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7/17/2019 Uveitis2lecturesbydr Khaled 110228080300 Phpapp02

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VASCULAR PIGMENTED LAYER


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VASCULAR PIGMENTED LAYER

The vascular pigmented layer, or uveal tract, consists,

from back to front, of the choroids, the ciliary body, and

the iris..

IRIS

The iris is a thin, contractile, pigente! !iaphrag

"ith a central apert#re $the p#pil%, it is s#spen!e! inthe aeo#s h#or 'et"een the cornea an! the

lens( The peripher) o* the iris, "hich is attache! to

the anterior s#r*ace o* the ciliar) 'o!) is calle! the

ciliar) argin, or root o* the iris( The p#pil iss#rro#n!e! ') the p#pillar) argin( The iris,

eas#ring a'o#t + in !iaeter, is thic-est

a'o#t *ro the p#pillar) argin an! is thinnest

at the ciliar) argin(


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The anterior s#r*ace o* the lens is con.e/ an!

presses lightl) against the iris, ca#sing it to '#lge

antreiorl)( The p#pil .aries in !iaeter *ro + to

0, an! in a'o#t 12 o* noral s#'3ects the

p#pils !i**er slightl) in si4e on the si!es(

The iris !i.i!es the space 'et"een the lensan! the cornea into an anterior an! a

posterior cha'er( The aeo#s h#or,

*ore! ') the ciliar) processes in the

posterior cha'er, circ#late thro#gh the p#pilinto the anterior cha'er an! *inall) e/its into

the sin#s .enos#s sclerae at the iri!ocorneal

angle(


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The 'l#e iris has less pigent in theelanoc)tes copare! "ith the 'ro"n

iris( The color res#lts *ro the

a'sorption o* light, "ith long"a.elengths an! the re*lection o* the

shorter 'l#e "a.es that are seen ') the

o'ser.er(


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Str#ct#re o* the iris

Microscopicall), the iris consistso* t"o la)ers5

+% the stroa, sit#ate! anteriorl)an! !eri.e! *ro esench)e,

% t"o epithelial la)ers locate!posteriorl) an! !eri.e! *ro

the ne#ral ecto!er(


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Str#ct#re o* the iris

The sphincter p#pillae #scle is locate!in the p#pillar) 4one o* the iris( It *ors a

ring o* sooth #scle *i'ers aro#n! the

p#pil, eas#ring a'o#t + "i!e(The '#n!les o* sooth #scle cells are

separate! ') connecti.e tiss#e that

contains 'loo! .essels an! otor an!sensor) ner.es( 6hen the sphincter

p#pillae contracts, the p#pil costricts(


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Ciliar) 'o!)5

The ciliar) 'o!) is contin#o#s posteriorl)"ith the choroi! an! anteriorl) "ith the

peripheral argin o* the iris( Consi!ere! as a

"hole, the ciliar) 'o!) is a coplete ring thatr#ns aro#n! the insi!e o* the anterior sclera(

It eas#res a'o#t 7 "i!e$7(1 on theteporal si!e an! 1(1 on the nasal si!e%

an! e/ten!s *or"ar! to the scleral sp#r an!

'ac-"ar! to the ora serrata o* the retina(


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Choroi!

The choroi! is a thin, so*t, 'ro"n coat liningthe inner s#r*ace o* the sclera( It is e/treel)

.asc#lar( The choroi! e/ten!s *ro the optic

ner.e posteriorl) to the ciliar) 'o!) anteriorl)(

It is thic-est at the posterior pole$a'o#t 8(

% an! gra!#all) thins anteriorl) $a'o#t8(+ %( Its inner s#r*ace is sooth an!

*irl) attache! to the pigente! la)er o* the

retina9 its o#ter s#r*ace is ro#ghene!(


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It is *irl) attache! to the sclera in the regiono* the optic ner.e an! "here the posterior

ciliar) arteries an! ciliar) ner.es enter the

e)e( It is also tethere! to the sclera "here the.orte/ .eins lea.e the e)e'all(

Str#ct#re o* the choroi! a) 'e !i.i!e! into

three la)ers5+% the .essel la)er,

% the capillar) la)er,

:% ;r#ch


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Its principal *#nction is tono#rish "ith its 'loo! .essels

the o#ter la)ers o* the retina, it

also ser.es to con!#ct an)

'loo! .essels *or"ar! to the

anterior regions o* the e)e(

=#nction o* the choroi!


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It is in*laation o* iris, ciliar) 'o!) an! choroi!(

Anterior #.eitis is iri!oc)clitis, posterior #.eitis ischoroi!itis( The -no"n ca#ses o* #.eitis a) 'e

classi*ie! as *ollo"s5

A.E/ogeno#s In*ections9tra#a, per*orate! corneal#lcer, s#rger)(

;( En!ogeno#s In*ections( These incl#!e 5

;acterial in*ections9 t#'erc#losis, streptococcal

in*ection, gonorrhea or s)philis(

Viral infections; mumps, smallpox, influenza or

herpes.

Parasitic In*estations9to/oplasosis an! to/ocara(

U.eitis


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C Uveitis Secondary to an Ocular atholo!y."his may #e

su#divided into three cate!ories $

U.eitis o* an In*ecti.e Nat#re>This ca#se! ') !irect sprea!

o* in*ection *ro an oc#lar in*laation, s#pp#rati.e

-eratitis or *ro a peri?oc#lar in*laation, e(g( or'italcell#litis(

Uveitis of a "oxic %ature."his is due to the presence of

unusual ocular products in the eye as in$

Intra?oc#lar neoplas(lntra?oc#lar heorrhage(

Long?stan!ing retinal !etachent(

Dislocate! or s#'l#/ate! lens(

Uveitis of an Aller!ic %anture "he uveal tract is often

tar!et for immunolo!ic reactions, e.!. $

S)pathetic ophthalitis(

En!ophthalitis

phaco?anaph)lactic #.eitis(


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&. >U.eitis D#e to ;acterial Allerg)( The t"o ost

classic e/aples are 5

Min#te t#'erc#lo#s *oc#s o* in*ection in the l#ng or

a l)ph no!e(

Streptococcal *ocal in*ection coonl) lo!ge! in

the teeth, sin#ses, tonsils or prostate(

E(>U.eitis Coplicating General Diseases(>The

*ollo"ing are coon e/aples 5

+( An-)losing spon!)litis('.Sarcoi!osis(

:( ;ehcet@s !isease(

( Vogt?Bo)anagi s)n!roe(


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A ?ACUTE IRIDCYCLITIS

Symptoms

1.Pain. The pain is due to toxic irritation of the

sensory nerve ending in the iris and to spasm of

the sphincter pupillae muscle.

2. Photophobia due to pupillary constriction

when exposed to light

3. Lacrimation.Reflex lacrimation occurs as aresult of irritation of the sensory nerve endings in

the iris.


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4. Blepharospasm. This is the result of

photophobia and lacrimation.

5. Mistness of Vision. This is due to the

presence of inflammatory exudates in the

anterior chamber. The plasmoid aqueous

which is high in its protein content

contribute to the impairment of vision.

Si


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Signs

The clinical signs of anterior uveitis vary considerable

and depend on the type and acuteness of the

inflammatory process and the uveal region preferentiallyaffected.

Signs o* Iritis(The essential features of acute iritisinclude

!.Hyperaemia and irc!mcorneal iliary "n#ection.

". $lare d!e to %&!dation in the 'nterior hamber.

3. Bl!rrin( and "ndistinctness of the "ris Pattern) leading

to the appearance of a m!ddy iris


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#. onstricted) "rre(!lar and *l!((ishly

+eactin( P!pil. $a% &echanical

contraction caused by hyperaemia of theradially disposed iris vessels and oedema of

the iris.

$b% 'rritation of the iris by toxic products

causing contraction of its plain musclefibres.


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C liti


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C)clitis(>

+((eratic recipitates. The leucocytes

circulating in the exudate which comes frominflammed ciliary body pass through the

pupil and adhere to the sticky corneal

endothelium.

'. Copious "hic) *xudate into the

Anterior Cham#er.This is due to theabundant accumulation of cells in the

aqueous and the vitreous


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*xudation into the Vitreous. (xudates

from the inflamed ciliary body pass into the

anterior vitreous which becomes ha)y dueto diffuse dust*like opacities.

+ntraOcular ressure.The tension isusually within normal, but a lowering of the

ocular tension may be taken as an

indication of long*standing involvement of

the ciliary body.


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-. ?CRNIC IRID?CYCLITIS

Chronic iri!o?c)clitis is an e/treel) chronic !iseaseChronic iri!o?c)clitis is an e/treel) chronic !isease

characteri4e! ') consi!era'le !iin#tion o* .ision "itho#tcharacteri4e! ') consi!era'le !iin#tion o* .ision "itho#to'.io#s ca#se( It is lia'le to e/acer'ations "ith gra!#al an!o'.io#s ca#se( It is lia'le to e/acer'ations "ith gra!#al an!

insi!io#s *oration o* posterior s)nechiae(insi!io#s *oration o* posterior s)nechiae(

Clinical =eat#resClinical =eat#res

D#st?li-e opacities in the .itreo#swhose consistency

has undergone some liquefaction due to defective

nutrition.

The presence o* e/#!ates an! in*laator) cells in the

anterior chamber, which become evident as keratic precipitates onthe corneal endothelium, and vitreous cavity.

Ten!erness on press#re o.er the ciliar) 'o!) region(

Mil! ciliar) in3ectioninvolving the deeper vessels.

C li ti * I i! litiCoplications o* Iri!oc)clitis


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;an!?Shape! Beratopath)5 calci# !eposition in the cornea(;an!?Shape! Beratopath)5 calci# !eposition in the cornea(

=oration o* Posterior S)nechiae5 a!hesion 'et"een iris an!=oration o* Posterior S)nechiae5 a!hesion 'et"een iris an!lens(lens(

=oration o* Posterior S)nechiae5 a!hesion 'et"een iris an!=oration o* Posterior S)nechiae5 a!hesion 'et"een iris an!lens(lens(Peripheral Anterior S)necchiae5 a!hesion 'et"een iris an!Peripheral Anterior S)necchiae5 a!hesion 'et"een iris an!

cornea(cornea(

Peripheral Anterior S)necchiae5 a!hesion 'et"een iris an!Peripheral Anterior S)necchiae5 a!hesion 'et"een iris an!

cornea(cornea(

R#'iosis iri!is5 neo.asc#lari4ation o* the iris(R#'iosis iri!is5 neo.asc#lari4ation o* the iris(R#'iosis iri!is5 neo.asc#lari4ation o* the iris(R#'iosis iri!is5 neo.asc#lari4ation o* the iris(

Paches o* Iris Atroph)5Paches o* Iris Atroph)5Paches o* Iris Atroph)5Paches o* Iris Atroph)5

Secon!ar) Gla#coa5 !#e to s)nechiaeSecon!ar) Gla#coa5 !#e to s)nechiaeSecon!ar) Gla#coa5 !#e to s)nechiaeSecon!ar) Gla#coa5 !#e to s)nechiae

Coplications o* Iri!oc)clitisCoplications o* Iri!oc)clitis

Cataract5 !e*ect in lens n#trition(Cataract5 !e*ect in lens n#trition(Cataract5 !e*ect in lens n#trition(Cataract5 !e*ect in lens n#trition(

C)clitic Me'rane5 organi4ation o* .itreo#s e/#!ates(C)clitic Me'rane5 organi4ation o* .itreo#s e/#!ates(C)clitic Me'rane5 organi4ation o* .itreo#s e/#!ates(C)clitic Me'rane5 organi4ation o* .itreo#s e/#!ates(

Vitreo#s pacities5 D#st?li-e opacities a) *or in theVitreo#s pacities5 D#st?li-e opacities a) *or in the

anterior part o* the .itreo#s(anterior part o* the .itreo#s(

Vitreo#s pacities5 D#st?li-e opacities a) *or in theVitreo#s pacities5 D#st?li-e opacities a) *or in the

anterior part o* the .itreo#s(anterior part o* the .itreo#s(


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Di i ! I ti ti * U itiDiagnosis an! In.estigations o* U.eitis


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't is most difficult to make an aetiologic diagnosis of uveitis

on clinical grounds because the morphologic features are

not characteristic. 'mportant clues regarding the probable

diagnosis of uveitis are to be taken from the following clinical

and laboratory investigations

't is most difficult to make an aetiologic diagnosis of uveitis

on clinical grounds because the morphologic features are

not characteristic. 'mportant clues regarding the probable

diagnosis of uveitis are to be taken from the following clinical

and laboratory investigations

+( The onset an! co#rse o* the !isease(+( The onset an! co#rse o* the !isease(

Diagnosis an! In.estigations o* U.eitisDiagnosis an! In.estigations o* U.eitis

( The present an! the past ophthalological an! e!ical

histories(

(The present an! the past ophthalological an! e!ical

histories(

:( The clinical pict#re o* the lesions(:( The clinical pict#re o* the lesions(

( General e!ical e/aination, partic#larl) the chest an! the

3oints,

( General e!ical e/aination, partic#larl) the chest an! the

3oints,

1( Certain general la'orator) in.estigations1( Certain general la'orator) in.estigations

T t t f ' id liti


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!. Treatment of the +ause.!. Treatment of the +ause.!. Treatment of the +ause.!. Treatment of the +ause.

Treatment of 'ridocyclitisTreatment of 'ridocyclitis

". Symptomatic Treatment.". Symptomatic Treatment.". Symptomatic Treatment.". Symptomatic Treatment.

a. tropine.to prevent synechiae, pain - photophobiaa. tropine.to prevent synechiae, pain - photophobiaa. tropine.to prevent synechiae, pain - photophobiaa. tropine.to prevent synechiae, pain - photophobia

b. ocal Steroid Therapy.b. ocal Steroid Therapy.b. ocal Steroid Therapy.b. ocal Steroid Therapy.

c. ocal /ot pplications.c. ocal /ot pplications.c. ocal /ot pplications.c. ocal /ot pplications.

d. Subcon0unctival 1entamycin. This may bed. Subcon0unctival 1entamycin. This may be

necessary in severe pyogenic cases.necessary in severe pyogenic cases.

d. Subcon0unctival 1entamycin. This may bed. Subcon0unctival 1entamycin. This may be

necessary in severe pyogenic cases.necessary in severe pyogenic cases.

e. n (ye 2ad and a 3andage.They keep the lidse. n (ye 2ad and a 3andage.They keep the lids

firmly closed over the eyes and thus provide rest andfirmly closed over the eyes and thus provide rest and

prevent photophobia.prevent photophobia.

e. n (ye 2ad and a 3andage.They keep the lidse. n (ye 2ad and a 3andage.They keep the lids

firmly closed over the eyes and thus provide rest andfirmly closed over the eyes and thus provide rest and

prevent photophobia.prevent photophobia.

: G l T t t: General Treatent


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a( S)steic Steroi! Therap), e(g( pre!nisolone

an! a!renocorticotrophic horone $ ACT %(>I*the local steroi! !rops alone are not e**ecti.e,

the treatent is s#ppleente! ') a co#rse o*

s)steic steroi!s to s#ppress the in*laator)process(

a( S)steic Steroi! Therap), e(g( pre!nisolone

an! a!renocorticotrophic horone $ ACT %(>I*the local steroi! !rops alone are not e**ecti.e,

the treatent is s#ppleente! ') a co#rse o*

s)steic steroi!s to s#ppress the in*laator)process(

:( General Treatent(:( General Treatent(

'( S)steic Anti'iotics an! Cheotherap)(>6hen'( S)steic Anti'iotics an! Cheotherap)(>6hengi.en alone, the) ha.e 'een *o#n! #ns#ccess*#l ingi.en alone, the) ha.e 'een *o#n! #ns#ccess*#l in

arresting the process o* #.eitis, 'eca#se the !iseasearresting the process o* #.eitis, 'eca#se the !isease

is an in*laation rather than an in*ection(is an in*laation rather than an in*ection(

'( S)steic Anti'iotics an! Cheotherap)(>6hen'( S)steic Anti'iotics an! Cheotherap)(>6hengi.en alone, the) ha.e 'een *o#n! #ns#ccess*#l ingi.en alone, the) ha.e 'een *o#n! #ns#ccess*#l in

arresting the process o* #.eitis, 'eca#se the !iseasearresting the process o* #.eitis, 'eca#se the !isease

is an in*laation rather than an in*ection(is an in*laation rather than an in*ection(


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Ann#lar Posterior S)nechiae Ann#lar Posterior S)nechiae


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( Phthisis ;#l'i( blind painful eye

should be enucleated.

( Ann#lar Posterior S)nechiae(( Ann#lar Posterior S)nechiae(

complete iridectomy or laser iridotomycomplete iridectomy or laser iridotomy

:( Total Posterior S)nechiae "ith Coplicate!

Cataract(Removal of the lens is indicated after

rupturing the posterior synechiae with an iris repositor(

PSTERIR UVEITISPSTERIR UVEITIS


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A?SUPPURATTVE CRIDITIS

S#pp#rati.e choroi!itis #s#all) *ollo"s the intro!#ction o* in*ecting

icro?organiss *ro o#tsi!e or .ia the 'loo! strea lea!ing to

en!ophthalitis or panophthalitis(E/ogeno#s Ca#ses(>S#pp#ration a) *ollo" 5

+( Per*orating "o#n!s o* the e)e( ( Per*orating corneal #lcer(

:( Postoperati.e in*ection(

En!ogeno#sCa#ses(>S#pp#ration a) *ollo" 5

+( Metastatic in*ection in p)eia( ( P#rp#ral septicaeia(

:( Cere'rospinal eningitis(

PSTERIR UVEITISPSTERIR UVEITIS

IN=LAMMATINS = TE CRIDIN=LAMMATINS = TE CRID

In*laations o* the choroi! Choroiditis/ occ#r in t"o *ors 5

A >S#pp#rati.e Choroi!itis(>T"o t)pes are generall) recogni4e! 5

*ndophthalmitis, i.e. in*laation o* the internal str#ct#res o* the e)e(

anophthalmitis, i.e. in*laation o* all the tiss#es o* the e)e(

-. >Non?S#pp#rati.e Choroi!itis(>This has 'een classi*ie! into 5

0ranulomatous Choroiditis.

%on0ranulomatous Choroiditis $E/#!ati.e U.eitis%(

ENDPTALMITISENDPTALMITIS


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Signs5 The e)e is se.erel) in3ecte! an! re!(

The con3#ncti.a 'ecoes cheotic(Beratic precipitates on the 'ac- o* the cornea(

The aeo#s 'ecoes t#r'i! "ith an) cells

circ#lating thro#gh it(

ENDPTALMITISENDPTALMITIS

En!ophthalitis is a p#r#lent in*laation o* the

entire #.eal tract, altho#gh the a!3acent tiss#es a)

'e secon!aril) a**ecte!(

S)ptos(>The patient #s#all) coplains o*

se.ere irritation in the e)e( E/cessi.e lacriation,

photopho'ia an! ar-e!?!iin#tion o* .ision are.er) coon(

T t tT t t


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Intensi.e local an! s)steic anti'iotic therap) #st

'e gi.en(

Local atropine, steroi! an! application o*heat are

.er) #se*#l(It a) 'e necessar) to gi.e s)steic steroi! in an

attept to s#ppress the in*laator) reaction(

Vitrecto) an! intraoc#lar in3ection o* anti'iotics(

6hen perception o* light is lost, en#cleation o* the

e)e'all sho#l! 'e consi!er(

TreatentTreatent

PANPTALMITIS


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Signs5S"elling o* the e)eli!s "ith intense congestion o* the

e)e'all(A sall !egree o* proptosis(

Cheosis o* the con3#ncti.a(

a4iness o* the cornea(

Anterior cha'er an! .itreo#s *ille! "ith p#s(Loss o* acc#rate pro3ection o* light, !#e to retinal

!etachent(

The e)e'all a) *inall) per*orate or the p#s a) escape

thro#gh the anterior ciliar) region an! e.ent#all) the e)e'all

shrin-s(

PANPTALMITISIs an intense p#r#lent in*laation o* the three coats o* the e)e( The

e)e'all is *ille! "ith p#s, an! the entire #.eal tract is in*iltrate! "ith

in*laator) cells, ainl) pol)orphon#clear le#coc)tes(

S)ptos5The s)ptos are #s#all) se.ere an! incl#!e 5+( =e.er an! general *e'rile s)ptos( ( ea!ache an!

.oiting( :( Se.ere pain in the e)e( ( Loss o* .ision(

TreatentTreatent


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Earl) #se o* intensi.e s)steic an! local

anti'iotic therap) a) pre.ent the

panophthalitis( The treatent a) 'e

s#ppleente! "ith s)steic steroi!s to

re!#ce in*laator) reactions(The a!inistration o* analgesics to control

pain, an! the application o* local heat to

ipro.e the 'loo! *lo" are #s#all)recoen!e! in se.ere cases(

Loss o* light perception is an in!ication *or

e.isceration o* the e)e'all(

TreatentTreatent


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Reference

2arsoan5s diseases of the eye.Stephen 6. /. &iller$"774%

uveitis2lecturesbydr khaled 110228080300 phpapp02

Documents

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