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UVEITIS

WINARTO Sub depart. of E.E.D.


DEPT. of OPHTHALMOLOGY FAC. of MEDICINE, DIPONEGORO UNIVERSITY / DR KARIADI HOSPITAL

S EMARAN G

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

posterior

UVEA
intermedia anterior lensa

cornea
conjungtiva retina choroid sclera uvea

UVEA t.d :
1. IRIS m spinchter pupilae : tepi, parasimpatis m. dilatator pupilae : radier, simpatis 2. 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 cembung 3. KHOROID fungsi : suplai nutrisi vask : a siliaris longus dan brevis saraf : n siliaris anterior longus dan brevis

Embriologi : neuroectoderm : otot otot iris dan corp siliaris mesoderm : stroma uvea
Fungsi : 1. Fs otot akomodasi 2. 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 anafilaktoid 2. Reaksi sitotoksik 3. Reaksi imun kompleks 4. 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 vitreous Bag. 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 ANTERIOR = IRIDOSIKLITIS

Production

Miosis

Vasodilatation

UVEITIS ANTERIOR

Keratic presipitat hipopion

UVEITIS ANTERIOR

Synechia posterior

Iris bombans

UVEITIS ANTERIOR

Oclusio pupillae

UVEITIS ANTERIOR

Seclusio pupillae = syn. post. perifer totalis

Secondary glaucoma mechanism Production >>>

Post. synechiae, occlusio pupillae, seclusio pupillae


Viscosity >>> Cells >>> Resistance >> Hypopion

Mata merah Injeksi konjungtiva


Injeksi konjungtiva Pembuluh darah melebar ke perifer Terdapat pada konjungtivitis

Mata merah Injeksi 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

FINE K.P.: pada non granulomatous iridocyclitis

MUTTON FAT K.P. : pada 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 Uveitis
Boke 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

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

Kaposi's sarcoma: multiple skin nodules and plaques


KONAS 03

Hairy leucoplakia

Oral candida

Miliary tuberculosis

Cryptococcus neoformans

Cerebral toxoplasmosis

KONAS 03

HIV VIRUS

HIV TRANSMISSION

Virus attached to mucosal receptors

Membrane or skin portal of entry Micros copic view of proces

Dendritic cells underlying skin shelter and amplify virus

Spread of virus to lymphatic organ, bone marrow, circulation

Life cycle of HIV

HIV infection in vivo

Stages in HIV infection


Periode of infectiousness (virus present)

Antibody (-)

Antibody (+)

2 weeks Infection

II
2 months

III
2- 15 years

IV
Months - years

Incubation period

Symptoms occur

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

Periocular Molluscum contagiosum Herpes zoster ophthalmicus

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


KONAS 03

Multiple Kaposis sarcoma on the bulbar conjungtiva

Conjungtival microvasculopathy

Varicella-zozter keratitis in the absence dermatitis

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