Ocular Manifestations of Systemic Disorders

Ocular Manifestations of Systemic Disorders Indian Medical PG Question 1: A 45 year old male, known case of Rheumatoid arthritis is on a monotherapy since many years. Symptoms of RA are controlled but suddenly patient develops blurring of vision. Which of the following drug is responsible for sudden effect on vision?

• A. Methotrexate
• B. Hydroxychloroquine (Correct Answer)
• C. Sulfasalazine
• D. Leflunomide

Ocular Manifestations of Systemic Disorders Explanation: ***Hydroxychloroquine*** - **Hydroxychloroquine** [1] is known to cause **retinal toxicity** (maculopathy) as a dose-dependent, long-term side effect, leading to **blurring of vision** and other visual disturbances. - Patients on long-term hydroxychloroquine therapy require regular **ophthalmological screening** to detect and prevent irreversible vision loss. *Methotrexate* - **Methotrexate** is a common DMARD used in RA [1], but its ocular side effects are typically rare and less severe, usually involving **conjunctivitis** or **periorbital edema**. - It does not commonly cause **maculopathy** or sudden profound blurring of vision. *Sulfasalazine* - **Sulfasalazine** [1] can cause a range of side effects, including gastrointestinal issues and various hypersensitivity reactions. - Ocular side effects are infrequent and generally mild, such as **conjunctivitis** or **periorbital edema**, and not severe blurring of vision due to retinal damage. *Leflunomide* - **Leflunomide** is an immunosuppressive DMARD [1] whose common adverse effects include hepatotoxicity, gastrointestinal upset, and hypertension. - Significant **ocular toxicity** leading to blurring of vision, particularly retinal damage, is not a characteristic side effect of **leflunomide**.

Ocular Manifestations of Systemic Disorders Indian Medical PG Question 2: Recurrent anterior uveitis with increased intraocular tension is seen in which of the following conditions?

• A. Posner-Schlossman syndrome (Correct Answer)
• B. Foster-Kennedy syndrome
• C. Vogt-Koyanagi-Harada syndrome
• D. Fuchs heterochromic iridocyclitis

Ocular Manifestations of Systemic Disorders Explanation: ***Posner-Schlossman syndrome*** - Characterized by **recurrent, unilateral, non-granulomatous anterior uveitis** associated with markedly **elevated intraocular pressure (IOP)**. - The condition is also known as **glaucomatocyclitic crisis**, highlighting the episodic inflammation and glaucoma. - Key features include **acute attacks** lasting hours to weeks with **dramatic IOP elevation** (often >40 mmHg). *Foster-Kennedy syndrome* - This syndrome is defined by ipsilateral **optic atrophy**, contralateral **papilledema**, and often **anosmia**, typically due to a frontal lobe tumor. - It does not involve anterior uveitis or primary elevated intraocular tension. - This is a neuro-ophthalmologic syndrome, not an inflammatory ocular condition. *Vogt-Koyanagi-Harada syndrome* - An autoimmune disorder affecting pigmented tissues, leading to **bilateral granulomatous panuveitis**, often with hearing loss, vitiligo, poliosis, and neurological symptoms. - While it involves uveitis, it is typically **bilateral and panuveitis**, not recurrent unilateral anterior uveitis. - IOP may be elevated but not the defining feature with dramatic episodic rises. *Fuchs heterochromic iridocyclitis* - A chronic, **unilateral, low-grade anterior uveitis** with characteristic iris heterochromia. - May have mild IOP elevation but **not recurrent episodic attacks** with marked pressure spikes. - Inflammation is typically **quiet and chronic** rather than acute and recurrent.

Ocular Manifestations of Systemic Disorders Indian Medical PG Question 3: Signs of increased intracranial tension are all except:

• A. Headache
• B. Seizures
• C. Papilledema
• D. Tachycardia (Correct Answer)

Ocular Manifestations of Systemic Disorders Explanation: ***Tachycardia*** - **Tachycardia** is generally *not* a sign of increased intracranial pressure (ICP); rather, **bradycardia** (Cushing's reflex) is a classic finding. - While other systemic responses may occur, a direct, consistent increase in heart rate due to elevated ICP is uncommon. *Papilledema* - **Papilledema** is a swelling of the **optic disc** due to increased ICP, a critical diagnostic sign [1]. - The increased pressure impedes venous return from the retina, causing the optic nerve head to bulge. *Headache* - **Headache** is a common and often early symptom of increased ICP due to the stretching of pain-sensitive meningeal and vascular structures [1]. - It is typically described as a dull, throbbing pain, often worse in the morning or with straining. *Seizures* - **Seizures** can result from increased ICP as the pressure on brain tissue can lead to electrical instability and abnormal neuronal discharge [2]. - This symptom indicates significant cortical irritation or dysfunction caused by the elevated pressure.

Ocular Manifestations of Systemic Disorders Indian Medical PG Question 4: Increased frequency of HLA-B 27 is seen in all the following diseases except

• A. Ankylosing spondylitis
• B. Reiters syndrome
• C. Acute anterior uveitis
• D. Myasthenia gravis (Correct Answer)

Ocular Manifestations of Systemic Disorders Explanation: ***Myasthenia gravis*** - **Myasthenia gravis** is an autoimmune disorder characterized by muscle weakness and fatigue due to antibodies against acetylcholine receptors at the neuromuscular junction; it is not associated with **HLA-B27**. - Its pathogenesis involves **antibodies** and T-cell mediated responses against muscle proteins, distinct from the **spondyloarthropathies**. *Ankylosing spondylitis* - **Ankylosing spondylitis** is a chronic inflammatory disease primarily affecting the spine and sacroiliac joints, showing a very strong association with **HLA-B27** (over 90% of cases) [1]. - The presence of **HLA-B27** is a key diagnostic and prognostic factor in this condition [1]. *Reiters syndrome* - **Reiter's syndrome**, now more commonly known as **Reactive arthritis**, is a seronegative spondyloarthropathy often triggered by an infection and strongly associated with **HLA-B27** [1]. - It classically presents with a triad of **arthritis**, **urethritis**, and **conjunctivitis**, linked to the **HLA-B27** allele [1]. *Acute anterior uveitis* - **Acute anterior uveitis** is an inflammation of the iris and ciliary body, and it commonly occurs in association with **HLA-B27** positive spondyloarthropathies, including ankylosing spondylitis and reactive arthritis [1]. - Approximately 50% of patients with **acute anterior uveitis** are **HLA-B27** positive, even in the absence of other systemic diseases [1].

Ocular Manifestations of Systemic Disorders Indian Medical PG Question 5: In diabetes mellitus the following findings are seen in ophthalmoscopy except:

• A. Flame shaped haemorrhage
• B. Dot haemorrhage
• C. Wet sponge haemorrhage (Correct Answer)
• D. Microaneurysm

Ocular Manifestations of Systemic Disorders Explanation: ***Wet sponge haemorrhage*** - **Wet sponge haemorrhage** is not a term typically used in the description of diabetic retinopathy or other retinal conditions found during ophthalmoscopy. - The appearance it suggests (diffuse, sponge-like bleeding) does not correlate with the characteristic hemorrhage types seen in diabetic retinopathy. - This is **not a recognized ophthalmologic finding** in diabetes mellitus. *Flame shaped haemorrhage* - **Flame-shaped haemorrhages** are superficial retinal hemorrhages in the nerve fiber layer, commonly seen in diabetic retinopathy as well as hypertensive retinopathy. - Their characteristic shape reflects the arrangement of nerve fibers in the retina. - These are seen in both non-proliferative and proliferative diabetic retinopathy. *Dot haemorrhage* - **Dot haemorrhages** are small, round hemorrhages located deeper in the retina (inner nuclear and outer plexiform layers). - These are a common early finding in diabetic retinopathy, often representing microaneurysms that have ruptured or deep intraretinal hemorrhages. - They indicate damage to retinal capillaries. *Microaneurysm* - **Microaneurysms** are the earliest and most characteristic clinical sign of diabetic retinopathy, appearing as small, red dots on the retina. - They represent focal outpouchings of retinal capillaries due to weakened vessel walls and pericyte loss. - Best visualized with fluorescein angiography but visible on ophthalmoscopy.

Ocular Manifestations of Systemic Disorders Flashcard 1 of 5

Question: Chronic Progressive External Ophthalmoplegia may occur isolatedly or in association with _____ syndrome or oculopharyngeal dystrophy

Answer: Kearns-Sayre

Ocular Manifestations of Systemic Disorders Flashcard 2 of 5

Question: Patients with hypertensive retinopathy will present on fundoscopy with _____-shaped retinal hemorrhages, arteriovenous nicking, microaneurysms, macular star, and cotton-wool spots

Answer: flame

Ocular Manifestations of Systemic Disorders Flashcard 3 of 5

Question: The most common ocular manifestation of rheumatoid arthritis is _____.

Answer: keratoconjunctivitis sicca

Ocular Manifestations of Systemic Disorders Flashcard 4 of 5

Question: _____ of margin and occlusion pupillae are seen in pupillary signs of anterior uveitis

Answer: Ectropion

Ocular Manifestations of Systemic Disorders Flashcard 5 of 5

Question: The most common ocular manifestation in mumps is _____.

Answer: dacrocystadenitis