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)