Disease of Uvea Zhou xinxin
reveiw: Aanatomy of Uvea • The eyeball is composed of • the wall, • the chambers • the contents, nerve, blood vessels and other tissues.
The wall of the globe divided into three layers: • Outer coat (fibrous tunic): cornea ， sclera ， corneoscleral limbus •
middle coat (uvea) iris ， ciliary body ， choroid . • inner coat (retina)
• The diseases of uvea include the inflammation, the tumors and the abnormalities. • We learn the inflammation of uvea (uveitis) in this class.
Uveitis • Uveitis is the inflammation of uvea. It is one of the common disease of the eye. Its cause is very complex. • We can classified the uveitis as follow. (1) according to the anatomical part, it is divided into:①anterior uveitis, ②posterior uveitis, ③intermediate uveitis ④ panuveitis
(2) according to the course, it is divided into: acute, subacute and chronic uveitis. (3) according to the cause, it is divided into: ①infective uveitis. ② noninfective uveitis inclued :special uveitis, autoimmune uveitis , uveitis caused by the systemic diseases, uveitis caused by trauma and tumor .
(4) according to the pathology, it is divided into: ①granulomatous uveitis: it is a chronic proliferative inflammation, the proliferation forming nodular is the characters ② non-granulomatous uveitis: it is a acute allergic reaction, no nodular formed
(5) according to the character of exudates, it is divided into: ①purulent uveitis: ② exudate uveitis, inclued serous and fibrinous
1.Anterior uveitis • •
Including iritis. iridocyclitis and anterior part cyclitis It is a common disease of the eye . In china . It accounts 50-60% in uveitis. • It is usually affects the young people. • The both eyes always involved and it is easy to recurrent attacks. • At the advanced stage .it can cause blindness because of the complication. •
Etiological factors of this disease besides trauma. operation and infection, are more to belong to endogenous. we must inquest the case history carefully, perhaps can discover the related system disease as rheumatism , tuberculosis, sarcoidosis ( 结节病） and so on.
Clinical Findings of anterior uveitis (1)symptom • Pain , Tearing and Photophobia Caused by cliliary spasm ( cyclospasm 睫状痉挛 ) and the tissue congestion, edema and toxin stimulating the ends of the trifacial nerve （三叉神经） .
The pain most limited only in ocular part ,or may extend to periorbit ,forehead and buccal （颊） part. In acute case, The patient is difficult to open the eye (Photophobia) and tearing.
Clinical Findings of anterior uveitis (1)symptom
• Visual decrease Opaque aqueous humor .
Keratic precipitate. Corneal edema and pigmentary doposition on lens surface. All of these can impede light passing through normally.
Ciliary spasm cause myopia. secondery glaucoma, Complicated cataract as well as macular edema may induce blurred vision further.
Clinical Findings of anterior uveitis
（ 2 ） sign • Ciliary injection It is the injection near limbus corneae . Purplish red. Must distinguish from conjunctival injection In the severity case , the two exist simultaneous . We call it mixed injection. Frequently combined with conjunctival edema.
Clinical Findings of anterior uveitis
（ 2 ） sign • keratic percipitates ， KP Formation :Because the barrier of blood vessels in
the iris and the ciliary body be destroyed by inflammation, more Infectious cells and fibrin enter aqueous humor. With constant convection influenced by difference of temperature. The exudate gradually deposits on corneal endothelium to form triangular keratic precipitates in lower part of the cornea. Its base is downward.
Clinical Findings of anterior uveitis (2)sign
• keratic percipitates ， KP Divided into ： Fine dusty KP: it is punctate
composed of lymphocyte and plasmacyte( 浆细胞） commonly seen in non-granulomatous uveitis .
“Mutton fat” KP:
it is white,Like small balls of “mutton fat” .composed of epithelioid cells and macrophages. commonly seen in granulomatous uveitis.
• 左：粉尘状 KP 右：羊脂状 KP
Clinical Findings of anterior uveitis （ 2 ） sign • Anterior chamber flare Caused by the bloodaqueous barrier be destroyed. more cells and protein contents enter in aqueous humor. When observation with slite-lamp microscope . Enhanced light hundle may be seen like white opacity . Because the anterior chamber flare also be seen at the restoration stage,so It can not mean the active inflammation.
Clinical Findings of anterior uveitis （ 2 ） sign
• anterior chamber cells • In the active inflammation, The • •
•
inflammatory cells , red blood cells, tumour cells and pigment cells enter into aqueous humor . In uveitis, the cells mainly are inflammatory cells. Slit-lamp examination can find the same size grayish-white dusty granule. rising near the iris, falling near the cornea. It is a reliable sign for the active inflammation . When a great quantity inflammatory cells settle at the below of anterior chamber,can form a fluid level,we call it hypopyon.
Clinical Findings of anterior uveitis （ 2 ） sign • Changes of the iris ： furrow becomes blurry because of the hyperemia and edema.
Posterior synechia The exudate and roliferation make the adhesion between the iris and the anterior capsule of the lens. A circle synechia will make the aqueous humor can not flow into the anterior chamber and retains in the posterior chamber. The iris is pushed forward with a shape of bulging called irris bomble.
Clinical Findings of anterior uveitis （ 2 ） sign
Anterior syuechia ： It means the synechia between the iris and the posterior surface of the cornea . If the synechia to happen in the chamber angle .we call it goniosynechia （前房角粘连） .
Clinical Findings of anterior uveitis （ 2 ） sign • Changes of the iris ： Iris nodules ：
Koeppe’s nodule ： it situated on the surface of pigmented epithelium at pupillary margin. It is non-granuloma mainly, but also can be granuloma.
Busacca nodule ： it is situated near to the contractive furrows in central part of the irris. It is granuloma mainly.
Granuloma iridis
： situated in the
stroma of the irris, the single opaque nodus, often existing in anterior uveitis caused by nodule disease.
Clinical Findings of anterior uveitis （ 2 ） sign • Change of pupil
constriction of pupil: the irris hyperenia and edema, cells infiltration and the stimulate of the exudation’s toxicity could cause the constriction of pulil. light reflection of iris will be slow or disappearance . The constriction of pupil is an important sign of indocyclitis.
Clinical Findings of anterior uveitis （ 2 ） sign
Change of pupil change of the shape ： In the condition of mydriasis, if there have the part posterior synechia and can’t be dilated. We can see the shape of the pupil changed irregularity. its shape may become plum blossom-like , pearlike or irregularity.
Clinical Findings of anterior uveitis （ 2 ） sign • Change of pupil Seclusion of pupil it means the whole circle posterior synechia. It not only can be the synechia of pupillary margin, but also can be all the posterior facies of irris synechia with the anterior surface of lens.
Clinical Findings of anterior uveitis （ 2 ） sign •
Change of pupil Occlusion of pupil a large amount of exudates forms a membrane to cover on the lens surface in pupillary area.
Clinical Findings of anterior uveitis （ 2 ） sign
• Change of lens ： The anterior surface of lens can be found the deposit of pigment.
when the fresh posterior synechia be pull away, we can find the circle pigment deposit on the anterior surface of lens. In the iridocyclitis after implant an intraocular lens(IOL), we often can see effusion as spot film or lattice fibers on the surface of the IOL . Also can form a membrane if the disease is vary serious, we call it frontal membrane of IOL.
Clinical Findings of anterior uveitis （ 2 ） sign
• Change of vitreous and posterior segment of the eye ： In iricyclitis or anterior cyclitis, inflammatory cells could be found in the anterior vitreous. And generally without vitreous opacity. The posterior segment of eye is always normal, occasionally could be found cystoid macular edema and optic disc edema.
Clinical manifestation of anterior aveitis
（ 3 ） complications • Secondary glaucoma ： due to the meshwork is blocked by imflammatory cells and pigmentary partides. Which also may be indnced by posterior synechia ,by peripheral anterior synechia of the iris, by secclusion of pupil . The way of aqueous outflow is impeded to cause secondary glaucoma.
• Complicated cataract ： if imflammation is active again and again for a long time . The character of aqueous humor which nourishes the lens is affected. Nomal physiological metabolism of the lens may be destoryed to cause complicated cataract. If drop corticosteroid for a long time , it also can result clouding of posterior lens capsule.
• Low IOP and atrophy ： if the inflammation continues for a long time, it can cause ablatio corporis ciliaris or atrophia.the generation of aqueous humor decreases and Low Iop.
anterior uveitis ： diagnosis : The diagnosis is mainly on the basis of clinical findings. •
If ciliary injection, miosis, KP and posterior synechia of the iris are discovered, Iridocyclitis may be diagnosed. Among the total, the aqueous flare and KP is especially important. • If there no ciliary injection and new inflammatory change, only have posterior synechia of the iris and pigmentary deposition on the lens anterior capsule which suggests iridocyclitis had been suffered form. • If the courses of disease in 6 weeks,we call it acute inflammation. However if it is slow and longer than 6 weeks, we call it chronic inflammation.
anterior uveitis ： differential diagnosis: it should be differentiated with acute conjunctivitis ,
acute angle closure glaucoma and intraocular tumor.
（ 1 ） acute conjunctivitis :pain, tesring ,
photophobia and ocular region injected. However the vision isn’t decrease usually and the anterior segment of eye is normal.
（ 2 ） acute angle-closure glaucoma ： pain , tearing, photophobia, ocular region injected and hypopsia and so on.but when this disease onset,it also have symptom as pupil dilation, anterior chamber extremely shallow, intraocular press extremely high and so on . This can help the differential diagnosis.
（ 3 ） intraocular tumor ： after necrosis of retinoblastoma, severe endophthalmitis and hypopyon may be induced. So it should be differentiated by history. Findings in examination, calcific spot in x-ray picture, ultrasonic and CTdiagnosis, it may be distinguished.
anterior uveitis treatment (1)mydriasis (dilating pupil) • Very important ! To prevent posterior synechia of the iris ! To diminish or to get rid of spasm of iris sphincter muscle and ciliary muscles. • If the anterior uveitis is acute and severe, mydriasis may use 1-2% atropine ointment to instill into the eye, 1-2 times daily . After 1-3 days to change to 2% homatropine ointment to instill into the eye . 1-2 times daily.
anterior uveitis treatment
• (1)mydriasis (dilating pupil) • It is better to use 2% homatropine ointment to instill into the eye in normal anterior uveitis. • At the stage of recovery , we often use 0.5-1% tropicamide solution to instill into the eye one times daily. • If the pupil is difficult to dilate duo to fresh posterior synechia. Mydriatic mixture(mixed solution in equal amout of 1% atropine .1% cocain . 0.1% adrenalin )may be use in subconjuctival injection in a dosage of 0.1-0.2ml.
Anterior uveitis Treatment (2) Glucocorticoid Gutta
• Can restrain inflam,reduce effusion. • Use 0.1% DEX gutta as usual, emergency and severe case can drop eyes every 15min, and every 1 hour after 4 times. Reduce the times everyday according to the disease condition after continuing application some days. • Other Glucocorticoid preparation can be used too.
Anterior uveitis Treatment • (2) Glucocorticoid Gutta • To reduce the complication of Glucocorticoid, we should avoid to use systemic administration and subconjunctival injection as far as possible. • But if the papilloedema and cystoid macular edema appear. the systemic administration and the tenon’ s capsule injection is needed.
Anterior uveitis Treatment • (3) non-steroidal anti-inflammatory drug • Can block the prostaglandin and the leukotriene to educe anti-inflammatory action. • Be obvious side-effect to the traumatic and postoperative anterior uveitis. • General eye drop: 0.5% indomethacin ,0.1% antifani, 0.1% pranoprofen. • Oral medication is not necessary as usual.
Anterior uveitis Treatment • (4) Etiological treatment • If we can identify the etiopathogenisis, we should treat in the field. • (5) Complication treatment • Secondarg glaucoma: Drip liquid medicine which can drop the intraocular press . Oral or intravenous medication can decrease the intraocular tension. It should be treated earlier by operation or laser therapy if pupil block.
Anterior uveitis Treatment • (5) Complication treatment • Complicated cataract: Perform the cataract extraction and implant intraocular lens after the inflammation be controled. Attention to the preoperative and postoperative antiinflammatory treatment.
2 、 Intermediate uveitis • Intermediate uveitis is the generic name of a set of phlegmasia and proliferating affections which involves ciliary body applanatio part, vitrina basilar part, peripheral retina and chorioid. • Almost insultus below 40 years,and have similar between male and female.It always involves both eyes, and has a feature as invasion delitescence and chronic course of disease.
Clinical situation of Intermediate uveitis • （ 1 ） Symptoms • In the earlier period,the symptoms are slight. It just can be felt that there`s shadow before the eyes, vision blur, temporary myopiosis. And some maybe have ophthalmalgia and red eyes. If complications like macular oedema and cataract appear, the vision may decrease observably. • （ 2 ） Physical signs • Corporis vitrei nivea • Ciliary body truncus part snowbank-form change （ Particular change of Intermediate uveitis ） • Inferior peripheral retinitis 、 retinal vasculitis and peripheral retino-choroiditis • （ 3 ） Complications • Macular oedema, Cataract
intermediate uveitis diagnosis • According to the pink clinical situation • It should be highly suspected to be the intermediate uveitis about the teenager`s noncausal macular, oedema,complic cataract,etc.
Intermediate uveitis Treatment •
It could do nothing to when the symptom and affection is
aslo slight,but should be symptomatic treated If the eyesight is lower than 0.5 point or the hyaloid cataract is manifest. • （ 1 ） Point partly or inject corticosteroid behind the apsule of tenon, and compounding systemic administration if the condition is serious. • （ 2 ） If it didn`t use,and the pathogenetic condition aggravated further,we could consider to using immune depressant systemicly. Using amboclorin is the first choice ， then cyclosporin,cyclophosphamide,etc. • （ 3 ） Ciliary body evenness part`s condense therapy and laser therapy are particularly suitable for that whose circumjacent part have new vascular proliferation.
3. Posterioruveitis • Posterioruveitis is the generic name of a set of phlegmasia affections which involves chorioid , retina , retinal vessel and corpus vitreum. • It clinically contains choroiditis , retinitis , choroidoretinitis , retinochoroiditis and retinal vasculitis,etc.
Clinical situation of Posterioruveitis •
（ 1 ） Symptoms
•
Hypopsia,shadow before the eyes and blindspot,flare,etc. The degree of the hypopsia is depended on the macular area is damaged or not and the degree of the damage. （ 2 ） Physical signs Inflammatory cells and cloudiness in the corpus vitreum 。 Focal chorioid and retina`s infiltrating focus of infection 。 Retinal vasculitis Retina and macular`s edema
• • • • • • •
Posterioruveitis is the generic name of a set of phlegmasia affections which involves chorioid 、 retina 、 retinal vessel and corpus vitreum
Posterioruveitis Diagnosis • According to the pink clinical situation • FFA is conducive to the decision of the retina and its vasculitis • ICGA is conducive to the decision of the choroid and its vascular lesion
Posterioruveitis Treatment • Etiological treatment If we can identify the etiopathogenisis ， we should treat it aiming directly at the etiopathogenisis. • Broil disease response control We can use corticosteroid 、 immune depressant.