眼科学：英文-葡萄膜疾病课件

DISEASEOFTHEUVEA

（葡萄膜疾病）

DISEASEOFTHEUVEA

（葡萄膜疾病）

uveaUvealtract:iris,theciliarybodyandthechoroid

uveaUvealtract:iris,theciluveachoroid

wellvascularized-nutritionandremovalofmetabolicwaste

melanocytes-darkbackground

Sclerotic

ExternalVascularPortionoftheChoroid

InternalVascularPortionoftheChoroid

PigmentCellLayer

MembranaLimitansInterna

uveachoroidScleroticExternalOutlineUveitis(Causes,etiologyandclassificationofuveitis)AnteriorUveitis（前葡萄膜炎）IntermediateUveitis（中间葡萄膜炎）PosteriorUveitis（后葡萄膜炎）Panuveitis（全葡萄膜炎）SomespecificuveitisSympatheticophthalmia（交感性眼炎）VKHsyndrome（Vogt-小柳原田综合症）AnteriorUveitisassociatedwithAnkylosingspondylitis（强直性脊柱炎）Behcet’ssyndromeFuchssyndromeARNsyndrome（急性视网膜坏死综合症）Tumorandcongenitaldiseasesofuvea

Iriscyst（虹膜囊肿）Malignantmelanomaofthechoroid（脉络膜恶性黑色素瘤）Metastaticcarcinomaofthechoroid（脉络膜转移瘤）Uvealcoloboma（葡萄膜缺损）OutlineUveitis(Causes,etiolUveitisDefinition:

Aninflammationoftheuvealtract

UveitisDefinition:CausesofUveitis

Infection

bacteria,virus(egherpes疱疹病毒),fungus,parasite

Immuneresponse

autoimmuneantigen:

retinalS,IRBP(interphotoreceptorretinoid-bindingprotein)

immune-complexesmediatedreactionTrauma

eyeinjury,surgery:releasearachidonicacid-apotentinflammatorymediatorGeneticassociations

Ankylosingspondylitis-HLA-B27Bechet'sdisease-HLA-B51VKH-HLA-DR4CausesofUveitis

InfectionClassificationofUveitis

Aetiological

infectious,noninfectiousPathological

granulomatous（肉芽肿性）,nongranulomatous（非肉芽肿性）Anatomical

anterior,intermediate,posterior,panuveitis

Clinical

acute(<3months),chronic(>3months)ClassificationofUveitis

AetAnteriorUveitis

-iritis&iridocyclitisSymptomsredness,

pain,photophobia,tearing,floaters,decreasedvision…AnteriorUveitis

-iritis&irSignsinjection(ciliaryormixed)睫状或混合充血Keraticprecipitates,KP角膜后沉着物anteriorchamberflare前方闪辉anteriorchambercell前方细胞posteriororanteriorsynechiaeoftheiris

虹膜后粘连或前粘连irisnodules虹膜结节seclusionorocclusionofthepupil

瞳孔闭锁或瞳孔膜闭somefibrinouspigmenteddepositsinthepupillaryarea

ofthelens瞳孔区晶体前表面纤维色素沉着AnteriorUveitisSignsAnteriorUveitisA)CiliaryInjectionB)EpiscleralInjectionC)ConjunctivalInjection

GradeSeverity0WhiteandQuiet1/2Slight,UsuallyNormal1to1+Mild2to2+Moderate3to3+SevereA)CiliaryInjectionCiliaryinjectionConjunctivalinjectionfestoonedpupilCiliaryinjectionConjunctivalKeraticprecipitates,KP

CellsorpigmentsdepositonthebacksurfaceofthecorneaFine,dust-likeKPs

—

neutrophilegranulocyte，lymphocyte，plasmacyte；herpeticuveitis,FuchssyndromeLarge,white，“muttonfat”-likeKPs—

Mononuclearmacrophages，epithelioidcell；granulomatousiridocyclitisBrownpigmentedKPs

oldstanding

lightcoloredKPs

recentaffectionKeraticprecipitates,KP

Cellslarge,whiteKPs”muttonfat”formatriangularshapewithaninferiorbasefinedust-likeKPsbrownpigmentedKPslarge,whiteKPs”muttonfat”anteriorchamberflareandcellTheexudationfromirisvesselsduetothedisruptionoftheblood-aqueousbarrier,composedofproteins(Tyndallphenomenon),inflammatorycells.Thepresenceofcells-“active”irititis,resultinginhypopyon(前房积脓).anteriorchamberflareandcelAnteriorChamberCells

Cellsintheanteriorchamberareasignofinflammationorbleeding.

AnteriorChamberFlareFlareintheanteriorchamberrepresentsanelevatedconcentrationofplasmaproteinsfrominflamed,leakingintraocularbloodvessels.AnteriorChamberCellsAnteriocellsandflareintheanteriorchamber,hypopyoncellsandflareintheanteriohypopyonhypopyonsynechiaeduetotheorganizationoffibrinlaiddownfromfibroblaststhatadheretheiristotheanteriorsurfaceofthelens

—

posteriorsynechiaetothecornealendothelialsurface

—

anteriorsynechiae

synechiaeduetotheorganizatianteriorsynechiaefestoonedpupilduetoposteriorsynechiaeSeclusionofpupilIrisbombeOcclusionofpupilanteriorsynechiaefestoonedpuChangesofthepupilmyoticpupil:contractionofsphincterciliarybodyspasmocclusionofpupil

athickfibrinmembraneChangesofthepupilmyoticpuplenticularchanges,afterusingmydriasisinseclusionofpupillenticularchanges,afterusinirisnodulescharacteristicofgranulomatousiritisaggregatesofepithelioidcellsandlymphocytesintheirisstromaonthepupillaryborder—

Koeppe’snodulesneartheirisroot—

Bussaca’snodulesirisnodulescharacteristicofKoeppe’snodules,onthepupillaryborderBussaca’snodules,neartheirisrootKoeppenodulesattheirismarginBusaccanodulesontheirissurfaceKoeppe’snodules,onthepupilComplicationsofanterioruveitisComplicatedcataract

Asacomplicationoftheinflammatoryprocess,orduetotheprolongeduseofcorticosteroidSecondaryglaucomablockageofthetrabeculameshworkwithinflammatorycells,theassociatedpupillaryblockcausedbyaseclusedpupil,theconsequentialformationofperipheralanteriorsynechiae…HypotonyandPhthisisBulbi（低眼压及眼球萎缩）ComplicationsofanterioruveiComplicatedcataractComplicatedcataractSecondaryglaucomaSecondaryglaucomaDiagnosisanddifferentialdiagnosis

ofacuteanterioruveitisDiagnosis

clinicalfindings,historytaking,ancillarytests…Differentialdiagnosisacuteconjunctivitisacuteangle-closureglaucoma

Hightensionwithsuddenmarkedlossofvision,middilatedpupilandedematouscorneasubconjunctivalhemorrhageDiagnosisanddifferentialdiaacuteangle-closureglaucomawithcornealcloudinganddiffuseconjunctivalinjectionacutemucopurulentbacterialconjunctivitis

subconjunctivalhemorrhageciliaryinjectionacuteanterioruveitisconjunctivalinjectionacuteangle-closureglaucomawAcuteconjunctivitisAcuteIridocyclitisAcutecongestiveglaucoma1-PainForeignbodyorgrittysensationNopain

Painradiatingalong1STdivision(ophthalmic)Of5thnerveSevereneuralgicpainradiatingalongall3divisionsof5thnerveassociatedwithnauseaandvomiting.2-VisionNotaffected,maybeslightlyblurred.Moderatediminision

GrossdiminisionsometimesreducedtojustPL.

3-Discharge

Mucopurulent

Watery(serous)Watery(serous)4-CongestionConjunctivalcongestionCiliaryandconjunctivalcongestionCiliaryandconjunctivalcongestion5-Cornea

clearsensationnormalmildoedemasensationnormalKPsonbackofcorneacloudyorsteamyinsensitiveDifferentialdiagnosis:AcuteconjunctivitisAcuteIri6-Anteriorchambernormalnormalordeepshallow7-PupilnormalsizereactionNormalsmall,irregularsluggishreactionlarge,verticallyovalfixed8-Intraocularpressurenormallow,normalorraisedmarkedlyraisedeyestonyhard9-CiliarytendernessabsentpresentabsentAcuteconjunctivitisAcuteIridocyclitisAcutecongestiveglaucomaAcuteiridocyclitisshouldalsobedifferentiatedfromothercausesofredeye--cornealulcer,scleritisetc.6-Anteriorchambernormalnorma

Clinicalcluetablesuggestingthepossibilityofseriouseyediseasecausingthe"redeye"---clinicalfeaturesthatmaynecessitateimmediateophthalmologistconsultationClinicalfeatureSuggestsSevereeyeachingIritis,keratitis,acuteangle-closureglaucoma,scleritis,orbitalcellulitisProminentphotophobiaIritis,keratitisImpairedvisionIritis,keratitis,acuteangle-closureglaucoma,orbitalcellulitisCloudycorneaKeratitis,acuteangle-closureglaucomaCornealopacificationKeratitis-chemicalorinfectiousCircumcornealconjunctivalinjectionIritis,keratitisCloudyanteriorchamberIritisPainoneyeballpalpationScleritis(+++),orbitalcellulitisProptosisOrbitalcellulitis,posteriorscleritisImpaired,orpainful,extraoculareyemovementsOrbitalcellulitisFever,toxicappearanceOrbitalcellulitis(+)Hyperpurulentdischargefroman"angry"eyeGonococcalconjunctivitis/endophthalmitisProminentnauseaandvomitingAcuteangle-closureglaucomaSmall,irregular,poorly-reactivepupilIritisFixedmid-dilatedpupilAcuteangle-closureglaucomaIncreasedintra-ocularpressureAcuteangle-closureglaucoma,iritis(secondarycomplication)Historyofconnectivetissuedisease,orgranulomatousdiseaseIritis,scleritis

ClinicalcluetablesuggestiTreatmentofacuteanterioruveitis

Principle：

Treatmentagainstinflammation(steroidsandnsaids)DilationofpupilPreventionofcomplicationsAim：Relievepainanddiscomfort.PreventsightlossEliminatecausesofdiseasewherepossibleTreatmentofacuteanterioruvMydriatics(pupildilators)

Dilatepupil:removespasmofciliarymuscleand

sphincter,relievepain,preventstickingofiristothelensMydriatics(pupildilators)DiSteroidsActionmainlyasbeinganti-inflammatoryandimmunosuppressant,althoughwiderangingeffectsMakeupthemajorpartofuveitistreatment.Usedindifferentforms:Eyedrops.Peri-ocularinjections.(injectionslocallyaroundtheeye).Systemicallyviathebloodstream,eitherbyoral(tablets)orintra-venousinfusion(drip).

SteroidsActionmainlyasbeingSteroidssubconjunctivalinjection球结膜下注射SteroidssubconjunctivalinjectTreatmentforthecauseTreatmentwillbedifferentdependingonwhatcausedtheuveitise.g.

Infection–antibiotic,anti-virusmedicineTrauma–woundrepairAutoantigen-eliminate

TreatmentforthecauseTreatmAncillarymedicineNonsteroid

anti-inflammatorydrugs(NSAIDs)

ImmunosuppressantAncillarymedicineNonsteroid

aTreatmentforthecomplicationslaseriridotomyforsecondaryglaucomaTreatmentforthecomplicationTreatmentforthecomplicationsphacoemulsificationforcataractTreatmentforthecomplicationIntermediateUveitisThepartoftheeyeaffectedistheperipheralpartoftheinnereyebetweentheposteriorandanteriorpartsIntermediateUveitisThepart眼科学：英文-葡萄膜疾病课件PosteriorUveitisPosterioruveitis,affectsthebackoftheeye.Theinflammationmayaffecttheretina(retinitis),oralsoariseinthebloodvesselsatthebackoftheeye(vasculitis).PosteriorUveitisPosterioruvPanuveitisPanuveitisuveitis,whichiscausedwhenthewholeuvealtractisaffectedbyuveitis.PanuveitisPanuveitisuveitis,RetinitisandvasculitisarisingfromPosterioruveitisVitritis（玻璃体炎）RetinitisandvasculitisarisipanuveitispanuveitisSympatheticOphthalmiaAnbinoculusgranulomatousuveitisinwhichapenetratinginjuryorintraocularsurgeryinoneeyeproducesautoimmuneinflammationinthefolloweye.

(Theinjuredeyeistermedthe"exciting"eyewhilethefollowoneisthe"sympathetic"eye.)

Sympatheticophthalmia(SO)israre,affecting0.2%to0.5%ofpenetrating-injurycases,andlessthan0.1%ofsurgicaleyes.NogenderorracialdifferencesinincidenceofSO.latentperiod:2w-1y,2w-4wdangerous,SympatheticOphthalmiaAnbinocDamagetoanimmuno-logicallyprivilegedsitecaninduceanautoimmuneresponsePathophysiologyTheoriginaleyeinjuryalwaysinvolvestheuvea,specificallytheciliarybody,releasinguvealpigmentintothebloodstream.Thistriggerstheformationofantibodieswhichcauseinflammationoftheuvea(uveitis)inthefolloweyewithgraduallyprogressivelossofvision.Damagetoanimmuno-logicallyClinicalfeaturesFloatingspotsandlossofaccommodationareamongtheearliestsymptoms.

Commonlytheeyeremainsrelativelypainlesswhiletheinflammatorydiseasespreadsthroughtheuvea,althoughthediseasemayprogresstosevereiridocyclitiswithpainandphotophobia.Theretina,however,usuallyremainsuninvolved,althoughperivascularcuffingoftheretinalvesselsmayoccur.Papilledema,secondaryglaucoma,vitiligo,andpoliosisoftheeyelashesmayaccompanySO.Inapproximately80%ofcases,theuveitisappearswithin2-12weeksafterinjury,and90%occurwithin1yearfromthetimeofinjury.ClinicalfeaturesFloatingspoMutton-fatKPonthecorneaDalen-Fuchs’nodulesSympatheticophthalmia-the"exciting"eyeSympatheticophthalmia-the"sympathetic"eyeMutton-fatKPonthecorneaDalPreventionandtreatmentDefinitivepreventionofSOrequiresprompt(withinthefirst7to10daysfollowinginjury)enucleationoftheinjuredeye.Thereisconcern,however,thateviscerationmayleadtoahigherincidenceofSOcomparedtoenucleation(reviewedbyMigliori,2002).However,instantdealingwithwoundismoreimportant.BecauseSOissorarelyencounteredfollowingeyeinjury,evenwhentheinjuredeyeisretained,thefirstchoiceoftreatmentmaynotbeenucleationorevisceration,especiallyifthereisachancethattheinjuredeyemayregainsomefunction(Gurdaletal.,2002).Additionally,withcurrentadvancedsurgicaltechniques,manyeyesonceconsiderednonviablenowhaveafairprognosis.ImmunosuppressivetherapyisthemainstayoftreatmentforSO.Mildcasesmaybetreatedwithlocalapplicationofcorticosteroidsandpupillarydilators.Moresevereorprogressivecasesrequirehigh-dosesystemiccorticosteroidsformonthstoyears.Patientswhobecomeresistanttocorticosteroidsordevelopsideeffectsoflong-termcorticosteroidtherapy,maybecandidatesfortherapywithchlorambucil,cyclophosphamide,orciclosporin.PreventionandtreatmentDefinIriscyst（虹膜囊肿）fluid-filledspherewhicharisesfromthebackoftheiris.mayremainattachedtotheiris,orbreakfreeandfloataroundintheanteriorchamberinsidetheeye.Manypatientswithiriscystsareneverbotheredbythem.Insomecases,iriscystscanbecomelargeenoughtoobscurevision.Lessoften,aniriscystmaypreventthepupilfromconstrictingproperly,ormayrubagainstthecorneaandcausecloudiness.Correctivesurgerycanalleviatevisionproblemsassociatedwithiriscysts.Thegoalistoreducethesizeofthecystbydrainingfluidoutofthecystwithaneedle,orpoppingthecystusingthelaser.Iriscyst（虹膜囊肿）fluid-filledspIrispigmentepithelialcyst(A)Anteriorsegmentphotographwithabroadbeamrevealsnormalirisappearance.(B)Withaslitbeam,anteriorbulgingoftheirisbecomesevident.(C)Noteecho-free,thin-walledcystonUBM(arrows).IrispigmentepithelialcystMalignantmelanomaofthechoroid

(脉络膜恶性黑色素瘤)themostcommonprimarymalignantintraoculartumorandthesecondmostcommontypeofprimarymalignantmelanomainthebody.arisesfromthepigmentedcellsofthechoroidoftheeye.maymetastasizetodistantareasofthebody(i.e.,theliverorlung)andcancausedeath.slightlymorefrequentlyinmenforallagegroups,exceptfrom20-39years.highestaroundage55years.Malignantmelanomaofthechormayproducenosymptomsinitiallyiflocatesawayfromthemacula（黄斑）;distortedand/orreducedvisionifdevelopsnexttoorinthemacula.mayproducechangesinthevisualfield(sideofvision),inthevitreous,andflashesoflightorfloatersasitenlarges.maycausearetinaldetachmentwhenfluidleakundertheretinafromlargetumors,withdistortedand/ordecreasedvision.rarelynoticesincreasedpigmentationonthesclera,anduncommonforsomeonetocomplainofpainunlessacomplicationsuchasglaucomahasdeveloped.Mostchoroidalmelanomasarethereforediscoveredbytheophthalmologistonroutineexamination,suchasultrasound,fluoresceinangiographyandMRI.Therearemanyformsoftreatmentavailableforchoroidalmelanoma,theoldesttechniqueisremovaloftheeye.Malignantmelanomaofthechoroidmayproducenosymptomsinitia眼科学：英文-葡萄膜疾病课件Choroidalmelanoticmelanomaina51-year-oldmanwithdecreasingvisioninthelefteye.(a)AxialT1-weightedMRimagedemonstratesaround,diffuselyhyperintensemassintheposterior-inferioraspectoftheleftglobe.(b)CoronalT2-weightedMRimageshowsmarkedsignalhypointensitywithinthelesion.(a)(b)ChoroidalmelanoticmelanomaiMetastaticcarcinomaofthechoroid（脉络膜转移癌）Malignanttumorsfromotherpartsofthebodycanspreadinandaroundtheeye.Thesetumorsmayneverbediscoveredunlesstheyaffectvision,arevisibletothepatient,orpushtheeyeforward.Themostcommonlocationforocularmetastas