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UveitisNatalia Wiryanto
NIM: 07120100027Pembimbing: dr. M. Sulaiman. Sp. M
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Uvea
-itis
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Pathogenesis Trauma pemicu proses inflamasi karena
kombinasi antara kontaminasi microbial danakumulasi produk nekrosis pada lokasi luka.
Infeksi reaksi imun terhadap molekul asingatau antigen dapat melukai pembuluh darahdan sel sel uveal tract.
Penyakit autoimmune reaksihipersensitivitas deposisi kompleks imun didalam uveal tract.
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Signs & Symptoms
Penyakit Gejala Tanda
Anterior
Akut Sakit, photophobia,merah, penglihatan
kabur
KPs, cells, flares, fibrin, hypopyon, pigmentdispersion, papillary miosis, iris nodule,
synechia anterior dan posterior, bandkeratopathy, aqueous flare, ciliary flush,
injeksi konjungtiva / sklera Kronik
Asimptomatik atau
penglihatan kabur
Intermediate Penglihatan kabur dan ada
floaters
Sel - sel peradangan vitreal, snowballopacities, snowbank, vitreal strands,
membran cyclitic, hypotony
Posterior
Penurunan tajam penglihatantanpa rasa sakit, floater,
photopsias, metamorphopsia,scotomata, nyctalopia,epiphora, photophobia
Infiltrat peradangan koroidal / retinal,
peradangan lapisan pelindung arteri / vena, pervascular inflamatory cuffing, retinal
pigment epithelial hypertrophy / atrophy,atrophy atau pembengkakan
retina/koroid/kepala saraf optik, fibrosis pre-
atau subretinal, exudative, tractional, ataurhegmatogenous retinal detachment
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Pemeriksaan Penunjang
Fluorescein angiography (FA) Indocyanine green (ICG) angiography Ultrasonography Optical coherence tomography (OCT) Anterior chamber paracentesis Vitreus biopsy Chorioretinal biopsy
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Pemeriksaan Penunjang FA chorioretinal & komplikasi struktural dari posterior
uveitis ICG angiography peradangan koroid vaskulopati
Tipe 1: peradangan choriocapillaropathies MEWDS (multiple
evanescence white dot syndrome) Tipe 2: stromal inflammatory vaskulopathies of choroid sarcoidosis,
sympathetic ophthalmia, birdshot chorioretinopathy, Vogt KoyanagiHarada
USG kekeruhan vitreus, penebalan koroidal, pelepasanretina, pembentukan membran siklitik
OCT uveitic CME, penebalan retina, cairan subretina yangberhubungan dengan koroidal neovaskularisasi, serous retinaldetachment
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Pemeriksaan Penunjang
Anterior chamber paracentesis + analisa aqueous humour pasien infectious uveitis dgn gejala atipikal, susp.primary intraokular lymphoma (reticulum cell sarcoma),toxoplasmosis
Vitreus biopsi susp. primary intraokular lymphoma(reticulum cell sarcoma) / endopthalmitis bakteri / fungal.Biasanya diikuti oleh pemeriksaan cytologic,cytofluorographic, dan microbiologis dari cairan vitreus,serta kultur bakteri dan jamur dari specimen vitreus dan
aqueous jika diduga infeksi Biopsi korioretinal necrotizing retinitis pada pasien AIDS
/ susp. Primary subretinal intraokular lymphoma
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Tatalaksana
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Medical Therapy
Midriatik dan siklopegik (tetes mata short acting:cyclopentolate hydrochloride, tetes mata longacting: atropine) mencegah dan menghentikanpembentukan sinekia posterior dan meringankanphotophobia sekunder akibat spasme siliar.
NSAIDs menghambat cyclooxygenase danmengurangi sintesis prostaglandin yangmemediasi peradangan pasca operasiperadangan dan CME, kronik iridosiklitis (JRA/JIA-berhubungan dengan iritis) dan kemungkinanCME.
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Medical Therapy
Kortikosteroid : Topikal anterior uveitis, vitritis dan macular edema
pada pasien pseudofaki atau afakia Periokular (triamcinolone acetonide 40mg atau
methylprednisolone acetate 40-80mg) intermediate / posterior uveitis, pasien dengan CME
Oral / IV topical kortikosteroid tidak memadai ataupenyakit sistemik juga membutuhkan terapi
Intravitreal (triamcinolone acetonide / kenalog) bukan untuk pengobatan kronik uveitis
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Medical Therapy Immunomodulator
Indikasi:
Note:
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Medical Therapy
Amantiades-Behcet uveitis,
intermediate uveitis, VKH,simpatetik ophthalmia, dannecrotizing scleritis
necrotizing scleritis yangberhubungan dengansistemik vaskulitis (Wegenergranulomatosis / relapsingpolychondritis), intermediateuveitis, VKH, simpatetikophthalmia, danadamantiades behcet
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Medical Therapy
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Surgical Therapy
Indikasi: endophthalmitis, primary intraocularlymphoma atau keganasan intraocular lain, infectiousposterior uveitis, dan jika diduga panuveitis.
Therapeutic vitrectomy dilakukan pada kasus uveitistertentu untuk membersihkan visual axis dari kekeruhanatau perdarahan, mengangkat epiretinal membrane,mengangkat subfoveal choroidal neovascularmembrane pada kasus kasus tertentu, memperbaikicomplex retinal detachments, mengurangi intravitrealcytokines dan chemokines untuk membantumengontrol inflamasi, dan mengurangi CME.
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Komplikasi Katarak
Glaucoma Hypotony CME terapi kortikosteroid dan immunomodulator Calcific band shaped keratopathy EDTA scrubs Vitreous opacification & vitris 3-port pars plana vitrectomy Retinal detachment pars plana vitrectomy dan endolaser dengan
internal silicone oil tamponade Retinalneovascularization kortikosteroid dan/atau
immunomodulator atau scatter laser photocoagulation di daerah iskemikdan area watershed yang berhubungan
Choroidal neovaskularisasi (CNV) kortikosteroid,immunomodulator, dan focal laser photocoagulation of peripapillary,extrafoveal, dan juxtafoveal CNV. Jika gagal, pars plana vitrectomy dansubfoveal CNV extraction
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Penanganan Komplikasi Operasi katarak (jika perlu, synechiolysis dengan viscoelastic /
iridodialysis spatula dilakukan & diikuti oleh capsulorrhexis,standard phacoemulsification dan penanaman IOL) Syarat operasi intraocular pada mata uveitis adalah tidak ada
peradangan >3 sebelum operasi Komplikasi post operative jangka panjang adalah peningkatan
kekeruhan kapsul posterior, glaucoma, dan CME mengurangi resiko
dgn: terapi immunosuppressive pre-operative yang lebih lama, controlketat peradangan perioperative, penggunaan topical corticosteroidselama 3 5 bulan pasca operasi, dan terapi immunosuppressiveperioperative secara agresif dan berkelanjutan
Hypotony Awal uveitic: terapi kortikosteroid dan siklopegik intensif Kronik: topical ibopamine, nonselective dopaminergic, dan
alpha dan beta adrenergic receptor Vitrectomy, membranectomy, dan intraocular silicone oil
dapat juga diperlukan pada keadaan tertentu.
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Penanganan Komplikasi Uveitic glaukoma
Sudut tertutup Akut: aggressive kortikosteroid terapi dan aqueous
suppressant Subakut: iridotomy & YAG / argon laser intensive topkial
kortikosteroid dan siklopegik terapi Kronik: goniosynechiolysis & trabeculectomy dengan
mitomycin C / glaucoma tube shunt placement Sudut terbuka
Akut: topical siklopegik, kortikosteroid, dan tatalaksana
spesifik terhadap agen infeksius Kronik: topical & oral glaucoma medication (carbonic
anhidrase inhibitors, B-blocker, dan alpha agonis) Jika gagal, maka diperlukan nonpenetrating deep sclerotomy
dengan atau tanpa penanaman drainage
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Terminologi Photopsia: the sensation of seeing lights, sparks, or colors caused
by retinal or cerebral disease. Also called photopsy . Metamorphopsia (distorted vision) the fovea are being warped
by submacular bleeding, edema, or scarring subretinal bleedingin age-related macular degeneration, an aging vitreous, trauma, andinflammation.
Scotoma (blind spot): an area of loss / impairment of visual acuitysurrounded by a field of normal or relatively well-preserved vision.Pathological: any part of the visual field, any shape / size. Affectcentral or macular vision severe visual handicap, peripheral part
of a visual field unnoticed. Nyctalopia (night blindness): inability to see well at night or in poor
light. Due to a disorder of the cells in the retina that are responsiblefor vision in dim light (myopia, glaucoma medications that work byconstricting the pupil, cataracts, retinitis pigmentosa, vitamin Adeficiency)
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Multiple evanescent white dot syndrome A group of idiopathic multifocal inflammatory conditions
involving the retina and the choroid.
Appearance of white dots in the fundus.
Sudden visual alterations in one eye with blurred vision,
temporal or paracentral scotomas, photopsia, anddyschromatopsia.
Acute posterior multifocal placoid pigment epitheliopathy(APMPPE), serpiginous choroiditis, multiple evanescent
white dot syndrome (MEWDS), multifocal choroiditis andpanuveitis (MCP), punctate inner choroidopathy (PIC), anddiffuse subretinal fibrosis (DSF).
http://emedicine.medscape.com/article/1227778-overview#showall
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Cystoid Macular Edema A painless disorder which affects the central retina ormacula Multiple cyst-like (cystoid) areas of fluid appear in the
macula retinal swelling or edema. Wavy / blurred vision Eye surgery (cataract surgery and repair of a detached
retina), diabetes, age-related macular degeneration,blockage in the small arteries or veins of the retina,inflammation of the eye, injury to the eye, side effects ofmedication.
Tatalaksana: retinal inflammation anti-inflammatorymedications (corticosteroids); vascular endothelial growthfactor (VEGF)- inhibitor class of drugs injection / laser toeliminate the macular edema; vitrectomy if the vitreuspulls on the macula causing CME.
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Fuch heterochromic iridocyclitis
chronic, unilateral iridocyclitis characterized by irisheterochromia. The uveitis typically occurs in the lighter colored eye of
a young adult with minimal ocular symptoms, no pain,and redness of the external eye or meiosis; no relatedsystemic disease is present.
Asimptomatik or floater, blurred vision, inflammation. Treatment: not necessary for typical low-grade
inflammation. Symptomatic flare-ups short-term
topical corticosteroids. Unlike other uveitides, topicalsteroids should not be used to eliminate cells from theanterior chamber as part of the cells and flare iscontributed by the breakdown of the blood-aqueousbarrier and leakage of inflammatory infiltrate. Surgery
is related to cataract and glaucoma.
Ad i d B h Di / Silk R d
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Adamantiades- Behcets Disease / Silk RoadDisease / Oad Disease)
Characterized by a triple-symptom complex of recurrent oral aphthousulcers, genital ulcers, and uveitis.
S&S: >3 eps of oral herpetiform or aphthous ulcerations within 12-month Confirmed if >2: Recurrent painful genital ulcers that heal withscarring; Ophthalmic lesions (ant / post uveitis, hypopyon, or retinal
vasculitis); Skin lesions (erythema nodosum like lesions,pseudofolliculitis, or papulopustular / acneiform lesions); Pathergy skintesting (+), defined as the formation of a sterile erythematous papule 2mm in diameter or larger that appears 48 hours following a skin prickwith a sharp sterile needle (22-24 gauge [a dull needle may be used as acontrol])
Tatalaksana for ocular dz: azathioprine, if severe cyclosporine A orinfliximab may be used in combination with azathioprine andcorticosteroids. Glaucoma, cataracts, and retinal detachment
occasionally warrant surgical intervention.
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Vogt Koyanagi Harada multisystemic disorder characterized by granulomatous panuveitis with
exudative retinal detachments that is often associated with neurologic andcutaneous manifestations.
3 kategori: complete (diffuse choroiditis, have evidence of neurologic,auditory, integumentary signs), incomplete (neurologic and auditorymanifestations or integumentary signs, but not both), probable VKH
(isolated ocular disease). 4 clinical stages: prodromal stage, uveitic stage, chronic stage, and recurrent
stage. Severe headache, neck stiffness, ringing in the ears (tinnitus), fever, and
possibly scalp tenderness, sudden loss of vision, ocular pain, photophobia.Rangsangan meningen gangguan saraf ablasi retina serosa bilateral,infiltrat pada koroid, kekeruhan badan kaca, edema papil, suar di dalam bilikmata depan. Biasanya pada yang berusia + 20 tahun.
Tatalaksana: early and aggressive kortikosteroid sistemik (prednisone). For
pigmentary changes in VKH disease treatment options mirror those fori ili Ch i VKH di i i i f