Download Treatment

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 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 causes: 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 stimulus 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 Behcet’s disease)
(4)Inflammatory mediators: prostaglandins(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
nongranulomatous
(4)Etiology: infectious uveitis and noninfectious uveitis
Description:
• It consists of iritis and iridocyclitis, often
associated with ankylosing spondylitis or
Reiter’s syndrome and so on
• It is more common than any other type of
uveitis and is usually unilateral and acute
in onset
Clinical findings
• 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 KP
Middle-sized KP
mutton fat KP
Aqueous cells
Hypopyon
• Posterior synechia
of iris
• Iris bombe
• Anterior synechia
of iris
• nodules
•goniosynechia




miosis
irregular shape
pupillary closure
occlusion of pupil
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 hypotension
• Atrophy of eyeball
1.Typical clinical findings:
symptoms and signs
2.Systemic disorders history:
joint disease like juvenile rheumatoid arthritis and
ankylosing spondylitis,Fuch’s heterochromic
iridocyclitis,lens-induced uveitis and etc.
3.Laboratory testings:
blood sedimentation accelerates, 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 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
IOP
Markedly elevated
normal
normal
Treatment myotica
mydriatic agents
anti-inflammatories
lower IOP
anti-inflammatories
antivirals
Principles: dilate the pupil
immediately in case of posterior
synechia of iris;use antiinflammatories rapidly to avoid eye
tissue damage and complication
occurrence; eliminate the pathogen.
Seldomly do: antibiotics and
systemic medicines.
Plans:
1.cycloplegics: ①prevent and seperate the posterior
synechia of iris in case the complications occur. ②
reduce discomfort from ciliary spasm. The first line is
Homatropine drops or ointments; when severe
inflammation occurs,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. Shortterm systemic medicines and periocular injections are
allowed when there is papilledema or macular edema.
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: antiglaucoma 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 bilateral、 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 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 vitreous 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,Behcet’s
disease,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 lens、fundus
fluorescein angiography
Treatment
• Corticosteroids:
drops、sub-Tenon’s 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
• Choroidoretinitis
• 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 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 treatment; 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
further diagnostic testing
• Tuberculosis,sarcoidosis, and syphilis should always be
considered in patients with diffuse uveitis
• Vogt-Koyanagi-Harada syndrome and Behcet’s disease
are the most common types
Diagnosis:
contain both the manifestations
of anterior and posterior uveitis
Treatment:
do as anterior 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,
complicated cataract, secondary glaucoma and
etc.
Diagnosis:
according to history, clinical
manifestations,fundus fluorescein
angiography, ncurolympy test
Treatment:
corticosteroids,other
immunosuppressants,surgeries
Behcet’s disease
• It is a marked by recurrent diffuse uveitis,recurrent
canker sore,polymorphous 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 imflammation
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 vessels 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
nacrosis,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:
antivirals(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 the 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. Bloodborne 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. 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 tips: ①early diagnosis is difficult. ②
typical fundus changes and symptoms. ③
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 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 orangecolored 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 limit the extent and degree of
associated serous detachment of the retina. Those
that fail to respond to photocoagulation-and especially
the more diffuse tumors-may require radiotherapy.
Enucleation may be necessary for tumors associated
with intractable,painful glaucoma
Metastatic carcinoma of choroids
• Because of its rich blood supply, the choroid is an important site for
blood-borne metastases. In females, carcinoma of the breast is
much the most common source. In males, lung,genitourinary,and
gastrointestinal malignancies are the usual primaries
• The usual presenting symptoms of the choroidal metastasis are
decreased vision and photopsia. The tumor appears as a pale,nonpigmented elevation of the choroid, often associated with serous
retinal detachment. There may be multiple lesions involving one or
both eyes, in which case the diagnosis is relatively easily made. A
solitary metastasis may be mistaken for an amelanotic choroidal
malignant melanoma
• Diagnosis:
tumor history and fundus features
• treatment:
Chemotherapy for concurrent metastatic disease
is usually effective against the choroidal
component. In the absence of other metastases,
local radiotheraphy is the treatment of choice.
Enucleation of eyeball is of no use
Iris cyst