What are these?

Description: Definition: It denotes inflammation of the choroid(choroiditis),ciliary body(intermediate uveitis,peripheral uveitis,or pars planitis),or iris(iritis).However,common usage includes inflammation of the retina(retinitis), retinal vasculature(retinal vasculitis),and optic nerve(optic neuritis) Features: It usually affects people years of age and account for 10-15% of cases of legal blindness in developed countries. It is often combined with autoimmune diseases and characterised by its severe complications and recurrency

etiology and pathogenesis: (1)External causes: infectious disorders (global penetration,intraocular foreign body, intraocular surgery and so on),noninfectious disorders (chemical burns,thermal burns,mechanical trauma or toxic stimulus). (2)Secondary causes: secondary to inflammation of the global itself or adjacent tissues or toxic stimulus from intraocular disorders. (3)Internal causes: infectious disorders (bacteria, viruses, fungi,parasites,protozoas),noninfectious disorders (combined with immunal or systemic disorders such as lens-induced uveitis,sympathetic ophthalmia and Behcet’s disease) (4)Inflammatory mediators: prostaglandins(PGS,PGE) (5)Oxidative damages(from free radical reactions)

classification: (1)Location-classified: anterior uveitis,intermediate uveitis,posterior uveitis and diffused uveitis (2)Clinical features: suppurative uveitis and nonsuppurative uveitis (3)Pathology: granulomatous uveitis and nongranulomatous (4)Etiology: infectious uveitis and noninfectious uveitis

Description: It consists of iritis and iridocyclitis, often associated with ankylosing spondylitis or Reiter’s syndrome and so on It is more common than any other type of uveitis and is usually unilateral and acute in onset

Clinical findings Symptoms: pain,photophobia,tearing and blurred vision. Signs: (1)ciliary or mixed congestion (2)keratic precipitates, KP (3)aqueous flare (4)iris changes (5)pupil changes (6)lens changes (7)vitreous and fundus changes

Episcleral vascular congestion around limbus.

dust-like KPMiddle-sized KP mutton fat KP

Aqueous cells Hypopyon

Posterior synechia of iris Posterior synechia of iris Iris bombe Iris bombe Anterior synechia of iris Anterior synechia of iris nodules nodules goniosynechiagoniosynechia

 miosis  irregular shape  pupillary closure  occlusion of pupil

Residual pigment on the surface of lens when the closed pupil opens again.

Cystoid macular edema or papilloedema cannot be seen frequently,but severe vision damage may occur once they happens.

Complications and Sequelae Complicated cataract Secondary glaucoma Ocular hypotension Atrophy of eyeball

1.Typical clinical findings: symptoms and signs 2.Systemic disorders history: joint disease like juvenile rheumatoid arthritis and ankylosing spondylitis,Fuch’s heterochromic iridocyclitis,lens-induced uveitis and etc. 3.Laboratory testings: blood sedimentation accelerates, HLA-B27 histocompatibility antigen test (+), specific pathogen and etc.

PACG acute iridocyclitis acute conjunctivitis Symptoms severe eye pain slight eye pain foreign body sensation headache photophobia burning nausea 、 vomiting tearing mucus or pus-like discharge Vision Markedly blurred Slightly blurred No effect on vision Congestion mixed ciliary or mixed conjunctival Cornea steamy edema 、 opacity transparent normal pigmentary KP hoar KP Pupil dilated and fixed miosis normal vertical oval irregular shapes Anterior shallow 、 aqueous normal or deep normal Chamber slight opacity aqueous opacity IOP Markedly elevated normal normal Treatment myotica mydriatic agents anti-inflammatories lower IOP anti-inflammatories antivirals

 Principles: dilate the pupil immediately in case of posterior synechia of iris;use anti- inflammatories rapidly to avoid eye tissue damage and complication occurrence; eliminate the pathogen.  Seldomly do: antibiotics and systemic medicines.

 Plans: 1.cycloplegics: ① prevent and seperate the posterior synechia of iris in case the complications occur. ② reduce discomfort from ciliary spasm. The first line is Homatropine drops or ointments; when severe inflammation occurs,our first choice comes to 1% Atropine, then change into Homatropine or tropicamide. 2.corticosteroids: Care should be taken to rule out an corneal epithelial defect in case of infection. Short- term systemic medicines and periocular injections are allowed when there is papilledema or macular edema.

3.nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin or local drops 4.antimicrobials: when caused by infection. 5.other immunosuppressants 6.treat the accompanied systemic disorders. 7.pathogen treatment. 8.other therapies: foment,and etc. 9.treat the complications and sequelae: anti- glaucoma surgeries,cataract surgeries under good control of the imflammation.

Description: It consists of pars planitis 、 the imflammation of vitreous base and peripheral retina It is the second most common type of intraocular imflammation,the hallmark of which is vitreous inflammation It is typically bilateral 、 slow in onset and tends to affect patients in their late teens or early adult years. Men are affected as commonly as women The cause is unknown and autoimmune disorders are always considered

Clinical findings Symptoms: floaters and blurred vision. Pain,photophobia and redness are usually absent or minimal Signs: (1)anterior segment is general normal, but if significant, there may exist the manifestations of anterior uveitis like KP, aqueous flare, aqueous imflammation cells, posterior synechia of iris and etc.

(2) The most striking finding on examination is vitritis, often accompanied by vitreous condensates, either free-floating as “snowballs” or layered over the pars plana and ciliary body as “snowbanking” (3) There may exist macular edema and optic neuritis 、 peripheral retina vasculitis 、 vacular white sheath and etc. (4) Systemic disorders: Mutiple sclerosis, infection,Behcet’s disease,imflammatory bowel disease and etc.

Complications: (1) complicated cataract (2) secondary glaucoma (3) macular edema (4)macular degeneration (5)retinal or choroidal detachment

Diagnosis Typical clinical findings: symptoms and signs Systemic disorders Ancillary tests: slit lamp with three-mirror lens 、 fundus fluorescein angiography

Treatment Corticosteroids: drops 、 sub-Tenon’s sac injection or take orally Other immunosuppressants: CsA. Pay attention to the toxicity and side-effects Laser coagulation or cryocoagulation Vitreous surgeries Pathogen therapy

Description Choroiditis Choroidoretinitis Retinochoroiditis Neurochoridoretinitis They may occur alone or combination

Clinical findings Symptoms typically include floaters, loss of visual field or scotomas, or decreased vision, which can be severe Retinal detachment, though infrequent, occurs most commonly in posterior uveitis and may be tractional, rhegmatogenous, or exudative in nature

Diagnosis and treatment Diagnosis: typical vitreous 、 retinal and/ or choroidal diseases; systemic disorders;fundus fluorescein angiography or ICGA;laboratory tests and other ancillary tests to determine the cause or type Therapy: anti-infectious treatment; corticosteroids;other immunosuppressants; surgeries

Description The term “diffuse uveitis” is used to denote a more or less uniform cellular infiltration of both the anterior and posterior segments. Associated findings such as retinitis 、 vasculitis 、 or choroiditis can occur and often prompt further diagnostic testing Tuberculosis,sarcoidosis, and syphilis should always be considered in patients with diffuse uveitis Vogt-Koyanagi-Harada syndrome and Behcet’s disease are the most common types

Diagnosis: contain both the manifestations of anterior and posterior uveitis Treatment: do as anterior and posterior uveitis

Vogt-Koyanagi-Harada syndrome It is a typically bilateral,granulomatous, recurren,diffuse uveitis combined by systemic meningismus,hearing impairment, vitiligo,whiten or fallen hair Ocular manifestations: decreased vision, sunglow-like fundus,Dalen-Fuchs nodules, complicated cataract, secondary glaucoma and etc.

Diagnosis: according to history, clinical manifestations,fundus fluorescein angiography, ncurolympy test Treatment: corticosteroids,other immunosuppressants,surgeries

Behcet’s disease It is a marked by recurrent diffuse uveitis,recurrent canker sore,polymorphous skin lesions and genital ulcer, involved in multiple systems, thus becomes a stubborn disease Diagnosis and treatment: according to clinical manifestations and laboratory tests results; therapy includes mydriatic agents, corticosteroids, immunosuppressants and surgeries under good control of imflammation

Fuchs heterochromic uveitis It is a chronic nongranulomatous uveitis, marked by iris hopochromia or atrophy. Anterior uveitis is the most common type Patients usually complain of blurred vision. KPs are often small and stellate and scattered over the entire endothelium.Telangiectatic blood vessels may be seen in the chamber angle on gonioscopy.Possible complications are subcapsular cataract and higher IOP Therapy: anti-inflammatories, lowing the IOP or surgeries

Acute retinal necrosis syndrome; ARN It is a severe unilateral diffuse uveitis accompanied by retinal arteritis,retinal nacrosis,severe vitreous opacity and subsequent retinal detachment Herpes simplex and herpes zoster are the most common causes. Adults are more susceptible. No sex difference. It is intractable to treat and prognosis is bad

Diagnosis: clinical manifestations,laboratory tests, PCR, biopsy Treatment: antivirals(Gancyclovir, Acyclovir), anticoagulants (heparin,small doses of aspirin), corticosteroids, laser coagulation or surgeries

Tumors Involving the Uveal Tract Malignant melanoma of the choroid Choroidal hemangioma Metastatic carcinoma of choroids Iris cyst

Malignant melanoma of the choroid It is the most common intraocular malignant tumor in the white population, second to retinoblastoma in China. It comes from pigment cells and nevus cells It may be seen in its early stages only accidentally during routine ophthalmoscopic examination or because of blurring due to macular invasion. Blood- borne metastases may occur at any time. Glaucoma may be a late manifestation

Intraocular malignant melanomas may extent into adjacent intraocular tissues or outside the eye through the scleral canals or by intravascular invasion Clinical manifestations are usually absent unless the macula is involved. In the later stages,grows of the tumor may lead to retinal detachment with decreased vision and loss of visual field Dome-shaped or mushroom-like tumor can be seen ophthalmoscopically

Four stages: intraocular stage,glaucoma stage,extraocular extension stage and systemic metastasis stage Diagnosis tips: ① early diagnosis is difficult. ② typical fundus changes and symptoms. ③ FFA,ICGA,ultrasonic,MRI,CT and biopsy may be of some value Treatment: local coagulation, local cryocoagulation,TTT,radiotheraphy,local resection and enucleation of eyeball

Choroidal hemangioma It is a kind of congenital vascular malformation. It is more likely to happen on the youngs It is isolated localized tumors or as diffuse hamartomas associated with Sturge-Weber syndrome. Ultrasonography can help distinguish these orange- colored tumors from amelanotic choroidal melanomas Visual loss is the result of secondary retinal detachment,degenerative changes in the retinal pigment epithelium or sensory retina,and secondary glaucoma

Occasionally,choroidal hemaniomas can be treated with photocoagulation to limit the extent and degree of associated serous detachment of the retina. Those that fail to respond to photocoagulation-and especially the more diffuse tumors-may require radiotherapy. Enucleation may be necessary for tumors associated with intractable,painful glaucoma

Metastatic carcinoma of choroids Because of its rich blood supply, the choroid is an important site for blood-borne metastases. In females, carcinoma of the breast is much the most common source. In males, lung,genitourinary,and gastrointestinal malignancies are the usual primaries The usual presenting symptoms of the choroidal metastasis are decreased vision and photopsia. The tumor appears as a pale,non- pigmented elevation of the choroid, often associated with serous retinal detachment. There may be multiple lesions involving one or both eyes, in which case the diagnosis is relatively easily made. A solitary metastasis may be mistaken for an amelanotic choroidal malignant melanoma

Diagnosis: tumor history and fundus features treatment: Chemotherapy for concurrent metastatic disease is usually effective against the choroidal component. In the absence of other metastases, local radiotheraphy is the treatment of choice. Enucleation of eyeball is of no use

Iris cyst