Ophthalmology - ophthalmological manifestations of chronic and systemic diseases
Description
- Systemic diseases with characteristic, often diagnostic, ocular findings across diabetes, hypertension, rheumatological, haematological, infectious and neurological disease
Epidemiology
- Diabetic retinopathy - leading cause of vision loss in working-age adults; risk rises with disease duration and glycaemic control
- Hypertensive retinopathy - correlates with cardiovascular risk and end-organ damage elsewhere
Aetiopathogenesis
- Diabetic retinopathy: chronic hyperglycaemia -> microvascular damage -> pericyte loss, capillary occlusion -> ischaemia -> VEGF-driven neovascularisation (proliferative disease) +/- macular oedema
- Hypertensive retinopathy: chronic pressure -> arteriolar narrowing/sclerosis -> Keith-Wagener-Barker grading (arteriolar narrowing -> AV nicking -> haemorrhages/exudates -> papilloedema)
- Rheumatological: scleritis/episcleritis (RA, GPA), uveitis (spondyloarthropathy, sarcoidosis, Behcet's), dry eye (Sjogren's)
- Thyroid eye disease: autoimmune orbital fibroblast activation (TSH-receptor antibody-mediated) -> proptosis, lid retraction, restrictive myopathy
- Infective/immunological: HIV retinopathy, CMV retinitis (severe immunosuppression), syphilitic uveitis
Diagnosis
- Diabetic retinopathy: staged non-proliferative (mild/moderate/severe) -> proliferative; diabetic maculopathy (macular oedema) assessed separately - screen annually from diagnosis (T2DM) or 5 years post-diagnosis (T1DM)
- Hypertensive retinopathy: fundoscopy grading correlates with systemic severity/organ damage
- Scleritis - deep boring pain, globe tenderness; episcleritis - milder, sectoral, blanches with phenylephrine
- Thyroid eye disease - clinical + TSH/TRAb, orbital imaging if severe/asymmetric
Management
- Diabetic retinopathy: glycaemic and blood pressure optimisation slows progression; anti-VEGF intravitreal injection for macular oedema/proliferative disease; panretinal photocoagulation for proliferative disease
- Hypertensive retinopathy: BP control is the treatment - no direct ocular therapy needed
- Scleritis: systemic NSAID/corticosteroid, treat underlying CTD; never treat with topical steroid alone - needs systemic approach and rheumatology involvement
- Thyroid eye disease: manage thyroid status, lubricants for exposure, teprotumumab (where available) or orbital decompression/corticosteroids for sight-threatening compressive optic neuropathy
- Regular multidisciplinary screening (ophthalmology + treating physician) for all chronic systemic disease with ocular risk
Associations
- Diabetic retinopathy - nephropathy and neuropathy often co-progress (microvascular triad)
- Hypertensive retinopathy - correlates with stroke, cardiac and renal risk
- Scleritis - substantial association with systemic vasculitis/RA, may be first presentation
Natural history & complications
- Diabetic retinopathy is largely preventable/modifiable with tight glycaemic and BP control and timely screening - a leading cause of preventable blindness when screening is missed
- Hypertensive retinopathy regresses partially with BP control; advanced grades (papilloedema) indicate malignant hypertension requiring urgent treatment
- Untreated scleritis can progress to scleral thinning/perforation
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