Intraocular manifestations of systemic neoplasms

There are multiple possible intraocular manifestations in patients with systemic neoplasms. At first line there are uveal, retinal and vitreous metastases from carcinomas, melanomas and lymphomas. In patients with von Hippel Lindau syndrome or familiar adenomatous polyposis coli (FAP), Gardner or Turcot syndromes, fundus examinations can help in the primary diagnosis and thereby facilitate the early detection of systemic neoplasms such as cerebral and spinal haemangioblastoma, kidney or bowel cancer. Furthermore there are rare ocular paraneoplastic syndromes such as the cancer- or melanoma-associated retinopathies (CAR/MAR), the paraneoplastic optic neuropathy (PON) and the bilateral diffuse melanocytic proliferation (BDUMP) that develop secondary to systemic malignancies and can be the primary manifestation.     

Ocular manifestations of sarcoidosis.

Sarcoidosis remains an enigmatic disease with serious ocular morbidity. Recent literature continues to expand our knowledge of the ocular manifestations and their sequelae. Advances in diagnostic clinical testing are reviewed, including updates on angiotensin-converting enzyme levels, gallium scanning, bronchoalveolar lavage, and transbronchial lung biopsy.     

Incidence of ocular manifestations in patients with histologically confirmed systemic sarcoidosis

BACKGROUND: Intraocular findings in sarcoidosis were described by US studies with 35 % anterior uveitis, 25 % posterior uveitis and 20 - 30 % for late complications in case of first presentation. We report on the spectrum and diagnostic possibilities in 38 German patients. PATIENTS AND METHODS: 38 patients (68 eyes) aged 11 - 58 years (average 42.7 y), who suffered of intraocular manifestations in histological confirmed systemic sarcoidosis (1987 - 1997), were completely evaluated retrospectively. For additional diagnostic tools fluorescein angiography, optical coherence tomography, nuclear magnetic resonance tomography and measurements of angiotensin-converting enzyme, lysozyme and calcium in serum were performed. RESULTS: 15 patients (22 eyes = 32.4 %) had anterior uveitis: granulomatous keratouveitis (10 eyes), granulomas of the iris (6), granulomas of the trabecular meshwork (3) and 22 patients (42 eyes = 61.8 %) an intermediate and posterior uveitis: granulomatous perivasculitis (18 eyes), cystoid maculopathy (8), pars planitis (6), neuroretinitis (4), optic neuritis (3), choroiditis (3). Late complications in case of first presentation were found in 22 patients (39 eyes = 57.4 %): posterior synechiae 14 x, secondary glaucoma 10 x, cataracta complicata 8 x, optic atrophy 6 x, intraocular calcification 1 x. CONCLUSION: Compared to previous studies with heterogeneous ethnic composition, intraocular inflammations with confirmed sarcoidosis in German patients show more than 60 % involvement of the posterior segment. We may speculate on the reasons for these discrepancies as being due to ethnic reasons, age and long-term follow-up. In case of typical ocular signs of sarcoidosis, treatment should be started immediately even without histological confirmation. In some cases histological confirmation is successful 8 years after first presentation.     

Ocular manifestations of systemic hypertension.

Recent population-based studies suggest that the fundus lesions of hypertension also occur in people without hypertension. In experimental studies, hypertensive lesions, which used to be the backbone of older classifications of the severity of hypertension, did not correlate sufficiently with severity to allow reliable grading. Hypertensive retinopathy, choroidopathy, and optic neuropathy are independent processes. Vascular narrowing appears to occur early in the disease process, whereas retinal hemorrhages and retinal lipid may occur later. Branch vein occlusion is a complication of hypertension, whereas open-angle glaucoma may not be. Choroidal neovascularization in the fellow eyes of patients with macular degeneration is associated with high blood pressure. Laser treatment for this disorder is less effective in patients with high blood pressure than it is in normotensive individuals, which suggests that choroidal neovascularization may be an expression of chronic hypertensive choroidopathy. Hypertensive optic neuropathy, a variant of ischemic optic neuropathy, has delayed onset compared with retinopathy and, in experimental studies, has not been linked to the severity of hypertension. Given these findings, it may be better to describe than to grade fundus lesions. In either event, it is important to take blood pressures accurately. Fundus lesions suggest high blood pressure. Sphygmomanometry is more specific and reliable than funduscopy in making that diagnosis.     

Ocular manifestations of systemic infections.

Systemic infections occasionally present with ocular involvement. Prompt diagnosis and management, aided by an internist, may lead to resolution of the infection without severe ocular sequelae. Recent literature discussing atypical ophthalmic manifestations, treatment options, or transmission risks of the following diseases is reviewed: infection with hepatitis viruses, toxoplasmosis, tuberculosis, bacteremia, and endogenous mycotic endophthalmitis.     

Ocular manifestations of systemic diseases.

The purpose of this review is to keep the optometrist informed as to the latest developments in the field of Ophthalmology. Papers reviewed are, almost exclusively, those published between Oct. 1st, 1973 and Sept. 30th, 1974. Emphasis will be placed on signs and symptoms of the disorders which are helpful in their detection or confirmation. No rare disorders will be discussed and although the literature has been especially rich in single cases this past year, they have been, for the most part, omitted from this review. Thus, to an ophthalmologist, the selection may appear arbitrary and incomplete. For purposes of reviewing, as in previous years, diseases reviewed are divided into non infectious and infectious. Infectious diseases are grouped according to the organ system or the system function predominantly affected, including hereditary and/or congenital diseases. The infectious diseases are grouped as to the causative pathogenic organism.     

Ocular manifestations in sarcoidosis]

PURPOSE: The ophthalmic examination of patients with diagnosed systemic sarcoidosis. MATERIAL AND METHODS: 33 patients (17 women, 16 men), aged 22-60 years had ophthalmic examination (visual acuity, anterior and posterior segment evaluation, applanation tonometry). In 8 patients repeated examination was performed (duration of observation: 2-31 months). RESULTS: In 27 patients no characteristic features of ocular sarcoidosis were found. In 6 persons (18.2%) variety of ocular lesions was recognized (nodular infiltrations of the eyelids, chronic uveal inflammation, signs of anterior and posterior uveitis in the past, optic disc oedema). In 3 cases ocular lesions preceded the signs of systemic sarcoidosis. This emphasizes the importance of the routine ophthalmic examination of patients with suspected or proven sarcoidosis.     

Corneal manifestations of the systemic mucopolysaccharidoses.

Newer biochemical understanding of the mucopolysaccharidoses now allows a better classification of these diseases. The dermatan and keratan sulfate-storing diseases have corneal clouding. The heparan sulfate-storing diseases have retinal changes and usually central nervous system manifestations.     

Diagnosis of ocular sarcoidosis by diagnostic criteria for systemic sarcoidosis

PURPOSE: To evaluate the diagnostic criteria for systemic sarcoidosis in diagnosis of ocular sarcoidosis. SUBJECTS AND METHODS: Subjects were 105 ocular sarcoidosis suspects and 37 patients with other uveitis. We diagnosed ocular sarcoidosis suspects using the diagnostic criteria for systemic sarcoidosis proposed by the Japanese Committee for Diffuse Lung Diseases. The criteria included histological and clinical diagnosis, and the clinical diagnosis required 5 systemic tests: 1) tuberculin skin test, 2) serum gamma-globulin(gamma-gl), 3) serum angiotensin converting enzyme(ACE), 4) serum lysozyme, and 5) 67Ga scintigraphy. Three positive findings including either 1) or 3) fulfilled the clinical diagnosis. RESULTS: Sixty-two patients were histologically and/or clinically diagnosed, and 43 patients remained undiagnosed. The histological and clinical diagnosis did not produce the same diagnostic yields. The sensitivity of ACE and gamma-gl was low. The percentage of patients showing increased lymphocytosis and/or CD 4/8 in bronchoalveolar lavage was similarly high in the diagnosed and undiagnosed, suggesting the presence of definitive ocular sarcoidosis in the undiagnosed. CONCLUSIONS: The diagnostic criteria for systemic sarcoidosis yielded false negative results in diagnosing ocular sarcoidosis. The selection and combination of systemic tests for clinical diagnosis should be further studied.     

Neuro-ophthalmologic manifestations of systemic and neurologic disease.

Neuro-ophthalmology is a difficult and challenging field for both ophthalmologists and neurologists. Unfortunately, signs and symptoms of these patients can be very subtle and easily overlooked. Although neuro-ophthalmologic cases are rare in the practice of a general ophthalmologist, missing the diagnosis can have a severe impact on the patient's health. This paper reviews last year's publications on neuro-ophthalmologic manifestations of systemic and neurologic disease.     

Choroidal granulomas in systemic sarcoidosis

PURPOSE: To evaluate the clinical course, including response to therapy, of patients with macular and peripapillary choroidal granulomas secondary to systemic sarcoidosis. METHODS: This is a retrospective case study and literature review. Nine patients with choroidal granulomas were identified. Eight patients had a tissue biopsy confirming sarcoidosis; one was diagnosed from clinical history and typical gallium scan. Ocular examinations included fundus examination, fluorescein angiography, and visual field examination. Eight patients had magnetic resonance imaging (MRI) scans looking for intracranial granulomas. Treatment consisted of oral prednisone in eight patients (one with concomitant subconjunctival triamcinolone); one patient received no treatment because of good vision and granuloma in the nasal retina. Variables studied included visual acuity (VA), response of granulomas to treatment, time to recurrence, and associated anterior segment findings. RESULTS: Eight of nine patients had a solitary lesion whereas one had multifocal involvement. The granulomas ranged in size from one half to four disk diameters. Eight patients had blurry vision; one was asymptomatic. All nine patients had hilar adenopathy and/or pulmonary parenchymal disease. No patient had nonocular neurologic symptoms and in eight patients who underwent MRI examination no intracranial granulomas were detected. Of the eyes that were treated (n = 8) all had decrease in the size of the choroidal mass at an average of 4 months of treatment. Two had complete resolution. Mean follow-up was 29.2 months. At the time of initial diagnosis only one patient had an active anterior uveitis. Five of nine patients had at least one recurrence. Mean time to recurrence was 7.6 months after discontinuing oral prednisone. The VA at presentation ranged from 20/30 to 20/300. Final VA was 20/30 or better in all patients. CONCLUSIONS: Choroidal granulomas related to systemic sarcoidosis respond well to oral corticosteroids. They may recur but good vision can be maintained. They are not typically associated with concomitant iritis and also do not appear to be associated with intracranial granulomas.     

Some ocular manifestations of systemic drug abuse.

Optometrists are increasingly likely to see patients who use illicit drugs, which may cause ocular signs which mimic other problems. This paper reviews pharmacologic effects on the eye of depressants, hallucinogens, inhalants, marijuana, opiates, and stimulants including amphetamines and cocaine. Drug abusers suffer from AIDS, CMV retinitis, fungal and bacterial endophthalmitis, quinine poisoning and talc retinopathy. The ocular signs and symptoms of these diseases are discussed. The most common presenting complaints in an optometric setting are emphasized.     

Intraocular pressure and systemic blood pressure in the elderly.

The intraocular and systemic blood pressure, height, weight, and haemoglobin were measured in 573 subjects over 60 years old from a general practice population. Intraocular pressure was positively and independently related to systemic blood pressure (P less than 0.0001) and obesity (P less than 0.01) as assessed by the ponderal index. Systolic pressure rather than diastolic or mean pressure was most closely correlated with intraocular pressure and it is suggested that the systolic head of pressure increases the filtrated fraction of aqueous humour to cause a small but sustained rise in intraocular pressure. It is also suggested that obesity may decrease the facility of aqueous outflow.