Eyes and the heart: what a clinician should know

Abstract

The eye is prone to various forms of afflictions, either as a manifestation of primary ocular disease or part of systemic disease, including the cardiovascular system. A thorough cardiovascular examination should include a brief ocular assessment. Hypertension and diabetes, for example, would present with retinopathy and dyslipidaemia would present with corneal arcus. Multisystem autoimmune diseases, such as Graves' disease, rheumatoid arthritis and sarcoidosis, would present with proptosis, episcleritis and scleritis, respectively. Myasthenia gravis, while primarily a neuromuscular disease, presents with fatigable ptosis and is associated with Takotsubo cardiomyopathy and giant cell myocarditis. Connective tissue diseases such as Marfan syndrome, which commonly presents with aortic root dilatation, would be associated with ectopia lentis and myopia. Wilson's disease, which is associated with arrhythmias and cardiomyopathies, would present usually with the characteristic Kayser-Fleischer rings. Rarer diseases, such as Fabry disease, would be accompanied by ocular signs such as cornea verticillata and such cardiac manifestations include cardiac hypertrophy as well as arrhythmias. This review examines the interplay between the eye and the cardiovascular system and emphasises the use of conventional and emerging tools to improve diagnosis, management and prognostication of patients.

Keywords: Atherosclerosis; Cardiomyopathies; Diabetes mellitus; Hyperlipidemias; Hypertension.

Figure 1

Eye examination and systemic diseases involving the cardiovascular system. This figure depicts the various parts of the eye, numbered accordingly from anterior to posterior. Correspondingly, each part is co-labelled with the respective pathology of significance. AION, anterior ischaemic optic neuropathy.

Figure 2

Image panel depicting the various ophthalmological pathologies that are pertinent to the cardiologist. (A) Xanthelasma palpebarum (white arrows) seen over both inner eyelids bilaterally. (B) Proptosis. (C) Ptosis, seen in a patient with myasthenia gravis. (D) Anterior scleritis. (E) Cornea verticillata (orange arrow) of a patient with Fabry disease. (F) Corneal arcus (red arrow) as seen in a patient with hypercholesterolaemia. (G) Ectopia lentis seen as a superiorly subluxated lens (white arrowhead). (H) Sarcoid nodules (black arrows) seen in the eye of a patient with sarcoidosis. (I) Colour fundus photograph of left eye showcasing central retinal artery occlusion. Thin retinal arterioles and cherry-red spot (red arrowhead). (J) Central retinal vein occlusion with widespread retinal haemorrhages in all four quadrants of the retina. (K) Roth spot (white arrow and box) in a patient who had bacterial endocarditis. (L) Ocular ischaemic syndrome with blot haemorrhages (black arrowheads) in the mid-periphery of the retina. This is caused by reduced perfusion pressure into the retina commonly due to significant carotid stenosis. Permission granted, International Ophthalmology, 20 June 2020.

Figure 3

This is a figure of a patient with Kayser-Fleischer ring (white arrow) secondary to copper overload.

Figure 4

Stages of hypertensive eye disease. The Scheie classification was used to describe the changes associated with retinal hypertensive retinopathy, with grade 1 reflecting the least and grade 4 reflecting the most. (A) Grade 1 hypertensive retinopathy with mild arteriolar narrowing (white arrows). (B) Grade 2 hypertensive retinopathy characterised by focal retinal arteriolar narrowing (white arrowhead). (C) Grade 3 hypertensive retinopathy. Findings are the same as grade 2, with retinal haemorrhages (black arrows) and cotton wool spots (red arrow). (D) Findings are the same as grade 3, with additional optic disc swelling and retinal exudates (black arrowhead).

Figure 5

Stages of diabetic retinopathy. (A) Mild non-proliferative diabetic retinopathy with microaneurysms (black arrow and box) only. (B) Moderate non-proliferative diabetic retinopathy with more than four blot haemorrhages (white arrows) in one hemifield. (C) Severe non-proliferative diabetic retinopathy. More than four blot haemorrhages can be seen in both hemifields. (D) Proliferative diabetic retinopathy with new vessels (black arrow) on disc and other regions.