uveitis dr winarto
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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
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
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