presentasi uveitis

8/11/2019 presentasi uveitis

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UveitisNatalia Wiryanto

NIM: 07120100027Pembimbing: dr. M. Sulaiman. Sp. M


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Uvea

-itis


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Pathogenesis Trauma pemicu proses inflamasi karena

kombinasi antara kontaminasi microbial danakumulasi produk nekrosis pada lokasi luka.

Infeksi reaksi imun terhadap molekul asingatau antigen dapat melukai pembuluh darahdan sel sel uveal tract.

Penyakit autoimmune reaksihipersensitivitas deposisi kompleks imun didalam uveal tract.


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Signs & Symptoms

Penyakit Gejala Tanda

Anterior

Akut Sakit, photophobia,merah, penglihatan

kabur

KPs, cells, flares, fibrin, hypopyon, pigmentdispersion, papillary miosis, iris nodule,

synechia anterior dan posterior, bandkeratopathy, aqueous flare, ciliary flush,

injeksi konjungtiva / sklera Kronik

Asimptomatik atau

penglihatan kabur

Intermediate Penglihatan kabur dan ada

floaters

Sel - sel peradangan vitreal, snowballopacities, snowbank, vitreal strands,

membran cyclitic, hypotony

Posterior

Penurunan tajam penglihatantanpa rasa sakit, floater,

photopsias, metamorphopsia,scotomata, nyctalopia,epiphora, photophobia

Infiltrat peradangan koroidal / retinal,

peradangan lapisan pelindung arteri / vena, pervascular inflamatory cuffing, retinal

pigment epithelial hypertrophy / atrophy,atrophy atau pembengkakan

retina/koroid/kepala saraf optik, fibrosis pre-

atau subretinal, exudative, tractional, ataurhegmatogenous retinal detachment


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Pemeriksaan Penunjang

Fluorescein angiography (FA) Indocyanine green (ICG) angiography Ultrasonography Optical coherence tomography (OCT) Anterior chamber paracentesis Vitreus biopsy Chorioretinal biopsy


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Pemeriksaan Penunjang FA chorioretinal & komplikasi struktural dari posterior

uveitis ICG angiography peradangan koroid vaskulopati

Tipe 1: peradangan choriocapillaropathies MEWDS (multiple

evanescence white dot syndrome) Tipe 2: stromal inflammatory vaskulopathies of choroid sarcoidosis,

sympathetic ophthalmia, birdshot chorioretinopathy, Vogt KoyanagiHarada

USG kekeruhan vitreus, penebalan koroidal, pelepasanretina, pembentukan membran siklitik

OCT uveitic CME, penebalan retina, cairan subretina yangberhubungan dengan koroidal neovaskularisasi, serous retinaldetachment


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Pemeriksaan Penunjang

Anterior chamber paracentesis + analisa aqueous humour pasien infectious uveitis dgn gejala atipikal, susp.primary intraokular lymphoma (reticulum cell sarcoma),toxoplasmosis

Vitreus biopsi susp. primary intraokular lymphoma(reticulum cell sarcoma) / endopthalmitis bakteri / fungal.Biasanya diikuti oleh pemeriksaan cytologic,cytofluorographic, dan microbiologis dari cairan vitreus,serta kultur bakteri dan jamur dari specimen vitreus dan

aqueous jika diduga infeksi Biopsi korioretinal necrotizing retinitis pada pasien AIDS

/ susp. Primary subretinal intraokular lymphoma


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Tatalaksana


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Medical Therapy

Midriatik dan siklopegik (tetes mata short acting:cyclopentolate hydrochloride, tetes mata longacting: atropine) mencegah dan menghentikanpembentukan sinekia posterior dan meringankanphotophobia sekunder akibat spasme siliar.

NSAIDs menghambat cyclooxygenase danmengurangi sintesis prostaglandin yangmemediasi peradangan pasca operasiperadangan dan CME, kronik iridosiklitis (JRA/JIA-berhubungan dengan iritis) dan kemungkinanCME.


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Medical Therapy

Kortikosteroid : Topikal anterior uveitis, vitritis dan macular edema

pada pasien pseudofaki atau afakia Periokular (triamcinolone acetonide 40mg atau

methylprednisolone acetate 40-80mg) intermediate / posterior uveitis, pasien dengan CME

Oral / IV topical kortikosteroid tidak memadai ataupenyakit sistemik juga membutuhkan terapi

Intravitreal (triamcinolone acetonide / kenalog) bukan untuk pengobatan kronik uveitis


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Medical Therapy Immunomodulator

Indikasi:

Note:


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Medical Therapy

Amantiades-Behcet uveitis,

intermediate uveitis, VKH,simpatetik ophthalmia, dannecrotizing scleritis

necrotizing scleritis yangberhubungan dengansistemik vaskulitis (Wegenergranulomatosis / relapsingpolychondritis), intermediateuveitis, VKH, simpatetikophthalmia, danadamantiades behcet


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Medical Therapy


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Surgical Therapy

Indikasi: endophthalmitis, primary intraocularlymphoma atau keganasan intraocular lain, infectiousposterior uveitis, dan jika diduga panuveitis.

Therapeutic vitrectomy dilakukan pada kasus uveitistertentu untuk membersihkan visual axis dari kekeruhanatau perdarahan, mengangkat epiretinal membrane,mengangkat subfoveal choroidal neovascularmembrane pada kasus kasus tertentu, memperbaikicomplex retinal detachments, mengurangi intravitrealcytokines dan chemokines untuk membantumengontrol inflamasi, dan mengurangi CME.


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Komplikasi Katarak

Glaucoma Hypotony CME terapi kortikosteroid dan immunomodulator Calcific band shaped keratopathy EDTA scrubs Vitreous opacification & vitris 3-port pars plana vitrectomy Retinal detachment pars plana vitrectomy dan endolaser dengan

internal silicone oil tamponade Retinalneovascularization kortikosteroid dan/atau

immunomodulator atau scatter laser photocoagulation di daerah iskemikdan area watershed yang berhubungan

Choroidal neovaskularisasi (CNV) kortikosteroid,immunomodulator, dan focal laser photocoagulation of peripapillary,extrafoveal, dan juxtafoveal CNV. Jika gagal, pars plana vitrectomy dansubfoveal CNV extraction


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Penanganan Komplikasi Operasi katarak (jika perlu, synechiolysis dengan viscoelastic /

iridodialysis spatula dilakukan & diikuti oleh capsulorrhexis,standard phacoemulsification dan penanaman IOL) Syarat operasi intraocular pada mata uveitis adalah tidak ada

peradangan >3 sebelum operasi Komplikasi post operative jangka panjang adalah peningkatan

kekeruhan kapsul posterior, glaucoma, dan CME mengurangi resiko

dgn: terapi immunosuppressive pre-operative yang lebih lama, controlketat peradangan perioperative, penggunaan topical corticosteroidselama 3 5 bulan pasca operasi, dan terapi immunosuppressiveperioperative secara agresif dan berkelanjutan

Hypotony Awal uveitic: terapi kortikosteroid dan siklopegik intensif Kronik: topical ibopamine, nonselective dopaminergic, dan

alpha dan beta adrenergic receptor Vitrectomy, membranectomy, dan intraocular silicone oil

dapat juga diperlukan pada keadaan tertentu.


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Penanganan Komplikasi Uveitic glaukoma

Sudut tertutup Akut: aggressive kortikosteroid terapi dan aqueous

suppressant Subakut: iridotomy & YAG / argon laser intensive topkial

kortikosteroid dan siklopegik terapi Kronik: goniosynechiolysis & trabeculectomy dengan

mitomycin C / glaucoma tube shunt placement Sudut terbuka

Akut: topical siklopegik, kortikosteroid, dan tatalaksana

spesifik terhadap agen infeksius Kronik: topical & oral glaucoma medication (carbonic

anhidrase inhibitors, B-blocker, dan alpha agonis) Jika gagal, maka diperlukan nonpenetrating deep sclerotomy

dengan atau tanpa penanaman drainage


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Terminologi Photopsia: the sensation of seeing lights, sparks, or colors caused

by retinal or cerebral disease. Also called photopsy . Metamorphopsia (distorted vision) the fovea are being warped

by submacular bleeding, edema, or scarring subretinal bleedingin age-related macular degeneration, an aging vitreous, trauma, andinflammation.

Scotoma (blind spot): an area of loss / impairment of visual acuitysurrounded by a field of normal or relatively well-preserved vision.Pathological: any part of the visual field, any shape / size. Affectcentral or macular vision severe visual handicap, peripheral part

of a visual field unnoticed. Nyctalopia (night blindness): inability to see well at night or in poor

light. Due to a disorder of the cells in the retina that are responsiblefor vision in dim light (myopia, glaucoma medications that work byconstricting the pupil, cataracts, retinitis pigmentosa, vitamin Adeficiency)


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Multiple evanescent white dot syndrome A group of idiopathic multifocal inflammatory conditions

involving the retina and the choroid.

Appearance of white dots in the fundus.

Sudden visual alterations in one eye with blurred vision,

temporal or paracentral scotomas, photopsia, anddyschromatopsia.

Acute posterior multifocal placoid pigment epitheliopathy(APMPPE), serpiginous choroiditis, multiple evanescent

white dot syndrome (MEWDS), multifocal choroiditis andpanuveitis (MCP), punctate inner choroidopathy (PIC), anddiffuse subretinal fibrosis (DSF).

http://emedicine.medscape.com/article/1227778-overview#showall


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Cystoid Macular Edema A painless disorder which affects the central retina ormacula Multiple cyst-like (cystoid) areas of fluid appear in the

macula retinal swelling or edema. Wavy / blurred vision Eye surgery (cataract surgery and repair of a detached

retina), diabetes, age-related macular degeneration,blockage in the small arteries or veins of the retina,inflammation of the eye, injury to the eye, side effects ofmedication.

Tatalaksana: retinal inflammation anti-inflammatorymedications (corticosteroids); vascular endothelial growthfactor (VEGF)- inhibitor class of drugs injection / laser toeliminate the macular edema; vitrectomy if the vitreuspulls on the macula causing CME.


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Fuch heterochromic iridocyclitis

chronic, unilateral iridocyclitis characterized by irisheterochromia. The uveitis typically occurs in the lighter colored eye of

a young adult with minimal ocular symptoms, no pain,and redness of the external eye or meiosis; no relatedsystemic disease is present.

Asimptomatik or floater, blurred vision, inflammation. Treatment: not necessary for typical low-grade

inflammation. Symptomatic flare-ups short-term

topical corticosteroids. Unlike other uveitides, topicalsteroids should not be used to eliminate cells from theanterior chamber as part of the cells and flare iscontributed by the breakdown of the blood-aqueousbarrier and leakage of inflammatory infiltrate. Surgery

is related to cataract and glaucoma.

Ad i d B h Di / Silk R d


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Adamantiades- Behcets Disease / Silk RoadDisease / Oad Disease)

Characterized by a triple-symptom complex of recurrent oral aphthousulcers, genital ulcers, and uveitis.

S&S: >3 eps of oral herpetiform or aphthous ulcerations within 12-month Confirmed if >2: Recurrent painful genital ulcers that heal withscarring; Ophthalmic lesions (ant / post uveitis, hypopyon, or retinal

vasculitis); Skin lesions (erythema nodosum like lesions,pseudofolliculitis, or papulopustular / acneiform lesions); Pathergy skintesting (+), defined as the formation of a sterile erythematous papule 2mm in diameter or larger that appears 48 hours following a skin prickwith a sharp sterile needle (22-24 gauge [a dull needle may be used as acontrol])

Tatalaksana for ocular dz: azathioprine, if severe cyclosporine A orinfliximab may be used in combination with azathioprine andcorticosteroids. Glaucoma, cataracts, and retinal detachment

occasionally warrant surgical intervention.


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Vogt Koyanagi Harada multisystemic disorder characterized by granulomatous panuveitis with

exudative retinal detachments that is often associated with neurologic andcutaneous manifestations.

3 kategori: complete (diffuse choroiditis, have evidence of neurologic,auditory, integumentary signs), incomplete (neurologic and auditorymanifestations or integumentary signs, but not both), probable VKH

(isolated ocular disease). 4 clinical stages: prodromal stage, uveitic stage, chronic stage, and recurrent

stage. Severe headache, neck stiffness, ringing in the ears (tinnitus), fever, and

possibly scalp tenderness, sudden loss of vision, ocular pain, photophobia.Rangsangan meningen gangguan saraf ablasi retina serosa bilateral,infiltrat pada koroid, kekeruhan badan kaca, edema papil, suar di dalam bilikmata depan. Biasanya pada yang berusia + 20 tahun.

Tatalaksana: early and aggressive kortikosteroid sistemik (prednisone). For

pigmentary changes in VKH disease treatment options mirror those fori ili Ch i VKH di i i i f

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