Uveitis Dr Winarto

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U V E I T I SWINARTOSub depart. of E.E.D.DEPT. of OPHTHALMOLOGY FAC. of MEDICINE, DIPONEGORO UNIVERSITY / DR KARIADI HOSPITAL S E M A R A N GMata normal Mata normal Silia posisi normalKonjungtiva tenangKornea jernihRefleks pupil normal

U V E AanteriorintermediaposteriorconjungtivasclerachoroidretinauveacornealensaUVEA t.d :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. KHOROIDfungsi : suplai nutrisivask : a siliaris longus dan brevissaraf : n siliaris anterior longus dan brevisEmbriologi : 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 AKOMODASIO Spinhter pupillae relaxasi Z Zinii kencang lensa pipihPROSES AKOMODASIO Spinhter pupillae konstriksi Z Zinii kendur lensa cembungImunologi : 4 tipe reaksi Gell & Coombs :1. Reaksi anafilaktoid2. Reaksi sitotoksik3. Reaksi imun kompleks4. Cell-mediated immunityTrauma pada uvea dapat sebabkan perusakan dan imunisasi sensitized cell atau antibodi pada mata yang tidak trauma (oftalmia simpatika)Peny. tertentu berhubungan dgn HLA-B27Mekanisme autoimun banyak bhb dgn bentuk inflamasi non-infeksi dari retina dan uvea : pars platinis, oftalmia simpatika, endoftalmitis anafilaktik, vaskulitis retinaKELAINAN KONGENITAL

1. Koloboma

2. Aniridia

II. U V E I T I SInternational Uveitis Study Group (anatomical) :Anterior UveitisIntermediate UveitisPosterior UveitisPan UveitisUVEITIS 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 keratopatiBag. 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 konsentrisUVEITIS ANTERIORProduction VasodilatationMiosis= IRIDOSIKLITISKeratic presipitathipopionUVEITIS ANTERIORUVEITIS ANTERIORSynechia posteriorIris bombansUVEITIS ANTERIOROclusio pupillaeUVEITIS ANTERIORSeclusio pupillae = syn. post. perifer totalisProduction >>>Viscosity >>>Cells >>>Resistance >>Secondary glaucoma mechanismHypopionPost. synechiae, occlusio pupillae, seclusio pupillaeMata merahInjeksi konjungtiva Injeksi konjungtivaPembuluh darah melebar ke periferTerdapat pada konjungtivitis

Mata merahInjeksi perikorneaInjeksi perikornealPembuluh darah kecil di sekitar limbus berwarna ungu, terdapat padaUveitisKeratitisGlaukoma 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 iridocyclitisFigure 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 :Diffuse inflammatory type :dust-like opacitiesSnowball-like precipitateNo massive snowbank-like exudatesExudative type :extensive exudations overs the ora and pars planaVasoproliferative type :vascular sheating, occlusion and neovascularisation

VITRECTOMY

PANUVEITISIII. 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 diketahuiteori : - 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 eyeIV. 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

ENDOPHTHALMITISV. IMPACT OF HIV INFECTION ON THE EYEOccur in advanced HIV, CD4+ < 200 cells x 106 / lEye complications : 70% - 80 %. HIV patients 90 % in Sub-Sahara Africa and SEA, eye complications different with developed countries.Opportunistic infectionsUnusual neoplasmHIV related inflammationAntiretroviral toxicityImmune recovery uveitisKONAS 03Advanced HIV : marked wasting, ("slim" disease)

Kaposi's sarcoma: multiple skin nodules and plaques

Hairy leucoplakia

Oral candidaKONAS 03

Miliary tuberculosis

Cryptococcus neoformansCerebral toxoplasmosis

HIV VIRUS

HIV TRANSMISSIONDendritic cells underlying skin shelter and amplify virusSpread of virus to lymphatic organ, bone marrow, circulationVirus attached to mucosal receptorsMicroscopic view of procesMembrane or skin portal of entry

Life cycle of HIV

HIV infection in vivoAntibody appears in serumStages in HIV infectionAntibody (-)Antibody (+)Periode of infectiousness (virus present)2 weeksIIIIIIIVInfection2 months2- 15 yearsMonths - yearsAcute symptoms of HIV infectionIncubation periodSymptoms occur

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

Herpes zoster ophthalmicus

Periocular Molluscum contagiosumKONAS 03

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

Multiple Kaposis sarcoma on the bulbar conjungtiva

Conjungtival microvasculopathy

Varicella-zozter keratitis in the absence dermatitis

132MicrovasculopathyCMV retinitisHIV 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 pallorVI. 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 atrophyVIII. UVEAL NEOPLASM Hyperplasty epithelial Naevus Melanoma maligna Neurilemmoma, neurofibroma, hemangioma Secondary tumor : Ca mammae, Ca pulmo