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U V E I T I S
WINARTO
Sub depart. of E.E.D.DEPT. of OPHTHALMOLOGY
FAC. of MEDICINE, DIPONEGORO UNIVERSITY /
DR KARIADI HOSPITAL
S E M A R A N G
Competence of general practitioners:
1. Able to diagnose of anterior uveitis which need
prompt treatment by ophthalmologist ASAP
2. Able to differentiate anterior uveitis from acute
angle closure glaucoma give initial tretment
3. Able to diagnose of vitreus opacity which needs
prompt treatment by ophthalmologist
4. Able to recognized an emergency cases of uveitis
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Autoimmunediseaseoftheeye
Eyecanbeaffectedbymanyautoimmunediseases
primarilytargeting theeye
targetotherpartsofthebodybutalsotheeye
Ocularsymptoms :
mildorseverevisualchanges
completelossofvision
devastatingsystemicandoculareffects
TheProblems:
Noninfectiousuveitisisanimportant
causeofblindness
Complicationscancausepermanent
structuresdamage
Uveitisrarebutmorbid
Cannotbediagnosedquickly
Noninfectiousuveitis:asight
threateningocularinflammation
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Thebeliefsthat
Difficulttofindtheunderlyingcause
Uselessmakingabigefforttofindthe
cause
Toodangeroustoconsidersystemic
chemotherapy
Mata normal
Matanormal
Siliaposisinormal
Konjungtivatenang Korneajernih
Reflekspupilnormal
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U V E A
anterior
intermedia
posterior
conjungtiva
sclera
choroid
retinauvea
cornea
lensa
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UVEA :
1. IRISmspinchterpupilae:tepi,parasimpatis
m.dilatatorpupilae:radier,simpatis
2.CORPUSSILIARIS,epitheliriskebelakang:
luar (pigmented) RPE
dalam(nonpigmented) humoraquos
terdiridari3macamotot:m.radialisint,m.
longitudinalisekstdanm.oblique kontraksi
lensacembung
3.KHOROID
fungsi:suplainutrisi
vask:asiliarislongusdanbrevis
saraf:nsiliarisanteriorlongusdanbrevis
DIAGNOSIS:
1. Riwayat penyakit
2. Pemeriksaan mata
3. Pemeriksaan tambahan:
a. Fluorescein angiography
b. OCT
c. B-scan
d. Pemeriksaan Lab.
Yeh S, Faia LJ, Nussenblatt RB. Semin Immunipathol; 2008;30:145-164
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I. KELAINAN KONGENITAL
1. Koloboma
2. Aniridia
UVEITIS
UVEITIS: adalahinflamasiuvea yang
mengancamketajamanpenglihatan.
Gejala:matamerah,nyeri,fotofobia,epifora,
kabur responinflamasi injeksi silier,
eksudasi khemosis.
UVEITIS:
Uvetisinfeksi
Uveitisnoninfeksi=idiopatik
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Penyebabterbesardarikebutaanyang
dapatdiobatipadausia25 65.
Penyebabkeduakebutaansetelah
retinopatidiabetik.
Merupakangabungandariberbagai
macamkeadaaninflamasimata.
Prevalensidinegarabarat115/100.000.
Kurangdarimemerlukanobat
immunosupresi 35%visustetap
kurang.
USA: 10 15%penyebabkebutaan
bilateral
22%penyebabkebutaanunilateral
UK:10%gangguantajampenglihatan
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Uveitismemerlukanpengobatansteroidjangkalama Efeksamping:
1.KadarGulanaik
2.Glukomasekunder
3.Katarak
4.Moonface
5.Hipertensi
6.Dll
Obatlain? efekterapidicapai,SEminimal
PATOGENESIS
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ETIOLOGIUVEITIS
INFEKSI AUTOIMMUNE
Steroid
ImprovedDiagnostics
AssessSeverity
MonitorResponseofTreatment
UnderstandingImmunology
IdentificationRiskofVisualAcuity
TargetedTherapy
KEMAJUANPENGOBATAN
NSAID
Imunologi:4tipereaksiGell&Coombs:1.Reaksianafilaktoid
2.Reaksisitotoksik
3.Reaksiimunkompleks
4.Cellmediatedimmunity
Traumapadauveadapatsebabkanperusakandan
imunisasisensitizedcellatauantibodipadamatayangtidaktrauma(oftalmiasimpatika)
Peny.tertentuberhubungandgnHLAB27
Mekanismeautoimunbanyakbhbdgnbentuk
inflamasinoninfeksidariretinadanuvea:pars
platinis,oftalmiasimpatika,endoftalmitis
anafilaktik,vaskulitisretina
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APC,selefektor,responimunlokaltdkterbentuk
SelT,selMast:ada
SelB,eosinofil,pmn:tdkada
Imuneprivilege
=ACAID(AnteriorChamberAssociated
ImmuneDeviation
Imunosupresisitokin&neuropeptide
Fungsi APCygunik
Inhibitorkomplemen
Uvea anterior
RobertE.ConeandRoshanPais.Hypothesis AnteriorChamberAssociated
ImmuneDeviation(Acaid):AnAcuteResponsetoOcularInsultProtectsfrom
Future ImmuneMediatedDamage?OphthalmologyandEyeDiseases2009:13340
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Hypothetical model for events in the anterior chamber following
the intracameral injection of antigen. The trauma of injection
induces damage associated molecular pattern (DAMP) molecules
that induce the production of MCP1 and TNFa. TNFa is also
induced and/or maintained by TGFb in aqueous humor. TNFa
increases the production of MCP1. MCP1 attracts circulating
F4/80+ cells that enter the anterior chamber and obtain
antigen from resident iris/ciliary body F4/80+,CD11c+ cells. The
infiltrated monocytes are influenced by TGFb and exit the
anterior chamber via Schlemms canal. These cells recirculate to
the thymus and spleen where they participate in the induction of
regulatory thymocytes and splenic T cells.
RobertE.ConeandRoshanPais.Hypothesis AnteriorChamberAssociated
ImmuneDeviation(Acaid):AnAcuteResponsetoOcularInsultProtectsfrom
Future ImmuneMediatedDamage?OphthalmologyandEyeDiseases2009:13340
Checkpointsindiseasepathogenesiscanserveastargetsforimmunotherapy.
CaspiRR.Mechanisms UnderlyingAutoimmuneUveitis.DrugDisvoveryToday:Disease
Mechanisms.2006;XXX(XX):17
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Keadaanawalpenyebabuveitispadamanusia
tidakjelas, proseskebutaandapatdisebabkan
terjadinyakerusakanjaringanakibatproses
inflamasi.
Uveamerupakanbagianygbanyak
mengandungpembuluhdarah,mensuplai
darah
dan
sel
imun.
Sehingga
uvea
merepresentasikankeadaanperadanganintra
okuler.
Peranoxidativestress
Yadav UCS, Kalariya NM and Ramana KV. Emerging Role of Antioxidants in the Protection of
Uveitis Complications. Current Medicinal Chemistry, 2011, 18, 931-942
Oxidativestressmempunyaiperansebagai
penyebabperadanganpadauveitisinfektif
maupunnoninfektif.
Pengurangankerusakanjaringandanfungsidenganpemberianantioxidandapat
memperbaikikomplikasivisual.
Yadav UCS, Kalariya NM and Ramana KV. Emerging Role of Antioxidants in the Protection of
Uveitis Complications. Current Medicinal Chemistry, 2011, 18, 931-942
Peranoxidative stress
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Effekantioxidanmencegahkomplikasipadauveitis
Yadav UCS, Kalariya NM and Ramana KV. Emerging Role of Antioxidants in the Protection of
Uveitis Complications. Current Medicinal Chemistry, 2011, 18, 931-942
CyclosporineA
Steroid, cyclosporine
II. UVEITIS
Pembagian :
1. Uveitis anterior
2. Uveitis intermedia3. Uveitis posterior
4. Panuveitis
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Bagian apakah yang terlibat inflammasipada Uveitis ?
1. Kornea
2. Iris
3. Conjungtiva
4. Uvea anterior
5. Sclera
6. Uvea posterior
Bagian apakah yang terlibat inflammasi
pada Uveitis ?
1. Kornea
2. Iris
3. Conjungtiva
4. Uvea anterior
5. Sclera
6. Uvea posterior
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II. U V E I T I S
International Uveitis Study Group (anatomical) :
1. Anterior Uveitis
2. Intermediate Uveitis
3. Posterior Uveitis
4. Pan Uveitis
UVEITIS adalah inflamasi uvea.Gejala : mata merah, nyeri, foto fobia, epifora,
kabur respon inflamasi cilier injeksi, eksudasi
khemosis.
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2004: Standardization of Uveitis
Nomenclature (SUN) menambah kriteriaonset, duration dancourse of the disease.
Manfred Zierhut,1 Christoph Deuter1 and Philip I Murray. Classification of
Uveitis Current Guidelines. EUROPEAN OPHTHALMIC REVIEW. 2007:77-
78
1987: International Uveitis Study Group(IUSG)
Type Primary Site of
Inflammation
Includes
Anterior uveitis Anterior chamber Iritis
Iridocyclitis
Intermediate uveitis Vitreous Pars planitis
Posterior uveitis Retina or choroid Focal, multifocal or
diffuse choroiditisChorioretinitis
Retinochoroiditis
Retinitis
Neuroretinitis
Panuveitis Anterior chamber,
vitreous and retina or
choroid
Table 1: SUN Working Group Classification of Uveitis
Manfred Zierhut,1 Christoph Deuter1 and Philip I Murray. Classification of
Uveitis Current Guidelines. EUROPEAN OPHTHALMIC REVIEW. 2007:77-
78
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Category Description Comme nt
Onset Sudden
Insidious
Duration Limited
Persistent
< 3 months duration
> 3 months duration
Course Acute
Recurrent
Chronic
Episode characterised by sudden onset
and limited duration.
Repeated episodes separated by periods
of inactivity without treatment >3months duration.
Persistent uveitis with relapse in 50
* Field Size is a 1 x 1 mm slit beam.
Manfred Zierhut,1 Christoph Deuter1 and Philip I Murray. Classification of
Uveitis Current Guidelines. EUROPEAN OPHTHALMIC REVIEW. 2007:77-
78
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Manfred Zierhut,1 Christoph Deuter1 and Philip I Murray. Classification of
Uveitis Current Guidelines. EUROPEAN OPHTHALMIC REVIEW. 2007:77-
78
Table 4: SUN Working Group Grading Scheme for Anterior
Chamber Flare
Grade Description
0 None
1+ Faint
2+ Moderate (iris and lens details clear)
3+ Marked (iris and lens details hazy)
4+ Intense (fibrin or plastic aqueous)
Manfred Zierhut,1 Christoph Deuter1 and Philip I Murray. Classification of
Uveitis Current Guidelines. EUROPEAN OPHTHALMIC REVIEW. 2007:77-
78
Table 5: SUN Working Group Activity of Uveitis Terminology
Term Definition
Inactive Grade 0 cells*
Worsening
activity
Two step increase in level of inflammation
(e.g. anterior chamber cells, vitreuas haze)
or increase from grade 3+ to 4+
Improved activity Two step decrease in level of inflammation(e.g. anterior chamber cells, vitreuas haze)
or decrease to grade 0
Remission Inactive disease for 3 months after
discontinuing all treatment for eye disease
PENTING UNTUK EVALUASI PENGOBATAN
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Ocular Manifestations of Autoimmune DiseaseDisease Ocularmanifestations
Rheumatoid
arthritis (25%)
Juvenile R.A
Sjgren's syndrome
Ankylosing
spondylitis
Uveitis
Reiter'ssyndrome Recurrentconjunctivitis,uveitis,keratitis,
arthritis(knee, sacroiliac),urethritis
Enteropathic
arthritis
Uveitis,episcleritis,peripheralulcerativekeratitis
Psoriaticarthritis Uveitis,conjunctivitis,keratitis
Sarcoidosis Uveitis,conjunctival nodules,cranialnerve
Disease Ocularmanifestations
Systemiclupus
erythematosus
Keratoconjunctivitis sicca,conjunctivitis, uveitis,episcleritis,
scleritis,keratitis,retinalhemorrhages,retinalvasculitis,
proliferativeretinopathy,opticneuritis,ischemicoptic
neuropathy,hemianopia,amaurosis,internuclear
ophthalmoplegia, pupillary abnormalities,oculomotor
abnormalities, visualhallucinations
Multiplesclerosis Afferent:opticneuritis,retrobulbar neuritis,visualfielddefects
Efferent:internuclear ophthalmoplegia,
dysmetria,
nystagmus,cranialnervepalsies
Giantcellarteritis Amaurosis fugax,diplopia,visionloss
Proptosis/exophthalmos,lidlagandretraction,keratitis,
decreasedvisualacuity,reducedvisualfields,relative
afferentpupillary defect,lossofcolorvision
Myastheniagravis Diplopia,eyelidptosis
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Disease Ocular Manifestations
Wegener'sgranulomatosis Proptosis/exophthalmos,orbitalcellulitis,
uveitis,corneal
ulcers,
optic
neuropathy
Uveitis ,hypopion
Antiphospholipid
syndromeVasoocclusiveretinopathy,ischemic
opticneuropathy
Polyarteritis nodosa Episcleritis,scleritis,opticneuropathy
Takayasu's arteritis Vasoocclusiveretinopathy,ischemic
opticneuropathy,
cataracts
Dermatomyositis Eyelid/conjunctival edema,uveitis
retinopathy
Ankylosing spondylitis
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ANTERIOR UVEITIS
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Iris dan pupil normal
Gambaran kripte iris jelas
Pupil bulat konsentris
Apakah yang menyebabkan glaukoma
sekunder pada Uveitis ?
1. Synekhia anterior
2. Produksi humor aquos berlebihan
3. Synekhia posterior
4. Iris bombans
5. Occlusio pupillae
6. Seclusio pupillae
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Apakah yang menyebabkan glaukomasekunder pada Uveitis ?
1. Synekhia anterior
2. Produksi humor aquos berlebihan
3. Synekhia posterior
4. Iris bombans
5. Occlusio pupillae
6. Seclusio pupillae
UVEITIS ANTERIORProduction
VasodilatationMiosis
= IRIDOSIKLITIS
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Keratic
presipitathipopion
UVEITIS ANTERIOR
UVEITIS ANTERIOR
Synechia posterior
Iris bombans
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UVEITIS ANTERIOR
Oclusio pupillae
UVEITIS ANTERIOR
Seclusio pupillae =syn. post. perifer totalis
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Production >>>
Viscosity >>>
Cells >>>
Resistance >>
Secondary glaucoma mechanism
Hypopion
Post. synechiae,occlusio pupillae,seclusio pupillae
Tanda:
Bag.depan :keraticprecipitat(KP)
*akut putih/abuabu,bulat
*kronik krenasi,hitam
Granulomatous:besarkekuningan,muttonfat
TIO:rendah,bisatinggibilaTMtertutupkotoran
inflamasi,siliarinjeksi,katarakkomplikata,band
keratopati
Bag.Intermedia :
selinflamasidivitreous
Bag.2/3posterior :
infiltratinflamasichoroid/retina kekeruhanCV,
oedem/atrofichoroid,retina
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DIAGNOSIS
DIAGNOSIS:
1. Riwayat penyakit
2. Pemeriksaan mata
3. Pemeriksaan tambahan:
a. Fluorescein angiography
b. OCT
c. B-scan
d. Pemeriksaan Lab.
Yeh S, Faia LJ, Nussenblatt RB. Semin Immunipathol; 2008;30:145-164
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Mata merah
Injeksi konjungtiva
Injeksi konjungtiva
Pembuluh darah
melebar ke perifer
Terdapat pada
konjungtivitis
Mata merah
Injeksi perikornea
Injeksi perikorneal
Pembuluh darah
kecil di sekitar
limbus berwarna
ungu, terdapat pada
Uveitis
Keratitis
Glaukoma
Endoftalmitis
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Iris dan pupil pada iridosiklitis
Gambaran kripte iris tidak jelas,
warna : muddy appearance Pupil kecil (miosis)
UVEITIS ANTERIOR
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ACUTE IRIDOCYCLIITS MUTTON FAT K.P.
FINE KERATIC PRECIPITATES
MUTTON FAT K.P. : pada
granulomatous iridocyclitis
FINE K.P.:
pada non
granulomatous
iridocyclitis
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Opticalcoherence
tomography (OCT).
(A)Normaleye. (B)uveitis
SeldiCOAdan
vitreus
PEM. SLIT LAMP dan OCT
ENDOPHTHALMITIS
DIAGNOSIS BANDING
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INTERMEDIATE UVEITIS
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Intermediate Uveitis
Boke subtype classification :
1. Diffuse inflammatory type :
dust-like opacities
Snowball-like precipitate
No massive snowbank-like exudates
2. Exudative type :
extensive exudations overs the ora and
pars plana
3. Vasoproliferative type :
vascular sheating, occlusion and
neovascularisation
Figure 1. Vitreous condensation (arrow) overlying
the pars plana with extension to the pars plicata
(white arrowhead). Sclera (asterisk). Anterior
chamber angle (black arrowhead).
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Figure 3. Vitreous condensation overlying the pars plana
and peripheral retina with thin filaments extending into the
vitreous (arrow). Anterior part of the pars plana
(arrowhead). Sclera (asterisk).
Figure 2. Vitreous condensation with smooth
surface (arrow) overlying the pars plana and
peripheral retina in a phakic patient after pars plana
vitrectomy. Anterior part of the pars plana
(arrowhead).
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Figure 4. Delicate epiretinal condensations of the vitreous (arrow).
Figure 5. Vitreous condensation with tractional force on the
peripheral retina (arrow) and towards the pars plana (arrowhead).
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Figure 6. Vitreous condensation with tractional force on the pars
plana/peripheral retina (arrow). Pars plicata (arrowhead).
POSTERIOR UVEITIS
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VITRECTOMY
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PANUVEITIS
PAN UVEITIS
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BECHET
Peradangan kronis berulang dengan
penyebab tidak diketahui, terdiri dari
peradangan mata, lesi oral dan genital,
kelainan kulit (erithema nodusum).Mengenai sendi, SSP dan gastrointestinal.
Terdapat vaskulitis retina buta.
Foste CS, Vitale AT. Diagnosis and Treatment of Uveitis.WB Saunders Co.2002.
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VOGT-KOYANAGI-HARADA
SYNDROMEPenyakit multiorgan meliputi mata,
telinga, saraf dan kulit. Lebih banyak
mengenai:
- orang berwarna dari pada kulit
putih.- usia dekade kedua keenam.
Minimum ada 3 dari 4 gejala:
1. Iridosiklitis bilateral kronis.
2. Uveitis posterior
3. Tanda saraf: tinitus, kaku leher, pusing,
masalah saraf pusat, LCS pleositosis.Foste CS, Vitale AT. Diagnosis and Treatment of Uveitis.WB Saunders Co.2002.
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ANKYLOSING
SPONDYLITISUveitis monokuler, berulang, dpt
binokuler.
Nyeri mendadak, fotopobia & kabur yang
ringan atau tanpa gejala.Reaksi inflamasi hebat hipopion.
Uvetis anterior tidak berhubungan dengan
beratnya spondylitis.
Uveitis anterior merupakan manifestasi
terbanyak, bisa konjungtivitis, skleritis.Foste CS, Vitale AT. Diagnosis and Treatment of Uveitis.WB Saunders Co.2002.
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PENGOBATAN
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MEMBINGUNGKAN
1. Mungkin merupakan manifestasi pertama
dari penyakit sistemik.
2. Merupakan gambaran penyakit yang
saling kait mengait.
Kosultasi ke internist dan pem lab seringkali
tidak mendapatkan penyebab.
Diagnosis awal hanya 17%, 85 % diagnosisdapat ditegakkan setelah diikuti bbrp lama,
berdasar pem klinik dan lab yang berulang.
Foster CS, Vitale AT. Diagnosis and Treatment of Uveitis.WB Saunders Co.2002.
FRUSTASI
1. Pada evaluasi seringkali tidak
mendapatkan apa-apa.
2. Idiopatik didapatkan pada 35% kasus.
3. Tidak adaclue untuk diagnostik walauanamnesis & diperiksa berulang (mata dan
sistemik) dan pem lab dokter menyerah.
Hal ini merupakan hal yang tragis karena
tanpa strategi diagnostik akan
menyebabkan kerugian besar.
Foster CS, Vitale AT. Diagnosis and Treatment of Uveitis.WB Saunders Co.2002.
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Pastikan adanya keadaan Inflamasi non
Infektif pada mata Risiko Buta.
Tegakkan Diagnosis Uveitis,
Tentukan: akut, intermiten, kronis
Rencana Pengobatan
Yeh S, Faia LJ, Nussenblatt RB. Semin Immunipathol; 2008;30:145-164
Daz-Llopis M, Gallego-Pinazo R, Garca-Delpech S et al. General Principles for the Treatment of Non-
Infectious Uveitis.Inflammation & Allergy - Drug Targets, 2009, 8, 260-265
UVEITIS NON INFEKSI
AKUT
INTERMITEN
KRONIS
Pengobatan lebih agresif, fokus
pada efek jangka pendek untuk
mengontrol peradangan.
Pengobatan perlu perspektiflebih luas. Rencana pengobatan
lebih moderat, untuk jangka
panjang, pakai dosis terkecil
mengontrol peradangan dengan
efek samping minimal.Daz-Llopis M, Gallego-Pinazo R, Garca-Delpech S et al. General Principles for the Treatment of Non-
Infectious Uveitis.Inflammation & Allergy - Drug Targets, 2009, 8, 260-265
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Pengobatan terdiri atas:
1. Sikloplegi
2. Steroid:
a. Topikal
b. Sistemik
c. Periokuler
3. NSAID
4. Immunomodulatory:
a. Antimetabolite
b. Transcription factor
c. Alkylating agent.
5. Biologic:
a. TNF- inhibitor
b. Daclizumab
IMMUNOMODULATORYTHERAPY
(IMT)
1. Antimetabolites:
a. Azathioprine
b. Methotrexate
c. Mycophenolate
mofetil2. Alkylatingagents:
a. Cyclophosphamide
b. Chlorambucil
3. Tcellinhibitor:
a. Cyclosporine
b. Tacrolimus
4. Cytokines:IFN
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CYCLOSPORINE
11aminoacidpeptidemembentukkompleks
dengancyclophilin,berikatankecalcineurin
hambattranslokasinukleussitosolyang
mengaktifkanTcells.
memotongprosestranskripsiTcell
danproduksisitokin(IL2&TNF).
inhibisiselektifpadaselT.
efeknyakecilpadaselB.
Metabolisme
Lipophilic.
Konsentrasipuncak:1 8jam.
MetabolismedihatilewatensimsytochromeP450,diekskresidiempedu.
Interaksiobat:eritromicin,azole,
kontrasepsi,androgens,
methylprednisolone,calciumchannel
antagonists meningkatkankonsentrasi.
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Effek samping
Palingsering:toksikpadaginjal
Padadosistinggi10mg/kg/duntuk
transplantasiorgan.
Padadosisrendahkurangtoksik(25
mg/kg/dunutkpenyakitautoimun).
Toxisitasdapatkembali(reversible)bilaobatdihentikan.
Disain:Randomised,doublemasked,
placebocontrolledclinicaltrial.Evaluasi:
minggu1,2,dan4dantiapbulansampai1
tahun.
Pasien:uveitisposterioridiopatik,
panuveitis/intermediateuveitis,kurang
responterhadapsteroid.
Tujuan:menilaiefektifitas,keamanandantolerabilitascyclosporine.
de Vries. J, Baarsma GS, Zaal, et al. Cyclosporine in the treatment of severe chronic
idiopathic uveitis.BritishJournal ofOphthalmology, 1990,74,344-349
1
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Daz-Llopis M, Gallego-Pinazo R, Garca-Delpech S and Salom-Alonso D. General Principles for the
Treatment of Non-Infectious Uveitis.Inflammation & Allergy - Drug Targets, 2009, 8, 260-265
de Vries. J, Baarsma GS, Zaal, et al. Cyclosporine in the treatment of severe chronic
idiopathic uveitis.BritishJournal ofOphthalmology, 1990,74,344-349
Probabilitytreatmentsuccespada27pasienidiopathic uveitis berat.
prednisonedancyclosporine prednisonedanplacebo.
p>005. Wilcoxon'sranksumtest,twosided.
Bulan1
12
TREATMENTSUCCES
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de Vries. J, Baarsma GS, Zaal, et al. Cyclosporine in the treatment of severe chronic
idiopathic uveitis.BritishJournal ofOphthalmology, 1990,74,344-349
Meanvisualacuitydanmean inflammatoryactivitypada27pasien
idiopathic uveitis berat. prednisonedancyclosporine
prednisonedanplacebo. p>005. Wilcoxon'sranksumtest,twosided.
VA dan Inflamasi
Pasienuveitisposteriorkronis:
Pasienrefrakterdengansteroid.
Rekurensaatdosisprednisolone
diturunkan
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Visus, kadar kreatinin dan
inflamasiMathews D, Mathews J, Jones NP. Low-dose cyclosporine treatment for sight-threatening uveitis:
Efficacy, toxicity, and tolerance.Indian J Ophthalmol: 2010;58:55-58.
Lee SH, Chung H, Yu HG. Clinical Outcomes of Cyclosporine Treatment forNoninfectious Uveitis .
Korean J Ophthalmol2012;26(1):21-25
SeoulNationalUnversity:uveitisnoninfeksi
2001 2010.
Siklosporin( 5mg/kb/hari)diberikanbila
steroidgagal,SEsteroid,imunosupresilain
gagal.
Siklosporin+steroid:161pasien
Siklopsorin+imunosupresi:46pasien
Aktifitas:inactive,slightlyactive,active
4
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Lee SH, Chung H, Yu HG. Clinical Outcomes of Cyclosporine Treatment forNoninfectious Uveitis .
Korean J Ophthalmol2012;26(1):21-25
Waktu Klinis terkontrol setelah
pengobatan
Slightly active
Inactive
SIMPULAN
Uveitis Non Infeksi merupakan peradangan
kronis uvea, rekurent, dapat menyebabkan
kebutaan.
Uveitis seringkali membingungkan karena
dapat merupakan penyakit mata, bersama
penyakit sistemik lain atau menifestasi mata
berbagai penyakit sistemik.
Sering menyebabkan frustasi karena
penyebab tidak ditemukan sehingga rencana
pengobatan terarah menjadi sukar.
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SIMPULAN
Kortikosteroid masih merupakan obat
andalan utama tetapi efek sampingnya sangat
merugikan pasien.
Perlu kombinasi obat lain untuk mengurangi
dosis kortikosteroid tetapi perbaikan klinis
dapat dicapai, dengansteroid-sparing
immunomodulary therapy (IMT).
Salah satu IMT adalah Siklosporin.
Kombinasi Siklosporin dengan kortikosteroid
atau imunosupresi lain merupakan pilihan
yang efektif pada pengobatan uveitis non
infeksi, karena mengurangi SE kortikosteroiddan toxisitas imunosupresi.
Pada penggunaan siklosporin perlu
monitoring efek toksik.
SIMPULAN
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Siklosporin mempunyai nilai terbatas
sebagai obat lini kedua pada uveitis
dengan JIA.
Efektifitasnya lebih baik bila digunakan
sebagai kombinasi dengan steroid pada
kasus yang resisten dengan
imunosupresi lain.
SIMPULAN
III. OFTALMIA SIMPATIKA
panuveitis granulomatosa bilateral, setelah trauma
satu mata ( exiting eye) yang diikuti periode laten
kemudian terjadi uveitis pada mata sebelahnya
(sympathizing eye)
# 4 12 mgg setelah trauma, sangat jarang
# klinis :exiting eye panuveitis berat
sympathizing eye keluhan visus turun, fotofobia,
merah ringan tanda panuveitis
# etiologi : tidak diketahui
teori : - hipersensitifitas Retinal S-Ag
- autoimun
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# diagnostik : anamnesis
- riwayat trauma
- riwayat operasi intraokuler
# terapi :
- steroid lokal, sistemik dan periokuler efektif
- sikloplegik : kurangi keluhan
- anti metabolit bila steroid tdk responsif / tdk
ada perbaikan :* enukleasi exiting eye
IV. ENDOLFTALMITIS
peradangan intraokuler yg mengenai ruang corpus
vitreum dan COA
# bentuk yg sering : endoftalmitis infeksi, yg jarang :
endofalmitis steril, berhub dgn sisa lensa atau
bahan toksik yg masuk ke mata ketika trauma atau
operasi intraokuler# gejala & tanda : visus turun, hipopion, dan vitritis
nyeri, hiperemia konjungtiva, khemosis, edema
palpebra dan kornea
# profilaksi :
- sterilisasi sac conj pre op
- disinfeksi daerah operasi povidone iodine
- inj AB sub konj.
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#diagnosa:klinis+lab aspirasihumoraquosusdan
vitreusuntukkulturdansensitivitytest
#terapi:
vitrektomi
ABintravitreal
kalauhebat,proginfaust eviscerasi
#prognosis:
tergantungsaatdatang,jenisendoftalmitis
HIVANDEYE
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V.IMPACTOFHIVINFECTIONONTHEEYE
OccurinadvancedHIV,CD4+
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Hairy leucoplakia Oral candida
KONAS 03
Miliary tuberculosisCryptococcus
neoformans Cerebral toxoplasmosis
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HIV VIRUS
HIV TRANSMISSION
Dendritic cellsunderlying skinshelter andamplify virus
Spread of virus tolymphatic organ,bone marrow,circulation
Virus attachedto mucosalreceptors
Microscopicview ofproces
Membraneor skin
portal of
entry
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Life cycle of HIV
HIV infection in vivo
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Stages in HIV infection
Antibody (-) Antibody (+)
Periode of infectiousness (virus present)
2 weeks
I II III IV
Infection
2 months 2- 15 years Months - years
Incubation period Symptoms occur
Association between virological, immunological, and
clinical events and time course of HIV infection
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Herpes zoster
ophthalmicus
Periocular Molluscum
contagiosum
KONAS 03
Squamous cell carcinoma of the conjunctiva:
associated with HIV infection.
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Multiple Kaposis
sarcoma on the bulbar
conjungtiva
Conjungtival
microvasculopathy
Varicella-zozter keratitis in the absence
dermatitis
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1 32
1. Microvasculopathy
2. CMV retinitis
3. HIV related retinitis
Retinal microvasculopthy with cotton-wool spots
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Active CMV retinitis with full-thickness
retinal whitening with hemorrhage
Intravitreal ganciclovir device in the
vitreal cavity. The device is firmly sutured
to the incision and is immobile.
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Peripheral zone III inactive CMV retinitis in the left eye
Active varicella-zoster virus retinitis
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Toxoplasmic retinochoroiditis
MultiplePneumocystis carinii choroidtits
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Papilledema due to cryptococcal meningitis
(A) Right and
(B) left colour
fundus
photographs
showing
bilateral optic
disc pallor
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VI. UVEA TRAUMA
direct / countercoup
Vossious pigment ring
Traumatic iritis, miosis, mydriasis,
iridodialisis, angle recession, hifema,
trauma choroid, choroiditis, efusi uvea
(ciliochoroidal)
VII. DEGENERATION and ATROPHY of UVEA
Aging
Sclerosis
Gyrate atrophy
Angioid streaks
Myopic choroidal atrophy
Secondary atrophy and dystrophy
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Gyrate atrophy
Angioid streak atrophy
VIII. UVEAL NEOPLASM
Hyperplasty epithelial
Naevus
Melanoma maligna
Neurilemmoma, neurofibroma,
hemangioma
Secondary tumor : Ca mammae, Ca pulmo
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THANK YOU
PREVENTION OF
ENDOPHTHALMITIS
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Infective endophthalmitis :
- infection of posterior segment
- rare complications.
- devastating, frequently results
in visual loss.
- even major advances inasepsis, surgical technique
and antibiotic therapy.
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ETIOLOGIC AGENT
Own bacterial flora :
eye lid margin, conjungtiva, pre ocular
tear film
microbiology
phage typingDNA finger print
TO TREAT
TO PREVENT
OR
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AGENT HOST
ENVIRONMENT
Innate immunity
Adaptive immunity
Normal microflora
Pathogenicity
Virulence
Infective dose
HOST AGENT RELATIONSHIP
Immunocom
promise
HOST AGENT RELATIONSHIP
ENDOPHTHALMITIS or NO
Operating theatre
S. epidermidisS. aureus
St. pneumoniaE coli
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TO PREVENT
PRE OPERATIF DURANTE OPERATIF POST OPERATIF
Primary line defence mechanism
Intact
Recovery ?
Damage
Risk of infection :
NONE HIGH HIGH ?
C L E A N O P E R A T I O N
Intact ?
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PRE OPERATIF DURANTE OPERATIF POST OPERATIF
PROPHYLACTIC ANTIBIOTICS
1 2 3
PRE OPERATIF
PERI OPERATIF
POST OPERATIF
4
1. Risk factor :
a. local : bacterial flora.
infecton : dermatitis, blepharitis,
conjungtivitis, dacryocystitis, prosthesis.
b. systemic : DM, malignancies.
2. No infection and Good host immunity
I. Reduce number of bacteria :
1. Antibiotics : quinolone ( levofloxacin )
Day before surgery, morning and at operation room
2. Desinfection:povidine iodine 5 % better than 1 %.
II. Avoid contamination : cilia drap
PRE OPERATIF
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Personnel : standard infection control measuresOperation time, operation condition : capsule
rupture, excessive manipulation, etc
DURANTE OPERATIF
1. Sterility
2. Minimal trauma
3. Avoid multiple op.
4. IOL ( silicone are at risk )
5. Avoid post capsule rupture
Postop. care
Wound leak
1. Hygiene
2. Medication :
antibiotics
POST OPERATIF
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PRE OPERATIF DURANTE OPERATIF POST OPERATIF
1. No infection
2. Good host
immunity
I. Reduce number of
bacteria :
1. Antibiotics
2. DesinfectionII. Avoid contami
nation : cilia,
Replace old ED bottle
1. Sterility
2. Minimal
trauma3. Multiple op.
4. IOL
Postop. Care
Wound leak
1. Hygiene
2. Medication
1. Personnel
2. Operation
condion
PERI OPERATIF ANTIBIOTIC PROPHYLACTIC
TO TREAT
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1. Clinical diagnosis
2. Microbiologic examination :
Anterior chamber aspirate
Vitreus tap
BA, CH.A, SDA, BHI, Thyogl. broth
aerobic anaerobic & Sens. Test.
Culture positive endophthalmitis
or
Sterile endophthalmitis
ANTIBIOTIC
DIRECTLY INJECT
INTO THE VITREUS
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a. Subconjungtival injection :
controversial.
b. Intra cameral / infusate : decreased
contamination, controversial.
c. Intra vitreal : EVS recomended
d. Systemic antibiotics : bad penetration
MIC within the eye variables
1. ANTIBIOTIC
The uses : controversial.
Animal models : concomitant use of
dexamethasone beneficial and no SE.
Despite the conflicting results,
dexamethasone frequently used in
severe cases
2. ANTI INFLAMMATORY DRUGS
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VA light perception :
core vitrectomy + intra vitreal AB
VA better than light perception :
biopsy vitrectomy + intra vitreal AB
Intra vitreal AB post vitrectomy (Gan 2001):
Vancomycin 0.2 mg in 0.1 ml PBS
Gentamicin 0.05 mg in 0.1 ml PBS
Second inj. 3-4 days AB levels within the
vitreus adequate over a week
3. VITRECTOMY
SUMMARY
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2. Ocular surface :
Important role of :
aseptic procedures : desinfection, sterility,
draped lashes.antiseptics : povidine iodine 5 %
topical antibiotics :
quinolone ciprofloxacin, ofloxacin,
levofloxacin, maxifloxacin, gatifloxacin.
1. Pre-operative preparation :
a. No external eye infection
b. No lacrimal obstruction
c. Prosthesis : be carefully
d. Previous eye drops change with fresh bottle.
PREVENTION
4. High Endophthalmitis Risk :
a. Wound leak.
b. Wide corneo-scleral incision.
c. Negative pressure during A/I.
d. Posterior capsule rupture.
e. Phaco-burn.
3. Intraocular antibiotics :
a. subconjungtival injection : controversial.
b. intra cameral / infusate : controversial.
c. intra vitreal
d. Post operative care.
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1. Established diagnosis :
Clinical and microbiological
2. Antibiotics :
a. intra vitreal, second injection.
b. concomitant systemic ? quinolone3. Vitectomy : depend on presenting VA
4. Anti inflammatory controversial.
TREATMENT = MANAGEMENT