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Lecture notes, cheat sheets
Eye diseases. Uveitis (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 17. Uveitis Uveitis is inflammation of the choroid (uveal tract) of the eye. Distinguish between the anterior and posterior sections of the eyeball. Iridocyclitis, or anterior uveitis, is inflammation of the anterior iris and ciliary body, and choroiditis, or posterior uveitis, is inflammation of the posterior, or choroid. Inflammation of the entire vascular tract of the eye is called iridocyclochoroiditis, or panuveitis. Etiology and pathogenesis. The main cause of the disease is infection. The infection penetrates from the external environment with eye injuries and perforated corneal ulcers and from internal foci with general diseases. In the mechanism of development of uveitis, the protective forces of the human body play an important role. Depending on the reaction of the choroid, atopic uveitis associated with the action of environmental allergens (pollen, food, etc.) is distinguished; anaphylactic uveitis caused by the development of an allergic reaction to the introduction of immune serum into the body; autoallergic uveitis, in which the allergen is the choroid pigment or lens protein; microbial-allergic uveitis, which develops in the presence of a focal infection in the body. clinical picture. The most severe form of uveitis is panuveitis (iridocyclochoroiditis). It can occur in acute and chronic forms. Acute panuveitis develops due to the entry of microbes into the capillary network of the choroid or retina and is manifested by sharp pains in the eye, as well as decreased vision. The process involves the iris and ciliary body, and sometimes the vitreous body and all the shells of the eyeball. Chronic panuveitis develops as a result of exposure to brucellosis and tuberculosis infection or the herpetic virus, occurs in sarcoidosis and Vogt-Koyanagi syndrome. The disease proceeds for a long time, with frequent exacerbations. Most often, both eyes are affected, resulting in reduced vision. When uveitis is combined with sarcoidosis, lymphadenitis of the cervical, axillary and inguinal lymphatic glands is observed, and the respiratory mucosa is affected. Peripheral uveitis affects people twenty to thirty-five years of age, and the lesions are usually bilateral. The disease begins with decreased vision and photophobia. Subsequently, due to clouding of the vitreous body and its peeling, a sharp decrease in vision is noted. With peripheral uveitis, the following complications are possible: cataract, secondary glaucoma, secondary retinal dystrophy in the macular region, swelling of the optic nerve head. The basis for the diagnosis of uveitis and its complications is eye biomicroscopy. Conventional research methods are also used. Treatment. For the treatment of acute uveitis, it is necessary to administer antibiotics: intramuscularly, under the conjunctiva, retrobulbar, into the anterior chamber of the eye and vitreous body. Provide rest to the organ and put a bandage on the eye. In chronic uveitis, along with specific therapy, hyposensitizing drugs and immunosuppressants are prescribed, and, according to indications, vitreous body moorings (adhesions) are excised. The treatment of peripheral uveitis is no different from the treatment of other forms of uveitis. 1. Influenza uveitis Influenza uveitis is characterized by an acute onset during and after influenza. Serous exudate is detected in the anterior chamber, posterior synechiae are easily ruptured when mydriatics are instilled, the precipitates are usually small. The disease lasts two to three weeks and, with timely treatment, usually ends safely. In children, it is often accompanied by symptoms of reactive papillitis. General treatment: oral durable (long-acting) preparations of broad-spectrum antibiotics (tetracyclines) and sulfonamides in age-appropriate doses, as well as antibiotics and sulfonamides, to which the conjunctival bacterial flora is sensitive, aspirin; intravenous 40% solution of methenamine; local mydriatics and vitamins. 2. Rheumatic uveitis It begins acutely, often against the background of a rheumatic attack; its seasonality is very characteristic. In children, a subacute course of the process is observed. Both eyes are often affected. A jelly-like exudate and a lot of easily ruptured posterior synechiae are found in the anterior chamber. In children, significant clouding of the vitreous body is observed. The disease lasts five to six weeks, and there is a tendency to relapse. Positive immune reactions to CRP, high titers of ASG and ASLO, a positive DFA test, and a positive skin allergy test with fibroallergenstreptococcus help in making a diagnosis. Treatment is general: inside aspirin (pyramidone, salicylic sodium, butadione), prednisolone, injections of cortisone, ACTH (intramuscularly), penicillin durant preparations. Doses are determined according to age. A diet rich in calcium and potassium salts, restriction of sodium chloride and liquid are recommended, mydriatics, vitamins, corticosteroids, sulfonamides, iontophoresis with pyramidon are locally prescribed. 3. Uveitis with focal infection Uveitis with focal infection is characterized by the presence of an inflammatory focus in the body (in the paranasal sinuses, tonsils, teeth, etc.), various-sized precipitates, and flaky opacities in the vitreous body. Treatment. It is necessary first of all to act on the root cause to remove carious teeth and roots, especially granulomas with cysts. Operations are performed on the paranasal sinuses against the background of the use of antibiotics and local therapy. 4. Uveitis in tuberculosis infection With tuberculosis infection, various forms of damage to the vascular tract are observed, depending on the state of the reactivity of the organism, the massiveness and virulence of the infection. Tuberculous lesions of the vascular tract are characterized by an inconspicuous onset, a sluggish course, the presence of "sebaceous" precipitates, "guns" along the pupillary edge of the iris, tuberculous tubercles, powerful, difficult to tear posterior synechiae. Sometimes the cornea is involved in the process. Sequential (complicated) cataracts often appear in early childhood. Additional research methods clarify the diagnosis: Pirquet, Mantoux tests, detection of focal reactions to tuberculin tests, biochemical studies of blood protein fractions before and after tuberculin tests, examination of sputum, washings of gastric contents for tuberculosis pathologies, tomographic examination of the lungs. Treatment. Complex therapy, specific antibacterial agents. First-line drugs (streptomycin, ftivazid, saluzide, tubazid) and second-line drugs (cycloserine, tibon, ethoxide, etc.) are used. Antibiotic treatment should be combined with PAS, but PAS should be used with caution in hemorrhagic forms. All drugs are prescribed according to the scheme according to age. Desensitizing and deallergizing agents are shown (diphenhydramine, diprazine, cortisone, calcium chloride, fish oil), vitamin therapy (vitamins D, A, B2, B1, rutin or vitamin P), diet therapy (food rich in fats, but with restriction of carbohydrates and sodium chloride ), climatotherapy. It is recommended to stay outdoors for a long time, observing the regime of work and rest. In the treatment of granulomatous tuberculous uveitis, PAS in the form of drops should be prescribed locally, as well as subconjunctival injections of a freshly prepared 2,8% PAS solution, alternating with subconjunctival administration of oxygen, iontophoresis with calcium chloride, streptomycin, saluzide under the conjunctiva, etc. Mydriatics are also indicated and corticosteroids. 5. Uveitis in nonspecific infectious polyarthritis It should be remembered that with this systemic disease caused by damage to connective tissue, the eyes can also be affected. The disease most often occurs in children aged three to four years. Characterized by acute or subacute onset, joint pain, and swollen lymph nodes. There is a lesion of connective tissue elements in the stroma of the cornea, conjunctiva, sclera, uveal tract, which is expressed in dry keratoconjunctivitis, corneal dystrophy, scleritis and episcleritis. First of all, the vascular tract is affected. The first signs of eye involvement in the pathological process are dry gray precipitates of various sizes on the posterior surface of the cornea. Chronic plastic iridocyclitis gradually develops with the formation of coarse stromal posterior synechia, leading to fusion and fusion of the pupil. The latter cause an increase in intraocular pressure. Further, dystrophic changes occur in the cornea near the limbus, respectively, at three and nine o'clock. Subsequently, the turbidity takes a ribbon-like form. Gradually, clouding of the lens develops, usually from the anterior layers. Thus, the presence of nonspecific polyarthritis, band-like corneal degeneration, chronic iridocyclitis, and sequential cataracts are characteristic features of Still's disease. However, there are cases when changes of this kind are not accompanied by infectarthritis for a long time and, therefore, are the earliest, and sometimes the only signs of this type of collagenosis. Treatment is comprehensive, restorative: intravenous 40% glucose solution, blood transfusions, physical therapy, joint exercises, electrophoresis of the joint area with calcium chloride, antiallergic and anti-inflammatory treatment (calcium gluconate, aspirin, butadione, chloroquine, delagil, corticosteroids, etc.). Vitamin therapy: vitamins B1, B12, B6 are prescribed intramuscularly; inside vitamins A, E, B1, B2, C. Absorption therapy: dionin, oxygen, ultrasound. Surgical treatment: partial layered keratectomy, iridectomy, cataract extraction in remission. 6. Toxoplasmosis uveitis The ophthalmic form of toxoplasmosis occurs as a sluggish serous iridocyclitis with significant clouding of the vitreous body. The central or peripheral exudative chorioretinitis is more often observed. Central chorioretinitis is manifested by a sharp decrease in visual acuity. Ophthalmoscopy reveals large white chorioretinal lesions with pigment in the central zone of the retina. Diagnostic positive serological reactions (RSK with the patient's blood serum) and a skin test with toxoplasmin help. In addition, with congenital toxoplasmosis, defects in the overall development of the child, hydro or microcephaly in combination with mental retardation can be observed. Radiological foci of calcification in the brain can be determined. Treatment. According to the scheme, in a certain dosage, depending on age, chloridine is prescribed in combination with sulfa drugs and cortisone. Local symptomatic therapy. 7. Principles of local treatment of uveitis of various etiologies Uveitis requires both general and local treatment. Local treatment is aimed at preventing the development of adhesions of the iris with the lens capsule, creating peace of the iris and ciliary body, for which it is necessary to achieve maximum pupil dilation using drugs that paralyze the sphincter (1% solution of atropine sulfate, 0,25% solution of scopolamine) and stimulating dilator (0,1% solution of hydrochloric adrenaline). To relieve pain, novocaine blockade and leeches on the skin of the temple are indicated. As anti-inflammatory drugs, injections under the conjunctiva of a 2% solution of pyramidon or a 0,51% solution of cortisone, electrophoresis with calcium chloride are used. 8. Metastatic ophthalmia The disease develops when the infection penetrates endogenously, as a result of the pathogen entering the eye with blood flow in pneumonia, cerebral meningitis, endocarditis, sepsis, etc., more often in young children, weakened, against the background of a very serious general condition. Usually one eye is affected. The process develops like endo or panophthalmitis. There is a rapid decline in visual acuity. With endophthalmitis, a mixed injection of the eye occurs; in transmitted light, a yellowish focus of various sizes is visible in the vitreous body. Panophthalmitis is characterized by severe swelling of the conjunctiva, chemosis, and massive mixed injection of the eyeball. The moisture in the anterior chamber becomes cloudy, the iris becomes yellow-brown, purulent yellow exudate is detected in the vitreous body, the general condition of the patient is serious. With a high virulence of the infection and a sharp weakening of the body, purulent melting of the eye tissue may occur, leading to its death. Sometimes the process ends with atrophy of the eyeball. Treatment. They act on the main cause of the disease, prescribe antibacterial and desensitizing therapy, antibiotics intramuscularly, intravenously, intraarterially and under the conjunctiva of the eyeball, sulfonamides, atropine, dry heat, UHF therapy are indicated locally. If the course of the process is unfavorable and the eyeball is atrophied, enucleation is performed. Author: Shilnikov L.V. << Back: Clinic and treatment of iritis and hemeralopia (Iritis. Hemeralopia) >> Forward: Choroiditis
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