《葡萄膜病》PPT課件.ppt

Uveal Tract Disease 葡萄膜病, Uveal Tract 葡萄膜包括: Iris 虹膜 Ciliary body 睫狀體 Choroid 脈絡(luò)膜 三者彼此相連,血供系統(tǒng)同源.,Uvitis 葡萄膜炎 Is the generic name of the inflammation of uvea ; retina ;retinal vessels and vitreous 葡萄膜、視網(wǎng)膜、視網(wǎng)膜血管和玻璃體炎癥的總稱 Always in young patient 多見于年輕人 Always combine with systemic autoimmune disease 常合并全身自體免疫性疾病 recurrence is often 易復(fù)發(fā) Always blind 常致失明,Etiology and pathogenesis 病因和發(fā)病機(jī)理 Etiology : bacteria; fungus ;virus ; parasite Rickettsia infect directly or by evoke the antigen antibody reaction and complement compound induce uveitis Such as leprosy ; tuberculosis; syphilis; aids. 由細(xì)菌、霉菌、病毒、寄生蟲、立克次體直接感染或?qū)е驴乖贵w反應(yīng)和免疫復(fù)合物引起葡萄膜炎。如麻風(fēng)、結(jié)核、梅毒、艾滋病, Autoimmunity: eyes have many antigen . Immune disorder lead to uveitis such as sympathetic uveitis Stills disease (juvenile rheumatoid arthritis) Harada-Vogt disease 自身免疫反應(yīng)：眼有很多抗原，免疫異常導(dǎo)致葡萄膜炎。例如交感性眼炎、晶體過敏性眼內(nèi)炎、 原田-小柳氏病、Behcet病等. 伴發(fā)葡萄膜炎自身免疫性疾病:風(fēng)濕性關(guān)節(jié)炎，系統(tǒng)性紅斑狼瘡. The function of metabolite of arachidonic acid always seen in surgery , drug and physical stimulation 氧自由基的作用 ：常見于手術(shù)、外傷、以及理化刺激等導(dǎo)致活性氧生成過多,造成組織損害-自身氧損傷.,Classification of uvitis 分類, classify in etiologyinfection or non-infection 病因分類感染和非感染 classify in pathologygranuloma or non-granuloma uveitis 臨床病理分類肉芽腫型和非肉芽腫型 classify in anatomy-1979 anterior ,intermediate ,posterior and panuveitis 解剖部位分前、中、后或全葡萄膜炎(現(xiàn)階段國(guó)際通用分類方法),Anterior uveitis 前葡萄膜炎,in China50-60% of uveitis are anterior uneitis 我國(guó)50-60葡萄膜炎病人是前葡萄膜炎 Including 3 types 三種類型 acute anterior uveitis 急性前葡萄膜炎 chronic anterior uveitis 慢性前葡萄膜炎 acute or chronic anterior uveitis 既可出現(xiàn)急性炎癥又可出現(xiàn)慢性炎癥的前葡萄 膜炎,Acute Anterior Uveitis 急性前葡萄膜炎 Clinical features 臨床表現(xiàn) Symptoms of anterior Uvitis 癥狀 Aching pain in the eye 劇烈眼痛 Rapid blurring of vision 視力急速下降 Photophobia 怕光 Tearing of the eye 流淚,Signs of anterior uveitis 體癥 Redness of the eye ciliary congestion or mixed congestion 眼球充血。 睫狀充血或混合 性充血 KP( keratitis Precipitate ） three types dust like or media size or suet like 角膜后沉著物 。 有三種類型：塵埃狀、中等大小 羊脂狀,KP is clumps of white cells and inflammatory debris The shape of distribution of Kp is triangle shape or in pupil area of cornea or diffused KP:成堆白血球和炎癥碎片，分布呈三角形或在瞳孔區(qū)或彌散分布 Aqueous flare the damage of aqueous and blood barrier protein exudate into aqueous cells and flare in the anterior chamber -tyndall sign 房閃:血-房水屏障受損蛋白滲 入前房,房水閃光陽(yáng)性（丁道爾現(xiàn)象）, Hypopyon Aqueous cells inflamination cells red cells pigment cells inflammary cells percipitate in the lower part of anterior chamber 前房積膿。房水細(xì)胞、紅細(xì)胞、上皮細(xì)胞 、炎癥細(xì)胞沉積在前房下方, changes of iris 虹膜改變 iris edema and muddy 虹膜水腫、紋理不清 Posterior synechia of the iris pupil irregular 后粘連而瞳孔不規(guī)則 iris bombe 虹膜膨隆 Peripheral anterior synechia of the iris 周邊前粘連 goniosynechia 房角粘連 iris nodules 虹膜結(jié)節(jié), changes of pupil 瞳孔變化 Miosis Pupil constriction: inflammatory spasm of the iris sphincter muscle 瞳孔縮小，由于瞳孔括約肌痙攣 irregular pupil 瞳孔不規(guī)則,Pupil posterior synechia 瞳孔后粘連,posterior Synechia 后粘連,Seclution of pupil 瞳孔閉鎖,Goniosynechia 房角粘連,Occulusion of pupil 瞳孔膜閉,Iris bombe 虹膜膨隆, Seclusion of pupilsynechia in 360 degree 瞳孔閉鎖360度后粘連 Occlusion of pupil-fibrous membrane cover the pupil 瞳孔膜閉纖維膜遮蓋瞳孔區(qū) lens -pigment participate in the anterior lens capsule ,after enlarge the posterior synechia pupil pigment remain 晶狀體前囊有色素沉著，當(dāng)拉開后粘連時(shí)，瞳孔區(qū)遺留色素。,posterior segment of eye changed 眼後段改變 vitreous opacity 玻璃體混濁 Particles in vitreous 玻璃體內(nèi)有顆粒狀物 reflective macular edema 反應(yīng)性黃斑水腫,Complication 并發(fā)癥 complicated cataract 并發(fā)性白內(nèi)障 the aqueous changed matabolism of the lens 房水改變使晶狀體代謝改變 Opacity under the posterior capsule.also due to long term use steroid drops 長(zhǎng)期應(yīng)用激素滴眼晶狀體后囊下混濁,Secondary glaucoma 繼發(fā)性青光眼 block the trebacular mash work peripherial anterior synechia pupil block the aqueous circle 小梁網(wǎng)阻塞以及瞳孔后粘連阻斷房水循環(huán) Low IOP 低眼壓 Atrophy of eyeball 眼球萎縮, Diagnosis 診斷 Diagnosis by Symptom and signs 根據(jù)癥狀和體征診斷 Pay attention to systemic condition specially Artheritis urea tract inflammation Reiter syndrome T.B.and syphilis etc. 注意全身情況特別是關(guān)節(jié)炎，結(jié)核，梅毒等合并 葡萄膜炎,Differential diagnosis 鑒別診斷 some times tumor also have hypopyon. check B scan、 CT、MRI 前葡萄膜炎主要與急性結(jié)膜炎、急性青光眼鑒別。 腫瘤有時(shí)也可有前房積膿。應(yīng)用B超、CT、 MRI 檢查以明確診斷。, Treatment 治療 Dilate the pupil instantly .prevent posterior synechia 立即散瞳，減輕炎癥反應(yīng)，預(yù)防后粘連。 release the pain due to the spasm of sphinter of pupil and ciliary muscle use mydriatic : 1-4% Homatropine not atropine posterior synechia use mixed mydriatics 應(yīng)用散瞳劑如阿托品、后馬托品或混合散瞳劑可緩解疼痛,Topical steroid 局部或周身應(yīng)用皮質(zhì)類固醇激素 NSAID nonsteriod anti-inflammatory drugs 應(yīng)用非淄體消炎藥如消炎痛、布洛芬等 Etiology therapy : antiinfection 病因治療：抗感染 complications in secondary glaucoma use diamox timolol 治療并發(fā)癥如繼發(fā)性青光眼應(yīng)用降眼壓藥物 In pupil block laser iridotomy or peripherial Iridectomy is needed 瞳孔阻滯可激光虹膜打孔 或周邊虹膜切除, Filter surgery is needed for the synechia of anterior chamber cases 廣泛房角粘連應(yīng)當(dāng)應(yīng)用青光眼濾過術(shù) After control the inflammation do cataract surgery and IOLImplant systemic use steroids to prevent uveitis 控制炎癥后做白內(nèi)障和人工晶體植入術(shù)，術(shù)前應(yīng)先用激素以免葡萄膜炎復(fù)發(fā),Intermediate uveitis 中間型葡萄膜炎,Clinical features 臨床表現(xiàn) Pars plana ciliary part and base of vitreous uveitis ;peripheral Retinal and choroid involved. 睫狀體平坦部和玻璃體基底部葡萄膜炎。周邊視網(wǎng)膜和脈絡(luò)膜受累 Always 40y.both eyes chronic onset 常常為 40歲，雙眼、發(fā)病緩慢,Sometimes have pain and red eye Symptom: can no symptom or see as flying mosquito ,blured vision , temporary myopia 可無癥狀或僅有飛蚊癥、視力模糊、一過性近視，有時(shí)有疼痛和紅眼。,Signs 體癥 Snow like vitreous opacity snow bank in pars plana always in the lower part as a tongue point to the vitreous 雪片樣玻璃體混濁， 睫狀體平坦部雪堤狀隆起常在 下方如舌狀伸向玻璃體,lesion of retinal and choroid always in the lower part of peripheral -retinitis ; retinal vasculitis ,and peripheral retinochoroiditis 視網(wǎng)膜和脈絡(luò)膜病變 常在下方周邊部有視網(wǎng)膜炎； 視網(wǎng)膜血管炎和周邊視網(wǎng)膜 脈絡(luò)膜炎,Complication 并發(fā)癥 Macular lesion : cystoid edema 、 premacular membrane、 macular hole etc. 黃斑病變:囊樣水腫、黃斑前膜、黃斑洞等 complicated cataract 并發(fā)性白內(nèi)障 Others: retinal neovascularization, vitreous hemorrhage, proliferative retinopathy, papilla edema, papilla atrophy 視網(wǎng)膜新生血管形成、玻璃體出血、 增殖性視網(wǎng)膜炎，視乳頭水腫、視神經(jīng)萎縮,Diagnosis 診斷 dusty figure in visual field 視野中有塵埃狀漂浮物 Subposterior capsule cataract 晶體后囊下混濁 macular edema 黃斑水腫 FFA can help diagnosis 眼底熒光 血管造影有 助診斷,Treatment 治療 Visual acuity 0.5 no inflammation in anterior segment just examine after a period of time 視力 0.5 前節(jié)無炎癥只需定期檢查 Vision 0.5 active inflammation in the anterior segment give steroids peritenons capsule for half year. 視力 0.5 前節(jié)有炎癥，給與激素激素治療半年，盡可能局部給藥。,Freezing of pars plana or use laser for neovascularization of retinal. 冷凍或激光治療視網(wǎng)膜新生血管 Surgery: Vitrectomy 手術(shù)： 玻璃體切割術(shù) Immune-suppressive agent 免疫抑制劑,Posterior uveitis 后葡萄膜炎, Choroiditis 脈絡(luò)膜炎 Retinalchoroiditis 視網(wǎng)膜脈絡(luò)膜炎 Retinitis 視網(wǎng)膜炎 Retinal vasculitis 視網(wǎng)膜血管炎,toxoplasmosis,幾種特殊類型的葡萄膜炎,Vogt-Koyanagi-Harada syndrome Vogt-小柳原田綜合癥,Cerebritis uveitis 又稱特發(fā)性葡萄膜大腦炎 Etiology 病因 自身免疫反應(yīng)所致 Clinical features 臨床表現(xiàn) 腦膜刺激征 pigment change in skin And hair depigmentation tinnitus vitiligo 皮膚色素改變、白發(fā)、耳鳴、白癜風(fēng), Both eye granular panuveitis 雙眼肉芽腫型全葡萄膜炎 vision lose 視力喪失 Fundus as rosy clouds just before sunset 晚霞樣眼底改變 Delen-fuchs nodus 有Delen-fuchs結(jié)節(jié) Diagnosis 診斷 FFA早期點(diǎn)狀熒光素滲漏， 逐漸擴(kuò)大融合, Treatment 治療 Steroid and antiimmune therapy 應(yīng)用皮質(zhì)類固醇和免疫 抑制劑治療,Behcet disease 白塞氏病,Recurent hypopyon uvitis ，Uveitis ，oral ulcer， skin lesion ，genital ulcer 復(fù)發(fā)性前房積膿型葡萄膜炎、 口腔潰瘍、皮膚損害、生殖器潰瘍?yōu)樘卣鞯亩嘞到y(tǒng)受累疾病。 Etiology 病因 May be related to bacteria or virus infection and autoimmune reaction. 由于細(xì)菌或病毒感染以及自身免疫反應(yīng)所致,Clinical features 臨床表現(xiàn) eye lesion 眼部病變 panuveitis 25% hypopyon retinitis 全葡萄膜炎 ，25是前房積膿性視網(wǎng)膜炎 Retinal vasculitis.occlusion of of retinal vessels 視網(wǎng)膜血管阻塞 complicated cataract 并發(fā)性白內(nèi)障, secondary glaucoma; 繼發(fā)性青光眼， proliferate retinopathy and optic atrophy 增殖性視網(wǎng)膜病變和視神經(jīng)萎縮, oral ulcer very pain 7-14d 口腔潰瘍十分疼痛,持續(xù) 7-14天 skin lesion : erythema nodus, acneform eruptions Needle point overaction vitiligo 皮膚病變：結(jié)節(jié)性紅班，多形紅斑，針刺過敏反應(yīng)，白癜風(fēng) Ulcer of outer genital urinary tract 外生殖器潰瘍,Diagnosis 診斷 Recurent hypopyon uvitis ，Uveitis ，oral ulcer， skin lesion ，genital ulcer 反復(fù)發(fā)作的葡萄膜炎、 口腔潰瘍、皮膚損害、 生殖器潰瘍。,Treatment 治療 Anterior Uveitis- use mydriatic 眼前段受累者-睫狀肌麻痹劑 Topical steroid 糖皮質(zhì)激素 Immune-suppressive agent 免疫抑制劑 Complicated cataract have a surgery and Secondary glaucoma treatment by drug 并發(fā)白內(nèi)障手術(shù);繼發(fā)青光眼藥物降眼壓, 手術(shù)應(yīng)慎重。,Sympathetic ophthalmia 交感性眼炎,following a perforating eye injury in the region of the ciliary body, bilaterial uveitis occurs 當(dāng)一眼睫狀體區(qū)發(fā)生穿通傷或一眼手術(shù)后，雙眼發(fā)生葡萄膜炎。受傷眼稱誘發(fā)眼，另一眼稱交感眼。 Etiology 病因 probably related to hypersensitivity of some element of the pigment -bearing cells in the uvea. 外傷或手術(shù)造成眼內(nèi)抗原暴露激發(fā)了自身免疫反應(yīng),Clinical features 臨床表現(xiàn) Granular uveitis 肉芽腫型葡萄膜炎?？蔀榍捌咸涯ぱ?、后葡萄膜炎、 中間葡萄膜炎或全葡萄膜炎。 Diagnosis 診斷 perforating eye injury in the region of the ciliary body 眼球穿通傷和內(nèi)眼手術(shù)史主要診斷依據(jù),Treatment 治療 use mydriatic Topical steroid 前葡萄膜炎:糖皮質(zhì)激素、睫狀肌麻痹劑 Posterior uveitis and all uveitis-Topical steroid and Immune-suppressive agent 后葡萄膜炎和全葡萄膜炎:糖皮質(zhì)激素、免疫抑 制劑,Acute retinal necrosis syndrome 急性視網(wǎng)膜壞死綜合癥 By herpes simplex retinal necrosis retinal artiritis vitreous opacity 單皰病毒引起的壞死性視網(wǎng)膜動(dòng)脈炎和玻璃體渾濁 retinal detachment in the later stage 后期發(fā)生視網(wǎng)膜脫離 Always single eye 常為單眼 Blur vision macular lesion 黃斑病變引起視力減退 high IOP 高眼壓, And then to posterior part of retina 早期在視網(wǎng)膜中段發(fā)生斑塊狀病變,以后向視網(wǎng)膜后部發(fā)展 Retinal vasculitis is an important sign 視網(wǎng)膜血管炎是重要體癥 Therapy: antivirus agent anti-coagulation steroids laser vitrectomy 治療：抗病毒治療，抗凝治療，激素，激光治療和 玻璃體切割術(shù)。,Choroidal hemangioma 脈絡(luò)膜血管瘤,congenital blood vessel deformation accompany with face hemangioma and glaucoma called Sturge-Weber syndrome. 先天性血管異常 合并面部血管瘤 和青光眼, always in young patients 常見于年輕人 lesion from disc and near macula isolated as a red ball elevated or scattered flat ,border is not clear.always have retinal detachment vision lose or glaucoma 病變起于視乳頭近黃斑部 呈紅色球樣隆起，邊界不清， 常有視網(wǎng)膜脫離，視力喪失 或青光眼。,Malignant melanoma of the choroid 脈絡(luò)膜惡性黑色素瘤, Always in adult 50-60y.single eye.from pigment cell or nevus of uvea. 多見于50-60歲成年人，單眼發(fā)病。源于色素細(xì)胞、色素痣或葡萄膜 vision disfiguration when tumour is in the macular 腫瘤累及黃斑部時(shí)視力下降 exudative retinal detachment ; metastasis 滲出性視網(wǎng)膜脫離，轉(zhuǎn)移 IOP increased in necrosis of tumour and block the vortex vein 眼壓增高 由于腫瘤壞死和阻塞渦靜脈,Cong