Chapter 16
Ocular Manifestations of Systemic Disease
This chapter summarises the effects of systemic eye disease on the eye. Most of the detailed information has already been discussed and can be found in the chapters on the diseases of the specific ocular structures.
Diabetes mellitus
Diabetes mellitus can cause the following ocular conditions:
•Lids:
styes (see p. 72)
chalazions (see p. 68).
•Cornea: keratitis (see p. 106).
•Iris:
rubeosis iridis from neovascularisation (see p. 144)
atrophy of the iris
spontaneous hyphaema from rubeosis iridis
•Chronic open-angle glaucoma.
•Secondary glaucoma from rubeosis iridis and peripheral anterior synaechiae (see p. 144).
•Lens:
cataract (see p. 152)
intermittent refractive errors due to changes in blood glucose levels and therefore changes in the glucose levels in the lens.
•Uveal tract: uveitis (see p. 123).
•Retina:
retinal vein occlusion (see p. 170)
retinopathy (see p. 172)
retinal detachment (see p. 165).
•Vitreous: haemorrhage (see p. 184).
•Optic nerve:
retrobulbar neuritis (see p. 183)
optic atrophy (see p. 183).
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•Nerve palsies: this occurs, rarely, due to inflammation of the third, fourth and sixth cranial nerves causing paralysis of the extra-ocular muscles.
Acquired immune deficiency syndrome (AIDS)
AIDS can cause the following conditions:
•Microvascular disease:
retina – usually asymptomatic:
(i)cotton wool spots
(ii)haemorrhages
(iii)microaneurysms
conjunctiva – vessels have altered appearance.
•Opportunistic infections affecting the retina:
cytomegalovirus (CMV) (see p. 178)
herpes simplex and zoster
toxoplasmosis
candida
tuberculosis
syphilis
molluscum contagiosum
pneumocystis.
•Neoplasms:
Kaposi’ s sarcoma:
(i)eyelid
(ii)conjunctiva
(iii)nose
(iv)orbit
Burkitt’s lymphoma: orbit.
•Neuro-ophthalmic:
cranial nerve palsies
visual field defects
papilloedema
optic atrophy.
Thyroid disease
Thyrotoxicosis affects the eye in the following ways (see p. 66):
•lid lag
•lid retraction
•exophthalmos
•conjunctival chemosis
•exposure keratitis
•ophthalmoplegia.
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Complications
•Corneal ulceration leading to perforation.
•Optic nerve compression.
•Glaucoma.
•Central retinal artery and vein occlusion.
•Cataract.
Hypertension
Hypertension causes a retinopathy (see p. 175).
Giant cell arteritis
Giant cell arteritis or temporal arteritis is a condition of those from the over 60s age group, affecting all arteries, having an effect especially on the heart and kidneys. It is also associated with polymyalgia rheumatica. In the eye it causes a sudden loss of vision in one or both eyes. This is caused by infarctions in the ciliary arteries which supply the optic nerve head causing ischaemia and swelling of the optic disc. The temporal artery is often prominent, hard and tender to touch.
Patient’s needs
•Relief of symptoms:
sudden loss of vision
general malaise
temporal headaches
pain on chewing
tenderness on scalp when combing hair.
•Institution of treatment.
Nursing priority
Inform the doctor of the patient’s history of sudden loss of vision.
Nursing action
•Instil prescribed mydriatic drops to facilitate ophthalmoscopy.
•Assist the doctor to take blood for ESR estimation. A high reading is indicative of giant cell arteritis. It can be as high as 100 mmHg in one hour.
•Prepare patient and equipment and assist the doctor in performing a temporal artery biopsy. This is not always performed as a false negative result can occur.
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•Admit the patient to hospital if the condition is severe enough to warrant high-dose systemic steroids, maybe via the intravenous route.
•If the patient is not admitted, explain the treatment by oral steroids and the importance of carrying a steroid card.
•Ensure the patient has an outpatient follow-up appointment.
•High doses of oral steroids are given to prevent further visual loss in the presenting eye if unilateral and to prevent the disease affecting the other eye. These steroids will be gradually reduced and the disease monitored by regular ESR estimations. A maintenance dose of steroids may need to be continued for several years. Patients with severe visual loss resulting from this disease may need to be registered as blind or partially sighted (see p. 2).
Herpes simplex virus
Herpes simplex virus causes a conjunctivitis and keratitis resulting in a dendritic corneal ulcer (see p. 108).
Herpes zoster virus
In the eye the herpes zoster virus affects the trigeminal nerve (see p. 109). Usually only the ophthalmic branch is involved, but the maxillary branch may be affected too. It causes:
•vesicular eruptions on the forehead, eyelids and nose of affected side of the face, which crust over
•keratitis
•conjunctivitis.
Complications
•Uveitis.
•Cataract.
•Glaucoma.
•Ophthalmoplegia.
•Persistent pain.
•Ptosis.
•Corneal scarring.
•Anaesthetic cornea.
Tuberculosis
Tuberculosis can cause a uveitis (see p. 123). Rarely miliary tuberculosis causes discrete yellow nodules in the choroid. A retinitis may develop. Phlyctenular conjunctivitis can be caused by tuberculosis.
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Sarcoid
Sarcoid can cause a bilateral uveitis (see p. 123) with mutton fat keratic precipitates present on the corneal endothelium. Dry eyes result from sarcoid involvement of the lacrimal gland (see p. 88).
Syphilis
Congenital syphilis can cause interstitial keratitis (see p. 111). It may, rarely, cause a dacryoadenitis.
Acquired syphilis can cause a uveitis and chorioretinitis.
Toxoplasmosis
This is shown in Colour Plate 8.
The toxoplasma parasite can be transmitted in utero if the mother has been infected by ingesting infected meat. It also spreads in the excreta of cats. It causes choroiditis and chorioretinitis (see p. 126).
Toxocara
The toxocara parasite is transmitted via the faeces of puppies and kittens and can cause a unilateral uveitis and choroiditis (see p. 126), affecting children under the age of ten years. A chronic endophthalmitis can occur, resulting in severe loss of vision. It can be treated with Pyrimethamine and steroids.
Rheumatoid arthritis
Rheumatoid arthritis can cause:
•episcleritis (see p. 119)
•scleritis (see p. 119)
•uveitis (see p. 123)
•dry eyes (see p. 88).
Stills disease
Stills disease or juvenile rheumatoid arthritis can cause uveitis (see p. 123).
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Ankylosing spondylitis
Ankylosing spondylitis is the main known cause of uveitis (see p. 123) and scleritis (see p. 119).
Ulcerative colitis and Crohn’s disease
Ulcerative colitis and Crohn’s disease can cause uveitis, scleritis and episcleritis (see pp. 123, 119, and 119 respectively).