《葡萄膜病》PPT课件.ppt

Uveal Tract Disease 葡萄膜病, Uveal Tract 葡萄膜包括: Iris 虹膜 Ciliary body 睫状体 Choroid 脉络膜 三者彼此相连,血供系统同源.,Uvitis 葡萄膜炎 Is the generic name of the inflammation of uvea ; retina ;retinal vessels and vitreous 葡萄膜、视网膜、视网膜血管和玻璃体炎症的总称 Always in young patient 多见于年轻人 Always combine with systemic autoimmune disease 常合并全身自体免疫性疾病 recurrence is often 易复发 Always blind 常致失明,Etiology and pathogenesis 病因和发病机理 Etiology : bacteria; fungus ;virus ; parasite Rickettsia infect directly or by evoke the antigen antibody reaction and complement compound induce uveitis Such as leprosy ; tuberculosis; syphilis; aids. 由细菌、霉菌、病毒、寄生虫、立克次体直接感染或导致抗原抗体反应和免疫复合物引起葡萄膜炎。如麻风、结核、梅毒、艾滋病, Autoimmunity: eyes have many antigen . Immune disorder lead to uveitis such as sympathetic uveitis Stills disease (juvenile rheumatoid arthritis) Harada-Vogt disease 自身免疫反应：眼有很多抗原，免疫异常导致葡萄膜炎。例如交感性眼炎、晶体过敏性眼内炎、 原田-小柳氏病、Behcet病等. 伴发葡萄膜炎自身免疫性疾病:风湿性关节炎，系统性红斑狼疮. The function of metabolite of arachidonic acid always seen in surgery , drug and physical stimulation 氧自由基的作用 ：常见于手术、外伤、以及理化刺激等导致活性氧生成过多,造成组织损害-自身氧损伤.,Classification of uvitis 分类, classify in etiologyinfection or non-infection 病因分类感染和非感染 classify in pathologygranuloma or non-granuloma uveitis 临床病理分类肉芽肿型和非肉芽肿型 classify in anatomy-1979 anterior ,intermediate ,posterior and panuveitis 解剖部位分前、中、后或全葡萄膜炎(现阶段国际通用分类方法),Anterior uveitis 前葡萄膜炎,in China50-60% of uveitis are anterior uneitis 我国50-60葡萄膜炎病人是前葡萄膜炎 Including 3 types 三种类型 acute anterior uveitis 急性前葡萄膜炎 chronic anterior uveitis 慢性前葡萄膜炎 acute or chronic anterior uveitis 既可出现急性炎症又可出现慢性炎症的前葡萄 膜炎,Acute Anterior Uveitis 急性前葡萄膜炎 Clinical features 临床表现 Symptoms of anterior Uvitis 症状 Aching pain in the eye 剧烈眼痛 Rapid blurring of vision 视力急速下降 Photophobia 怕光 Tearing of the eye 流泪,Signs of anterior uveitis 体症 Redness of the eye ciliary congestion or mixed congestion 眼球充血。 睫状充血或混合 性充血 KP( keratitis Precipitate ） three types dust like or media size or suet like 角膜后沉着物 。 有三种类型：尘埃状、中等大小 羊脂状,KP is clumps of white cells and inflammatory debris The shape of distribution of Kp is triangle shape or in pupil area of cornea or diffused KP:成堆白血球和炎症碎片，分布呈三角形或在瞳孔区或弥散分布 Aqueous flare the damage of aqueous and blood barrier protein exudate into aqueous cells and flare in the anterior chamber -tyndall sign 房闪:血-房水屏障受损蛋白渗 入前房,房水闪光阳性（丁道尔现象）, Hypopyon Aqueous cells inflamination cells red cells pigment cells inflammary cells percipitate in the lower part of anterior chamber 前房积脓。房水细胞、红细胞、上皮细胞 、炎症细胞沉积在前房下方, changes of iris 虹膜改变 iris edema and muddy 虹膜水肿、纹理不清 Posterior synechia of the iris pupil irregular 后粘连而瞳孔不规则 iris bombe 虹膜膨隆 Peripheral anterior synechia of the iris 周边前粘连 goniosynechia 房角粘连 iris nodules 虹膜结节, changes of pupil 瞳孔变化 Miosis Pupil constriction: inflammatory spasm of the iris sphincter muscle 瞳孔缩小，由于瞳孔括约肌痉挛 irregular pupil 瞳孔不规则,Pupil posterior synechia 瞳孔后粘连,posterior Synechia 后粘连,Seclution of pupil 瞳孔闭锁,Goniosynechia 房角粘连,Occulusion of pupil 瞳孔膜闭,Iris bombe 虹膜膨隆, Seclusion of pupilsynechia in 360 degree 瞳孔闭锁360度后粘连 Occlusion of pupil-fibrous membrane cover the pupil 瞳孔膜闭纤维膜遮盖瞳孔区 lens -pigment participate in the anterior lens capsule ,after enlarge the posterior synechia pupil pigment remain 晶状体前囊有色素沉着，当拉开后粘连时，瞳孔区遗留色素。,posterior segment of eye changed 眼後段改变 vitreous opacity 玻璃体混浊 Particles in vitreous 玻璃体内有颗粒状物 reflective macular edema 反应性黄斑水肿,Complication 并发症 complicated cataract 并发性白内障 the aqueous changed matabolism of the lens 房水改变使晶状体代谢改变 Opacity under the posterior capsule.also due to long term use steroid drops 长期应用激素滴眼晶状体后囊下混浊,Secondary glaucoma 继发性青光眼 block the trebacular mash work peripherial anterior synechia pupil block the aqueous circle 小梁网阻塞以及瞳孔后粘连阻断房水循环 Low IOP 低眼压 Atrophy of eyeball 眼球萎缩, Diagnosis 诊断 Diagnosis by Symptom and signs 根据症状和体征诊断 Pay attention to systemic condition specially Artheritis urea tract inflammation Reiter syndrome T.B.and syphilis etc. 注意全身情况特别是关节炎，结核，梅毒等合并 葡萄膜炎,Differential diagnosis 鉴别诊断 some times tumor also have hypopyon. check B scan、 CT、MRI 前葡萄膜炎主要与急性结膜炎、急性青光眼鉴别。 肿瘤有时也可有前房积脓。应用B超、CT、 MRI 检查以明确诊断。, Treatment 治疗 Dilate the pupil instantly .prevent posterior synechia 立即散瞳，减轻炎症反应，预防后粘连。 release the pain due to the spasm of sphinter of pupil and ciliary muscle use mydriatic : 1-4% Homatropine not atropine posterior synechia use mixed mydriatics 应用散瞳剂如阿托品、后马托品或混合散瞳剂可缓解疼痛,Topical steroid 局部或周身应用皮质类固醇激素 NSAID nonsteriod anti-inflammatory drugs 应用非淄体消炎药如消炎痛、布洛芬等 Etiology therapy : antiinfection 病因治疗：抗感染 complications in secondary glaucoma use diamox timolol 治疗并发症如继发性青光眼应用降眼压药物 In pupil block laser iridotomy or peripherial Iridectomy is needed 瞳孔阻滞可激光虹膜打孔 或周边虹膜切除, Filter surgery is needed for the synechia of anterior chamber cases 广泛房角粘连应当应用青光眼滤过术 After control the inflammation do cataract surgery and IOLImplant systemic use steroids to prevent uveitis 控制炎症后做白内障和人工晶体植入术，术前应先用激素以免葡萄膜炎复发,Intermediate uveitis 中间型葡萄膜炎,Clinical features 临床表现 Pars plana ciliary part and base of vitreous uveitis ;peripheral Retinal and choroid involved. 睫状体平坦部和玻璃体基底部葡萄膜炎。周边视网膜和脉络膜受累 Always 40y.both eyes chronic onset 常常为 40岁，双眼、发病缓慢,Sometimes have pain and red eye Symptom: can no symptom or see as flying mosquito ,blured vision , temporary myopia 可无症状或仅有飞蚊症、视力模糊、一过性近视，有时有疼痛和红眼。,Signs 体症 Snow like vitreous opacity snow bank in pars plana always in the lower part as a tongue point to the vitreous 雪片样玻璃体混浊， 睫状体平坦部雪堤状隆起常在 下方如舌状伸向玻璃体,lesion of retinal and choroid always in the lower part of peripheral -retinitis ; retinal vasculitis ,and peripheral retinochoroiditis 视网膜和脉络膜病变 常在下方周边部有视网膜炎； 视网膜血管炎和周边视网膜 脉络膜炎,Complication 并发症 Macular lesion : cystoid edema 、 premacular membrane、 macular hole etc. 黄斑病变:囊样水肿、黄斑前膜、黄斑洞等 complicated cataract 并发性白内障 Others: retinal neovascularization, vitreous hemorrhage, proliferative retinopathy, papilla edema, papilla atrophy 视网膜新生血管形成、玻璃体出血、 增殖性视网膜炎，视乳头水肿、视神经萎缩,Diagnosis 诊断 dusty figure in visual field 视野中有尘埃状漂浮物 Subposterior capsule cataract 晶体后囊下混浊 macular edema 黄斑水肿 FFA can help diagnosis 眼底荧光 血管造影有 助诊断,Treatment 治疗 Visual acuity 0.5 no inflammation in anterior segment just examine after a period of time 视力 0.5 前节无炎症只需定期检查 Vision 0.5 active inflammation in the anterior segment give steroids peritenons capsule for half year. 视力 0.5 前节有炎症，给与激素激素治疗半年，尽可能局部给药。,Freezing of pars plana or use laser for neovascularization of retinal. 冷冻或激光治疗视网膜新生血管 Surgery: Vitrectomy 手术： 玻璃体切割术 Immune-suppressive agent 免疫抑制剂,Posterior uveitis 后葡萄膜炎, Choroiditis 脉络膜炎 Retinalchoroiditis 视网膜脉络膜炎 Retinitis 视网膜炎 Retinal vasculitis 视网膜血管炎,toxoplasmosis,几种特殊类型的葡萄膜炎,Vogt-Koyanagi-Harada syndrome Vogt-小柳原田综合症,Cerebritis uveitis 又称特发性葡萄膜大脑炎 Etiology 病因 自身免疫反应所致 Clinical features 临床表现 脑膜刺激征 pigment change in skin And hair depigmentation tinnitus vitiligo 皮肤色素改变、白发、耳鸣、白癜风, Both eye granular panuveitis 双眼肉芽肿型全葡萄膜炎 vision lose 视力丧失 Fundus as rosy clouds just before sunset 晚霞样眼底改变 Delen-fuchs nodus 有Delen-fuchs结节 Diagnosis 诊断 FFA早期点状荧光素渗漏， 逐渐扩大融合, Treatment 治疗 Steroid and antiimmune therapy 应用皮质类固醇和免疫 抑制剂治疗,Behcet disease 白塞氏病,Recurent hypopyon uvitis ，Uveitis ，oral ulcer， skin lesion ，genital ulcer 复发性前房积脓型葡萄膜炎、 口腔溃疡、皮肤损害、生殖器溃疡为特征的多系统受累疾病。 Etiology 病因 May be related to bacteria or virus infection and autoimmune reaction. 由于细菌或病毒感染以及自身免疫反应所致,Clinical features 临床表现 eye lesion 眼部病变 panuveitis 25% hypopyon retinitis 全葡萄膜炎 ，25是前房积脓性视网膜炎 Retinal vasculitis.occlusion of of retinal vessels 视网膜血管阻塞 complicated cataract 并发性白内障, secondary glaucoma; 继发性青光眼， proliferate retinopathy and optic atrophy 增殖性视网膜病变和视神经萎缩, oral ulcer very pain 7-14d 口腔溃疡十分疼痛,持续 7-14天 skin lesion : erythema nodus, acneform eruptions Needle point overaction vitiligo 皮肤病变：结节性红班，多形红斑，针刺过敏反应，白癜风 Ulcer of outer genital urinary tract 外生殖器溃疡,Diagnosis 诊断 Recurent hypopyon uvitis ，Uveitis ，oral ulcer， skin lesion ，genital ulcer 反复发作的葡萄膜炎、 口腔溃疡、皮肤损害、 生殖器溃疡。,Treatment 治疗 Anterior Uveitis- use mydriatic 眼前段受累者-睫状肌麻痹剂 Topical steroid 糖皮质激素 Immune-suppressive agent 免疫抑制剂 Complicated cataract have a surgery and Secondary glaucoma treatment by drug 并发白内障手术;继发青光眼药物降眼压, 手术应慎重。,Sympathetic ophthalmia 交感性眼炎,following a perforating eye injury in the region of the ciliary body, bilaterial uveitis occurs 当一眼睫状体区发生穿通伤或一眼手术后，双眼发生葡萄膜炎。受伤眼称诱发眼，另一眼称交感眼。 Etiology 病因 probably related to hypersensitivity of some element of the pigment -bearing cells in the uvea. 外伤或手术造成眼内抗原暴露激发了自身免疫反应,Clinical features 临床表现 Granular uveitis 肉芽肿型葡萄膜炎。可为前葡萄膜炎、后葡萄膜炎、 中间葡萄膜炎或全葡萄膜炎。 Diagnosis 诊断 perforating eye injury in the region of the ciliary body 眼球穿通伤和内眼手术史主要诊断依据,Treatment 治疗 use mydriatic Topical steroid 前葡萄膜炎:糖皮质激素、睫状肌麻痹剂 Posterior uveitis and all uveitis-Topical steroid and Immune-suppressive agent 后葡萄膜炎和全葡萄膜炎:糖皮质激素、免疫抑 制剂,Acute retinal necrosis syndrome 急性视网膜坏死综合症 By herpes simplex retinal necrosis retinal artiritis vitreous opacity 单疱病毒引起的坏死性视网膜动脉炎和玻璃体浑浊 retinal detachment in the later stage 后期发生视网膜脱离 Always single eye 常为单眼 Blur vision macular lesion 黄斑病变引起视力减退 high IOP 高眼压, And then to posterior part of retina 早期在视网膜中段发生斑块状病变,以后向视网膜后部发展 Retinal vasculitis is an important sign 视网膜血管炎是重要体症 Therapy: antivirus agent anti-coagulation steroids laser vitrectomy 治疗：抗病毒治疗，抗凝治疗，激素，激光治疗和 玻璃体切割术。,Choroidal hemangioma 脉络膜血管瘤,congenital blood vessel deformation accompany with face hemangioma and glaucoma called Sturge-Weber syndrome. 先天性血管异常 合并面部血管瘤 和青光眼, always in young patients 常见于年轻人 lesion from disc and near macula isolated as a red ball elevated or scattered flat ,border is not clear.always have retinal detachment vision lose or glaucoma 病变起于视乳头近黄斑部 呈红色球样隆起，边界不清， 常有视网膜脱离，视力丧失 或青光眼。,Malignant melanoma of the choroid 脉络膜恶性黑色素瘤, Always in adult 50-60y.single eye.from pigment cell or nevus of uvea. 多见于50-60岁成年人，单眼发病。源于色素细胞、色素痣或葡萄膜 vision disfiguration when tumour is in the macular 肿瘤累及黄斑部时视力下降 exudative retinal detachment ; metastasis 渗出性视网膜脱离，转移 IOP increased in necrosis of tumour and block the vortex vein 眼压增高 由于肿瘤坏死和阻塞涡静脉,Cong