U V E I T I S

WINARTOSub depart. of E.E.D.

DEPT. of OPHTHALMOLOGY FAC. of MEDICINE, DIPONEGORO UNIVERSITY /

DR KARIADI HOSPITAL S E M A R A N G

Mata normal

Mata normal – Silia posisi normal– Konjungtiva tenang– Kornea jernih– Refleks pupil

normal

U V E A

anterior

intermedia

posterior

conjungtiva

sclera

choroid

retinauvea

cornea

lensa

UVEA t.d :1. IRIS m spinchter pupilae : tepi, parasimpatis m. dilatator pupilae : radier, simpatis2. CORPUS SILIARIS, epithel iris kebelakang : - luar (pigmented) RPE - dalam (non pigmented) humor aquos terdiri dari 3 macam otot :

* m. radialis int, m. longitudinalis ekst dan m. oblique kontraksi lensa cembung3. KHOROID

fungsi : suplai nutrisivask : a siliaris longus dan brevissaraf : n siliaris anterior longus dan brevis

Embriologi : neuroectoderm : otot – otot iris dan corp siliaris mesoderm : stroma uvea

Fungsi : 1. Fs otot akomodasi2. Fs nutrisi : - humor aquosus

- choriocapilaris maintenance retina bag luar

Vaskularisasi :a opthalmika a ciliaris anterior dan posterior

PROSES AKOMODASI

O Spinhter pupillae relaxasi Z Zinii kencang lensa pipih

PROSES AKOMODASI

O Spinhter pupillae konstriksi Z Zinii kendur lensa cembung

Imunologi : 4 tipe reaksi Gell & Coombs :1. Reaksi anafilaktoid2. Reaksi sitotoksik3. Reaksi imun kompleks4. Cell-mediated immunity

Trauma pada uvea dapat sebabkan perusakan dan imunisasi sensitized cell atau antibodi pada mata yang tidak trauma (oftalmia simpatika)

Peny. tertentu berhubungan dgn HLA-B27

Mekanisme autoimun banyak bhb dgn bentuk inflamasi non-infeksi dari retina dan uvea : pars platinis, oftalmia simpatika, endoftalmitis anafilaktik, vaskulitis retina

I. KELAINAN KONGENITAL

1. Koloboma

2. Aniridia

II. U V E I T I S

International Uveitis Study Group (anatomical) :

1. Anterior Uveitis

2. Intermediate Uveitis

3. Posterior Uveitis

4. Pan Uveitis

UVEITIS adalah inflamasi uvea.Gejala : mata merah, nyeri, foto fobia, epifora, kabur respon inflamasi cilier injeksi, eksudasi khemosis.

Tanda : Bag. depan : keratic precipitat (KP)

* akut putih / abu-abu, bulat* kronik krenasi, hitam

Granulomatous : besar kekuningan, mutton-fat TIO : rendah, bisa tinggi bila TM tertutup

kotoran inflamasi, siliar injeksi, katarak komplikata, band keratopati

Bag. Intermedia : sel inflamasi di vitreousBag. 2/3 posterior : infiltrat inflamasi choroid / retina kekeruhan CV,

oedem / atrofi choroid, retina

Iris dan pupil normal

• Gambaran kripte iris jelas• Pupil bulat konsentris

UVEITIS ANTERIORProduction

VasodilatationMiosis

= IRIDOSIKLITIS

Keratic presipitat

hipopion

UVEITIS ANTERIOR

UVEITIS ANTERIOR

Synechia posterior

Iris bombans

UVEITIS ANTERIOR

Oclusio pupillae

UVEITIS ANTERIOR

Seclusio pupillae = syn. post. perifer totalis

Production >>>

Viscosity >>>Cells >>>

Resistance >>

Secondary glaucoma mechanism

Hypopion

Post. synechiae, occlusio pupillae, seclusio pupillae

Mata merahInjeksi konjungtiva

• Injeksi konjungtiva– Pembuluh darah

melebar ke perifer– Terdapat pada

konjungtivitis

Mata merahInjeksi perikornea

• Injeksi perikorneal

• Pembuluh darah kecil di sekitar limbus berwarna ungu, terdapat pada– Uveitis– Keratitis– Glaukoma – Endoftalmitis

Iris dan pupil pada iridosiklitis

• Gambaran kripte iris tidak jelas, warna : muddy appearance• Pupil kecil (miosis)

UVEITIS ANTERIOR

MUTTON FAT K.P. : pada granulomatous iridocyclitis

FINE K.P.: pada non granulomatous iridocyclitis

Figure 1. Vitreous condensation (arrow) overlying the pars plana with extension to the pars plicata (white arrowhead). Sclera (asterisk). Anterior chamber angle (black arrowhead).

Figure 2. Vitreous condensation with smooth surface (arrow) overlying the pars plana and peripheral retina in a phakic patient after pars plana vitrectomy. Anterior part of the pars plana (arrowhead).

Figure 3. Vitreous condensation overlying the pars plana and peripheral retina with thin filaments extending into the vitreous (arrow). Anterior part of the pars plana (arrowhead). Sclera (asterisk).

Figure 4. Delicate epiretinal condensations of the vitreous (arrow).

Figure 5. Vitreous condensation with tractional force on the peripheral retina (arrow) and towards the pars plana (arrowhead).

Figure 6. Vitreous condensation with tractional force on the pars plana/peripheral retina (arrow). Pars plicata (arrowhead).

Intermediate UveitisBoke subtype classification :

1. Diffuse inflammatory type :

dust-like opacities

Snowball-like precipitate

No massive snowbank-like exudates

2. Exudative type :

extensive exudations overs the ora and pars plana

3. Vasoproliferative type :

vascular sheating, occlusion and neovascularisation

VITRECTOMY

PANUVEITIS

III. OFTALMIA SIMPATIKA panuveitis granulomatosa bilateral, setelah trauma satu mata ( exciting eye) yang diikuti periode laten kemudian terjadi uveitis pada mata sebelahnya (sympathizing eye)

# 4 – 12 mgg setelah trauma, sangat jarang# klinis : exiting eye panuveitis berat sympathizing eye keluhan visus turun, fotofobia,

merah ringan tanda panuveitis# etiologi : tidak diketahui

teori : - hipersensitifitas Retinal S-Ag - autoimun

# diagnostik : anamnesis - riwayat trauma- riwayat operasi intraokuler

# terapi :- steroid lokal, sistemik dan periokuler efektif- sikloplegik : kurangi keluhan

- anti metabolit bila steroid tdk responsif / tdk ada perbaikan :

* enukleasi exiting eye

IV. ENDOLFTALMITIS peradangan intraokuler yg mengenai ruang corpus vitreum dan COA

# bentuk yg sering : endoftalmitis infeksi, yg jarang : endofalmitis steril, berhub dgn sisa lensa atau bahan toksik yg masuk ke mata ketika trauma atau operasi intraokuler

# gejala & tanda : visus turun, hipopion, dan vitritis nyeri, hiperemia konjungtiva, khemosis, edema

palpebra dan kornea# profilaksi :

- sterilisasi sac conj pre op- disinfeksi daerah operasi – povidone iodine- inj AB sub konj.

# diagnosa : klinis + lab aspirasi humor aquosus dan vitreus untuk kultur dan sensitivity test

# terapi : - vitrektomi- AB intravitreal- kalau hebat, prog infaust eviscerasi

# prognosis :tergantung saat datang, jenis endoftalmitis

ENDOPHTHALMITIS

V. IMPACT OF HIV INFECTION ON THE EYE

Occur in advanced HIV, CD4+ < 200 cells x 106 / l

Eye complications : 70% - 80 %. HIV patients 90 % in Sub-Sahara Africa and SEA, eye complications different

with developed countries.

1. Opportunistic infections

2. Unusual neoplasm

3. HIV related inflammation

4. Antiretroviral toxicity

5. Immune recovery uveitis

KONAS 03

Advanced HIV : marked wasting, ("slim" disease)

Kaposi's sarcoma: multiple skin nodules and plaques

Hairy leucoplakia Oral candida

KONAS 03

Miliary tuberculosisCryptococcus neoformans Cerebral toxoplasmosis

HIV VIRUS

HIV TRANSMISSION

Dendritic cells underlying skin shelter and amplify virus

Spread of virus to lymphatic organ, bone marrow, circulation

Virus attached to mucosal receptors

Microscopic view of proces

Membrane or skin

portal of entry

Life cycle of HIV

HIV infection in vivo

An

tib

ody

a pp

ear s

in s

e ru

m

Stages in HIV infection

Antibody (-) Antibody (+)

Periode of infectiousness (virus present)

2 weeks

I II III IVInfection

2 months 2- 15 years Months - years

Acu

te s

ymp

t om

s o f

HIV

infe

c tio

n

Incubation period Symptoms occur

Association between virological, immunological, and clinical events and time course of HIV infection

Herpes zoster ophthalmicus

Periocular Molluscum contagiosum

KONAS 03

Squamous cell carcinoma of the conjunctiva: associated with HIV infection.

Multiple Kaposi’s sarcoma on the bulbar

conjungtiva

Conjungtival microvasculopathy

Varicella-zozter keratitis in the absence dermatitis

1 32

1. Microvasculopathy

2. CMV retinitis

3. HIV related retinitis

                                 

Retinal microvasculopthy with cotton-wool spots

                                 

Active CMV retinitis with full-thickness retinal whitening with hemorrhage

Intravitreal ganciclovir device in the vitreal cavity. The device is firmly sutured

to the incision and is immobile.

Peripheral zone III inactive CMV retinitis in the left eye

                                 

Active varicella-zoster virus retinitis

                                 

Toxoplasmic retinochoroiditis

                                 

Multiple Pneumocystis carinii choroidtits

                                 

Papilledema due to cryptococcal meningitis

(A) Right and (B) left colour

fundus photographs

showing bilateral optic

disc pallor

VI. UVEA TRAUMA

• direct / countercoup

• Vossious pigment ring

• Traumatic iritis, miosis, mydriasis,

iridodialisis, angle recession, hifema,

trauma choroid, choroiditis, efusi uvea

(ciliochoroidal)

VII. DEGENERATION and ATROPHY of UVEA

• Aging

• Sclerosis

• Gyrate atrophy

• Angioid streaks

• Myopic choroidal atrophy

• Secondary atrophy and dystrophy

Gyrate atrophy

Angioid streak atrophy

VIII. UVEAL NEOPLASM

• Hyperplasty epithelial

• Naevus

• Melanoma maligna

• Neurilemmoma, neurofibroma,

hemangioma

• Secondary tumor : Ca mammae, Ca pulmo