眼科学教学课件：Uveal Disease

1、 What are these? Description: Definition: It denotes inflammation of the choroid(choroiditis),ciliary body(intermediate uveitis,peripheral uveitis,or pars planitis),or iris(iritis).However,common usage includes inflammation of the retina(retinitis), retinal vasculature(retinal vasculitis),and optic

2、nerve(optic neuritis) Features: It usually affects people 20-50 years of age and account for 10-15% of cases of legal blindness in developed countries. It is often combined with autoimmune diseases and characterised by its severe complications and recurrency etiology and pathogenesis: (1)External ca

3、uses: infectious disorders (global penetration,intraocular foreign body, intraocular surgery and so on),noninfectious disorders (chemical burns,thermal burns,mechanical trauma or toxic stimulus). (2)Secondary causes: secondary to inflammation of the global itself or adjacent tissues or toxic stimulu

4、s from intraocular disorders. (3)Internal causes: infectious disorders (bacteria, viruses, fungi,parasites,protozoas),noninfectious disorders (combined with immunal or systemic disorders such as lens-induced uveitis,sympathetic ophthalmia and Behcets disease) (4)Inflammatory mediators: prostaglandin

5、s(PGS,PGE) (5)Oxidative damages(from free radical reactions) classification: (1)Location-classified: anterior uveitis,intermediate uveitis,posterior uveitis and diffused uveitis (2)Clinical features: suppurative uveitis and nonsuppurative uveitis (3)Pathology: granulomatous uveitis and nongranulomat

6、ous (4)Etiology: infectious uveitis and noninfectious uveitis Description: It consists of iritis and iridocyclitis, often associated with ankylosing spondylitis or Reiters syndrome and so on It is more common than any other type of uveitis and is usually unilateral and acute in onset Clinical findin

7、gs Symptoms: pain,photophobia,tearing and blurred vision. Signs: (1)ciliary or mixed congestion (2)keratic precipitates, KP (3)aqueous flare (4)iris changes (5)pupil changes (6)lens changes (7)vitreous and fundus changes Episcleral vascular congestion around limbus. dust-like KPMiddle-sized KP mutto

8、n fat KP Aqueous cells Hypopyon Residual pigment on the surface of lens when the closed pupil opens again. Cystoid macular edema or papilloedema cannot be seen frequently,but severe vision damage may occur once they happens. Complications and Sequelae Complicated cataract Secondary glaucoma Ocular h

9、ypotension Atrophy of eyeball 1.Typical clinical findings: symptoms and signs 2.Systemic disorders history: joint disease like juvenile rheumatoid arthritis and ankylosing spondylitis,Fuchs heterochromic iridocyclitis,lens-induced uveitis and etc. 3.Laboratory testings: blood sedimentation accelerat

10、es, HLA-B27 histocompatibility antigen test (+), specific pathogen and etc. PACG acute iridocyclitis acute conjunctivitis Symptoms severe eye pain slight eye pain foreign body sensation headache photophobia burning nausea、vomiting tearing mucus or pus-like discharge Vision Markedly blurred Slightly

11、blurred No effect on vision Congestion mixed ciliary or mixed conjunctival Cornea steamy edema、opacity transparent normal pigmentary KP hoar KP Pupil dilated and fixed miosis normal vertical oval irregular shapes Anterior shallow、aqueous normal or deep normal Chamber slight opacity aqueous opacity I

12、OP Markedly elevated normal normal Treatment myotica mydriatic agents anti-inflammatories lower IOP anti-inflammatories antivirals uPrinciples: dilate the pupil immediately in case of posterior synechia of iris;use anti- inflammatories rapidly to avoid eye tissue damage and complication occurrence;

13、eliminate the pathogen. uSeldomly do: antibiotics and systemic medicines. uPlans: 1.cycloplegics: prevent and seperate the posterior synechia of iris in case the complications occur. reduce discomfort from ciliary spasm. The first line is Homatropine drops or ointments; when severe inflammation occu

14、rs,our first choice comes to 1% Atropine, then change into Homatropine or tropicamide. 2.corticosteroids: Care should be taken to rule out an corneal epithelial defect in case of infection. Short- term systemic medicines and periocular injections are allowed when there is papilledema or macular edem

15、a. 3.nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin or local drops4.antimicrobials: when caused by infection. 5.other immunosuppressants 6.treat the accompanied systemic disorders. 7.pathogen treatment. 8.other therapies: foment,and etc. 9.treat the complications and sequelae: anti- glaucoma

16、 surgeries,cataract surgeries under good control of the imflammation. Description: It consists of pars planitis、the imflammation of vitreous base and peripheral retina It is the second most common type of intraocular imflammation,the hallmark of which is vitreous inflammation It is typically bilater

17、al、 slow in onset and tends to affect patients in their late teens or early adult years. Men are affected as commonly as women The cause is unknown and autoimmune disorders are always considered Clinical findings Symptoms: floaters and blurred vision. Pain,photophobia and redness are usually absent

18、or minimal Signs: (1)anterior segment is general normal, but if significant, there may exist the manifestations of anterior uveitis like KP, aqueous flare, aqueous imflammation cells, posterior synechia of iris and etc. (2) The most striking finding on examination is vitritis, often accompanied by v

19、itreous condensates, either free-floating as “snowballs” or layered over the pars plana and ciliary body as “snowbanking” (3) There may exist macular edema and optic neuritis、 peripheral retina vasculitis、vacular white sheath and etc. (4) Systemic disorders: Mutiple sclerosis, infection,Behcets dise

20、ase,imflammatory bowel disease and etc. Complications: (1) complicated cataract (2) secondary glaucoma (3) macular edema (4)macular degeneration (5)retinal or choroidal detachment Diagnosis Typical clinical findings: symptoms and signs Systemic disorders Ancillary tests: slit lamp with three-mirror

21、lens、fundus fluorescein angiography Treatment Corticosteroids: drops、sub-Tenons sac injection or take orally Other immunosuppressants: CsA. Pay attention to the toxicity and side-effects Laser coagulation or cryocoagulation Vitreous surgeries Pathogen therapy Description Choroiditis Choroidoretiniti

22、s Retinochoroiditis Neurochoridoretinitis They may occur alone or combination Clinical findings Symptoms typically include floaters, loss of visual field or scotomas, or decreased vision, which can be severe Retinal detachment, though infrequent, occurs most commonly in posterior uveitis and may be

23、tractional, rhegmatogenous, or exudative in nature Diagnosis and treatment Diagnosis: typical vitreous、retinal and/ or choroidal diseases; systemic disorders;fundus fluorescein angiography or ICGA;laboratory tests and other ancillary tests to determine the cause or type Therapy: anti-infectious trea

24、tment; corticosteroids;other immunosuppressants; surgeries Description The term “diffuse uveitis” is used to denote a more or less uniform cellular infiltration of both the anterior and posterior segments. Associated findings such as retinitis、 vasculitis、or choroiditis can occur and often prompt fu

25、rther diagnostic testing Tuberculosis,sarcoidosis, and syphilis should always be considered in patients with diffuse uveitis Vogt-Koyanagi-Harada syndrome and Behcets disease are the most common types Diagnosis: contain both the manifestations of anterior and posterior uveitis Treatment: do as anter

26、ior and posterior uveitis Vogt-Koyanagi-Harada syndrome It is a typically bilateral,granulomatous, recurren,diffuse uveitis combined by systemic meningismus,hearing impairment, vitiligo,whiten or fallen hair Ocular manifestations: decreased vision, sunglow-like fundus,Dalen-Fuchs nodules, complicate

27、d cataract, secondary glaucoma and etc. Diagnosis: according to history, clinical manifestations,fundus fluorescein angiography, ncurolympy test Treatment: corticosteroids,other immunosuppressants,surgeries Behcets disease It is a marked by recurrent diffuse uveitis,recurrent canker sore,polymorphou

28、s skin lesions and genital ulcer, involved in multiple systems, thus becomes a stubborn disease Diagnosis and treatment: according to clinical manifestations and laboratory tests results; therapy includes mydriatic agents, corticosteroids, immunosuppressants and surgeries under good control of imfla

29、mmation Fuchs heterochromic uveitis It is a chronic nongranulomatous uveitis, marked by iris hopochromia or atrophy. Anterior uveitis is the most common type Patients usually complain of blurred vision. KPs are often small and stellate and scattered over the entire endothelium.Telangiectatic blood v

30、essels may be seen in the chamber angle on gonioscopy.Possible complications are subcapsular cataract and higher IOP Therapy: anti-inflammatories, lowing the IOP or surgeries Acute retinal necrosis syndrome; ARN It is a severe unilateral diffuse uveitis accompanied by retinal arteritis,retinal nacro

31、sis,severe vitreous opacity and subsequent retinal detachment Herpes simplex and herpes zoster are the most common causes. Adults are more susceptible. No sex difference. It is intractable to treat and prognosis is bad Diagnosis: clinical manifestations,laboratory tests, PCR, biopsy Treatment: antiv

32、irals(Gancyclovir, Acyclovir), anticoagulants (heparin,small doses of aspirin), corticosteroids, laser coagulation or surgeries Tumors Involving the Uveal Tract Malignant melanoma of the choroid Choroidal hemangioma Metastatic carcinoma of choroids Iris cyst Malignant melanoma of the choroid It is t

33、he most common intraocular malignant tumor in the white population, second to retinoblastoma in China. It comes from pigment cells and nevus cells It may be seen in its early stages only accidentally during routine ophthalmoscopic examination or because of blurring due to macular invasion. Blood- bo

34、rne metastases may occur at any time. Glaucoma may be a late manifestation Intraocular malignant melanomas may extent into adjacent intraocular tissues or outside the eye through the scleral canals or by intravascular invasion Clinical manifestations are usually absent unless the macula is involved.

35、 In the later stages,grows of the tumor may lead to retinal detachment with decreased vision and loss of visual field Dome-shaped or mushroom-like tumor can be seen ophthalmoscopically Four stages: intraocular stage,glaucoma stage,extraocular extension stage and systemic metastasis stage Diagnosis t

36、ips: early diagnosis is difficult. typical fundus changes and symptoms. FFA,ICGA,ultrasonic,MRI,CT and biopsy may be of some value Treatment: local coagulation, local cryocoagulation,TTT,radiotheraphy,local resection and enucleation of eyeball Choroidal hemangioma It is a kind of congenital vascular

37、 malformation. It is more likely to happen on the youngs It is isolated localized tumors or as diffuse hamartomas associated with Sturge-Weber syndrome. Ultrasonography can help distinguish these orange- colored tumors from amelanotic choroidal melanomas Visual loss is the result of secondary retinal detachment,degenerative changes in the retinal pigment epithelium or sensory retina,and secondary glaucoma Occasionally,choroidal hemaniomas can be treated with photocoagulation to