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Uveitis

Natalia Wiryanto
NIM: 07120100027
Pembimbing: dr. M. Sulaiman. Sp. M
Uvea
-itis
Pathogenesis
Trauma pemicu proses inflamasi karena
kombinasi antara kontaminasi microbial dan
akumulasi produk nekrosis pada lokasi luka.

Infeksi reaksi imun terhadap molekul asing
atau antigen dapat melukai pembuluh darah
dan sel sel uveal tract.

Penyakit autoimmune reaksi
hipersensitivitas deposisi kompleks imun di
dalam uveal tract.
Signs & Symptoms
Penyakit Gejala Tanda
Anterior
Akut
Sakit, photophobia,
merah, penglihatan
kabur
KPs, cells, flares, fibrin, hypopyon, pigment
dispersion, papillary miosis, iris nodule,
synechia anterior dan posterior, band
keratopathy, aqueous flare, ciliary flush,
injeksi konjungtiva / sklera
Kronik
Asimptomatik atau
penglihatan kabur
Intermediate
Penglihatan kabur dan ada
floaters
Sel - sel peradangan vitreal, snowball
opacities, snowbank, vitreal strands,
membran cyclitic, hypotony
Posterior
Penurunan tajam penglihatan
tanpa 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, atau
rhegmatogenous retinal detachment
Pemeriksaan Penunjang
Fluorescein angiography (FA)
Indocyanine green (ICG) angiography
Ultrasonography
Optical coherence tomography (OCT)
Anterior chamber paracentesis
Vitreus biopsy
Chorioretinal biopsy
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 Koyanagi
Harada
USG kekeruhan vitreus, penebalan koroidal, pelepasan
retina, pembentukan membran siklitik
OCT uveitic CME, penebalan retina, cairan subretina yang
berhubungan dengan koroidal neovaskularisasi, serous retinal
detachment
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
Tatalaksana
Medical Therapy
Midriatik dan siklopegik (tetes mata short acting:
cyclopentolate hydrochloride, tetes mata long
acting: atropine) mencegah dan menghentikan
pembentukan sinekia posterior dan meringankan
photophobia sekunder akibat spasme siliar.

NSAIDs menghambat cyclooxygenase dan
mengurangi sintesis prostaglandin yang
memediasi peradanganpasca operasi
peradangan dan CME, kronik iridosiklitis (JRA/JIA-
berhubungan dengan iritis) dan kemungkinan
CME.



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 atau
penyakit sistemik juga membutuhkan terapi
Intravitreal (triamcinolone acetonide / kenalog)
bukan untuk pengobatan kronik uveitis

Medical Therapy
Immunomodulator
Indikasi:





Note:

Medical Therapy
Amantiades-Behcet uveitis,
intermediate uveitis, VKH,
simpatetik ophthalmia, dan
necrotizing scleritis
necrotizing scleritis yang
berhubungan dengan
sistemik vaskulitis (Wegener
granulomatosis / relapsing
polychondritis), intermediate
uveitis, VKH, simpatetik
ophthalmia, dan
adamantiades behcet
Medical Therapy
Surgical Therapy
Indikasi: endophthalmitis, primary intraocular
lymphoma atau keganasan intraocular lain, infectious
posterior uveitis, dan jika diduga panuveitis.

Therapeutic vitrectomy dilakukan pada kasus uveitis
tertentu untuk membersihkan visual axis dari kekeruhan
atau perdarahan, mengangkat epiretinal membrane,
mengangkat subfoveal choroidal neovascular
membrane pada kasus kasus tertentu, memperbaiki
complex retinal detachments, mengurangi intravitreal
cytokines dan chemokines untuk membantu
mengontrol inflamasi, dan mengurangi CME.
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 iskemik
dan area watershed yang berhubungan
Choroidal neovaskularisasi (CNV) kortikosteroid,
immunomodulator, dan focal laser photocoagulation of peripapillary,
extrafoveal, dan juxtafoveal CNV. Jika gagal, pars plana vitrectomy dan
subfoveal CNV extraction
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, control
ketat peradangan perioperative, penggunaan topical corticosteroid
selama 3 5 bulan pasca operasi, dan terapi immunosuppressive
perioperative 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.
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

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 bleeding
in age-related macular degeneration, an aging vitreous, trauma, and
inflammation.
Scotoma (blind spot): an area of loss / impairment of visual acuity
surrounded by a field of normal or relatively well-preserved vision.
Pathological: any part of the visual field, any shape / size. Affect
central 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 responsible
for vision in dim light (myopia, glaucoma medications that work by
constricting the pupil, cataracts, retinitis pigmentosa, vitamin A
deficiency)
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, and
dyschromatopsia.

Acute posterior multifocal placoid pigment epitheliopathy
(APMPPE), serpiginous choroiditis, multiple evanescent
white dot syndrome (MEWDS), multifocal choroiditis and
panuveitis (MCP), punctate inner choroidopathy (PIC), and
diffuse subretinal fibrosis (DSF).

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

Cystoid Macular Edema
A painless disorder which affects the central retina or
macula
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 of
medication.
Tatalaksana: retinal inflammation anti-inflammatory
medications (corticosteroids); vascular endothelial growth
factor (VEGF)- inhibitor class of drugs injection / laser to
eliminate the macular edema; vitrectomy if the vitreus
pulls on the macula causing CME.
Fuch heterochromic iridocyclitis
chronic, unilateral iridocyclitis characterized by iris
heterochromia.
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 related
systemic 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, topical
steroids should not be used to eliminate cells from the
anterior chamber as part of the cells and flare is
contributed by the breakdown of the blood-aqueous
barrier and leakage of inflammatory infiltrate. Surgery
is related to cataract and glaucoma.
Adamantiades-Behcets Disease / Silk Road
Disease / Oad Disease)
Characterized by a triple-symptom complex of recurrent oral aphthous
ulcers, 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 with
scarring; Ophthalmic lesions (ant / post uveitis, hypopyon, or retinal
vasculitis); Skin lesions (erythema nodosumlike lesions,
pseudofolliculitis, or papulopustular / acneiform lesions); Pathergy skin
testing (+), defined as the formation of a sterile erythematous papule 2
mm in diameter or larger that appears 48 hours following a skin prick
with a sharp sterile needle (22-24 gauge [a dull needle may be used as a
control])
Tatalaksana for ocular dz: azathioprine, if severe cyclosporine A or
infliximab may be used in combination with azathioprine and
corticosteroids. Glaucoma, cataracts, and retinal detachment
occasionally warrant surgical intervention.

Vogt Koyanagi Harada
multisystemic disorder characterized by granulomatous panuveitis with
exudative retinal detachments that is often associated with neurologic and
cutaneous manifestations.
3 kategori: complete (diffuse choroiditis, have evidence of neurologic,
auditory, integumentary signs), incomplete (neurologic and auditory
manifestations 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 bilik
mata depan. Biasanya pada yang berusia + 20 tahun.
Tatalaksana: early and aggressive kortikosteroid sistemik (prednisone). For
pigmentary changes in VKH disease, treatment options mirror those for
vitiligo. Chronic VKH disease requires monitoring for many years.