Upload
anumeha-jindal
View
227
Download
0
Embed Size (px)
Citation preview
7/29/2019 Fungal Uveitis
1/30
7/29/2019 Fungal Uveitis
2/30
Dr. Anumeha
7/29/2019 Fungal Uveitis
3/30
Pathogenesis:
Caused by Histoplasma capsulatum
By inhalation of infective mycelia or spores withdust particles
POHS represents an immunologic mediatedresponse in individuals previously exposed to
fungus
Inc prevalence of HLA-B7 and HLA-DR2
7/29/2019 Fungal Uveitis
4/30
Key features are:
Occurs From area, endemic for histoplasmosis Whites
20-50 years of age
Fundus picture:
Multiple peripheral atrophic scars
Macular disciform scar
Peripapillary choroidal scars
Linear peripheral streak lesions Lack of aqueous and vitreous inflammation
HLA-B7-and HLA-DR2-positive patients
7/29/2019 Fungal Uveitis
5/30
Multiple peripheral atrophic scars
vary in number, shape, size, and pattern are at the level of the outer retina(retinal pigment
epitheliuminner choroid)
usually 0.2 to 0.7 DD in size
mostly nonpigmented, but central pigmentclumps, peripheral pigmentation, or diffusepigmentation may be seen
occur bilaterally usually remains unchanged through out life
7/29/2019 Fungal Uveitis
6/30
Peripheral atrophic scar
7/29/2019 Fungal Uveitis
7/30
Peripapillary choroidal scars and macular scars
Peripapillary scars raisessuspicion of disciformmaculopathy also
FAngio of inactive scars shows loss of pigmentepithelium and choriocapillaris in the area of thescar.
neovascularization with asymptomatic leakage isseen occasionally.
Hemorrhagic peripapillary choroidalneovascularization may also occur, with permanentloss of central vision if spread to the macula occurs
7/29/2019 Fungal Uveitis
8/30
Peripapillary scars with associated choroidal neovascularization extending into the macul
7/29/2019 Fungal Uveitis
9/30
Peripheral linear streak lesions
variable length, width, and pigmentation in the equatorial region and oriented parallel to
the ora serrata
result from loss of choriocapillaris and retinal
pigment epithelium and appear to represent alinear aggregation of peripheral atrophichistoplasmosis spot
The linear distribution at the equator is because
anterior and the posterior choroids are suppliedseparately and the watershed zone is at theequator
7/29/2019 Fungal Uveitis
10/30
Linear peripheral streak lesion
7/29/2019 Fungal Uveitis
11/30
Macular choroidal neovascularization
Brings the patient to the ophthalmologist
Symptoms: Metamorphopsia blurred vision, or
loss of central vision
Fundus shows: Rarely, choroidal neovascularization can occur
in the macula without a prior scar or pigmentarychange.
These macular lesions can also cause RD butmost are hemorrhagic lesions. It is usually 1 disc diameter or less in size and is
greenish gray in color.
7/29/2019 Fungal Uveitis
12/30
D/d:
o Granulomatous disease of the fundus:
Tuberculosis Sarcoidosis
Coccidioidomycosis
Cryptococcosis
o Multifocal choroiditis with panuveitis
o High myopia
o Punctate inner choroidopathy
o Birdshot chorioretinopathy
7/29/2019 Fungal Uveitis
13/30
Diagnosis:
Histoplasmin skin test: clinically helpful
lasts lifetimeocular lesion may
reactivate aft this
Serological tests:Complement fixation is quantity test
Antibodies are present up to2- 5 yrs aft infec
Chest Xray: Calcifications seen of previous infec FFA
7/29/2019 Fungal Uveitis
14/30
Prognosis: If untreated choroidal neovascular membranes in the
macula result in a final visual acuity
7/29/2019 Fungal Uveitis
15/30
T/t
Laser photocoagulation of choroidalneovascularization
it is effective when the extent of the new vesselsis well defined and does not extend beneath the
foveaboth argon and krypton laser are used
Corticosteroids may be beneficial if new vesselsare beneath the fovea
Surgical removal of subfovealneovascularization is still experimental.
7/29/2019 Fungal Uveitis
16/30
FFA showing leakage with foveal involvement
7/29/2019 Fungal Uveitis
17/30
After t/t with laser photocoagulation closure of choroidal neovascular membrane
7/29/2019 Fungal Uveitis
18/30
Caused by candida albicans
Occurs in three main groups: IV drug addicts
Pts with long term indwelling catheters
Immunocompromised pts
7/29/2019 Fungal Uveitis
19/30
C/f
Gradual u/l blurring of vision
Floaters
Signs:
Focal or multifocal chorioditis
Small,round, white slightly elevated lesions withindistinct borders
Enlargement of lesions and extension intovitreous making cotton ball colonies
Chronic endoph
Retinal necrosis and RD
7/29/2019 Fungal Uveitis
20/30
Multifocal candida retinitis with cotton ball vitreous colonies
7/29/2019 Fungal Uveitis
21/30
D/D of Candida Endophthalmitis
Endogenous bacterial endophthalmitis
Toxoplasmin retinochoroiditis
Primary intraocular lymphoma Cytomegalovirus retinitis
Syphilitic chorioretinitis
Aspergillus endophthalmitis
7/29/2019 Fungal Uveitis
22/30
Treatment
Oral 5-flucytosine 150 mg daily
+
Ketoconazole 200-400mg daily for 3weeks
In resistant cases IV amphoterecin-B in5%dextrose
Pars plana vitrectomy: in endop cases
Intravitreal inj of ampho is also given.
7/29/2019 Fungal Uveitis
23/30
Caused by cryptococcus neoformans (encapsulatedcyst)
Present in soil contaminated with pigeon droppings
Mode of transmission is inhalation
Occurs in cell mediated immune dysfunction and aids pts
Histologically, there is usually acute and granulomatousinflammation
S/s
Meningitis assoc manifes-most common
Papilloedema
Optic neuropathy
Ophthalmoplegia
Ptosis
6th N palsy
7/29/2019 Fungal Uveitis
24/30
Earliest clinical manifestation is multifocalchorioretinitis
Lesions vary in size, and there may beoverlying retinitis and vitritis
In severe cases,
vascular sheathing,
mutton fat keratic precipitates, orendophthalmitis can occur
7/29/2019 Fungal Uveitis
25/30
multifocal necrotizing lesions of the retina.
7/29/2019 Fungal Uveitis
26/30
T/t
IV amphotericin B or
oral fluconazole and oral 5-flucytosine
7/29/2019 Fungal Uveitis
27/30
Caused by mold aspergillus
Found in decaying veg matter
Infection by inhalation of spores
In immuno-compromised host::
abuse intravenous drugs,
alcoholic patients
organ transplant recipients
patients on chemotherapy formalignancy
7/29/2019 Fungal Uveitis
28/30
Presentation rapid onset of pain and visual loss.
yellowish infiltrate: in the macula beginning in the choroid
and subretinal space. retinal vascular occlusion and full-thickness retinal
necrosis.
Intraretinal hemorrhages usually occur.
dense vitritis varying degrees of cell in AC,
flare
hypopyon
The macular lesions heals to form a central atrophicscar.
In severe infection, subretinal abscess andendophthalmitis occurs
7/29/2019 Fungal Uveitis
29/30
T/T
systemic treatment with intravenousamphotericin B
intravitreal injection of 510 g of
amphotericin B.may be reinjected weekly
Intravitreal corticosteroids may be used
7/29/2019 Fungal Uveitis
30/30