Systemic Ophthalmology

Eye manifestations of systemic diseases

The eye is a unique organ

In Development In Position In Structure

Systemic diseases affect eyes in various ways BUT ALSO Many of the systemic diseases may be first diagnosed by ophthalmologist 

Endocrine Disorders 

Diabetes Mellitus 

Thyroid gland Pituitary gland Anemia leukemia Astherosclerosis Hypertension 

Cardiovascular & blood disorders 

Most i

orta t relations are: 

Collagen vascular diseases 

Congenital Acquired: Rheu atoid arthritis Migraine. Pa illoede a. O tic neuritis. Pseudotu our cerebri. hakomatosis Vitamin A, B, C, D HIV 

Neurological Disorders 


Vitamin deficiency 

Infectious diseases 


Eye manifestations of diabetes

Eye lids 

Recurrent styes Xanthelasmas

Conjunctiva & Cornea 

Conjunctivitis Cornea: recurrent erosions, ulcers..


Rubiosis irides Edema & vesiculation of pigment epithelium: easy scattering of iris pigment by mild trauma.

Neovascular glaucoma 


Senile catarct in diabetic patient, density accelerates more. True diabetic cataract 

Develops quickly & rapidly progressive. Starts flocculent, snow flake, milky white cortical opacities.


Intraocular hge
Hyphema  Vitreous hge  Retinal hge  

Lipemia retinalis 

Milky retinal vessels. vessels.



Optic nerve 

Retrobulbar neuritis:

(diabetic optic neuropathy)
Usually bilateral  Rapid onset  Often painless. painless. 

Extraocular muscles 

Extraocular muscle palsy: 

Diabetic third nerve palsy: palsy: 

most common cause of isolated 3rd n. palsy..micro infarctions 

Sixth nerve palsy

Visual Disturbances 

Transient refractive changes:  Changes in the state of lens hydration & alteration of the refractive index of the lens due to osmotic changes.  Hypermetropia: in hypoglycemia Hypermetropia:  Myopia: hyperglycemia. hyperglycemia.


Visual Disturbances 

Accomodative disorders: 

Weakness of accomodation due to weak ciliary muscles due to peripheral neuritis involving its nerve supply. supply. 

Subjective visual disturbances: 

Amaurosis in severe cases Flshes due to visual cortex disturbances in insulin overdose.

Causes of Visual Loss & Blindness in DR
Vitreous Haemorrhage from PDR Tractional Retinal Detachment involving the macula Maculopathy, Maculopathy, exudative and ischaemic Neovascular Glaucoma In addition: higher cataract prevalence 


Charecterized by excess of uric acid in blood, urate deposits of cartilages of small joints. Starts in big toe,,,then polyarticular.



Conjunctivitis Marginal corneal ulcer Episcleritis Tenonitis Iridocyclitis

Vitamin Deficiency

Vitamin A

Vitamin A deficiency 

Night blindness: defective or degenerative night vision. Dry eye (Xerophthalmia) Bitot¶ Bitot¶s spots Corneal thinning keratomalacia
Blepharitis Recurrent styes & chalazia.

Vitamin A deficiency

Vitamin B deficiency

Vitamin B1 B1

Vitamin B1 B1

Vitamin B1 deficiency
(Thiamine deficiency: Beri Beri: eri: (cardiac, (cardiac, muscular weakness, neuritis) neuritis) 

Conjunctivitis Nystagmus Papilloedema Retinal hge Extra ocular muscle paralysis

Vitamin B2 (Riboflavin)

Vitamin B2 deficiency Riboflavin deficiency
Conjunctivitis: Conjunctivitis: typical manifestation  Peripheral corneal vascularization  Cataract  Fundus changes: changes: 

Papilledema. Papilledema.  Pigmentary changes of macula.  Partial optic atrophy. 

Vitamin C

Vitamin C deficiency

Vitamin C deficiency
Eye Manifestations 

Subconjunctival  Palpebral  Orbital  Retinal  

Keratoconjunctivitis Cataract

Vitamin D

Vitamin D

Vitamin D deficiency
Daily therapeutic dose 2500 IU 

Lamellar cataract Associations
High myopia  Phlyctenular conjunctivitis  keratoconus 

Endocrinal Disorders

Thyroid Disorders

Thyroid Eye Disease
Patient may be: Hyper thyroid, euthyroid, Hypothyroid


Soft tissue involvement
1. 2. 3.

Periorbital and lid swelling Conjunctival hyperaemia Conjunctival chemosis. chemosis.

2. 3. 4. 5.

Eye lid retraction Proptosis Optic neuropathy Restrictive myopathy

Soft tissue involvement
Periorbital and lid swelling Conjunctival hyperaemia


Superior limbic keratoconjunctivitis

Eyelid Retraction
Occurs in about 50%

Bilateral lid retraction ‡ No associated proptosis ‡

Bilateral lid retraction ‡ Bilateral proptosis ‡

Unilateral lid retraction ‡ Unilateral proptosis ‡

Lid lag in downgaze ‡

Occurs in about 50% TED is the commonest cause of proptosis (unilateral or bilateral) in adults

Axial and permanent in about 70%

May be associated with choroidal folds

Optic Neuropathy
Occurs in about 5% Early defective colour vision Usually normal disc appearance

Caused by optic nerve compression at orbital apex by enlarged recti

Often occurs in absence of significant proptosis

Restrictive Myopathy
Occurs in about 40% ‡ Due to fibrotic contracture

Elevation defect - most common

Abduction defect - less common

Depression defect - uncommon

Adduction defect - rare



Puffiness of eyelids. Loss of hair from outer third of the eye brow. Madarosis. Madarosis. Discrete spots in the central cornea. Whitish opacities of the lens periphery. Bilateral retrobulabar neuritis. Optic atrophy.

Parathyroid gland

Photophobia  Cortical lens opacity  Lid twitches.  Conjunctivitis & keratitis 


Calcium crystal deposition in the conjunctiva  Band shaped keratopathy. keratopathy. 



Subconjunctival hemorrhages. Dilated tortous retinal veins. Edema, exudates. dema, Optic neuritis


Ocular effects 

Orbital infiltration Proptosis. Exophthalmos. Iritis with hypopion Spontaneous hyphema & subconj. hge.

Posterior Segment  

Retinal edema, hemorrhages, tortous vessels, Roth¶s spots. Roth¶ Papillitis. Papillitis.


Grading of arteriolosclerosis

Ocular effects 

Arcus senilis Lipid keratopathy Arteriolar narrowing, focal or diffuse Arteriolar colour changes AV crossing changes, e.g. nicking ± flame hges, vessel sclerosis, threading


Hypertensive retinopathy
Arteriolar constriction


Generalized Extravascular signs

Arteriolosclerosis (A-V changes)

Flame-shaped retinal haemorrhages

Cotton-wool spots and macular star

Disc oedema

Ocular associations of hypertension

Retinal vein occlusion

Retinal artery macroaneurysm

Anterior ischaemic optic neuropathy

Ocular motor nerve palsies


Connective Tissue Disorders

Connective tissue disorders 


Marfan¶s syndrome: Ectopia lentis, lentis, 2ry glaucoma, retinal detachment. EhlersEhlers-Danlos syndrome: Blue sclera, keratoconus, keratoconus, ectopia lentis, angioid streaks lentis, 

Marfan¶s syndrome
Ectopia lentis, lentis,  2ry glaucoma,  retinal detachment. 

EhlersEhlers-Danlos syndrome 

Blue sclera keratoconus, keratoconus, ectopia lentis, lentis, angioid streaks

Acquired connective tissue disorders: Rheumatoid arthritis  


Peripheral corneal thinning (CL Cornea). Iritis & its complications episcleritis Scleritis Scleromalacia perforans

Infectious Diseases

Infectious diseases 



Phlycten Uveitis Choroidal deposits

Interstitial keratitis Uveitis Chorioretinopathy BSK

Infectious diseases 



Microphthalmia Cataract Glaucoma Uveitis Salt & pepper retinopathy

Viral infections: VaricellaVaricellaZoster 


Parasitic: Toxoplasmosis Granulomatous: Sarcoid Fungal

Ocular regions related to systemic diseases


The corneal epithelium is of ectodermal embryologic origin 

so it is affected by diseases of the skin and mucous membranes. 

The rest of the cornea is of mesodermal embryologic origin: 

so it is affected by disorders of collagen metabolism


Much of the cornea is made of collagen and mucopolysaccharide ground substance, 

so systemic diseases affecting collagen may indirectly affect the cornea by way of auto antibodies in the circulation leading to limbal and marginal ulcerations.   

The cornea stores materials made in excess by the body, so damage to the cornea may occur indirectly by accumulation of metabolic products. Systemic metabolic diseases that produce elevated levels of certain precursors and that may opacify the cornea. The cornea is the most anterior part of the eye, exposed to environmental harm.


Lens fibers opacify as a response to alterations of the physical and chemical medium within the semipermeable lens capsule.
Chromosomal disorders  Diseases of skin & mucous membrane  Metabolic disorders & infections  Toxic substances produced systemically 


Secondary glaucomas may arise
as complications of the systemic disease itself  or from its therapy. 

Inlftammation of the iris, ciliary body, and choroid may be caused by a wide variety of diseases. 

Systemic allergic diseases. Cardiovascular diseases: endocarditis (subacute bacterial). Collagen diseases Diseases of skin and mucous membranes Metabolic diseases Gastrointestinal and nutritional diseases Neoplastic disease Infectious diseases

Retinal veasels, choroid: (Microaneurys, Hemorrhages, Exudates, Hemangiomas, Choroiditis). Neural tissue (Retinitis, Rxudative retinal detachment, Selective rod and cone destruction). Retinal pigment epithelium (Loss of pigment, Accumulation of toxic substances).

Is vulnerable to these systemic diseases: 

Cardiovascular diseases Collagen diseases Chromosomal disorders Endocrine diseases Diseases of skin and mucous membranes Gastrointestinal and ntritional diseases Hematologic disease Inlectious diseases Phacomatoses: most affect the retina. Pulmonary diseases Renal diseases Metabolic diseases

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