What conditions can we diagnose through the eyes?  Systemic diseases

03/05/2018

The text below is an introduction to a series of short conversations between an internal medicine doctor and an ophthalmologist. A dialogue whereby we aim to stress the importance of cause and effect relations that very often exist between different common, general diseases or infections affecting the body and the eyes.

Dr. Rey (Internal Medicine:  IM)

Dr. Borja Salvador (Ophthalmologist: OPH)

• IM: A few days ago I was chatting over WhatsApp with an ex-intern about an interesting case.

• OPH: How is she doing? Where is she working?

• IM: This doctor is working in Valencia and she asked my opinion on a particularly intriguing case; she didn't know how to interpret the results of a biopsy carried on a 50 year-old male who had undergone a heart operation months before due to a valve infection, namely endocarditis. At that time he had a swollen eyelid and, despite receiving treatment, it had gotten worse. This is why she decided to have him undergo a biopsy.

• OPH: It must be some type of autoimmune disease or skin inflammation condition. What do you think?

• IM: I was thinking the same thing. But the biopsy suggested a "general", not local, case of infection—a metastatic infection, let's say.  The result could be interpreted as a recurrent cardiac infection. You'll have to ask around, I told her.

• OPH: That really is strange; it doesn't quite tally with an eyelid condition.

• IM: It's very rare. A cardiac valve infection can send embolisms to other organs. Well, a valve that is till "infected", and then we have to take a look at the heart.

• OPH: Wow, it's still a pretty uncommon diagnosis. With regard to the eye, endocarditis can affect not only the conjunctiva but the retina too, however, it's rarely found in the eyelid.

• IM: Endocarditis causes distant infectious nodules to appear on the fingers and toes. But clearly this would be a rare assumption. To sum up, after a few days, doctors in the Internal Medicine Department diagnosed endocarditis.

• OPH: Wow! Although this type of case is very uncommon, every day we see the general and systemic illnesses reflected in the eyes under the light of the slit lamp. And these cases need to be analysed along with the Internal Medicine Dept.

• IM: It's true; there are many cases where we need to work together.  

• OPH: We could do a review, from the most superficial to the most in-depth aspects. For example, on patients with cholesterol deposits around the eyes, xanthelasma and flaccid eyelids, seen in sleep apnoea.

• IM: Although only fifty percent of patients with high cholesterol have these deposits, there are other causes: primary biliary cholangitis, autoimmune hepatitis, etc. Floppy eyelid syndrome arises along with sleep apnoea. These people have not undergone a snoring study. And if the patient suffers from this, their risk of suffering from other eye conditions and risk of cardiovascular diseases increases.

• OPH: It can be diagnosed at an eye check-up. Take a look at the cornea: dry eyes; I remember a case with symptoms of dryness lasting for years, and fibromyalgia as well. When we carried out a general study, we were able to diagnose an autoimmune disorder: Sjögren syndrome.

• IM: His whole body was in agony; Sjögren's patients may have joint pain, which is why they are diagnosed with fibromyalgia. But if you look back at the clinical history and an ophthalmologist sees it, you'll hit the diagnosis on the head.  There is a specific treatment for this pain.

• OPH: People affected by dry eyes really suffer a lot. We find it more and more in our consultations, although we only refer a selection to the Internal Medicine Department when there other are dry mucosa or clinical presentation.

• IM: I receive some cases, the ones that your department assesses. I rule out general illnesses that cause dryness e.g. chronic hepatitis C, sarcoidosis, Sjögren, etc.

• OPH: Do you remember that patient with red eye who had swollen blood vessels in his conjunctiva and retina? We sent him for a vascular assessment.

• IM: Yes, I do remember: unilateral red eye. I checked his chest with the stethoscope because if there was a fistula between the artery and the vein behind the eye, I'd be able to hear a murmur. But I did not hear anything in particular in this case. I requested a brain MRI and a magnetic resonance angiography, which led to the following diagnosis: a carotid arterial fistula with a cavernous sinus. The patient presented with mild, chronic headaches, but the main problem was eye discomfort which is what led to the diagnosis.

• OPH: We come across all types of stories here!