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Caused by Herpes simplex virus (HSV) or Varicella zoster
Can present with anterior uveitis, blurred vision and
severe eye pain
Peripheral retinitis progresses centrally. Regresses over
2-3 weeks & can cause retinal traction & tears leading to
retinal detachment
Treatment: IV and PO acyclovir
Can result in retinal detachment
Prophylactic laser photocoagulation is considered
beneficial following resolution of retinitis.
Outer Retinal Necrosis
Cream-colored areas of retinal necrosis with atrophic holes
http://www.retinalphysician.com/archive%5C2008%5CNovember%5Cimages/RP_Nove
mber_A04_Fig02.jpg
Other Common
Ophthalmologic Diagnoses
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Glaucoma
Macular Degeneration
Cataract
Glaucoma
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Main types: primary open angle glaucoma, angle
closure glaucoma (ACG)
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POAG – chronic progressive optic neuropathy that
leads to peripheral vision loss and blindness
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Treatment – IOP lowering drops, close monitoring of visual
fields; surgery in those who fail medical management
Often runs in families; higher prevalence among Blacks12
ACG – acute closure of aqueous drainage channels
that leads to elevated eye pressure, pain, nausea,
vomiting and vision loss
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Treatment – IOP lowering drops, peripheral iridectomy
Optic Nerve
Normal
Glaucoma
http://www.besteyesurgery.co.uk/images/glaucoma/glaucoma_optic_nerve.jpg
Humphrey Visual Field
Normal
Superior Visual Field
Deficit
Advanced Glaucoma
with Sparing of
Central Vision
Age Related Macular Degeneration2
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A leading cause of severe, irreversible vision impairment
in developed countries
The prevalence, incidence, and progression of AMD
increase with age
Late stages of AMD are more common among whites
than blacks
Smoking doubles the risk of AMD
Additional risk factors may include low levels of
antioxidants, which led to the development of AREDS
vitamins
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beneficial effect of high doses of antioxidant vitamins
(vitamins C, E, beta-carotene) and zinc supplementation in
reducing progression
“Dry” = drusen and “Wet” = neovascularization
Screening – abnormalities on Amsler grid
Treatment – anti-VEGF intravitreal injections,
photodynamic therapy, laser photocoagulation
Amsler Grid
Normal
Scotoma & Metamorphopsia
http://www.vrmny.com/images/amsler_lg.jpg
Dry AMD
http://www.blackwelleyesight.com/wp-content/uploads/2008/05/mac-deg-1.jpg
Wet AMD
http://www.clevelandsightcenter.org/resources/conditions/images/wet_macular_fundus.jpg
Cataract3
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A cataract is a degradation of the optical quality of the
crystalline lens.
Cataracts are the leading cause of blindness worldwide
Early development and/or more rapid progression in
diabetics and with corticosteroid use
Indications for Surgery
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Primary: visual function that no longer meets the patient’s needs
and for which cataract surgery provides a reasonable likelihood
of improved vision
Secondary: anisometropia, interference with optimal diagnosis or
management of posterior segment conditions, causing
inflammation, inducing angle closure
Cataract
Screening Recommendations
for Adults14
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Age 20-29: a complete eye exam at least once
Age 30-39: a complete eye exam at least twice
Age 40-64: baseline exam at 40, then follow-up as per
ophthalmologist
Age > 65: every 1-2 years
Patients with risk factors for eye disease – family history,
history of eye injury, diabetes, hypertension, etc. should
be seen regularly
Patients with symptoms – i.e. flashes, floaters, visual
changes or distorted vision, etc. should be seen as soon
as possible
QUESTIONS?
REFERENCES
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American Academy of Ophthalmology Preferred Practice Patterns – Diabetic Retinopathy
American Academy of Ophthalmology Preferred Practice Patterns – Age Related Macular Degeneration
American Academy of Ophthalmology Preferred Practice Patterns – Cataract in the Adult Eye
R Klein, B E Klein, and S E Moss. The relation of systemic hypertension to changes in the retinal vasculature: the Beaver Dam Eye
Study. Trans Am Ophthalmol Soc. 1997; 95: 329–350.
Grosso A, Veglio F, Porta M, Grignolo FM, Wong TY. Hypertensive retinopathy revisited: some answers, more questions. Br J
Ophthalmol. 2005 Dec;89(12):1646-54.
Wong TY, Coresh J, Klein R, et al. Retinal microvascular abnormalities and renal dysfunction: the Atherosclerosis Risk in
Communities Study. J Am Soc Nephrol 2004;15:2469–76.
Dodson PM, Kritzinger EE. Medical cardiovascular treatment trials: relevant to medical ophthalmology in1997. Eye 1997;11 (Pt 1)
:3–11
Cunningham ET, Margolis TP. Ocular manifestations of HIV infection. N Eng J Med 1998;339:236-44
Biswas J, Fogla R, Gopal L, Narayana KM, Banker AS, Kumarasamy N, Madhavan HN. Current approaches to diagnosis and
management of ocular lesions in human immunodeficiency virus positive patients. Indian J Ophthalmol. 2002 Jun;50(2):83-96.
Whitley RJ, Jacobson MA, Friedberg DN, Holland GN, Jabs DA, Dieterich DT et al. Guidelines for the treatment of cytomegalovirus
diseases in patients with AIDS in the era of potent antiretroviral therapy. Arch Intern Med 1998;158:957-59.
Kupperman BD, Petty JG, Richman DD, Mathews WC, Fullerton S, Richman ST et al. Correlation between CD4+ counts and
prevalence of cytomegalovirus retinitis and human deficiency. Am J Ophthalmol 1993;1125:575-82.
Congdon N, O’Colmain B, Klaver CC, Klein Are, Munoz B, Friedman DS, et al, for the Eye Disease Prevalence Research Group.
Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122: 477–85.
http://www.herzig-eye.com/assets/images/cataract.jpg
http://www.eyecareamerica.org/eyecare/treatment/eye-exams.cfm