By F. Seruk. Sonoma State University.

The sup- bilateral optic neuropathy that manifests as cen- erior part of the disc is pale buy clopidogrel 75 mg otc. Anaemia secondary to blood loss can give rise to ocular hypoper- Emboli fusion order clopidogrel 75 mg on-line, which leads to anterior ischaemic optic Cholesterol emboli can be seen in the retinal neuropathy cheap clopidogrel 75 mg without prescription. Examination of the conjunctiva is arteries, sometimes in association with arterial perhaps of more value or at least is certainly occlusion. These usually arise from atheroma- an easier way of assessing the haemoglobin tous plaques in the carotid artery. Calcied level and this part of the examination of the eye emboli can be seen in association with diseased should, of course, precede ophthalmoscopy. The Leukaemias Ischaemic Optic Neuropathy All ocular tissue can be involved in leukaemia. Some elderly patients complaining of visual loss The eye changes can occur at any time during in one eye are found to have a pale swollen optic the course of leukaemia, or they can make up disc and sometimes evidence of branch retinal the presenting features of the disease. These artery occlusion, giving an altitudinal defect of changes are more common in the acute the visual eld. About one-third of these patients develop example thrombocytopenia, increased blood bilateral disease. Less common manifestations include When the haemoglobin concentration in the choroidal inltrations, and retinal and optic blood is abnormally low, this becomes apparent disc neovascularisations. The changes, the vision can be impaired by Systemic Disease and the Eye 175 deformable compared with normal, leading to occlusion of the small retinal blood vessels especially in the retinal periphery. Sickle-cell retinopathy can be divided into two types: (1) nonproliferative and (2) proliferative. When central retinal arterial or venous occlusion, macular arteriolar occlusion or choroidal ischaemia occurs, there is signicant visual decit. Such peripheral neovas- cularisation can respond to laser photocoagula- tion or cryotherapy of the retina. The name river blindness is derived from the occurrence of the disease in focal areas along rivers and streams where the blacky Sickle-cell Disease (Similium) breeds in fast-owing water. The blacky can travel several kilometres and does This condition is mentioned separately because not respect international borders. The sickle-cell haemoglo- worms encased in nodules and the invasion of binopathies are inherited and result from the the body by microlaria produced by the adult affected person having one or more abnormal worms. It is endemic in equatorial Africa West haemoglobins as recognised by the electro- and Central and Central and South America. It is estimated that there are about half a million Haemoglobins S and C are the most important blind people because of onchocerciasis. Newly usually lead a normal life and do not have any produced microlariae migrate to the eye systemic or ocular complications. The are rm, round masses in the dermis and sub- earlier stages of the disease are often asympto- cutaneous tissue, especially close to joints in the matic (Table 21. In Intraocular microlariae can be seen in the Africa, it is generally a heterosexual disease, and anterior chamber. Dead microlariae are usually a signicant paediatric population is also seen in the cornea (especially peripherally). Transmission is through sexual inter- Other ocular features are punctate keratitis course, parenteral or transplacental routes. Optic atrophy and neurysms, telangiectasia, cotton-wool spots and neuropathy are not uncommon. Retinal peripheral Diagnosis is conrmed by skin snip and the perivascular sheathing may sometimes occur Mazzoti test, which depends on a Herxheimer in the absence of intraocular infections. Noninfectious retinopathy: (a) cotton-wool spots (b) retinal haemorrhages (c) microvascular changes. Neoplasms of the conjunctiva, Pneumocystis carinii choroiditis lids and orbit, and neurophthalmic complica- tuberculous choroiditis tions are other features. Neoplasms: (a) conjunctival, palpebral and orbital Kaposi s sarcoma (b) intraocular lymphoma (c) other neoplasms: conjunctival squamous carcinoma palpebral and orbital lymphoma. Pallor of neurological and neurosurgical departments, the disc is caused by loss of nerve tissue and and neuro-ophthalmology is now in itself a sub- small blood vessels of the surface of the disc. Retrobulbar neuritis, for example, is a severe optic atrophic cupping, there is exposure condition that presents quite commonly to eye of the underlying sclera. The myopic disc is rel- casualty departments and usually requires atively pale, whereas the hypermetropic disc is further investigation by a neurologist. There are These are better dened in myopic than in many other, sometimes rare, conditions, which hypermetropic subjects. It is common to see a The Optic Disc crescent of pigment on the temporal side of the disc. Frequently, an area of chorioretinal Normal Disc atrophy is present at the disc margin in myopes and can give rise to difculty in deciding where One must be familiar with some of the vari- the true disc margin is. The optic discs mark the entrance of the optic nerves to the eye and this small circ- In general, a central retinal artery and vein ular part of the fundus is nonseeing and cor- divide into upper and lower branches, which in responds with blind spots in the visual eld. Many variations in the features are to be noted: the colour, the margins pattern are seen normally. The veins are darker or contour, the vessel entry, the central cup and and wider than the arteries and, unlike the the presence or absence of haemorrhages. In Colour the other 20% of normal individuals, venous The disc is pink but often slightly paler on the pulsation at the disc can be induced by gentle temporal side. The central cup might be lled in by drusen small hyaline deposits, which can be found on the surface or buried in the sub- stance of the disc. Alternatively, the central cup might be hollowed out further by a congenital pit in the disc. The central cup can be lled in by persistent rem- a nants of the hyaloid artery (Bergmeister s papilla), which runs in the embryo from disc to lens. Some of these and other congenital abnor- malities of the disc can be associated with visual eld defects that are not progressive but which can cause diagnostic confusion. Pale Disc Optic Atrophy Optic atrophy means loss of nerve tissue on the disc, and the resulting abnormal pallor of the disc must be accompanied by a defect in the visual eld,but not necessarily by a reduction in b the visual acuity. The number of small vessels, which can be counted on the disc, is sometimes used as an index of atrophy in difcult cases. Central Cup Classication of the causes of optic atrophy The centre of the disc is deeper (i. The terms primary and second- (or less) of the total disc diameter in normal ary atrophy are also used but because these subjects. The ratio between the vertical diame- terms are confusing a simple aetiological ter of the cup and the total disc diameter is classication will be used here. Thus, the borne in mind that it is not usually possible to normal cup-to-disc ratio is <0. Even the cupped, pale disc of chronic glaucoma can be mimicked Haemorrhages by optic atrophy because of chiasmal compres- Haemorrhages are never seen on or adjacent sion. If present, they warrant optic disc, there is more gliosis than when it is further investigation.

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However discount clopidogrel 75 mg with amex, some cattle with small full-thickness the cow will usually be dead in less than 24 hours cheap clopidogrel 75 mg with amex. The laxative be suspected buy clopidogrel 75 mg amex, and the exact cause will escape detection diet and species difference in fecal consistency preclude unless an autopsy is performed. This simple, autosomal, recessive defect results in con- Permanent tail paralysis may persist and result in a striction at the anorectal region and vulva-vestibule soiled perineum and tail, as well as possible vulvovagi- region. Fibrous tissue at these areas prevents rectal ex- nal fecal contamination, which interfere with fertility. Jersey cattle with this Surgical repair may be possible for show animals or very defect also appear especially prone to severe parturient valuable breeding animals in which a fractured tail udder edema. Af- fected calves show signs shortly after birth because they Pneumorectum may be caused by conformational de- are unable to pass manure. The rectal lumen usually bulges subcutane- rectum usually does not require treatment because it ously in the normal region of the anus when the abdo- does not cause illness unless it persists and becomes men is compressed. Although simple cutaneous puncture severe, in which case one or more epidurals may be often allows fecal passage, these incisions often brose needed as treatment. Cows can get into a vicious cycle and lead to anal stricture, tenesmus, and abdominal of sucking air and straining such that they will be- distention. When a rectal examination is essential for diag- has not been documented, the ethics of performing this nostic purposes (e. This may be accomplished by a gentle sweeping of the rectum until a contraction band can be grasped and pulled caudally Constipation to express the air from the rectum. The procedure may This condition is uncommon in cattle and, when ob- need to be repeated several times to complete evacua- served, generally points to neurologic decits or painful tion and is quite successful except in instances of severe conditions that interfere with defecation. Because matic caudal spinal cord injury include lymphosarcoma, the rectum traverses the right upper abdominal quad- neurobroma, and ascending cauda equine myelitis as- rant, the ping occurs from the tuber coxae through the sociated with tail head cellulitis caused by perivascular right paralumbar fossa and a variable distance cranially. Poor aseptic technique during repeated epidural this nding creates a broad differential diagnosis (cecal administration is another possible cause of ascending myelitis. Fractures of the base of the tail involving the sacro- coccygeal junctional area may cause so much pain and can also cause neurologic defects that the cow shows signs of constipation. The most common cause of tail fractures in cattle is being ridden by other cows or bulls during standing estrus. Sadistic tail restraint that frac- tures the tail may also cause severe pain, constipation, tail head swelling, and accidity of the tail. Treatment for tail fractures is symptomatic in most cases and includes analgesics, antiinammatories, and laxative diets. Uterine perforation during dystocia and penetrating abdom- Pneumoperitoneum inal wounds are other causes of pneumoperitoneum Etiology that would have additional distinct signs or historical Pneumoperitoneum is dened as air or gas free in the features. Whereas the most common cause of this disorder is exploratory laparotomy, other causes such Diagnosis as perforation/rupture of distended abdominal organs The diagnosis is made by physical examination and rectal may result in pneumoperitoneum. This disorder must be differentiated from other pneumoperitoneum appears to be more commonly as- causes of abdominal distention by careful auscultation/ sociated with abomasal perforation rather than traumatic percussion and rectal evaluation (Table 5-4). Pneumothorax or pneumo- ping is present bilaterally, there seldom should be confu- mediastinum also occasionally progresses to involve the sion. If a cow has had laparotomy surgery recently, the abdomen, thereby creating pneumoperitoneum. Although more easily heard on the right In mild cases of pneumoperitoneum following explor- side because of the rumen mass lling the left abdomen, atory surgery, no treatment is necessary. In moderate to this ping generally is detectable to some degree on both severe cases, affected cattle are so distended that dis- sides. Fluid is not present when the abdomen is ballotted comfort and lack of appetite may result. When rectal examination is free air in the abdomen should be evacuated by suction performed, the examiner will nd the rectum uniformly through needle puncture in the right paralumbar compressed against the hand and arm by the pressure of fossa. In these cattle, the typical ping and uid content of a displaced abomasum will be present along with the signs of pneumoperito- neum and fever. Local- ized abdominal pain also may be present in the area of the displacement when perforation coexists. Right para- median laparotomy to best gain access to the abomasum is recommended, but the prognosis is guarded because the abomasum may be afxed to the body wall by brin- ous adhesions and is prone to rupture or leak contents through the perforating ulcer when surgical manipula- tions detach the organ from the body wall. Immediate surgical exploration from the right paramedian approach conrmed a small perforating abomasal ulcer, which was oversewn and an abomaso- Peritonitis pexy performed. Well-known causes of peritonitis in the dairy cow include traumatic reticuloperitonitis, perforating abomasal ul- Prevention cers, improperly performed blind tack and toggle-pin Prevention of severe pneumoperitoneum is only possi- procedures, and uterine rupture following dystocia. Less ble for those animals at risk because of exploratory lapa- frequent causes of peritonitis exist, but because of both rotomy and is accomplished by an attendant pushing on their rare occurrence and high mortality, discussion of the opposite side of the cow s abdomen to evacuate the these will be limited. It may be observed in neonatal calves that apparently have been stepped on by their dam or other adult cows. It also occurs in adult cattle during parturition when a loop of small intestine is entrapped and subsequently squeezed between the maternal pelvis and the fetus within the birth canal. Uterine Perforation by Pipette Injury This lesion results in peritonitis or abscessation involving the uterus and is caused by neophytic or overaggressive attempts at uterine infusion especially when attempt- ing to infuse a cow with septic metritis less than 2 weeks postpartum when the cervix and uterus cannot possibly be elevated into the pelvis for routine infusion. This le- sion is typically non life-threatening but can limit the individual s future reproductive use and value. Vaginal Perforation Perforation of the vagina has been observed following natural mating, pipette injuries, dystocia, or sadism. These include the umbilical remnants or dorsal to the large purulent uid accumulation (see region and the omental bursa. Abscesses also may develop subse- Displacement of the Omasum quent to rumen trocharization. These cases were be seen secondary to toxic rumenitis, but these tend to rst brought to our attention by Dr. Occasional full- have been conrmed on exploratory laparotomy and at thickness ruminal perforations with associated peritoni- necropsy. Cows often have a several-day history of de- tis will occur because of penetrating foreign bodies, but creased appetite and production. The omasum has been palpated rectally on serum globulin often is elevated, serum albumin is a couple of the cows. An appropriate surgical repair decreased, and the abdominal uid usually reects in- method has not been determined at this time. Ultrasonography Idiopathic Eosinophilic Enteritis may help localize the lesion such that surgical drainage may be attempted. Appropriate antibiotic therapy is This is a rare but well-documented cause of chronic di- based on culture and sensitivity results from the abscess. Brenner J, Orgad U: Epidemiological investigations of an outbreak of intestinal atresia in two Israeli dairy herds, J Vet Med Sci 65: 141-143, 2003. B, Drainage dicators in cattle with abomasal volvulus, J Am Vet Med Assoc of the neoplastic peritoneal uid seen in A. A spontaneous tumor, nonpermissive for papillomavirus American College Veterinary Internal Medicine Forum 1992, p. Proceedings: 11th Annual American College Veterinary Internal Medi- Svendsen P: Etiology and pathogenesis of abomasal displacement in cine Forum 1992, p. Clinical presentation and surgical management, Vet Surg 8: control of abomasal acid secretion.

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Because your body is not as filled with morbid wastes buy clopidogrel 75mg online, you will feel more comfortable while on the fast than will a person who is sick order clopidogrel 75mg mastercard. Fasting once or twice a year is a powerful tool to help the body cleanse itself of accumulated wastes order clopidogrel 75mg online. But if you are very thin, it is best to have not more than 3 fasts a year, with only 3 days on each fast. Some individuals do best by skipping only a single meal and going to bed during that time. So it would be well to amplify on the above Tilden principles by giving several examples of how he used them in giving his treatments. Purgative or laxative may take as long as 10 hours before the cleansing effects occur, but an enema will do it in just 10 minutes. During that 10 hours, much toxic absorption from the bowels into the bloodstream can take place. Follow the enema with a heat application of one or two heating pads or an electric blanket, to warm up the body parts which are chilled. Give him some fruit juice with water (half a grapefruit in half a glass of cold water or juice of half a lemon in half a glass of cold or hot water, unsweetened). The body cannot properly digest even good food, much less junk food, while fighting an infectious inflammation. Give only fruit juice and water until the nose has ceased to discharge watery or thick material. If a headache is present, place a cold moist towel or icebag on the forehead or on top of the head. When the headache is caused by congestion and nerve strain, it will clear up quickly without any medicines if the person is allowed to rest quietly in bed, even if he cannot sleep. Convalescing from a cold requires one week, possibly two, to properly build up strength to resist a future cold. Let it work itself out properly, and your life will be more pleasant, freer from later crippling disease, and you will live longer. If you try to stop the process too early, especially by taking drugs, then the problem has been stifled, not eliminated and years later more serious diseases will result. After 3 days on a fruit diet, the noon and evening meal may include steamed vegetables and a small raw salad with some almonds or pecans or a baked potato. By this time, the bowels should be moving normally and enemas are no longer needed. Breakfast: Juices of two fruits and some solid fruit, for which there is an appetite. Half of the above breakfast is eaten first thing in the morning and the other half in mid- morning. In addition, 2 steamed vegetables (1 green and 1 yellow) may be given instead of bread. This person had a good digestive system, did not have a healing crisis, and needed to solve an ongoing problem. It consisted of 2-3 kinds of fruit, and he was told to eat one kind only every hour. He was told to eat the nuts and fruit at one time and the bread and some sweeter fruit an hour or two hours after the nuts. Mid-afternoon: Glass of freshly made orange juice and glass of raw vegetable juice. The patient was given showers or sponge baths instead of tub baths which are more debilitating. After the first 3 weeks of treatment, instead of the nuts at noon, the patient was given a baked potato twice a week with the noon meal, alternating with brown rice or buckwheat once or twice a week. Because eggs are needed to build up the blood, his breakfast was modified to include 2 eggs every morning. After 5 weeks, he was strong enough to take his own tub bath and walk around outside. This would include grapefruits, apples that are not too sweet, peaches, and pears. The sub-acid and acid fruits help burn up excess sugar from the blood and tissues. The raw salads provide alkaline mineral ash, which tends to soak up cellular wastes, and help prevent diabetic gangrene and other complications. Feeding him a breakfast of sour fruits, such as slightly diluted lemon juice, grapefruit, and raw apple helps reduce sugar in the blood and urine to an impressive degree. Da Costa used lemon juice as a medicine to oxidize excess blood sugar in the body of the diabetic. And it quenches thirst very well, because it burns up excess blood sugar without causing insulin shock. When he is ready for food other than raw fruits or vegetables, give him slightly cooked leafy green vegetables, without seasoning. Be very careful about giving him any fats, because he cannot metabolize fat as a normal person can. But if the one you are working with is thin, you must still give him some oil, but only a small amount. Starchy foods must be used in great moderation by diabetics, especially the young, but also older folk. But young people, participating in energy-consuming activities, must have some starch. At his beside is always one or two glasses of fruit juice with an ice cube or two in it. Cold drinks are not only soothing, but also a good substitute to satisfy the craving for liquor. By this time, there will be a good appetite for a full breakfast: a slice of toast, a small dish of cereal with almond nut milk on it. For lunch, a steamed vegetable, baked potato or rice, and a glass of raw vegetable juice. Nearly all their remarkable healing work was done with fasting, simple diet, rest, and water therapy. Therefore, with the additional nutritional information available today (and much of it is included in this encyclopedia), we should all the more easily be able to resist and overcome disease. In addition, far too many of us pay for high-priced poisons which we regularly take for our many ailments, brought on by the other poisons in our environment and food. So, when we become ill, let us not swallow or inject an additional load of toxic substances. He was one of the foremost natural healing experts of the late 19th and early 20th centuries.

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This has been dened as a unilateral impair- ment of visual acuity in the absence of any other Retinopathy of Prematurity demonstrable pathology in the eye or visual pathway clopidogrel 75 mg on line. This rather negative denition fails to In the early 1940s cheap clopidogrel 75mg without prescription, premature infants with explain that there is a defect in nerve conduc- breathing difculties began to be treated with tion because of inadequate usage of the eye in oxygen discount clopidogrel 75mg with mastercard, and 12 years elapsed before it was 162 Common Eye Diseases and their Management realized that the retinopathy seen in premature important examination of the cornea. During disease is suspected, the infant should be admit- the course of oxygen therapy in a premature ted to hospital and treated with penicillin drops infant, the retinal vessels become narrowed and every hour. When the oxygen conjunctival culture before treatment is started treatment is stopped, the retinal vessels become and by looking for the inclusion bodies of the engorged and new vessels grow from the chlamydial virus in a smear. The history of peripheral arcades in the extreme periphery of infection in the parents needs to be explored the fundus. The infant can rapidly become blind, although some are mini- Uveitis mally affected. The management of the con- Uveitis is rare in childhood; it can take the form dition now involves screening of those children of choroiditis, sometimes shown to be because at risk and monitoring of blood oxygen levels. Now that children are similar to that of the adult, but recurrences can being born at an earlier and earlier stage, it result in severe visual loss in spite of treatment. Optic Atrophy One must be rather wary about the diagnosis of Ophthalmia Neonatorum optic atrophy in young children because the It is important to realise that in the early part of optic discs tend to look rather pale in normal this century, a large proportion of the inmates individuals. Occasionally, unilateral visual loss of blind institutions had suffered from oph- with or without a squint is found to be associ- thalmia neonatorum. The causes of optic atrophy in childhood the most serious cause of blindness but a are numerous but the important ones can be number of other bacteria have been incrimi- listed as follows: nated, including staphylococci, streptococci and Causes of optic atrophy without systemic pneumococci. It has also been shown that disease include: chlamydial infection of the genital tract can hereditary optic atrophy lead to the same problem, as can infection by drug toxicity. The blindness that Causes of optic atrophy with systemic resulted from this condition was so serious that disease include: any excessive discharge from the eyes has been glioma of chiasm and craniopharyngioma a notiable disease in this country since 1914. Ophthalmia neonatorum is caused by unhy- post meningitic gienic conditions at birth and its relative rarity post traumatic after head injury nowadays is because of the fact that midwives hydrocephalus are trained to screen for the condition. Bacter- cerebral palsy ial conjunctivitis usually occurs between the disorders of lipid metabolism. Purulent or Juvenile Macular Degeneration mucopurulent discharge is evident and the eyelids can become tense and swollen so that it This is a rare cause of progressive visual loss in is difcult to open them and carry out the all- children, the diagnosis being made perhaps The Child s Eye 163 once in a lifetime at primary care level. Gliomata can develop in show dominant inheritance and so the family the optic nerves and scattered pigment cafe au history can be important. In tuberose sclerosis, mental deciency and epilepsy are associated The Phakomatoses with a raised nodular rash on the cheeks and mulberry-like tumours in the optic fundus. Von The three conditions Von Recklinghausen s Hippel Lindau disease presents to the ophthal- neurobromatosis, tuberose sclerosis (Bourn- mologist as angiomatosis retinae. Vascular ville s disease) and Von Hippel Lindau disease tumours appear in the peripheral retina, are classed together under this name. They all which can leak and expand and lead to detach- involve the eye but might not become evident ment of the retina. The disease is more prevalent in other serious ocular complication, the eye can be countries. Diabetic retinopathy is the common- affected in a number of other ways and it is con- est cause of legal blindness in patients between venient to consider the various ocular manifes- the age of 20 and 65 years such that about 1000 tations of diabetes in an anatomical manner, people are registered blind from diabetes per beginning anteriorly. The management of diabetic eye disease has improved greatly over the past 20 Eyelids years so that much of the blindness can now be prevented. In spite of this, most general prac- It is usual to check the urine of patients pre- titioners are aware of tragic cases of rapidly pro- senting with recurrent styes but in practice, it is gressive blindness in young diabetics. Ocular Movements Diabetes is,therefore,the most important sys- temic (noninfective) disease that gives rise to Elderly diabetic patients are more prone to blindness. Many diabetics remain free of eye develop transient third and sixth cranial nerve problems, but a diabetic is 25 times more palsies than nondiabetics of the same age group. A fasting blood When taking an eye history from diabetic sugar might be required in patients presenting patients, it is especially important to note the with isolated third nerve palsies. Hypertension duration of the diabetes and the age of onset, and arteriosclerosis need exclusion. Diabetic retinopathy is extremely rare under Some diabetics have microcirculatory changes, the age of ten years; it does not usually appear for example conjunctival vascular irregularity until the disease has been present for some and dilatation. If left ge untreated, few eyes with rubeosis iridis retain Duration of diabetes useful sight. Once developed, cataracts also progress more quickly in diabet- to the cornea can lead to the formation of indo- ics compared with nondiabetics. In addition, a lent chronically nonhealing or infected ulcers, rapidly advancing type of cataract is seen in which respond slowly to intensive treatment young poorly controlled patients. This consists of snowake posterior or anterior opac- problem occurs especially in diabetics with ities, matures rapidly and is similar to the rare severe vascular disease and typically in a patient cataract seen in starvation from whatever cause. The routine testing of urine of patients with cataracts produces a good return of positive Anterior Chamber results, making this an essential screening test. It was also mentioned in a previous chapter A particular kind of iritis is occasionally seen in that the refractive power of the lens might diabetics after cataract surgery when there is a change in response to a rise in the blood sugar severe plastic reaction. This results from increased hydration of cases are treated adequately to prevent the the lens in patients with high uncontrolled development of posterior synechiae, which will blood sugar levels. They can then obtain some to use mydriatic drops (cyclopentolate) after distance glasses and subsequently consult their cataract surgery in diabetics. By this time the glasses are made and, of course, turn out to Iris be unsatisfactory, because the index myopia can improve with treatment. In some instances The iris itself often shows degenerative changes index myopia proves irreversible, being the rst in longstanding diabetics. The surgeon can appreciate that pigment is easily lost from the iris when it is handled, and it is interesting that a characteristic vacuolation of the pigment epithelium lining the posterior surface of the iris is seen in histological sections. When dia- betes seriously interferes with the circulation of the eye,the iris can become covered on its anter- ior surface by a brovascular membrane. To the naked eye, the iris takes on a pinkish colour, but examination with the slit-lamp biomicroscope or a magnifying lens soon reveals the minute irregular blood vessels on its surface. Systemic Disease and the Eye 167 Retina and Vitreous Diabetic retinopathy is the most serious compli- cation of diabetes in the eye and often reects severe vascular disease elsewhere in the body. Background re- tinopathy is common when diabetes has been present for some years and is less of a threat to the sight than the proliferative variety. Diabetic maculopathy is a special form of retinopathy that can occur with either background or prolifera- tive disease. It is important that the doctor is able to recognise diabetic retinopathy and especially a important that he or she should be familiar with the warning signs that indicate proliferative changes and signicant maculopathy. Diabetic retinopathy is essentially a small vessel disease affecting the retinal precapillary arterioles, capillaries and venules. The vascular disease can take the form of vascular leakage or closure, with resultant ischaemia, or both. These might come and go over months and the overall picture could be unchanged for several years.