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Uveal Tract
Dr. Bambang Setiohadji, SpM
Anatomy
• Is a vascular layer that consists of :– Iris– Cilliary body– Choroid
• Function :– Nutrition supply
Iris
• Is a diaphragm that dividing ocular chamber into two parts:– Anterior– Posterior
• Building a hole at the center called as pupil• Anterior part ---> origins from corneal endothelia• Posterior part --> origins from retinal endothelia
• Muscles :– M. Spchiter pupil ---> circular, N III
(parasympatic), myosis– M. dilator pupil ---> radier, sympatic, midriatics
• Root of the Iris are thin ---> tear easily• Vascularization :
– From A. ciliaris posterior longus
• Pupil– As a aperture that can found in an ordinary
photographic camera– Normal : round, central, isokor– If > 1 : ‘Polikoria’, if not central : ‘korektopia’– Pupil reaction :
• toward to the direct and indirect light• toward to the close point• toward to the drugs
• Toward to the light :
retina N II Chiasma optic
Optical tractBrachium Coliculus sup.
Nc. Eidinger Westphal Parasymphatic fiber
N IIIPupil
Afferent
Efferent
• Toward to the close distance :– Trias :
• convergence• miosis• accommodation
• Toward to the drugs :– Miotic : esserine, pilocarpine– Midriatic : atropine, homatropine, cocaine,
adrenaline
• Pupil reaction anomaly are depend on :– afferent– efferent
• Argyle Robertson Pupil :– ‘efferent’ damage, direct and indirect light
reaction (-)– irregular miosis– anisokor
• Horner syndrome :– miosis, ptosis, enofthalmus, anhydrous,
paralysis of M. dilatator pupil
• Cilliary body :– triangle form, the basis is at the front which the iris
attached spreads until the Choroid– consist of :
• M. ciliaris for accommodation (longitudinal, circular, radier)
• Ciliar processus :– inside part divided into:
• pars plana• pars corona
– originating zonula zinii fibers : suspending the lens, for accommodation process
• On severe inflammation --> damage of ciliary body ---> atrophy ---> secretion ---> ptisis bulbi
– perforating injuries can occurring SO
Congenital Iris Anomalies
• Pupil membrane persistency– Fetus : pupil closed ---> 7 - 8 pregnancy
If absorption altered
Fine cotton in front of the lens
---> born : open pupil
• Iris coloboma– Two forms :
• Congenital : anomalies of formation• Acquired : after glaucoma operation, optical
iridectomy– Usually followed with “Choroid coloboma”
• Iris heterochromia• bilateral ; unilateral• differences colors between different area of the iris• Two forms :
• Congenital : glaucoma congenital• Acquired : iris atrophy after iridocyclitis/glaucoma
Traumatic Iris Disturbances• Iridoplegi
– if affected by blunt injury, because of parese• N. III temporary (2 - 3 weeks)
permanent– Th/
• Using of black eye glasses• Do not read (can not accommodate)• R/ pilocarpine ---> for myotics
• Iridodialisis– E/ : injuries ---> tearing of iris root --> pupil
excentric– Th/
• Midriatics• banded• diplopia (+) ---> iris reposition
• Hifema– E/ : injury --> rupture of blood vessels --> blood in the
anterior chamber (hifem)– There is two types :
• Primary : straight after injuries• Secondary :
– fifth days after injuries– > severe– if immediately reabsorption of the clot & regeneration not occurred
• Complication :– IOP elevated– Corneal hemosiderosis– Uveitis– Muddying of vitreous body
• Th/– totally bed rest– IOP observation & condition of hifema– IOP high --> diamox, glycerin
--> 24 hours still high ---> parasintesa --> if normal & hifema still >>> --> parasintesa
Iris Neoplasm
• Iris Tumor– Nevus Pigmentosus Iridis --> benign melanoma
• clear border• brown spotted• not progressive• no disturbances
– Malignant• deep brown spotted• rough surface• not clear border• Metastasis to preaulicular glands
• Therapy :– Metastasis (-) : Iridectomy– Metastasis (+) : Enucleation
Inflammation of The Iris
• Inflammation of the Iris : Iritis• Usually followed by inflammation of the ciliary body :
Iridocyclitis• E/ :
– Systemic disease : • lues, TBC, gout, GO, focal infection, tooth, ENT, urinary tract,
infection (virus, fungal, worm), DM– Secondary iridocyclitis around eye region– Perforating trauma– SO– Idiopathic ----> Immune reaction
• Clinical Finding– Subjective :
• Spontaneous pain of the eye ball, headache reference to temporal regions
• Photophobia• Decreasing visual acuity
– Objective :• Palpebra : edema• CB : ciliar injection• C : muddying, KP in endothel• COA : Flare (+), Hipopion +/-, mild
---> narrow if iris bombe is present
• P : Irregular --> sinechia post. Pupil : seclusion & oclusion
• Complication :– muddiness of vitreous– cataract– IOP low or high
• Sequels :– pupil seclusion– pupil occlusion– posterior synechia– Iris bombe– glaucoma
• Uveitis anterior clinically divided into :– Granulomatous– Non-granulomatous– Mixed
• Uveitis Granulomatous– Non acute– Cellular reaction >>> vascular– Blurred iris surface– KP in thick endothel– deep COA– muddying vitreous
• Uveitis Non Granulomatous– E/ allergy ?– Acute reaction >>> cellular– Fine KP– Vitreous not so muddy– COA : Hipopion +/-
• Mixed : all of signs above
• Iridocylitis caused by virus :– Bechet syndrome, uveitis, stomatitis, genital ulcer
• Vogt. Kyanagi syndrome : uveitis, tinnitus, alopecia, vitiligo
• Th/ :– Midriatics :
• SA 0,5 % ed/eo• for lowering blood vessel congestion/inflammation• resting the eye (relaxation of M. spinchter pupil & M ciliaris)
– If IOP high ----> diamox 3 x I tablets– Contra Indications :
• kidney disturbances• diamox allergy• signs :
– stomach uncomfort– lips dryness
– Analgesic ---> to relieve the pain
• Causative & symptomatic therapy – Local & systemic corticosteroid
• Local : e.d. sub conjungtival 2 X 1/week• Systemic high dose, short terms 1 X 12 tablets ---> tapering off
– Contra Indication :• Pulmonary TBC, Hypertension, DM, Coronary disturbances, Physiological disease,
peptic ulcer
– Continuing observation (important):• Blood glucose• Blood pressure• Weight body• Water retention
– The eye should be bandaged
Choroid
• Consists of several layer :– Epithelium– Bruch membrane– Chorio capillaries– Blood vessels (medium and large size)– Suprachoroid
• Artery : origins from A. ciliaris breves• Vein : 4 V. Vortikalis from 4 posterior quadrant ---
> V. ophthalmic --> cavernous sinus
Non-inflammation Choroid Anomalies
• Coloboma• Degenerative :
– Choroid Bodies Drusen– Myoris Degenerative
• Blunt trauma– Macular tearing ---> white sclera– Th/ : SA --> relaxation of the eye
• Tumor– Benign : melanoma, white spotted below retinal blood vessel
---> visual disturbances– malignant :
• secondary glands melano sarcoma• Th/ :
– Metastasis (-) : Enucleation– Metastasis (+): Excenteration
Inflammation of The Choroid
• Choroiditis : Posterior Uveitis• Disturbances near the Retina ---> usually
followed by retinal infection : Chorioretinitis• Dividing into two forms :
– Exudative Choroiditis : Non purulent– Purulent Choroiditis : Supurative
Exudative Choroiditis
• Clinical manifestation depend on location of the lesion --> macula ---> visual acuity decreased, even the inflammation is not severe
• Divided into :– Disseminate– Diffuse– Sircumscripted :
• Centralized/Macular• Paracentralized/paramacular• Juxta Papillary• Periphery
• Sircumsripted Choroiditis :– limited exudat area, solitaire :– PD : TBC, Lues, toxoplasma, focal infection
• Disseminated Choroiditis– small exudat in just one area or all around the fundus– PD : miliary TBC
• Diffuse Choroiditis– Exudat are spreading to healthy area
Supurative Choroiditis
• E/ :– Pyogenic bacteria, which exogenous acquired
----> ocular bulb perforating– Endogenous --> hematogen metastasis
percontinuitatum• Main clinical sign :
– Pus in the Vitreous
• Supurative Endophthalmitis– Looks like without clinical sign manifestation if
observed outside the eye– Signs :
• subjective : fast loss of visual acuity• objective : yellow vitreous, fundus is not clearly
seen– Inflammation is not reach the ciliary body
• Septic Endophthalmitis– The inflammation reaching the ciliary body– Clinical sign :
• Cilar injection (+), hipopion, choroid abscess & ciliary body
• Loosing fast of visual acuity, not reversible– Th/ :
• Antibiotics• Corticosteroid• Analgesic• Roborantia
– If severe pain present ---> evisceration, not enuclation
• Panophthalmitis– All of eye tissue are infected including the adnexa– Clinical signs :
• bulb protorsio, difficulty to move the eye, palpebral edema, conjugtival chemosis, muddying of cornea, perforating, visus 0, headache
– Th/ :• bulbar evisceration• Local & systemic antibiotics
– Periphery --> even severe inflammation occurred, visual acuity good --> scotoma occur
• (+) : blind spot• (-) : blind spot with perimeter examination
– Clinical signs :• Objective with ophthalmoscopy :
– yellow spotted, clear border with retinal blood vessel above– Blood vessels (-) : if the inflammation reach the retina– Vitreous are muddy if inflammation cells are present
• Subjective :– Visual acuity disturbances : metamorphosis --> macropsi & micropsi– If exudat + infiltrate pressing the retina --> visual cell stacking– Hemeralopia/nyctalopia --> if chronic– Scotoma– Fotopsi– Photophobia
Symphatic Ophthlamia
• Unique granulomatous iridocyclitis• bilateral• leading from wound of one eye --->
infection ---> iridocyclitis (exiting eye)• followed by other eye ( sympathizing eye)
• Etiology :– Wound :
• Injury ---> wounding of ciliary body• Operation --> ciliary body ; iris ; capsule lentis are trauma
– Corpus Alineum in Intra Ocular space– Perforating of Corneal ulcer– Corneal ulcer
• Incubation – 3 - 8 weeks after the eye wounding– can also happen after 20 years
• Beware :– Wounding eye --> recurrent iridocyclitis for more than 3 weeks– Observe the other eye if iritasio simpatica occur :
• photophobia• lacrimation• blurred vision• pain• flare (+)
– Enucleating wounding eye as soon as possible– If neglected/doubtfully ---> iritatio oftalmia --> symphatic
ophthalmia
Stadium I (Iritation)
• Signs of Symphatic ophthalmic :– Muddying of cornea– small pupil– greeny muddy vitreous body
• Therapy :– Same as iridocyclitis
Stadium II(stadium simpatica)