Arteriosclerosis and vascular hypertension

The eye is the one structure in the body in which the blood vessels are easily visible to the examiner. Changes observed in the retinal vessels mirror changes that are taking place in other parts of the body, particularly those in the brain. In arteriosclerosis, degenerative changes occur in the walls of arteries that lead to thickening of arterial walls and narrowing of blood vessels and may give rise to complete occlusion (blockage) of a vessel. If the central retinal artery that supplies blood to the inner retina is affected, loss of vision is profound and sudden and, unless the obstruction can be relieved right away, permanent. Occlusion of the retinal veins is more common than arterial occlusion and also has dramatic effects caused by the damming up of blood in the eye. Blockage of retinal veins results in the bursting of small vessels, retinal swelling, and multiple hemorrhages scattered over the retina. Some degree of recovery of vision is usual but depends on whether a branch of the central vein or the central vein itself is occluded.

Vascular hypertension, or raised blood pressure, usually occurs in association with arteriosclerosis. Typical changes can be recognized in the small vessels of the fundus (the back portion of the interior of the eyeball). In severe cases, multiple hemorrhages, exudates (leaking proteinaceous fluid), and swelling of the optic disk (the head of the optic nerve) may be present. As with arteriosclerosis, hypertension can lead to vascular occlusions of the retina. The presence of hypertension typically worsens the effects of diabetic eye disease in patients having both afflictions.

Diabetes

Diabetic eye disease is a major cause of vision loss and blindness. It occurs more commonly with increasing duration of the disease and increasing patient age. People with advanced diabetic retinal disease are at increased risk of heart, kidney, and peripheral vascular disease. The actual cause of the changes in the retinal vessels is not clear, but the natural history of the disease is well recognized. Two general types of diabetic eye disease are known and are characterized as nonproliferative diabetic retinopathy (which lacks abnormal blood vessel growth) and proliferative diabetic retinopathy (in which abnormal blood vessels are present in the retina and sometimes the iris). Each type possesses different levels of severity, although one common cause of vision loss in diabetes, macular edema, can occur in either type at any level of severity. Nonproliferative diabetic retinopathy features changes due to damaged, weakened blood vessels, in which tiny aneurysms form and small hemorrhages and swelling within the retina can be seen. Areas of retinas that no longer receive appropriate blood flow, a condition called ischemia, can also appear. Visual loss at this stage may be absent or caused by retinal swelling or ischemia. If unchecked, nonproliferative diabetic retinopathy can lead to worsened blood flow to the retina, more severe damage, and the appearance of new abnormal blood vessels on the optic disk, retina, and even iris (proliferative diabetic retinopathy). Changes in these abnormal vessels can cause hemorrhage into the vitreous cavity, retinal detachment, and glaucoma.

Prevention or control of diabetic retinopathy relies on control of blood glucose levels. Various types of laser photocoagulation of the retina are used in certain forms of diabetic retinopathy in an attempt to halt or slow its progression. In cases of retinal detachment or persistent or recurrent hemorrhage within the vitreous gel, more extensive surgical treatments are employed. Glaucoma stemming from diabetic eye disease is often difficult to treat, but both medical and surgical approaches can be attempted.

Thyroid disease

Graves ophthalmopathy (an eye disease related to thyroid dysfunction) usually occurs in people with hyperthyroidism, although it can occur in people with normal or even reduced thyroid function. It is characterized by swelling and inflammation of the orbital tissues, including the extraocular muscles, that may lead to retraction of the eyelids, restriction of eye movement (causing double vision), and bulging forward of the eyeball (called proptosis). If severe, this could lead to corneal exposure, ulceration, and, in rare cases, loss of the eye. In addition, pressure on the optic nerve behind the eyeball from swollen tissues could cause vision loss. In most uncomplicated situations treatment is conservative, relying only on artificial lubrication, but in severe cases the lids may need to be partially sutured together or surgery may be required to relieve pressure in the orbit. Further eye muscle and lid surgeries may also be needed to correct persistent eye problems related to Graves ophthalmopathy.

Rheumatoid arthritis

The ocular complications of rheumatoid arthritis involve the sclera and cornea and can cause dry eye. Inflammation of the sclera, called scleritis, can cause intense, boring pain and, if severe, could be associated with life-threatening systemic disease. Treatment varies, depending on the disease severity, but generally includes anti-inflammatory and immune-modulating agents.

Floaters, blind spots, and flashes

One of the most common visual symptoms is the sensation of small black objects floating in front of the eye, known as “floaters.” These move with the eye but lag slightly at the beginning of an eye movement and overshoot when the movement stops. They are due to proteins, cells, and fragments of debris in the vitreous cavity of the eye. In certain conditions, as when looking at a blue sky, almost everybody can perceive them, and they are normal phenomena. However, a sudden increase in their number may indicate degenerative changes in the vitreous, which are particularly likely to occur in nearsighted individuals and in older people. These changes, although annoying, are of no serious import. The appearance of many floaters, however, may be associated with inflammation, bleeding in the eye, or a retinal tear and should be evaluated urgently.

Blind areas in the field of vision, called “blind spots,” occasionally force people to seek medical advice. Any condition that causes failure of function of part of the retina, the optic nerve, or the optic pathway to the brain can cause such a blind spot, and the symptom requires careful investigation. There is a naturally occurring blind spot in each visual field that corresponds with the lack of retinal elements where the optic nerve leaves the eye. The brain is so skillful in filling in the visual pattern that the normal blind spot can be detected only by special methods.

Flashing lights in the field of vision are caused by stimulation of the retina by mechanical means. Most commonly this occurs when the vitreous degenerates and pulls slightly on its attachments to the retina. Similar symptoms also arise when the retina becomes torn or detached, causing brief flashing lights to be seen. The combination of the abrupt onset of multiple flashes and floaters with a sensation of a shadowy “curtain” or “veil” coming across the vision strongly suggests the presence of a retinal tear and detachment.