Medical Ophthalmology

Medical ophthalmologists (or ophthalmic physicians) investigate, diagnose and manage eye disorders relating to systemic disease. The physician's approach and knowledge of internal medicine is crucial in managing both the systemic problem and the eye. Therefore, the training encompasses both ophthalmology

and medicine.

An Exciting and Emerging Interdisciplinary Specialty

Currently there is a training programme in the United Kingdom which is undertaken after basic physician training. In Australia and Ireland, medical ophthalmology training can be undertaken after basic or advanced ophthalmology training.

Nima Ghadiri, MA MB BChir MRCP(UK), Medical Ophthalmology Trainee, Addenbrooke’s Hospital, Cambridge, UK

This poster spotlights the role of the medical ophthalmologist as an interdisciplinarian who has expertise in both the eye itself, and the various physician specialties which affect the eye.

CHEST

Sarcoid (Chest and Multi-system granulomatous inflammation - ? Infectious)

Eyes: conjunctiva uveitis, choroiditis, retinal vasculitis, optic neuropathy)

2 Months before referral At referral

Pleural effusions (rarely, if ever, arise in sarcoid)

Note neuroretinitis and arterial sheathing. Characteristics of tuberculosis, not found in sarcoid

25yr old Caucasian student referred from a London teaching hospital “Pneumonia with pleural effusion”, followed by “ocular sarcoidosis, uncontrollable by immunosuppression”. Bilateral visual loss (HM, 6/36).

Good response to anti-tuberculous treatment with steroids, visual recovery to 6/60, 6/5.

Tuberculosis (Multi-system granulomatous infection, Latency/reactivation)

Eyes : conjunctiva uveitis, choroiditis, retinal vasculitis, (arterial and venous sheathing retinitis, neuroretinitis

NEUROLOGICAL

Retinal vasculitis and multiple sclerosis

Visual pathways: Inflammation (autoimmune, infection), tumors, vascular *(anomalies, disease), drug toxicity

50yr old Indian woman with unresponsive scleritisRight visual obscuration and afferent pupil defect, headache, tinnitus, jaw claudication, weight loss, ANCA positive. Wegeners’ Meningitis suspected.Meningeal enhancement on MRIS.Diagnosis by meningeal biopsy.Treatment: Rituximab

CARDIOVASCULAR

Emboli to retinal and posterior ciliary artery territories: occlusive/bacterial

Cardiac arrhythmias, valvular heart disease, aortic and carotid atheroma, right-to-left shunting (atrial septal defects and patent foramen ovale), bacterial endocarditis

Anterior segment vascular imaging: ocular ischaemic syndromes/systemic vasculitis

Optic disc of 29yr old man with visual loss due to chronic severe hypertension

AUTOIMMUNE

Temporal arteritis, ANCA positive vasculitis systematic lupus erythematosus, Behcet’s syndrome

MRI scan of orbital Wegener’s Granulomatosis.

An inflammatory mass wraps the right optic nerve

Acute retinitis in patient with Behcet’ssyndrome

JOINTS

Rheumatoid disease: scleritis and keratitis

HLA-B27: uveitis +/- reactive arthritis

67yr old woman: rheumatoid disease, uncontrollable necrotizing sclerokeratitis

[Prosthetic R shoulder joint had been removed due to Staph aureus infection]

Search for infectious drives by indium leucocyte scan: Collection in the Right humerus.

• Surgical removal of cement restrictor (iv antibiotic and steroid cover)

• Systemic immunosuppression (prednisolone + cyclophosphamide)

+4yrs: immunosuppression withdrawn

+5yrs: scleritis complicating Staph aureus orbital cellulitis (responded to antibiotics, then immunomodulation)

INFECTIONS

Bacterial:

Surface: upper respiratory tract and conjunctiva share organisms.

Intraocular: latent (reactivation) / endogenous endophthalmitis / SBE

Viral: adenovirus, herpesviruses (simplex, zoster, cytomegalovirus)

Parasitic: toxoplasma, toxocara

60yr old: Polymyalgia rheumatic for 6yrs: methotrexate, azathioprine

Episodic R visual loss: prednisolone 120mg/day

+3 months: L stroke

+5 months: L granulomatous uveitis + retinal arteritis

+8 months: Prednisolone 20mg, azathioprine 175mg

Cytomegalovirus retinitis

Azathioprine stopped, Prednisolone reduced (17.5mg>)

Ganciclovir, then valganciclovir

Eye inflammation and systemic symptoms resolved

HAEMATOLOGICAL

Thrombophilia (retinal arterial and venous occlusions)

Lymphoma (orbital, conjunctival, intraocular)

69yr old woman with uveitis

Left-sided facial sensory loss

Progression despite steroids

Features of lymphoma: cords of vitreous cells

Brain biopsy: High-grade B-cell lymphoma

expanding before Rx contracting before Rx

Months

0 CF, CF → Methylprednisolone x3, cyclosporine A 200ug/1, nifedipine

1 6/60, 6/24 → Methylprednisolone x3

10 6/12, 6/9

11 colour vision full, driving

4yr 6/12, 6/9 → Block/replace withdrawn no immunosuppression

ENDOCRINE

Medical treatments for thyroid eye disease

At presentation 4 years later

49yr old diabetic woman with treated thyrotoxicosis

Reduced right vision 6/36, 6/9

R surgical orbital decompression: awoke with bilateral visual loss (CF, CF)

Orbits hard vision (no colour vision on R)

OTHERS

Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) - Uveitis

Gastrointestinal

Urinary Tract

Skin and Mucus Membranes

Interstitial nephritis – uveitis

Systemic vasculitis – scleritis, keratitis

Stevens-Johnson Syndrome, ocular cicatricialpemphigoid

OCULAR

Ocular and orbital inflammatory disease

Management of macular oedema

Perioperative management in ocular inflammatory disease

Post-operative eye infections (exogenous endopthhalmitis)

Ocular vascular disease

New techniques for imaging microcirculations

Adhesions between iris and lens in uveitis

Bacterial deposits in lens capsule after cataract surgery

Haemoglobin video imaging study of normal human

conjunctival microcirculation

AN INTERDISCIPLINARY SPECIALTY

This interdisciplinary speciality has an important role in managing complex patient groups throughout the world and in bridging the gap between hospital ophthalmic services, inpatient medical care and community care.

Therapeutic options can be very effective, in many cases circumventing the need for potentially risky surgery. The continued development of new treatments mean that the speciality has an exciting future.