1、DISEASE OF THE UVEA（葡萄膜疾病）uveanUveal tract:iris,the ciliary body and the choroid uveanchoroid well vascularized-nutrition and removal of metabolic waste melanocytes-dark background Sclerotic External Vascular Portion of the Choroid Internal Vascular Portion of the Choroid Pigment Cell Layer Membrana
2、 Limitans Interna OutlinenUveitis (Causes,etiology and classification of uveitis)nAnterior Uveitis（前葡萄膜炎）（前葡萄膜炎）nIntermediate Uveitis（中间葡萄膜炎）nPosterior Uveitis（后葡萄膜炎）nPanuveitis（全葡萄膜炎）nSome specific uveitisnSympathetic ophthalmia（交感性眼炎）（交感性眼炎）nVKH syndrome（Vogt-小柳原田综合症）nAnterior Uveitis associated w
3、ith Ankylosing spondylitis（强直性脊柱炎）nBehcets syndromenFuchs syndromenARN syndrome（急性视网膜坏死综合症）nTumor and congenital diseases of uvea nIris cyst（虹膜囊肿）nMalignant melanoma of the choroid（脉络膜恶性黑色素瘤）nMetastatic carcinoma of the choroid（脉络膜转移瘤）nUveal coloboma（葡萄膜缺损）UveitisnDefinition:An inflammation of the u
4、veal tract Causes of UveitisnInfection bacteria,virus(eg herpes疱疹病毒),fungus,parasitenImmune response autoimmune antigen:retinal S,IRBP(interphotoreceptor retinoid-binding protein)immune-complexes mediated reaction nTrauma eye injury,surgery:release arachidonic acid-a potent inflammatory mediator nGe
5、netic associations nAnkylosing spondylitis-HLA-B27nBechets disease-HLA-B51 nVKH-HLA-DR4 Classification of Uveitis nAetiological infectious,noninfectiousnPathological granulomatous（肉芽肿性）,nongranulomatous（非肉芽肿性）nAnatomical anterior,intermediate,posterior,panuveitis nClinical acute(3months)Anterior Uve
6、itis-iritis&iridocyclitisnSymptomsuredness,upain,uphotophobia,utearing,ufloaters,udecreased visionnSignsuinjection(ciliary or mixed)睫状或混合充血uKeratic precipitates,KP 角膜后沉着物uanterior chamber flare 前方闪辉uanterior chamber cell 前方细胞uposterior or anterior synechiae of the iris 虹膜后粘连或前粘连uiris nodules 虹膜结节use
7、clusion or occlusion of the pupil 瞳孔闭锁或瞳孔膜闭usome fibrinous pigmented deposits in the pupillary area of the lens 瞳孔区晶体前表面纤维色素沉着Anterior UveitisA)CiliaryInjectionB)EpiscleralInjectionC)ConjunctivalInjectionGradeSeverity0WhiteandQuiet1/2Slight,UsuallyNormal1to1+Mild2to2+Moderate3to3+SevereCiliary injec
8、tionConjunctival injectionfestooned pupilKeratic precipitates,KPnCells or pigments deposit on the back surface of the corneauFine,dust-like KPs neutrophile granulocyte，lymphocyte，plasmacyte；herpetic uveitis,Fuchs syndromeuLarge,white，“mutton fat”-like KPs Mononuclear macrophages，epithelioid cell；gra
9、nulomatous iridocyclitisuBrown pigmented KPs old standing light colored KPs recent affectionlarge,white KPs”mutton fat”form a triangular shape with an inferior basefine dust-like KPsbrown pigmented KPsanterior chamber flare and cellnThe exudation from iris vessels due to the disruption of the blood-
10、aqueous barrier,composed of proteins(Tyndall phenomenon),inflammatory cells.nThe presence of cells-“active”irititis,resulting in hypopyon(前房积脓).Anterior Chamber Cells Cells in the anterior chamber are a sign of inflammation or bleeding.Anterior Chamber FlareFlare in the anterior chamber represents a
11、n elevated concentration of plasma proteins from inflamed,leaking intraocular blood vessels.cells and flare in the anterior chamber,hypopyonhypopyonsynechiaendue to the organization of fibrin laid down from fibroblasts that adhere the iris to the anterior surface of the lens posterior synechiaento t
12、he corneal endothelial surface anterior synechiae anterior synechiaefestooned pupil due to posterior synechiaeSeclusion of pupilIris bombeOcclusion of pupilChanges of the pupilnmyotic pupil:contraction of sphincter ciliary body spasmocclusion of pupil a thick fibrin membranelenticular changes,after
13、using mydriasis in seclusion of pupiliris nodulesncharacteristic of granulomatous iritisnaggregates of epithelioid cells and lymphocytes in the iris stromanon the pupillary border Koeppes nodulesnnear the iris root Bussacas nodulesKoeppes nodules,on the pupillary borderBussacas nodules,near the iris
14、 rootKoeppe nodules at the iris margin Busacca nodules on the iris surfaceComplications of anterior uveitisnComplicated cataract As a complication of the inflammatory process,or due to the prolonged use of corticosteroidnSecondary glaucoma ublockage of the trabecula meshwork with inflammatory cells,
15、uthe associated pupillary block caused by a seclused pupil,uthe consequential formation of peripheral anterior synechiaenHypotony and Phthisis Bulbi（低眼压及眼球萎缩）Complicated cataractSecondary glaucomaDiagnosis and differential diagnosis of acute anterior uveitisnDiagnosis clinical findings,history takin
16、g,ancillary testsnDifferential diagnosisuacute conjunctivitisuacute angle-closure glaucoma High tension with sudden marked loss of vision,middilated pupil and edematous cornea usubconjunctival hemorrhageacute angle-closure glaucoma with corneal clouding and diffuse conjunctival injection acute mucop
17、urulent bacterial conjunctivitis subconjunctival hemorrhageciliary injectionacute anterior uveitisconjunctival injectionAcute conjunctivitis Acute Iridocyclitis Acute congestive glaucoma 1-Pain Foreign body or gritty sensationNo pain Pain radiating along 1ST division(ophthalmic)Of 5th nerveSevere ne
18、uralgic pain radiating along all 3 divisions of 5th nerve associated with nausea and vomiting.2-VisionNot affected,may be slightly blurred.Moderate diminision Gross diminision sometimes reduced to just PL.3-Discharge Mucopurulent Watery(serous)Watery(serous)4-CongestionConjunctival congestionCiliary
19、 and conjunctival congestionCiliary and conjunctival congestion5-Cornea clear sensation normal mild oedema sensationnormal KPs on back of corneacloudy or steamy insensitiveDifferential diagnosis:shallow normal or deep normal 6-Anterior chamberlarge,vertically oval fixedsmall,irregular sluggish react
20、ion normal size reaction Normal7-Pupilmarkedly raised eye stony hardlow,normal or raised normal 8-Intraocular pressureabsentpresent absent 9-Ciliary tenderness Acute conjunctivitisAcute Iridocyclitis Acute congestive glaucoma Acute iridocyclitis should also be differentiated from other causes of red
21、 eye-corneal ulcer,scleritis etc.Clinical clue table suggesting the possibility of serious eye disease causing the red eye-clinical features that may necessitate immediate ophthalmologist consultationClinical featureSuggestsSevereeyeachingIritis,keratitis,acuteangle-closureglaucoma,scleritis,orbital
22、cellulitisProminentphotophobiaIritis,keratitisImpairedvisionIritis,keratitis,acuteangle-closureglaucoma,orbitalcellulitisCloudycorneaKeratitis,acuteangle-closureglaucomaCornealopacificationKeratitis-chemicalorinfectiousCircumcornealconjunctivalinjectionIritis,keratitisCloudyanteriorchamberIritisPain
23、oneyeballpalpationScleritis(+),orbitalcellulitisProptosisOrbitalcellulitis,posteriorscleritisImpaired,orpainful,extraoculareyemovementsOrbitalcellulitisFever,toxicappearanceOrbitalcellulitis(+)HyperpurulentdischargefromanangryeyeGonococcalconjunctivitis/endophthalmitisProminentnauseaandvomitingAcute
24、angle-closureglaucomaSmall,irregular,poorly-reactivepupilIritisFixedmid-dilatedpupilAcuteangle-closureglaucomaIncreasedintra-ocularpressureAcuteangle-closureglaucoma,iritis(secondarycomplication)Historyofconnectivetissuedisease,orgranulomatousdiseaseIritis,scleritisTreatment of acute anterior uveiti
25、s Principle：n Treatment against inflammation(steroids and nsaids)n Dilation of pupiln Prevention of complicationsAim：nRelieve pain and discomfort.nPrevent sight loss nEliminate causes of disease where possible Mydriatics(pupil dilators)nDilate pupil:remove spasm of ciliary muscle and sphincter,relie
26、ve pain,prevent sticking of iris to the lensSteroidsnAction mainly as being anti-inflammatory and immunosuppressant,although wide ranging effectsnMake up the major part of uveitis treatment.nUsed in different forms:uEye drops.uPeri-ocular injections.(injections locally around the eye).uSystemically
27、via the blood stream,either by oral(tablets)or intra-venous infusion(drip).Steroidssubconjunctival injection球结膜下注射球结膜下注射Treatment for the cause nTreatment will be different depending on what caused the uveitis e.g.u Infection antibiotic,anti-virus medicine u Trauma wound repairu Autoantigen-eliminat
28、e Ancillary medicinenNonsteroidanti-inflammatory drugs(NSAIDs)nImmunosuppressantTreatment for the complicationsnlaser iridotomy for secondary glaucomaTreatment for the complicationsphacoemulsification for cataractIntermediate Uveitis nThe part of the eye affected is the peripheral part of the inner
29、eye between the posterior and anterior parts Posterior Uveitis nPosterior uveitis,affects the back of the eye.The inflammation may affect the retina(retinitis),or also arise in the blood vessels at the back of the eye(vasculitis).PanuveitisnPanuveitis uveitis,which is caused when the whole uveal tra
30、ct is affected by uveitis.Retinitis and vasculitis arising from Posterior uveitisVitritis（玻璃体炎）panuveitisSympathetic OphthalmianAn binoculus granulomatous uveitis in which a penetrating injury or intraocular surgery in one eye produces autoimmune inflammation in the follow eye.(The injured eye is te
31、rmed the exciting eye while the follow one is the sympathetic eye.)nSympathetic ophthalmia(SO)is rare,affecting 0.2%to 0.5%of penetrating-injury cases,and less than 0.1%of surgical eyes.No gender or racial differences in incidence of SO.nlatent period:2w-1y,2w-4w dangerous,Damage to an immuno-logica
32、lly privileged site can induce an autoimmune response Pathophysiology nThe original eye injury always involves the uvea,specifically the ciliary body,releasing uveal pigment into the bloodstream.nThis triggers the formation of antibodies which cause inflammation of the uvea(uveitis)in the follow eye
33、 with gradually progressive loss of vision.Clinical features nFloating spots and loss of accommodation are among the earliest symptoms.nCommonly the eye remains relatively painless while the inflammatory disease spreads through the uvea,although the disease may progress to severe iridocyclitis with
34、pain and photophobia.nThe retina,however,usually remains uninvolved,although perivascular cuffing of the retinal vessels may occur.nPapilledema,secondary glaucoma,vitiligo,and poliosis of the eyelashes may accompany SO.nIn approximately 80%of cases,the uveitis appears within 2-12 weeks after injury,
35、and 90%occur within 1 year from the time of injury.Mutton-fat KP on the corneaDalen-Fuchs nodulesSympathetic ophthalmia-the exciting eye Sympathetic ophthalmia-the sympathetic eyePrevention and treatment nDefinitive prevention of SO requires prompt(within the first 7 to 10 days following injury)enuc
36、leation of the injured eye.There is concern,however,that evisceration may lead to a higher incidence of SO compared to enucleation(reviewed by Migliori,2002).However,instant dealing with wound is more important.nBecause SO is so rarely encountered following eye injury,even when the injured eye is re
37、tained,the first choice of treatment may not be enucleation or evisceration,especially if there is a chance that the injured eye may regain some function(Gurdal et al.,2002).Additionally,with current advanced surgical techniques,many eyes once considered nonviable now have a fair prognosis.nImmunosu
38、ppressive therapy is the mainstay of treatment for SO.Mild cases may be treated with local application of corticosteroids and pupillary dilators.More severe or progressive cases require high-dose systemic corticosteroids for months to years.Patients who become resistant to corticosteroids or develop
39、 side effects of long-term corticosteroid therapy,may be candidates for therapy with chlorambucil,cyclophosphamide,or ciclosporin.Iris cyst（虹膜囊肿）nfluid-filled sphere which arises from the back of the iris.nmay remain attached to the iris,or break free and float around in the anterior chamber inside
40、the eye.nMany patients with iris cysts are never bothered by them.In some cases,iris cysts can become large enough to obscure vision.Less often,an iris cyst may prevent the pupil from constricting properly,or may rub against the cornea and cause cloudiness.nCorrective surgery can alleviate vision pr
41、oblems associated with iris cysts.The goal is to reduce the size of the cyst by draining fluid out of the cyst with a needle,or popping the cyst using the laser.Iris pigment epithelial cyst(A)Anterior segment photograph with a broad beam reveals normal iris appearance.(B)With a slit beam,anterior bu
42、lging of the iris becomes evident.(C)Note echo-free,thin-walled cyst on UBM(arrows).Malignant melanoma of the choroid(脉络膜恶性黑色素瘤)nthe most common primary malignant intraocular tumor and the second most common type of primary malignant melanoma in the body.narises from the pigmented cells of the choro
43、id of the eye.nmay metastasize to distant areas of the body(i.e.,the liver or lung)and can cause death.nslightly more frequently in men for all age groups,except from 20-39 years.nhighest around age 55 years.nmay produce no symptoms initially if locates away from the macula（黄斑）;distorted and/or redu
44、ced vision if develops next to or in the macula.nmay produce changes in the visual field(side of vision),in the vitreous,and flashes of light or floaters as it enlarges.nmay cause a retinal detachment when fluid leak under the retina from large tumors,with distorted and/or decreased vision.nrarely n
45、otices increased pigmentation on the sclera,and uncommon for someone to complain of pain unless a complication such as glaucoma has developed.nMost choroidal melanomas are therefore discovered by the ophthalmologist on routine examination,such as ultrasound,fluorescein angiography and MRI.nThere are
46、 many forms of treatment available for choroidal melanoma,the oldest technique is removal of the eye.Malignant melanoma of the choroidChoroidal melanotic melanoma in a 51-year-old man with decreasing vision in the left eye.(a)Axial T1-weighted MR image demonstrates a round,diffusely hyperintense mas
47、s in the posterior-inferior aspect of the left globe.(b)Coronal T2-weighted MR image shows marked signal hypointensity within the lesion.(a)(b)Metastatic carcinoma of the choroid（脉络膜转移癌）nMalignant tumors from other parts of the body can spread in and around the eye.These tumors may never be discover
48、ed unless they affect vision,are visible to the patient,or push the eye forward.The most common location for ocular metastasis is the choroid(choroidal metastasis).nCancer metastasis that appear in and around the eye are usually from a breast cancer(in women)and lung cancer(in men).Other less common
49、 sites of origin include the prostate,the kidney and the gastrointestinal tract.nOnce a patient is diagnosed with choroidal metastasis,we try to find where it came from.In 18%of patients,we do not find the source of choroidal metastasis.In these cases,we may have to biopsy the ocular tumor and look
50、at its cell-type.A)Choroidal metastases lesion from breast cancer showing peripheral,yellow,plateau-shaped lesion.B)Choroidal metastases lesion in lower right quadrant causing serous retinal detachment.C)Choroidal metastases lesion in upper temporal quadrant as seen on a fluorescein angiogram.White
