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 tract Parasymphatic fiber N III

Brachium Coliculus sup. Nc. Eidinger Westphal Afferent Efferent Pupil

 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
---> born : open pupil If absorption altered

Fine cotton in front of the lens

 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 CB C COA : edema : ciliar injection : muddying, KP in endothel : Flare (+), Hipopion +/-, mild ---> narrow if iris bombe is present : 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 E/ allergy ? Acute reaction >>> cellular Fine KP Vitreous not so muddy COA : Hipopion +/-

Uveitis Non Granulomatous

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 (+)

Stadium I (Iritation)

Enucleating wounding eye as soon as possible If neglected/doubtfully ---> iritatio oftalmia --> symphatic ophthalmia

 Signs of Symphatic ophthalmic :

Muddying of cornea small pupil greeny muddy vitreous body
Stadium II (stadium simpatica)

Therapy :
Same as iridocyclitis