• Roshni Patel, BSc (Hons) MCOptom
   

Accordingly, signs of hypertension that optometrists look for in the eye include any arteriolar constriction, vascular wall changes, arteriovenous nipping, haemorrhaging (particularly ‘flame’ shaped), yellow hard exudates, or optic disc oedema.

High Cholesterol
Indications of high cholesterol that may develop around the eyes include xanthelasma, which are deposits of fat beneath the skin on the eyelids, or an arcus, which is a white ring around the
outer edge of the cornea. Both may occur without high cholesterol but should prompt consultation with a GP. More threatening is vision loss from retinal artery occlusion, which generally appears as a painless loss of vision in one eye, and should be dealt with directly and urgently alongside an investigation into cholesterol levels.
 

Auto-Immune Conditions

Hyperthyroidism
An overactive thyroid produces an increase in thyroid hormones, and can be caused by a number of conditions, including the autoimmune condition, Graves’ disease. This can lead to thyroid eye disease, also known as Graves' orbitopathy, which sees the muscles and soft tissues in and around your eye socket swell. Your eyes may also become dry, and you may experience redness or pain on eye movement, as well as double vision. The condition can also cause the eyes to protrude.

Rheumatoid Arthritis
The inflammation that affects joints can also affect the eye. Symptoms include dry eyes, blurry vision, scleritis (a very serious condition, which causes redness, light sensitivity and pain), and episcleritis, which is limited to the episclera and less serious: both can be identified through standard eye tests.

Sjögren’s Disease
Sjögren’s disease affects areas of the body that produce fluids and, therefore, can present in the eyes as dryness (aqueous deficiency); it may also be linked with other autoimmune diseases such as lupus or rheumatoid arthritis.

Inflammatory Conditions

Sarcoidosis, Ulcerative Colitis, and Ankylosing Spondylitis
Inflammatory conditions can present as uveitis, namely anterior, in the form of iritis, in which the eye may become very painful, red, and sensitive to light. Uveitis is a serious condition and needs prompt medical attention.

Sarcoidosis may also entail episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation as it can affect all structures within the eye.

Neurological Conditions

Brain Tumours
Tumours can cause swelling of the optic nerve at the back of the eye (papilloedema) - due to raised intracranial pressure individuals can experience a loss in visual field (the type will vary based on the location of the tumour), extreme headaches (worse on waking), and double vision.

Multiple sclerosis
Multiple sclerosis may be the underlying cause of optic neuritis (inflammation of the optic nerve), though not all cases of optic neuritis lead to MS. An example follows in which a patient was diagnosed with optic neuritis, allowing investigation into whether she had MS to start as early as possible:

“A young lady came in for a second opinion after being seen elsewhere, due to a sudden onset of ‘patchy’ vision and dull pain in one eye and told it was down to dry eyes.

“When I assessed her vision in the affected eye, she had minimal perception, and could only register light. This was not indicative of dry eyes and noting her gender, age and suspicious pupil reaction to light I had an inkling that it may be optic neuritis.

“On assessing the back of her eyes, especially her optic nerves, everything appeared normal. This is quite common in ‘retrobulbar neuritis’ where the swelling/inflammation occurs behind the optic nerve head. We took photos of the back of the eye, allowing me to analyse the eye in more detail, and I noticed a very subtle area of swelling.

"There was no point in performing a visual field assessment as her affected eye only had light perception, but patients with optic neuritis often have a distinctive visual field loss. I referred her to Neurology, and she was confirmed as having optic neuritis."

• Roshni Patel, BSc (Hons) MCOptom
   

Other symptoms that may be reported by those with MS may include double vision, impaired colour vision, and pain or difficulty moving the eye.

Cancerous Conditions

Pancoast Tumour in the Lungs
Pancoast tumours are cancers in the top part of the lungs and are relatively rare with just 5% of cases of lung cancer being a result of a pancoast tumour.

Patients can experience symptoms such as severe pain in the shoulder and arm as well as weakness in the hand on the side of your body that is affected. Another sign of this cancer is Horner’s syndrome, which is a combination of signs and symptoms that can occur in a patient. It typically includes having a smaller pupil, drooping eyelid, and reduced sweating on the affected side of the face. If of sudden onset or associated with other signs and symptoms, patients need to be seen by a doctor immediately.

Roshni provides a case study on a patient suffering from a pancoast tumour:

“I was taught at university to always assess a patient when they walk into practice (i.e. do they have mobility issues, have they got a head tilt etc to get a very high-level idea about general health and potential eye conditions to look out for), so when this elderly gentleman sat down in my chair mentioning his prolonged shoulder pain in passing, I instantly thought arthritis and dry eye. However, that was not the case, unfortunately.
“His main reason for attending was because he suddenly noticed the pupil in 1 eye was a lot smaller than the other.
“After assessing his pupils in different light settings, I knew it was Horner’s syndrome. He also had a very subtle dropping of his eyelid of the affected eye. Horner’s syndrome can occur for many reasons but in his case, as confirmed by the hospital, it was down to a tumour in his lung – Pancoast tumour.”

•  Roshni Patel, BSc (Hons) MCOptom
   

Conclusion
With the above symptoms in mind, it’s important to recognise that the eye can be an early indicator of disease across not just vision-related areas, but also the rest of the body.

Optometrists need to be constantly aware of how a sign or symptom may be as a result of wider disease and offer appropriate and timely management.
 

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