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7/31/2019 Anatomy and Diseases of the Uvea
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Anatomy and diseases of theuvea
Anatomy:Uvea is the vascular coat of eye ball and
lies between the sclera and retina. Uvea is
composed of three parts i.e. iris, ciliary
body and choroid. These three portions
are intimately connected and a disease of
one part also affects the other portionsthough not necessarily to the same
degree.
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Uvea
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IRIS
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Anterior surface has two zones:
1) Papillary zone: is flat and has a dark
border at the papillary margin , known aspapillary ruff. Junction of papillary and
ciliary zone is marked by a smooth ridge
known as collaret.
2) Ciliary zone: towards the ciliary
border has ciliary crypts. Histologically
iris has got 5 layers (from before
backward).1- Endothelium: flat nucleated cells
absent over the crypts probably to allow
free movement of the aqueous in and out
of the iris.
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2- Vessel layer: consist of blood
vessels lying in collagen fibers,
chromotophores etc.,3- Muscular layer: two muscles:
a) Sphincter pupillae- plain muscle
developed from neuroectoderm- suppliedby parasympathetic fibers coming through
the 3rd nerve (relayed in ciliary ganglion).
b) Dilator pupillae- also arise from
neuroectoderm and supplied by cervicalsympathetic fibers reaching the eye through
long ciliary nerves (not relayed in ciliary
ganglion).
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4- Pigmented epithelium- two layers.
The two layers are loosely attached to
each other and there is a potential space
between the 2 layers. In iridocyclitis
there is adhesion of the iris to the lens.
When a mydriatic is applied the posteriorlayer of pigment epithelium gets partly
detached. This produces pigment
deposition and pigmented patches on the
anterior lens capsule (broken posteriorsynechiae).
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5- Internal limiting membrane- fine and
homogenous structure, not consistently
present.
Function of the iris:
1- Regulates the entry of light into the eye
by changing the size of papillary aperture.
2- Cuts away the peripheral aberrations.
3-Absorption of aqueous also takes place
from its surface.
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Ciliary body
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The inner surface is directed towards
the cavity of the eye ball and is divided
into two portions anterior (pars plicata )
and posterior (pars plana).
Ciliary muscle consists of:
1. Meridional fibers.
2. Circular fibers.
3. Radiating fibers.
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Meridional fibers on contraction pull the
suprachoroidea forwards and release the
suspensory ligament allowing the lens tobecome more convex as in
accommodation. The pars plicata has
about 70 ciliary processes. They secrete
aqueous.
Functions of ciliary body:
1. Brings about accommodation.
2. Formation of aqueous.3. Helps in drainage of aqueous at the
angle of anterior chamber.
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3) Choroid:Choroid is the analogue of pia-arachnoid
of the brain and serves the same purposeof supplying nutrition to the neural
portion of eye i.e. retina. Choroid is
composed of five portions.
1. The outer most is
SUPRACHOROIDEA a potential space
between the choroid and sclera. This is
lined by endothelium and traversed byfibrous trabeculae.
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This space is utilized for the treatment of
aphakic glaucoma in the operation of
cyclodialysis.
Deeper to it are three vascular layers.
2. Layer of LARGE BLOOD VESSELS is
outer most.
3. Next comes MEDIUM SIZED BLOOD
VESSELES.
4. and SMALL BLOOD VESSELES or
CHOROIDO-CAPILLARIES.
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Layer of choriocapillaries is the most
important. It serves to provide nutrition to the
outer layers of retina. The choriocapillaries
are much wider than the capillaries
elsewhere. Their diameter varies from 10 to
30 microns.
5. The innermost layer is avascular known as
MEMBRANE of BRUCHS. This is
composed of elastic and cuticular lamina and
pigment epithelium of retina is intimatelyattached to it.
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Classification:A) Depending upon the site of
inflammation:
1) Anterior uveities
- iritis.
- cyclitis.- iridocyclitis.
As iris and ciliary body are continuous,
iritis seldom occurs without some
inflammation of the ciliary body and viceversa.
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Iritis
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cyclitis
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choroiditis
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choroiditis
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NonGranulomatousGranulomatous
Acute onset of severe
inflammation (red eye).
Short.
Small KPs.
Intense aqueous flare.
Absent.
(11) Onset: insidious,
eye relatively white.
2) Course: chronic.
3) KPs: medium and large
and often mutton fat.
4) Slight aqueous flare.
5) Nodules on iris present
Koeppe's nodules are
seen on the pupillary
margin. Busacca's
nodules are seen near
coflarette.
C) Clinicopathological classification:
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Fine synechiae.
Tends to affect anterior
uvea.
Fine punctate opacities in
the vitreous.
Allergy.
Complications: few.
6) Dense broad based
posterior synechiae.
7) Tends to affect entire
uvea.
8) Heavyvitreous exudate
or veils common.
9) Etiology: direct
organismal infection.
10)Complications: more
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Etiology:
In most cases it remains obscure.
1) Infection:
a. Exogenous- the organisms reach the eye
from outside.
i) Perforating injury.ii) Perforating corneal ulcer.
iii)Intraocular operation.
This usually leads to suppurative iridocyclitis,
endophthalmitis and even panophthalmitis.
b. Secondary- due to spread from one or other
of the ocular tissue- corneal ulcer, scleritis.
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c. Endogenous: Organisms primarily lodged
in some other organ of the body reach the
eye through the blood stream.i) Viral- herpes simplex, herpes zoster,
measles, mumps, rubella.
ii)Bacterial: tuberculosis- syphilis, leprosy,
gonorrhea, brucellosis.
iii) Fungal: histoplamosis, asperigillosis,
candida albicans, actionomycosis.
iv) Protozoa: Toxoplasmosis.v) Nematodes: ankylostomiasis, filariasis.
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2) Allergy:
a. Bacteria:
i) T.B. usually of the lungs, lymph nodes.ii) Streptococci- teeth, tonsils, sinuses,
urogenital tract.
Primarily source of infection exists at these
sites. At one time the infection wasgeneralized by the escape of organisms into
the blood stream when the ocular tissue- uvea
had become sensitized to them. At a later
date further dissemination of the organisms
or their proteins meeting the sensitized uveal
tissue excites an allergic response.
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b. Lens proteins- phako- anaphylactic
reaction. They have also a toxic action on
iris.c. Uveal pigment- sympathetic ophthalmitis.
3) Constitutional disorders:
Diabetes mellitus, gout, rheumatoid arthritis(adult and juvenile), ankylosing spondylitis.
4) Trauma:
a. Blunt.b. Sympathetic ophthalmitis.
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5) Idiopathic:
a. Sarcoidosis.
b. Vogt- Koyanagi- Harada's disease.c. Behcet's disease.
6) Miscellaneous:
Intraocular haemorrhage, intraocular tumour.
Pathology:
Inflammation of the iris and ciliary body has
the same characteristic as other vascularconnective tissue.
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Sarcoidosis
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1. dilatation of the blood vessels.
2. exudation of protein rich fluid into the
tissue space with leucocytes or
lymphocytes.
1) Pupil: small and reacts sluggishly to
light owing to
a. hyperemia of the radially disposed
vessels of the iris.
b. exudate contains toxic substances whichirritate the sphincter pupillae (this muscle in
more powerful than dilator pupillae).
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2) Delicate patterns of iris:crypts-
become blurred and indistinct (muddy iris).
3) Colour of iris:undergoes change-
brown iris becomes grayish.
4) Exudate in AC:a. Aqueous flare.
b. Sometimes hypopyon.
5)Exudate in posterior chamber:induces adhesion between posterior surface
of iris and the lens (posterior synechiae).
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6) Exudate in vitreous: vitreous haze.
Symptoms:1) Pain the eye ball:
It is dull aching, worse at night, it may be
referred to the forehead along the 1st
division (ophthalmic) of the trigeminal. It isdue to:
a. The iris has a rich nerve supply; the nerve
endings are stimulated by a high
concentration of toxic substances.
b. Spasm of ciliary muscle.
c. Secondary glaucoma.
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2) Diminition of vision due to:
a. Spasm of ciliary muscle- pseudo myopia.
b. turbidity of aqueous, vitreous.c. exudate in papillary area.
d. choroidities when associated in
panuveitis.
e. Secondary glaucoma.
f. complicated cataract.
g. cyclitic membrane.
h. retinal detachment.
3) Photophobia, redness, watering.
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Signs:
1) Oedema lids in severe cases with watery
discharge.2) Ciliary and conjunctival congestion.
3) Cornea:
May show oedema, KPs- These are small
accumulations of cells derived from theuveal tract upon the back of the cornea.
They are found in iridocyclitis, and
choroidities. In iridocyclitis the nutrition of
the corneal endothelium becomes affected
so that the cells become sticky and may
desquamate in places.
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5) pupil:Is small, irregular (due to posterior
synechiae) and reacts sluggishly to light.This irregularity is exaggerated when pupil
is dilated with mydriatic- festooned pupil
(resembles a wreath such as is placed on a
war memorial). Posterior synechiae may be:
a) filiform seen in non granulomatous
uveitis.
b) broad based posterior synechiae seen ingranulomatous uveitis.
c) annular or ring synechiae or seclusion
pupillae.
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In severe cases of plastic iridocyclitis or after
recurrent attacks the whole circle of the
papillary margin may become tied down to theanterior lens capsule.
It is of great danger to the eye since if
unrelieved it inevitably leads to secondary
glaucoma- the aqueous unable to pass forwards
into the anterior chamber, collects behind the
iris which becomes bowed forward like a sail, a
condition which is called iris bombe. Regardedfrom in front, the anterior chamber is seen to be
funnel shaped, deepest in the centre and
shallowest at the periphery.
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OCCLUSIO PUPILLAE (blockedpupil):
In severe cases of irido cyclitis the exudates
may cover or may organize across the entire
papillary area which becomes ultimately
filled by a film of opaque fibrous tissue- thecondition is called occlusio pupillae
occlusion pupillae and seclusion pupillae
often occur together.
Occlusion pupillae may occur with totalposterior synechiae.
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6) IRIS:a- "Muddy iris"delicate pattern or iris
crypts become blurred and indistinct.b- nodules- these may be of 2 types:
i) pseudo nodules: These consists of
accumulations of lymphocytes and epitheloid
cells which are deposited on the iris koeppes
nodules near the papillary border and
Busacca's nodules near the collarette.They
disappear without fibrosis.
ii)True nodules: These arise in the stroma of
the iris and on healing leave behind a scar or
an atrophic patch.
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nodules
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Ophthalmia
nodosa
Sarcoid
nodule
Leprosy
nodule
Syphilitic
nodule
Tuberculous
nodule
Pink
vascularReddish
vascular
capillaries
pass over and
in the nodule
Pale
avascular
Yellowish-red
avascular
Grey or yellow
avascular
capillaries pass
over nodule.
1.Colour
Any partAny partPupillaryregion
Pupillary or
ciliary regionPupillary or
ciliary region2.Location
Grow slowlyGrow slowlyGrowslowly
Grow
relatively
quickly
Grow slowly3.Progress
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Syphilitic nodule
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9) CILIARY TENDERNESS: particularly when cyclitis
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9) CILIARY TENDERNESS: particularly when cyclitisis predominant.
Active iridocyclitisHealed iridocyclitis
1) symptoms:
Pain, redness,
photophobia, diminished
vision
Diminished vision may be
present.
2)signs:
a- ciliary and conjunctival
congestion
b-KPs grayish white,
circular with regular
margin.
c- Aqueous flare present.
d- Ciliary tenderness
present.
Eye is white
Pigmented KPs with
crenated or serrated
margin.
Absent
Absent
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COMPLICATIONS:
1) Secondary glaucoma:hypertensive
iridocyclitis. This may be due to:i) clogging of trabecular meshwork by
inflammatory exudates- plasmoid aqueous.
ii) seclusio pupillae.
iii) seclusio pupillae produces iris bombewhich gives rise to peripheral anterior
synechiae.
iv) occlusion pupillae.
v) increased capillary hydrostatic pressure
leading to increased aqueous formation.
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2) Complicated cataract:Refer lens
chapter.
3) Cornea:a) a corneal opacity may result from
persistent oedema.
b) band shaped keratopathy particularly in
cases of Stills disease.c) Retrocorneal membrane due to
organization to exudates behind the cornea.4) Cyclitic membrane:
It is a membrane formed in the anterior
vitreous behind the lens due to organization
of inflammatory exudates.
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Significance:
1-causes diminision of vision
2- causes traction retinal detachment.3- one of the causes of pseudoglioma in
children.5) Retinal detachment:a) due to contraction of cyclitic membrane.
b) It may be exudative retinal detachment
when iridocyclitis is associated with
choroiditis.
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Retinal detachment
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6) Phthisis bulbi:a) damage to ciliary body occurs due to
organization of exudates on the surface.b) contraction of cyclitic membrane may
detach the ciliary body. These result in
decreased production of aqueous leading
to ocular hypotony and phthisis bulbi.
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Phthisis bulbi
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INVESTIGATIONS:
1.General examination for evidence of leprosy,
tuberculosis, syphilis, rheumatoid arthritis etc.2.Urinealbumin, sugar and microscopic
examination for pus cells.
3.Stools- ova and cyst.
4.TuberculosisMantoux test, X-ray chest5.Syphilisblood VDRL
6.Rheumatoid arthritis- Rose- waaler test.
7.Toxoplasmosis: HA test, dye test and ELISA
test.
8.Thorough dental, ENT, and gynaecological
check up to rule out septic foci
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TREATMENT:-I) Local:
i. Cycloplegic mydriatic therapy:a) 1% atropine drops or ointment t.d.s. This isthe most important drug in the treatment of
iridocyclitis. It acts as follows:
1-puts the iris and ciliary body at rest.2-diminishes congestion of iris and ciliary
body.
3-prevents the formation of posterior
synechiae or tends to break those alreadyformed.
4-has mild anaesthetic action.
b) I h il d dil i h
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b) In cases where pupil does not dilate with
atropine, subconjunctival injection of 0.3 cc
mydricaine is given (this contains atropine,
adrenaline and procaine and is a potent
mydriatic).
c) In cases of atropine allergy- 2%
homatropine, 1% cyclopentolate, 0.5%hyoscine may be used.
ii) Cortisone drops or ointment 3-6 times a
day. This is useful because of the allergicnature of the disease. In severe cases
subconjunctival injection of Dexamethasone is
given.
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NB: Indiscriminate and long term use ofcorticosteroid may cause rise in intraocular
pressure.iii) Hot fomentation t.d.s.
iv) dark glasses.
II) General(11)Treatment of causative factor- T.B.,
infected teeth etc., should be treated or
eliminated.
2) Analgesics- paracetamol.3) Systemic corticosteroid in severe cases of
iridocyclitis or when associated with
choroiditis.
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III) Treatment of complications:
1) secondary glaucoma:
a) local use of 1% atropine,corticosteroid, hot fomentation.
b) Tab. Diamox 250 mg t.d.s.
c) surgical- paracentesis. Peripheral
iridectomy can be done to relieve the
papillary block in cases of iris bombe. In
cases with extensive peripheral anterior
synechiae due to iris bombe,trabeculectomy may be required.
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Earlier, Fuchs four dot iridotomy was
done by passing Von Graefes knife across
AC puncturing and counter puncturingboth cornea and iris. This is now of
historical interest only.
2) Complicated cataract: Refer lens
chapter.
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Choroiditis
Etiology:
I-Infection
1) Endogenous
a. virus - Rubella.
b. bacteria - TB, syphilis.
c. fungi - histoplasmosis.
d. protozoa - toxoplasmosis.
e. Nematodes - ankylostomiasis, filariasis.
2) Exogenous : perforating injury; perforated corneal ulcer ect,these lead to suppurative choroiditis , endophthalmitis and
even panophthalmitis.3) Secondary : spread of inflammation from posterior scleritis
II) Idiopathic: sarcoidosis ,Vogtkoyanagi - haradas disease
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Fundus examination shows :
1) vitreous haze and vitreous opacities.
2) patches of choroiditis. These patches areyellowish or yellowish white with ill definedfluffy margin.
3) Later the exudates undergo resolution byfibrosis and the patches become white with
well defined margin.
Complication :
1) complicated cataract result from defective
nourishment of the lens.2) Exudative retinal detachment due to exudation offluid between pigment epithelium and rods andcones .
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3) optic neuritis : result when the inflammatory
patch is close to optic disc .
4) consecutive optic atrophy : from the destructionof retinal ganglion cells .
Varieties of posterior uveitis :
It classified according to the situation and character
of the patches:1.Circumscribed choroidities.
2.Diffuse choroiditis.
3.Disseminated choroiditis.
4.Anterior choroiditis.
5.Central choroiditis.
6.juxta papillary choroiditis of Jensen.
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Symptoms :Visual disturbances are common:
1) visual acuity may become defective more markedlywhen:
a- the lesion is in the central area near the posteriorpole.
b- cloudiness of vitreous is present.
2) metamorphpsiadistortion of object may be seen .
3) micropsia and macropsiaobjects appear smaaleror bigger, due to separation or crowding ofretinal elements respectively.
4) photopsiasubjective flashes of light, due to
irritation or retinal elements by exudates.
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5) positive scotoma: perception of black spot before the eye.
6) negative scotoma: hiatus in the field of vision ( patient is notaware of this ).
specific type of posterior uveitis :
Tuberculosis of the choroid occurs in acute milliary and chronicforms:
1) acute - in milliary tuberculosis there are multiple small spotsscattered all over the fundus varying in size from pin point to2mm diameter.
2) chronic tuberculosis - may result in:
-diffuse choroiditis.- disseminated choroiditis.
- solitary or conglomerate tubercle.
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Differences between active and healed choroiditis :
Active choroiditis Healed choroiditis
1-Vitreous haze is present.
2-Yellow patch with
feathery margin.
3-Borders are not
pigmented.
4-Produces passive scotoma
due to inflammatory
exudates in front of
light sensitive element.
5-Underlying choroidal
vessels obscured.
6- Often requires treatment.
Vitreous is clear.
White patch with
circumscribed margin.
Borders are pigmented.
Produce negative scotoma
due to destruction of
photoreceptors.
Large choroidal vessels.
No treatment required.
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congenital abnormalities of the uveal tract:
persistent pupillary membrane - in the early foetaleye pupil is covered over by a delicatemembrane known as pupillary membrane.
conginital aniridia : failure of iris to develop.There is usually associated nystagmus andfoveal hypoplasia.
heterochromia iridis : part of the same irisusually a sector may differ in colour from theremainder .
heterochromia iridum : one iris may havedifferent colour from the other.
behcets syndrome: it is an acute iridocyclitis seenin young adult associated with:- hypopyon,ulcerative lesion in mouth.
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Congenital aniridia
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Iris coloboma
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heerfordts disease: it is a bilateral affection characterized byinvolvement of the entire uveal tract, the parotid gland andcranial nerve.
Vogt koyanagi haradas syndromeFuchs heterochromic iridocyclitis
Sympathetic ophthalmitis
Rubeosis iridis: it is characterized by the development of newand enlarged vessels on iris.and is seen in:
i) diabetes mellitusii)After central retinal vein occlusion
iii)After central retinal artery occlusion
In cases of diabetes mellitus with rubeosis and mature cataractiridectomy may have to be omitted or peripheral iridectomydone in an area where rubeosis is not present
Complication:secondary glaucoma due to fibro vascularmembrane blocking trabecular meshwork and due torecurrent hyphaema
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Vogt koyanagi haradas
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og oya ag a adasyndrome
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Nodules on the iris are seen in the following disease
1) Iridocyclitis: due to tuberculosis, syphilis, leprosy
2)Iris melanoma:usually seen in people between 40 and 50years and presents as a solitary pigmented nodule on thelower half of iris feature that should arouse suspicion ofmalignancy include:
- ectropion uveae
- pupillary distortion
- neovascularization
- raised IOP
- increase in nodule size
3) Lisch nodules
4) Juvenile xanthogranuloma
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Iris melanoma
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Lisch nodules
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PANOPhTHALMITISDefinition:
An intense suppurative inflammation of the entire uvealtract which fills the eye ball with pus, extends to all thestructures of the eye and ends in complete destruction ofthis organ.
Etiology:
Infection is by pyogenic organisms:
1) ps. Pyocyanea
2) pneumococcus
3) staph
4)strept5) E. coli
6) gonococcus
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i) Exogenous infection:
1) perforated corneal ulcer
2) penetrating wounds
3) intraocular operation
ii) Endogenous infection
Results from septic embolism of a retinal or a choroid vessels.Such cases occur in the course of infectious diseasepneumonia, meningitis
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5) AC filled with pus
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5) AC filled with pus.
6) increased I.O.P .
7) in severe cases the pus bursts through the wallof the globe.
Treatment:
I- At early stage :1) intensive treatment by antibiotics both localand systemic.
2) analgesics- tap.paracetamol.
3)hot fomentation.
II A it b id t th t th
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II- As soon as it becomes evident that the eye
cannot be saved evisceration is done.
Frill excision: if the entire sclera is left. There is
considerable pain, reaction and delayed healing.
It is not considered advisable to enucleate in cases
of panophthalmitis on account of the danger of
causing meningitis.
Prognosis:is always bad. However the condition does not
cause sympathetic ophthalmitis.
H t h i d h
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Hetrochromia waardenhurgs
l
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Iris prolapse
Iris hemangioma
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Iris hemangioma
Iris cyst
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y
Iris nevus
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Iris nevus
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Iris tumor
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Iris neovascuralization
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Herberts pits
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hypopyon
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Keratouveitis
' d l
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Koeppe's nodule
S h
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Synechiae posterior
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pseudo exfoliation
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Thanks