《葡萄膜病》PPT课件

UvealTractDisease葡萄膜病,UvealTract葡萄膜包括:Iris虹膜Ciliarybody睫状体Choroid脉络膜三者彼此相连,血供系统同源.,Uvitis葡萄膜炎Isthegenericnameoftheinflammationofuvea;retina;retinalvesselsandvitreous葡萄膜、视网膜、视网膜血管和玻璃体炎症的总称Alwaysinyoungpatient多见于年轻人Alwayscombinewithsystemicautoimmunedisease常合并全身自体免疫性疾病recurrenceisoften易复发Alwaysblind常致失明,Etiologyandpathogenesis病因和发病机理Etiology:bacteria;fungus;virus;parasiteRickettsiainfectdirectlyorbyevoketheantigenantibodyreactionandcomplementcompoundinduceuveitisSuchasleprosy;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:eyeshavemanyantigen.ImmunedisorderleadtouveitissuchassympatheticuveitisStillsdisease(juvenilerheumatoidarthritis)Harada-Vogtdisease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.Thefunctionofmetaboliteofarachidonicacidalwaysseeninsurgery,drugandphysicalstimulation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.,Classificationofuvitis分类,classifyinetiologyinfectionornon-infection病因分类感染和非感染classifyinpathologygranulomaornon-granulomauveitis临床病理分类肉芽肿型和非肉芽肿型classifyinanatomy-1979anterior,intermediate,posteriorandpanuveitis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),Anterioruveitis前葡萄膜炎,inChina50-60%ofuveitisareanterioruneitis我国50-60葡萄膜炎病人是前葡萄膜炎Including3types三种类型acuteanterioruveitis急性前葡萄膜炎chronicanterioruveitis慢性前葡萄膜炎acuteorchronicanterioruveitis既可出现急性炎症又可出现慢性炎症的前葡萄膜炎,AcuteAnteriorUveitis急性前葡萄膜炎Clinicalfeatures临床表现SymptomsofanteriorUvitis症状Achingpainintheeye剧烈眼痛Rapidblurringofvision视力急速下降Photophobia怕光Tearingoftheeye流泪,Signsofanterioruveitis体症Rednessoftheeyeciliarycongestionormixedcongestion眼球充血。睫状充血或混合性充血KP(keratitisPrecipitate）threetypesdustlikeormediasizeorsuetlike角膜后沉着物。有三种类型：尘埃状、中等大小羊脂状,KPisclumpsofwhitecellsandinflammatorydebrisTheshapeofdistributionofKpistriangleshapeorinpupilareaofcorneaordiffusedKP: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Aqueousflarethedamageofaqueousandbloodbarrierproteinexudateintoaqueouscellsandflareintheanteriorchamber-tyndallsign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）,HypopyonAqueouscellsinflaminationcellsredcellspigmentcellsinflammarycellspercipitateinthelowerpartofanteriorchamber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,changesofiris虹膜改变irisedemaandmuddy虹膜水肿、纹理不清Posteriorsynechiaoftheirispupilirregular后粘连而瞳孔不规则irisbombe虹膜膨隆Peripheralanteriorsynechiaoftheiris周边前粘连goniosynechia房角粘连irisnodules虹膜结节,changesofpupil瞳孔变化MiosisPupilconstriction:inflammatoryspasmoftheirissphinctermuscle瞳孔缩小，由于瞳孔括约肌痉挛irregularpupil瞳孔不规则,Pupilposteriorsynechia瞳孔后粘连,posteriorSynechia后粘连,Seclutionofpupil瞳孔闭锁,Goniosynechia房角粘连,Occulusionofpupil瞳孔膜闭,Irisbombe虹膜膨隆,Seclusionofpupilsynechiain360degree瞳孔闭锁360度后粘连Occlusionofpupil-fibrousmembranecoverthepupil瞳孔膜闭纤维膜遮盖瞳孔区lens-pigmentparticipateintheanteriorlenscapsule,afterenlargetheposteriorsynechiapupilpigmentremain晶状体前囊有色素沉着，当拉开后粘连时，瞳孔区遗留色素。,posteriorsegmentofeyechanged眼後段改变vitreousopacity玻璃体混浊Particlesinvitreous玻璃体内有颗粒状物reflectivemacularedema反应性黄斑水肿,Complication并发症complicatedcataract并发性白内障theaqueouschangedmatabolismofthelens房水改变使晶状体代谢改变Opacityundertheposteriorcapsule.alsoduetolongtermusesteroiddrops长期应用激素滴眼晶状体后囊下混浊,Secondaryglaucoma继发性青光眼blockthetrebacularmashworkperipherialanteriorsynechiapupilblocktheaqueouscircle小梁网阻塞以及瞳孔后粘连阻断房水循环LowIOP低眼压Atrophyofeyeball眼球萎缩,Diagnosis诊断DiagnosisbySymptomandsigns根据症状和体征诊断PayattentiontosystemicconditionspeciallyArtheritisureatractinflammationReitersyndromeT.B.andsyphilisetc.注意全身情况特别是关节炎，结核，梅毒等合并葡萄膜炎,Differentialdiagnosis鉴别诊断sometimestumoralsohavehypopyon.checkBscan、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Dilatethepupilinstantly.preventposteriorsynechia立即散瞳，减轻炎症反应，预防后粘连。releasethepainduetothespasmofsphinterofpupilandciliarymuscleusemydriatic:1-4%Homatropinenotatropineposteriorsynechiausemixedmydriatics应用散瞳剂如阿托品、后马托品或混合散瞳剂可缓解疼痛,Topicalsteroid局部或周身应用皮质类固醇激素NSAIDnonsteriodanti-inflammatorydrugs应用非淄体消炎药如消炎痛、布洛芬等Etiologytherapy:antiinfection病因治疗：抗感染complicationsinsecondaryglaucomausediamoxtimolol治疗并发症如继发性青光眼应用降眼压药物InpupilblocklaseriridotomyorperipherialIridectomyisneeded瞳孔阻滞可激光虹膜打孔或周边虹膜切除,Filtersurgeryisneededforthesynechiaofanteriorchambercases广泛房角粘连应当应用青光眼滤过术AftercontroltheinflammationdocataractsurgeryandIOLImplantsystemicusesteroidstopreventuveitis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,Intermediateuveitis中间型葡萄膜炎,Clinicalfeatures临床表现Parsplanaciliarypartandbaseofvitreousuveitis;peripheralRetinalandchoroidinvolved.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Always0.5前节无炎症只需定期检查Vision0.5activeinflammationintheanteriorsegmentgivesteroidsperitenonscapsuleforhalfyear.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。,Freezingofparsplanaoruselaserforneovascularizationofretinal.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-suppressiveagent免疫抑制剂,Posterioruveitis后葡萄膜炎,Choroiditis脉络膜炎Retinalchoroiditis视网膜脉络膜炎Retinitis视网膜炎Retinalvasculitis视网膜血管炎,toxoplasmosis,几种特殊类型的葡萄膜炎,Vogt-Koyanagi-HaradasyndromeVogt-小柳原田综合症,Cerebritisuveitis又称特发性葡萄膜大脑炎Etiology病因自身免疫反应所致Clinicalfeatures临床表现脑膜刺激征pigmentchangeinskinAndhairdepigmentationtinnitusvitiligo皮肤色素改变、白发、耳鸣、白癜风,Botheyegranularpanuveitis双眼肉芽肿型全葡萄膜炎visionlose视力丧失Fundusasrosycloudsjustbeforesunset晚霞样眼底改变Delen-fuchsnodus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Steroidandantiimmunetherapy应用皮质类固醇和免疫抑制剂治疗,Behcetdisease白塞氏病,Recurenthypopyonuvitis，Uveitis，oralulcer，skinlesion，genitalulcer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Mayberelatedtobacteriaorvirusinfectionandautoimmunereaction.由于细菌或病毒感染以及自身免疫反应所致,Clinicalfeatures临床表现eyelesion眼部病变panuveitis25%hypopyonretinitis全葡萄膜炎，25是前房积脓性视网膜炎Retinalvasculitis.occlusionofofretinalvessels视网膜血管阻塞complicatedcataract并发性白内障,secondaryglaucoma;继发性青光眼，proliferateretinopathyandopticatrophy增殖性视网膜病变和视神经萎缩,oralulcerverypain7-14d口腔溃疡十分疼痛,持续7-14天skinlesion:erythemanodus,acneformeruptionsNeedlepointoveractionvitiligo皮肤病变：结节性红班，多形红斑，针刺过敏反应，白癜风Ulcerofoutergenitalurinarytract外生殖器溃疡,Diagnosis诊断Recurenthypopyonuvitis，Uveitis，oralulcer，skinlesion，genitalulcer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AnteriorUveitis-usemydriatic眼前段受累者-睫状肌麻痹剂Topicalsteroid糖皮质激素Immune-suppressiveagent免疫抑制剂ComplicatedcataracthaveasurgeryandSecondaryglaucomatreatmentbydrug并发白内障手术;继发青光眼药物降眼压,手术应慎重。,Sympatheticophthalmia交感性眼炎,followingaperforatingeyeinjuryintheregionoftheciliarybody,bilaterialuveitisoccurs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probablyrelatedtohypersensitivityofsomeelementofthepigment-bearingcellsintheuvea.外伤或手术造成眼内抗原暴露激发了自身免疫反应,Clinicalfeatures临床表现Granularuveitis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perforatingeyeinjuryintheregionoftheciliarybody眼球穿通伤和内眼手术史主要诊断依据,Treatment治疗usemydriaticTopicalsteroid前葡萄膜炎:糖皮质激素、睫状肌麻痹剂Posterioruveitisandalluveitis-TopicalsteroidandImmune-suppressiveagent后葡萄膜炎和全葡萄膜炎:糖皮质激素、免疫抑制剂,Acuteretinalnecrosissyndrome急性视网膜坏死综合症Byherpessimplexretinalnecrosisretinalartiritisvitreousopacity单疱病毒引起的坏死性视网膜动脉炎和玻璃体浑浊retinaldetachmentinthelaterstage后期发生视网膜脱离Alwayssingleeye常为单眼Blurvisionmacularlesion黄斑病变引起视力减退highIOP高眼压,Andthentoposteriorpartofretina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Retinalvasculitisisanimportantsign视网膜血管炎是重要体症Therapy:antivirusagentanti-coagulationsteroidslaservitrectomy治疗：抗病毒治疗，抗凝治疗，激素，激光治疗和玻璃体切割术。,Choroidalhemangioma脉络膜血管瘤,congenitalbloodvesseldeformationaccompanywithfacehemangiomaandglaucomacalledSturge-Webersyndrome.先天性血管异常合并面部血管瘤和青光眼,alwaysinyoungpatients常见于年轻人lesionfromdiscandnearmaculaisolatedasaredballelevatedorscatteredflat,borderisnotclear.alwayshaveretinaldetachmentvisionloseorglaucoma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。,Malignantmelanomaofthechoroid脉络膜恶性黑色素瘤,Alwaysinadult50-60y.singleeye.frompigmentcellornevusofuvea.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visiondisfigurationwhentumourisinthemacular肿瘤累及黄斑部时视力下降exudativeretinaldetachment;metastasis渗出性视网膜脱离，转移IOPincreasedinnecrosisoftumourandblockthevortexvein眼压增高由于肿瘤坏死和阻塞涡静脉,CongenitalDisordersofUvea葡萄膜先天异常,Aniridia先天性无虹膜photophobiacorneaandlensopecity怕光，角膜和晶状体混浊Col