十二章葡萄膜疾病ppt课件

1、The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University第十二章葡萄膜疾病第十二章葡萄膜疾病UVEA DISEASES The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University一、概述一、概述o葡萄膜

2、由于富含血管和色素组织故又称葡萄膜由于富含血管和色素组织故又称血管膜或色素膜。血管膜或色素膜。o包括虹膜、睫状体、脉络膜，故病变相包括虹膜、睫状体、脉络膜，故病变相互影响。互影响。o葡萄膜病是常见病，以炎症最为常见。葡萄膜病是常见病，以炎症最为常见。The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University概述概述o多发于青壮年，常合并糸统性本身免疫多发于青壮年，常合并糸统性本身免疫性疾病，病情反复

3、，常引起严重的并发性疾病，病情反复，常引起严重的并发症。症。o病程：小于病程：小于3个月为急性个月为急性o 大于大于3个月为慢性。个月为慢性。The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo按解剖部位分类o前葡萄炎Anterior uveitiso中间部葡萄炎Intermediate uveitiso后匍萄膜炎Posterior uveitiso全葡萄膜炎Generalized uvei

4、tis概述概述The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University二、前葡萄膜炎二、前葡萄膜炎Anterior uveitiso概述：概述：o包括虹膜炎、虹膜睫状体炎和前部包括虹膜炎、虹膜睫状体炎和前部睫状体三种类型睫状体三种类型o是最常见类型，占我国葡萄膜炎总是最常见类型，占我国葡萄膜炎总数的数的50%-60%o病因：大多数为内源性，例如细菌、病因：大多数为内源性，例如细菌、病毒、风湿性疾病

5、等，其次与外伤病毒、风湿性疾病等，其次与外伤及手术有关及手术有关The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University前葡萄膜炎前葡萄膜炎o病症： o刺激病症：眼痛、畏光、流泪、视物模糊o视力下降oThe second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Univ

6、ersityan Jiaotong Universityo体症：体症：o睫状或混合性充血睫状或混合性充血o角膜后冷静物角膜后冷静物KPo房水闪辉房水闪辉Aqueous flareo房水细胞房水细胞o虹膜改动虹膜改动o瞳孔改动瞳孔改动o晶状体改动晶状体改动o眼后段改动眼后段改动前葡萄膜炎前葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn睫状或混合性充血睫状或混合性充血前葡萄膜炎前葡

7、萄膜炎-体征体征The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn角膜后冷静物n定义：炎症细胞或色素堆积在角膜后外表被称为KP，其构成需求角膜内皮损伤和炎性细胞或色素细胞的同时存在n分类： n 粉尘状KP淋巴/浆n 羊脂状KP类上皮/巨噬n 色素性KP前葡萄膜炎前葡萄膜炎体征体征The second hospital of Medical college, XiThe second hos

8、pital of Medical college, Xian Jiaotong Universityan Jiaotong UniversityThe second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn房水闪辉Aqueous flare：n 在炎症时虹膜睫状体的血管扩张，大量的蛋白质或纤维素成分及炎性细胞渗出至房水中使房水变得混浊不清前葡萄膜炎前葡萄膜炎体征体征The second hospita

9、l of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn前房细胞：n主要为炎性细胞n裂灯下表现为大小一致的灰白色颗粒n炎性细胞运动规律n前房积脓Hypopyon前葡萄膜炎前葡萄膜炎体征体征The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Unive

10、rsityn虹膜改动：n虹膜后粘连Posterior synechia of the irisn虹膜膨隆Iris bomben虹膜前粘连Anterior synechia of the irisn房角粘连Goniosynechia前葡萄膜炎前葡萄膜炎体征体征虹膜后粘连虹膜膨隆，房角粘连The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn瞳孔改动：n梅花状、梨状、不规状瞳孔n瞳孔闭锁Seclu

11、sion of pupiln瞳孔膜闭Occlusion of pupil前葡萄膜炎前葡萄膜炎体征体征The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn晶状体改动：n晶体外表环形色素n晶体外表斑块状色素n眼后段改动：n前玻璃体炎性细胞n偶见反响性黄班囊样水肿或视盘水肿前葡萄膜炎前葡萄膜炎体征体征The second hospital of Medical college, XiThe sec

12、ond hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo前葡萄膜炎并发症o继发性青光眼：o并发性白内障o低眼压和眼球蒌缩前葡萄膜炎前葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo诊断诊断Diagnosis：o诊断根据：睫状充血；诊断根据：睫状充血；KP；房水闪；房水闪辉；瞳孔

13、减少；虹膜后粘连。其中以辉；瞳孔减少；虹膜后粘连。其中以KP和房水闪辉阳性最为重要和房水闪辉阳性最为重要o仅有虹膜后粘连、晶体前外表色素冷仅有虹膜后粘连、晶体前外表色素冷静，有虹睫炎病史，而无睫状充血、静，有虹睫炎病史，而无睫状充血、KP和房水闪辉等活动性病变那么诊和房水闪辉等活动性病变那么诊断为陈旧性虹睫炎断为陈旧性虹睫炎o病因诊断困难，留意有无关节、消化病因诊断困难，留意有无关节、消化道和免疫性疾病道和免疫性疾病前葡萄膜炎前葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college

14、, Xian Jiaotong Universityan Jiaotong University签别诊断签别诊断 急性结膜炎急性结膜炎 虹睫炎虹睫炎 急闭青光眼急闭青光眼 充血充血 结膜性结膜性 睫状睫状/混合混合 混合性混合性角膜角膜 透明透明 透明透明KP 水肿水肿瞳孔瞳孔 正常正常 小小 大大眼压眼压 正常正常 大多正常大多正常 高高前葡萄膜炎前葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong U

15、niversityo治疗治疗Treatment-散大瞳孔散大瞳孔o目的目的:o防止虹膜后粘连、瞳孔闭锁，以减少防止虹膜后粘连、瞳孔闭锁，以减少继发性青光眼继发性青光眼o解除或减少虹膜括约肌和睫状肌痉挛，解除或减少虹膜括约肌和睫状肌痉挛，使其处于休憩形状，刺激病症减轻，使其处于休憩形状，刺激病症减轻，有利于病情的恢复。有利于病情的恢复。o促进睫状体的血液循环促进睫状体的血液循环前葡萄膜炎前葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Unive

16、rsityan Jiaotong Universityn常用药物：常用药物：n炎症活动期给予炎症活动期给予 2%后马托品眼膏后马托品眼膏1836hn瞳孔散不大时给予强散瞳剂瞳孔散不大时给予强散瞳剂0.2ml结膜下注结膜下注射射n炎症恢复期给予托品酰胺滴眼液炎症恢复期给予托品酰胺滴眼液前葡萄膜炎治疗前葡萄膜炎治疗The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn部分部分n0.5%考的松滴眼液

17、点眼考的松滴眼液点眼n庆大霉素庆大霉素2万万u十地塞米松十地塞米松 5mg结膜下注射结膜下注射n全身全身n0.9%NS250ml+D.X.M10mg静脉滴静脉滴注注n强的松：强的松：20mg,q.d.前葡萄膜炎前葡萄膜炎-治疗治疗The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn抗前列腺素类药物：抗前列腺素类药物：n阿斯匹林阿斯匹林0.5 tidn消炎痛消炎痛25mg tidn病因治疗：病

18、因治疗：n感染感染抗菌素抗菌素n结核结核抗结核抗结核前葡萄膜炎前葡萄膜炎-治疗治疗The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityn并发症治疗并发症治疗n瞳孔阻滞导致的青光眼瞳孔阻滞导致的青光眼虹膜根切术虹膜根切术n房角堵塞导致的青光眼房角堵塞导致的青光眼滤过手术滤过手术n并发性白内障只需光感光定位准确并发性白内障只需光感光定位准确 ECCE+IOL或或PHACO+IOLn低眼压或眼球萎缩

19、目前尚无有效治疗方法，低眼压或眼球萎缩目前尚无有效治疗方法，必要时为维持眼球形状，作羟基磷灰石人工必要时为维持眼球形状，作羟基磷灰石人工义眼台植入。义眼台植入。前葡萄膜炎前葡萄膜炎-治疗治疗The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University三、中间葡萄膜炎三、中间葡萄膜炎Intermediate uveitiso概述概述o主要累及睫状体平坦部、玻璃体基底主要累及睫状体平坦部、玻璃体基底部、周

20、边视网膜和脉络膜的炎症性和部、周边视网膜和脉络膜的炎症性和增殖性疾病增殖性疾病o多见于儿童、多见于儿童、40岁以下年轻人，常岁以下年轻人，常累及双眼，可先后或同时发病累及双眼，可先后或同时发病o1979年国际葡萄炎研讨组命名为中年国际葡萄炎研讨组命名为中间葡萄膜炎间葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo病症：轻者无，重那么飞蚊症，视物模病症：轻者无，重那么飞蚊症，视物模

21、糊糊o体征：体征：o眼前段：羊脂状眼前段：羊脂状/尘状尘状KP，轻度房闪，轻度房闪/房房水中细胞。无睫状充血但儿童可水中细胞。无睫状充血但儿童可o眼后段：玻璃体雪球状混浊，睫状体平眼后段：玻璃体雪球状混浊，睫状体平坦部雪堤样改动，周边网膜静脉周围炎坦部雪堤样改动，周边网膜静脉周围炎o易发生周边网膜血管炎及网膜脉络膜炎易发生周边网膜血管炎及网膜脉络膜炎中间葡萄膜炎中间葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jia

22、otong University中间葡萄膜炎中间葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo并发症并发症o黄斑囊样水肿黄斑囊样水肿:o并发性白内障：并发性白内障：中间葡萄膜炎中间葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong

23、Universityan Jiaotong Universityo诊断诊断o根据典型的玻璃体雪球状混浊，睫根据典型的玻璃体雪球状混浊，睫状体平坦部雪堤样改动，周边网膜状体平坦部雪堤样改动，周边网膜静脉周围炎即可诊断静脉周围炎即可诊断o对飞蚊症有加重倾向，不能以其它对飞蚊症有加重倾向，不能以其它缘由解释的晶体后囊下混浊或黄斑缘由解释的晶体后囊下混浊或黄斑囊样水肿应结合三面镜，间接检眼囊样水肿应结合三面镜，间接检眼镜，检查，综合分析，作出诊断镜，检查，综合分析，作出诊断中间葡萄膜炎中间葡萄膜炎The second hospital of Medical college, XiThe second

24、hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo治疗治疗o对症治疗为主对症治疗为主o视力视力0.5但伴有玻璃体混但伴有玻璃体混浊给予结膜下注射浊给予结膜下注射DXM5mg或选用或选用强的松强的松20mg qdo网膜新生血管给予网膜新生血管给予YAG激光治疗激光治疗o如炎症继续加重可用免疫抑制剂，环如炎症继续加重可用免疫抑制剂，环磷酰胺，环胞素治疗磷酰胺，环胞素治疗中间葡萄膜炎中间葡萄膜炎The second hospital of Medical college, XiThe second

25、hospital of Medical college, Xian Jiaotong Universityan Jiaotong University三、后葡萄膜炎三、后葡萄膜炎(脉络膜炎脉络膜炎)o概述概述o它包括了脉络膜、玻璃体后部及视网膜它包括了脉络膜、玻璃体后部及视网膜的炎性病变的炎性病变o脉络膜有睫状后动脉供血，脉络膜有睫状后动脉供血， 可单独发可单独发病病o视网膜外层由脉络膜供血，脉络膜视网视网膜外层由脉络膜供血，脉络膜视网膜炎，甚至视神经视网膜炎膜炎，甚至视神经视网膜炎o按病灶分布，可分为局灶型、播散型及按病灶分布，可分为局灶型、播散型及弥漫型弥漫型The second hosp

26、ital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University后葡萄膜炎后葡萄膜炎o病因病因o感染性：如细菌，真菌，寄生虫感染性：如细菌，真菌，寄生虫和病毒和病毒o非感染性：如免疫性或过敏性及非感染性：如免疫性或过敏性及对坏死组织的炎性反响对坏死组织的炎性反响The second hospital of Medical college, XiThe second hospital of Medical college, Xian J

27、iaotong Universityan Jiaotong Universityo临床表现临床表现o脉络膜炎时眼部病症轻。位于前方仅脉络膜炎时眼部病症轻。位于前方仅有黑影；后极部者，视物变形、中心有黑影；后极部者，视物变形、中心视力减退视力减退o眼前段无充血及炎症改动眼前段无充血及炎症改动o尘埃状及絮状玻璃体浑浊尘埃状及絮状玻璃体浑浊o活动期病灶灰黄色，视网膜水肿混浊活动期病灶灰黄色，视网膜水肿混浊o瘢痕期炎症衰退，脉络膜萎缩，遗留瘢痕期炎症衰退，脉络膜萎缩，遗留色素脱失及瘢痕组织色素脱失及瘢痕组织后葡萄膜炎后葡萄膜炎The second hospital of Medical college

28、, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo并发症并发症o黄斑水肿黄斑水肿o视盘充血水肿视盘充血水肿o视网膜血管炎视网膜血管炎o视网膜脱离视网膜脱离o眼球萎缩眼球萎缩后葡萄膜炎后葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo鉴别诊断鉴别诊断o

29、眼内肿瘤：根据超声波、眼内肿瘤：根据超声波、X线、线、FFA区别区别o老年性黄斑盘状变性老年性黄斑盘状变性o脉络膜渗漏：此脱离部位随体位改脉络膜渗漏：此脱离部位随体位改动动o视网膜色素变性视网膜色素变性后葡萄膜炎后葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo治疗治疗o理想治疗：病因理想治疗：病因o非特异性治疗法：如伴前节炎症，非特异性治疗法：如伴前节炎症，散瞳、睫状肌麻木剂、

30、部分激素；散瞳、睫状肌麻木剂、部分激素；后葡萄膜炎及全葡萄膜炎需全身激后葡萄膜炎及全葡萄膜炎需全身激素治疗；非甾体类抗炎剂；免疫抑素治疗；非甾体类抗炎剂；免疫抑制剂制剂o最好是病因治疗，缘由不明、病情最好是病因治疗，缘由不明、病情严重者可试用广谱抗生素严重者可试用广谱抗生素后葡萄膜炎后葡萄膜炎The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University四、全葡萄膜炎四、全葡萄膜炎o累及前、中、后、整个

31、葡萄膜的累及前、中、后、整个葡萄膜的炎症称为全葡萄膜炎炎症称为全葡萄膜炎o治疗同上治疗同上The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University五、几种常见的特殊葡萄炎五、几种常见的特殊葡萄炎o强直性脊椎炎强直性脊椎炎oBehcet病病o交感性眼炎交感性眼炎oFuchs综合症综合症The second hospital of Medical college, XiThe second hospi

32、tal of Medical college, Xian Jiaotong Universityan Jiaotong Universityo强直性脊椎炎强直性脊椎炎Ankylosing sopndylitiso是一种病因不清、主要累及轴骨骼的是一种病因不清、主要累及轴骨骼的特发性炎症疾病，并发急性前葡萄炎，特发性炎症疾病，并发急性前葡萄炎，发于青壮年男性。发于青壮年男性。o往往双眼交替性发作，易复发。往往双眼交替性发作，易复发。o诊断：主诉腰骶部疼痛诊断：主诉腰骶部疼痛o治疗：同前葡萄膜炎治疗：同前葡萄膜炎The second hospital of Medical college, XiT

33、he second hospital of Medical college, Xian Jiaotong Universityan Jiaotong UniversityoBehcet病病o定义：一种以复发性葡萄膜炎、口腔定义：一种以复发性葡萄膜炎、口腔溃疡、皮肤多形性损害、生殖器溃疡溃疡、皮肤多形性损害、生殖器溃疡为特征多系统受累的疾病。为特征多系统受累的疾病。o临床表现临床表现o眼部损害眼部损害o口腔溃疡口腔溃疡o皮肤损害皮肤损害o生殖器溃疡生殖器溃疡The second hospital of Medical college, XiThe second hospital of Medic

34、al college, Xian Jiaotong Universityan Jiaotong Universityo国际国际Behcet病研讨组诊断规范病研讨组诊断规范o1.复发性口腔溃疡一年至少复发三次复发性口腔溃疡一年至少复发三次o2.下面下面4项中出现项中出现2项即可确诊项即可确诊oA.复发性生殖器溃疡或生殖器瘢痕复发性生殖器溃疡或生殖器瘢痕oB. 前后葡萄膜炎，玻璃体内细胞或网前后葡萄膜炎，玻璃体内细胞或网膜血管炎膜血管炎oC.皮肤结节性红斑，假毛囊炎，痤疮样皮肤结节性红斑，假毛囊炎，痤疮样结节结节 oD皮肤过敏反响阳性皮肤过敏反响阳性Behcet病病The second hospi

35、tal of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong UniversityBehcet病病o治疗：治疗：o前段受累前段受累-阿托品点眼阿托品点眼o糖皮质激素，普通为糖皮质激素，普通为20-30mg/do免疫抑制剂：环胞霉素免疫抑制剂：环胞霉素A 5mgkg.do并发性白内障、继发性青光眼在炎并发性白内障、继发性青光眼在炎症完全控制下可思索手术症完全控制下可思索手术The second hospital of Medical college, Xi

36、The second hospital of Medical college, Xian Jiaotong Universityan Jiaotong Universityo交感性眼炎交感性眼炎Sympathetic ophthalmiao概念：指发生于一眼穿通伤或内眼术概念：指发生于一眼穿通伤或内眼术后的双侧肉芽肿性葡萄膜炎称为交感后的双侧肉芽肿性葡萄膜炎称为交感性眼炎性眼炎o受伤眼称为诱发眼；另一眼侧称为交受伤眼称为诱发眼；另一眼侧称为交感眼感眼o病因：主要由外伤或手术呵斥眼内抗病因：主要由外伤或手术呵斥眼内抗原暴露并激发本身免疫应对所致原暴露并激发本身免疫应对所致The second hospital of Medical college, XiThe second hospital of Medical college, Xian Jiaotong Universityan Jiaotong University交感性眼炎交感性眼炎n临床表现：临床表现：n可发生于外伤或手术后可发生于外伤或手术后5d至至56年内，但多年内，但多发生于发生于2周至周至2个月内。个月内。n普通发病隐匿，为肉