Ophthalmology Notes @ OphthalNotes.blogspot.com

Ophthalmology Notes @ OphthalNotes.blogspot.com
A comprehensive collection of ophthalmology revision notes that cover a broad range of topics.

UVEA NOTES

UVEA

ANATOMY-
/L AYERS OF THE IRIS-
1.Anterior endothelium.
2 .Iris stroma
3. Smooth ms- Sphincter pupillae
                     -Dilator pupillae
4.Posterior  2 layers of epithelium

NERVE SUPPLY OF IRIS-
  • Sensory- Nasociliary N
  • Sphincter pupillae- III N
  • Dilator pupillae- Sympathetic chain

Q. Which is the safe zone of the eye ?
A  Pars plana- as it is avascular

Avascular struc in eye-cornea,lens,pars plana,vitreous.

MAJOR ARTERIAL CIRCLE-
Formed by- 2 Long posterior ciliary As + 7 Anterior ciliary As

CHOROID- 3 layers of BVs-
  1. Outer- large vessel layer of Haller
  2. Middle-medium vessel layer of Sattler
  3. Choriocapillaries

   CHOROID- layers-
  1. Suprachoroidal lamina
  2. Stroma-Haller’s layer & Sattler’s layer
  3. Choriocapillaries
  4. Bruch’s membrane

BRUCH’ MEMBRANE-layers
  1. BM of RPE
  2. Inner collagen layer
  3. Middle elastic layer
  4. Outer collagen layer
  5. BM of choriocapillaries

MUTTON FAT KPs-
  • Tb
  • Leprosy
  • Fungal
  • Syphillis
  • Sarcoidosis
  • Sym oph
  • VKH syn
  • Toxoplasm

TRANSILLUMINATION DEFECTS-
  • Peri-pupillary- PXF
  • Mid-peripheral-PDS
  • Diffuse- Albinism, Senile iris atrophy
  • Sectorial- Herpes zoster iritis, Iris prolapse in phaco

CLASSN OF UVEITIS-
a) ANATOMICAL
1.Anterior- Iritis
                -Ant. Cyclitis
                -iridocyclitis
2.Intermediate-Post cyclitis
                      -Pars planitis
                      -Hyalitis
                      -Basal retinochoroiditis
3.Posterior-Choroiditis-Focal
                                   -Multifocal
                                   -Diffuse
                - Chorioretinitis
                -Retinochoroiditis
                -Neurouveitis
4.Panuveitis

b) CLINICAL-
Acute- < 3 wks
Chronic > 3 wks

c) PATHOLOGICAL-
GRANULOMATOUS UVEITIS [type-IV hypersens]
NON-GRANULOMATOUS UVEITIS / EXUDATIVE
Insidious onset & chronic course
Acute onset & short course
Nodules [Koeppe,s & Bussaca,s ]
No nodules
Mutton fat KPs [lymphocytes derived from the aqueous]
Fine KPs [lymphoid cells & polymorphs]
Mild flare
Intense flare
Ant uvea & retina- choroid equally inv
Mainly limited to ant  uvea
Tb,leprosy,sarcoidosis
Idiopathic & allergic
Minimum inflammation
Exudative

c) AETIOLOGICAL CLASS-
  1. Infective-
-Exogenous- D/t introd of org into eye thru a perforating wound/ulcer [ usually acute iridocyclitis & suppurative type]
-Endogenous-Other organ of body→bld cir→eye
-Secondary inf-Spread from other ocular tiss-cor,sclera,retina
\-…
BACTERIAL-             VIRAL-                PROTOZOA-
  • Tb                           * Mumps                * Toxoplasma
  • Syphillis                  * Smallpox
  • Gonorrhoea              * Influenza
  • Brucellosis

  1. Immune-mediated
Prim source of inf→spread thru bld stream→eye gets sensitized→renewal of activity→org/proteins meet the sensitized tiss→excite an immune response→deposition of immune complexes

  1. Hypersensitivity to autologous tiss-
  • Still’s dis
  • SLE
  • Weg gr
  • Sarcoidosis
  • Ankylosing spond
  • Reiter,s dis
  • Behc\et,s syn
  • RA

4.NEOPLASTIC
  • RB
  • Iris melanoma
  • Reticulum sarcoma
  • Leukemia                      →
  • Lymphoma                    → + uveitis→ Masquerade syn    
  • Histiocytic cell sarcoma→

5.TRAUMA-
Blunt
Perforating
Surgery- Cataract
    • Trab
    • VR surg

     INVESTIGATIONS  IN  UVEITIS
1] HAEMATOLOGICAL-
1 ) Hb ,TLC, DLC, ESR-
Important wen antimetabolites are to be started

2) CD4 / CD8  lymphocyte ratio- 2.0
Single best predictor of imminent opportunistic inf in AIDS
In AIDS ratio reverses [ 0.5-1]
CD4 > 400/cmm
CD8- 200-800 /cmm

2] IMMUNOLOGICAL –
1) RF- Seropositive  arthropathy- rare cause of uveitis
        -Seronegative  -     “     -     - JRA & Anky spond

2) Antinuclear antibodies-
*  Detected by Immunofluorescence / ELISA
*  Positive in- SLE & JRA

3) Anti DNA antibodies- SLE
4)  Antineutrophilic Cytoplasmic antibodies (ANCA)
    - Wegener’s Granul
    -PAN
5)  Angiotensin converting enzyme (ACE)
  Raised in – Sarcoidosis
    • DM
    • Leprosy
    • Hyperthyroidism
    • Chr renal dis
    • Cirrhosis
    • Amyloidosis
    • Tb
  1. Serum Globulin –Raised in Sarcoidosis
  2. Serum Lysozyme-          “
  3. Serum C-reactive protein-non-specific

3] SEROLOGICAL TESTS-
For toxoplasmosis-
  1. Sabin Feldman dye test
  2. Haemagglutination test
  3. Indirect Immunofluorescent test
  4. ELISA

For Syphiilis
  1. FTA-ABS [fluorescent treponemal antibody absorption ]
  2. VDRL
  3. Rapid plasma reagin

4] RADIOLOGICAL TESTS-
*  X-ray skull- Congenital Toxoplasmosis
*  Chest- Sarcoidosis- Bil Hilar LNpathy
            -Tb
            -Malignancy
* Sacro-iliac & spinal- Anky spond
* Gallium scan- Sarcoidosis

5] HLA typing-
*  Behcet- HLA B5
*  Ank spond- HLA B27
*  Reiter’s – HLA B27
*  Birdshot retinochoroidopathy- HLA A29
* Sympathetic oph- HLA A11
* VKH –HLA DR4 & HLA DW15

6] SKIN TEST-
1. Tb – Mantoux
2. Histoplasmosis- Histoplasmin test
3. Sarcoidosis- Kweim test
4. Behcet- pathergy test & dermatographism

7] USG-
-To  reveal retinochoroidal thickening & exud RD in-
*  VKH
*  sympathetic oph
-To rule out longstanding RD ,IO tum or coat’s dis
-useful in parsplanitis

8] FFA
*  To confirm diagnosis of chorioretinitis
* Detect- cystoid / non-cystoid macular edema
            - dye leakage
            -SRNV
*  Any case of ant uveitis / intermed uveitis with unexplained visual loss must be investigated with FA to r/o CME
*  assess response to t/t

8] DIAGNOSTIC INVASIVE PROCEDURES-
1. paracentesis-
-To detect org by direct exam or culture
-Microscopic study to r/o-RB
                                       - leukemia
-Biological enzyme- aqueous ACE is more sensitive than ser ACE in sarcoidosis
--PCR in Herpes
2. Vitreous aspiration /biopsy
Ind- Uveitis not responding to t/t
     -Infection
     -Ocular reticulum cell sarcoma
     -Phacoanaphylactic uveitis
3. Retinal /retinochoroidal biopsy-
Ind- Bil lesion threatening ARN
    -No response to t/t in retinochoroidal lesion
Complication-
    • Choroidal h’age
    • RD
    • PVR
    • Inf

KERATIC PRECIPITATES-
  • Def- Cellular deposits on the cor endothelium
  • Nutrition of the cornea affected→ cells become sticky & desquamate at places.Exud tends to stick here forming KPs
  • Derived from the uvea
  • Wander in the aqueous by convection current & stick to cor endothelium
  • Mutton fat KPs- Granul uveitis
  • Fine KPs- Fuch’s uveitis
                       -herpes zoster uveitis
* Fresh KPs-white,round & dome shaped
* Old KPs-Flatter, smaller,crenated & pigmented.Ground-glass appear

Arlt’s triangle-KPs are arranged in a base down triangular area at the lower part of the cor

AQUEOUS CELLS-[2mm height,1mm width] by Hogan
            GRADE
CELLS PER FIELD
                0
                  0
               1+
              5- 10 cells
               2+
              10-20 cells
               3+
               20-50cells
               4+
                > 50cells

AQUEOUS FLARE-
       GRADE                              
                  FLARE          
               0
               Absent
               1+ [faint]
  Barely detectable            
               2+[mild]
  Iris & lens details visible
               3+[mod]
  Iris & lens details hazy
               4+[intense]
  Fibrinous aqueous

Aq flare is d/t scattering of light [Tyndall effect] by proteins that have leaked into the aq hum thru the damaged iris BVs.

In the absence of cells,aq flare is not indicative of active inflamn
IRIS NODULES-
KOEPPE’S NODULES- pupillary border
BUSSACA NODULES-away from pupil

Juvenile chronic arthritis + Acute anterior uveitis→
  • RF- Neg
  • ANA- Neg
  • HLA-B 27 – positive

Juvenile chronic arthritis + Chronic anterior uveitis→
  • RF- Neg
  • ANA- Positive
  • HLA-B27- low incidence

VIVA- Why do you get sluggish pupillary reaction in iritis?
  1. Exudation → Iris becomes a water-logged sponge full of sticky fluid→ Impaired iris movts→ so sluggish / abolished reac
  2. Irritants in the extravasated fluid cause the muscle fibres to contract→ sphincter overcomes the dilator→ pupil constricts

In acute iritis ,pain is typically worse at night
Inv oph div of V n
Refers to forehead & scalp,cheeks,malar bone,nose & teeth

PLASMOID AQUEOUS-
Aqueous contains leucocytes , flakes of coagulated protein & fibrin

PLASTIC IRITIS-
Exudates poured out by iris & CB cover  the iris surface as a thin film & also the pupil.When this becomes profuse,iritis is k/as plastic

                MASQUERADE SYNDROME
DEF-Simulation of an inflame condition by a neoplastic process

Conditions that prod MS-
1} Primary central nervous system lymphoma-
 *  vitreitis
*    Creamy yellow retinal,subretinal & subRPE infiltrates
*    cranial n palsies

2} B cell lymphoma-
-vitreitis
-retinal vasculitis
-necrotizing retinitis
-diffuse choroiditis
-hypopyon

3} T cell lymphoma-
-Ant uveitis
Vitreitis
-chorioretinitis

4} Mycosis fungoides-
-Ant uveitis
-vitreitis
-papilloedema

5} HTLV-I lymphoma-
-ret vasculitis
-CW spots
-vitreitis
-subreyt infilt
-CME

6}Hodgkin’s lymphoma
-AU
-CR
-papill
-periphlebitis

7] leukemia-
-IR H’age
-CWS
-Roth’s spots
-MA
-peripheral NV
-Exud RD

8] Uveal melanoma
-episcleritis
-AU
-PU
-Endophthalmitis
-Panophthalmitis

9]RB
-Lack of calcification
-AU
-Shifting white hypopyon

10]Juvenile xanthogranuloma
-Yellowish iris nodules
-heterochromia
-spontaneous hyphaema

11]Metastatic tum
-MC prim site-lung & breast
-Plateau shaped yellow posterior seg lesion with SRF
-iris nodules

                               CMV RETINITIS [d-05]
  • MC opportunistic inf in AIDS
  • Agent-ds DNA Herpes virus
  • Transmission-inf body flds
-bld
-transplacental
-transplanted organ
C /F-
SYMPTOMS-
  • Blurring of vision
  • Floaters
  • Scotoma
  • Photophobia
INDOLENT RETINITIS-
  • starts in the periphery
  • progresses slowly
  • mild granular opacification

FULMINATING RETINITIS-
  • Dense ,white, geographical area of opacification
  • Vasculitis
  • Mild vitritis
  • ‘Brushfire-like’ extension along ret BVs
  • RD / consecutive OA

REGRESSION-
  • Few h’ages
  • Less opacification
  • Diffuse atrophic & pigmentary changes

FACTORS AFFECTING VISION-
  • Optic neuropathy
  • Direct ON inv
  • Retinitis at macula
  • RD

FACTOR PREDICTING CMV DEVELOPMENT  IN AIDS-
Falling CD- 4 Count- 50 cells / ml

T/T     -[D-05]
1 .Ganciclovir-

A]  IV 10mg/kg BD for 14 days [induction]
          5mg/kg every 24 hrs          [ maintenance]
           S/E- neutropenia.[Rx-G-CSF ]
B]  oral 300mg daily
     Advantage- less neutropenia
                      -no central line sepsis
C] .Intravitreal Ganciclovir-
     Inj. 200-2000µg in 0.05-0.1ml once/ twice wkly
     Implant[vitrasert]- 1µg/hr
     Complication- VH
                           -RD
                           -Endophthalmitis

2 .Foscarnet-Iv Induction→ 90mg/kg BD for 2wks
                   -Maintainence→ 90mg/kg OD
S/E-1. Nephrotoxic
      2. Neurotoxic

3.Cidofovir- 5mg/kg once wkly for 2 wks &then every 2wks.
  S/E- nephrotoxic
  Given along with probenecid

PROGRESSIVE OUTER RETINAL NECROSIS            [D-04]
  • 2nd MC inf in aids
  • Varicella Zoster
  • C/F- rapidly prog visual loss
  • Initially UL ,later BL
  • SIGNS-Multifocal, deep, yellow white ret infiltrates
               -Outer & peripheral ret
               -Min vitritis
               -Rapid confluence
               -Full thickness ret necrosis
               -Early macular inv
* Inv-PCR of vitreous
T/T-1) IV Ganciclovir 10mg/kg  BD for 14 days [induction]
                                  5mg/kg 24hrs [maintenance]
     2) –Foscarnet-90 mg/kg BD for 2wks [Induct]
                           -90mg/kg  OD
* Blindness d/t macular necrosis&Rd
3)-Vitrectomy + silicone oil tamponade & Relaxing retinotomy

        ACUTE RETINAL NECROSIS
  • Necrotizing retinitis
  • Biphasic-< 15 yrs- HSV 2
-older-HZV & HSV 1
  * twice MC in Males

C/F- Painful visual impairment
     -  floaters
SIGNS
  • Ant granulomatous uveitis & vitritis-universal
  • Peripheral periarteritis
  • Multifocal, deep,yellow white ret infiltrates
  • Gradual confluence→ full thickness ret necrosis
  • Post pole spared.Therefore good vision
  • Disc edema,choroidal thickness & ret h’ages
INV-
  • Inv-PCR assay of aq & vit
  • Complications- RD
                          -AION
                          -Ret vascular occlusion
T/T* Acyclovir Iv 10mg/kg for 14 days
Orally 800mg 5 times daily for 5 days

           * famciclovir 500mg Tds for 3 mo
           * Sys steroid
           * Aspirin for vas occln
           *argon laser for RD
           *silicone oil tamponade

                TOXOPLASMA   RETINITIS
  • Obligate intracellular parasite
  • Definitive host- cat
  • Intermediate host- man & mice
  • 3 forms- Sporocysts[oocysts]
-Bradyzoites
-Tachyzoites
* Toxon means a crescent
* LIFE-CYCLE-
Cat’s intestine→ Male + Female Gametocyte →Zygote→zygote becomes surrounded by an oocyst wall→oocyst gets excreted in cat’s faeces→infective form-contaminated hands→
                                            -undercooked inf meat→
                                            -bld transfusion/organ transpl→      
                                            -transplacental→        Human inf
                                            -raw milk→

Human intestine→oocyst wall digested by gastric enzymes→release of tachyzoites→proliferative form→multiply intracellularly→If good host response→tachyzoites transform into bradyzoites-predilection for-heart,ms,neural tiss& ret.

CLASSN-
1] Congenital
2] Acquired
3] Toxo in immunocompromised

CONGENITAL TOXO-
Classic triad- Retinochoroiditis
                   -cerebral calcification
                   -convulsions
Others-
-hydrocephalus
-microcephaly
-organomegaly
-Jaundice
-MR

-Incidence is more if acqd in III trim
-severity is more in I trim

ACQUIRED TOXO-
-subclinical & asymptomatic
-Fever
-LNpathy
-malaise
-maculopapular rash [spares palms & soles]

TOXO IN IMMUNOCOMPROMISED-
-Pneumonitis
-Myocarditis
-Encephalitis
-Necrotizing retinochoroiditis-sight threatening

OCULAR FEATURES-
SIGNS-
1. QUIESCENT- Healed lesion-Foci of chorioret atrophy &        scarring with pigmented borders.
                         -Bil
2.FOCAL RETINITIS-
- Satellite lesion- A solitary inflame focus with overlying vitreous haze adjacent to an old pigmented scar.
-‘Headlight in fog’-sev vitritis impairing fundus visualization
-vasculitis
-Detached post hyaloid face becomes covered with inflame ppts
-Jensen choroiditis-Papillitis [inflame of optic n hd] sec to juxtapapillary retinitis.
-Atypical lesions-immunocompromised indiv
                             -Bilateral
                             -multifocal
                             -Discrete foci/confluent areas of retinitis
                             -Pre-existing scars –nt [means newly acqd inf or dissemination from EO sites.]

INV-
  1. Indirect immunofluorescent antibody test
  2. Haemagglutination test
  3. ELISA[Enzyme linked Immunosorbent Assay]
  4. Sabin Feldman dye test-titer.1:16
  5. Serial tests for immunoglobulins-IgG & IgM
  6. Western Blot analysis
  7. PCR
  8. X ray skull-calcification
  9. CT SCAN & MRI- lesions in corticomedullary junction & basal ganglia
10. FFA- early- hypofluorescence & late-hyperfluorescence

T/T-
INDICATIONS-
Immunocompetant –
  • Lesion threatening the macula,PM bundle,ONH or major BV
  • Very sev vitritis→vit fibrosis→ tractional RD

Immunocompromised-All lesions
Rx- C2 A2 PS
  1. Clindamycin 300mg Qid for 3 wks
  2. Sulphadiazine –loading dose-2g→1g Qid for 3 wks [S/E-stevenjohnson syn]
  3. Pyrimethamine-loading dose-50mg→25-50mg daily for 4wks.[ shud not be used in AIDS ]
  4. Co-trimoxazole- Trimethoprim-160mg + Sulphamethoxazole 800mg [960mg] Bd orally for 4-6 wks
  5. Atovaquone 750mg TDS
  6. Azithromycin 500mg daily on 3 successive days
  7. Topical steroids
  8. topical cycloplegics
  9. Photo & cryo
  10. PPV –for RD sec to vit traction

        FUCH’S UVEITIS SYNDROME

  • Also k/as Fuch’s Heterochromic cyclitis
DEF-
  • Chronic,
  • Non-granulomatous
  • Ant uveitis
EPID-
  • Insidious onset
  • Typically unilateral
  • M=F
  • 3rd -4th decade

  • Symptoms-Gradual blurring d/t cataract
-Floaters
                        -Colour diff bet 2 eyes
* Signs-KPs-small,round , scattered,grey-white [Stellate KPs]
           -Faint flare
          -cells +2
          -vitritis & stringy opacities
          -Gonio-Amsler’s sign-fine ,radial ,twig like Vs in the angle                                                            
           Responsible for filiform h’age which dev on AC paracentesis opp the puncture site.
          -PAS
Iris signs-
  • No post synechiae
  • Diffuse stromal iris atrophy
  • Loss of iris crypts
  • Washed out appear
  • Prominent radial iris BVs
  • Post iris pigment layer atrophy-transillumn def
  • Iris nodules
  • Rubeosis iridis
  • Mydriasis
  •  Heterochromia iridis-affected eye is hypochromic & d/t disturbance of symp n supply which controls chromatophores

COMPLICATIONS-
  • cataract
  • glaucoma

T/T-
   1. Topical steroids
2.Post subtenon inj of triamcinolone acetonide
3.vitrectomy
4.Topical steroid & mydriatics are ineffective

Q- what are the complications of cataract surgery in Fuch’s ?
A-Pre-oper-Pupil does not dilate well d/t iris atrophy.
  -Peri-oper-Hyphaema d/t abnml iris Vs. [ Amsler’s sign ]

               PARS PLANITIS [j-07]

DEF- IO inflamn centered around ant vit, peripheral ret &pars plana

EPIDEM-
  • Bimodal –young-5-15 yrs &old-20-40yrs
  • M=F
AETIO  ( association)-
  1. Sarcoidosis
  2. MS
  3. Lyme’s dis
  4. Peripheral toxocariasis
  5. Syphillis
  6. Tb
  7. Human T cell lymphoma virus

C/F-
  • insidious &gradual
  • Bil asymmetric
  • Symp- blurring of vision
             -floaters
             -mild pain
             -photophobia
-red eye
SIGNS-
  • Aq flare+2
  • “spill –over” ant uveitis
  • Post synechiae
  • Vitritis-sine qua non
  • Vit snowballs[ exud ]-inferior vit
  • “snow Bank”-inflam exud accumulate over pars plana
  • Periphlebitis
  • CW spots & h’age rare
  • CME d/t inflam & vit  traction
  • NV-NVE,NVD,NVI
  • Papillitis
  • Subret exud adjacent to snowbank→serous RD
  • Ret traction→ret tear→rheg RD/ retinoschisis
  • RET traction→PVR or cyclitic memb formn

COMPLICATIONS-
  • Band KP
  • Post subcapsular cataract
  • Sec glaucoma
  • CME

INV-
  1. complete bld count
  2. Tests for sarcoidoses-
  • chest x-ray-hilar LNpathy
  • Raised ACE
  • Ser lysozyme
  • Ser Ca++
  • Inorganic phosphorous
  • Gallium scan-increased uptake

    3.Tests for Lyme,s dis-
    * Indirect immunofluorescence
    * ELISA
     4. Tests for syphyllis-
       -FTA ABS
       -VDRL
       -Rapid plasma reagin antibody test
     5.Tests for Tb-
        -montoux test
        -X ray chest
        -Sputum exam for AFB
     6. Tests for multiple sclerosis
         -MRI –periventricular plaques

    7..FA-CME- petalloid
            -dye leakage from inflamed Vs
            -Optic n hd staining
    8 .UBM- Exud / memb over pars plana
    9 .Pathology-
      * snowball opacities- epitheloid cell granuloma
       Snowbank-condensed vit,hyperplastic non-pigmented epith of    pars plana
10  .Immunopathological study-CD4/CD8

T/T-KAPLAN’ 4 STEP APPROACH- [j-07]
STEP 1→Post sub-tenon inj of methyl prednisone/triamcinolone acetonide 40 mg 0.1ml
If active & sev parsplanitis- oral steroids

STEP 2→Cryopexy
-Eliminates NV & ischaemic tiss
-Double freeze & Thaw tech

STEP 3→PPV
-Removes vit antigen,inflame cells & mediators
-Removes vit opacities
-Eliminates vit traction

STEP 4→Immunosuppressive therapy
-cyclophosphamide 1-2mg/kg before meals
-chlorambucil 2mg/ day orally
-azathioprine 1-3mg/kg/d orally

Cataract extraction in pars planitis-
  • eye shud be quiet 3-6 mo prior to surg
  • Topical steroid + periocular steroid + oral steroid→ ECCE+ PCIOL+PPV

D/Ds-1. Coat’s dis-UL
                             -intra-retinal angiomatosis
                             -Exud RD
                             -Vit flare is striking
2.Tumours- RB, MM
 These can disemínate into the vit & simulate PP
  1. Fuch’s heterochromic iridocyclitis-vitris
                                                          -CME
                                                          -no snowbank
                                                          -stellate KPs

  1. IOFB
  2. Chr RD
  3. Sarcoidosis
  4. Lyme’s dis
  5. Retinal vasculitis ( weg gr,behcet’)

                     RUBEOSIS IRIDIS   -viva
           [ IRIS NEOVASCULARIZATION-]
  1. DR
  2. CRVO
  3. BRVO
  4. RD
  5. RB
  6. Eale’s dis
  7. Sickle cell RP
  8. Coat’s Dis
  9. Giant cell Arteritis
10.Aortic arch syn
11.Carotid A occlusion
12.CRAO
13.Retrolental fibroplasias
14.Carotid cavernous fistula
15.PHPV
16.Choroidal melanoma
17.Endophthalmitis
18.Open angle glaucoma
19.Trauma
20.Iris tumours

-Tiny tufts of BVs are seen over the papillary margin
-Complication- NVG
-T/T- PRP

MALIGNANT  MELANOMA-patho

EPIDEM-
  • Light skinned
  • Age-50 yrs
  • Choroid-85%
  • CB-9%
  • Iris-6%
  • Usually UL [L>R]
  • Choroid-post pole-temporal

              MALIGNANT MELANOMA-CHOROID
MC prim IO malign in adults
STAGES-
  1. symptomless
  2. EO extension
  3. Glaucoma
  4. Metastasis

C/F-
  • Asymptomatic-detected as a mass on routine o’scopy
  • Circumscribed,elevated,round masses protruding into vit cavity
  • Shape indicates extent-
    • Choroid- globular/elliptical
    • Bruch’s membrane-mushroom shaped/ collar-button
After Bruch’s memb has been perforated→Exud RD
  • visual field defect- localized
  • Intractable sec UL glauc

PATHOLOGY-            [D-05]
* origin-some say-neural crest cell
           -others say-mature melanocytes in the stroma of iris,CB -
& choroids
  • Callender,s class-
  1. Spindle A cell-Slender spindle shaped
                          -flattened nuclei
                          -devoid of nucleolus
                          -best prognosis

2.Spindle B cell-larger cells
                         -round/oval nuclei [plump nuclei]
                         -prominent nucleolus
                         -2nd best prognosis

3.Epitheloid cell-same as spindle B cell
                         -Eosinophilic cyto
                         -increased mitotic fig
                         -worst prognosis

  1. Mixed cell-spindle + epitheloid
                     -intermed prog

5.Fascicular cell-‘Palisading’ / ribbon like arrangement in parallel rows
                         -spindle A/B cells

6.Necrotic-insufficient bld supply/autoimmune mech→necrosis→actual cell type cannot be recogonised

MODE OF SPREAD-
  1. EO spread by perforating Vs & Ns
  2. IO spread –rare
  3. sys metastasis- liver & lungs

INV-
  1. Medical-chest x-ray & LFT
  2. Exam of other eye- PRIM MM ARE ALMOST ALWAYS UL
  3. Indirect O’scopy-diff flat[ naevus] from elevated lesion
-melanomas>3mm can be diagnosed
                                   -shifting SRF-hallmark of exud RD
    
   4.3-mirror contact lens-
     * surface changes over tum-pigment
     * SRF
     *cystoid changes over sensory ret
      * dilated Vs within the tum

5.Transillumination-
   Dark shadow-pigmented tum
                        -dense h’age
   Transmit light-non-pigmented tum
                          -exud RD
                          -Solid Rd
6.Visual field defect-localised-
7.fundus photo-
  Serial photo-whether the lesion is enlarging
Stereoscopic photo-flat/elevated lesion

8.FFA-pinpoint foci of hyperfluorescence→depicts site of future break thru bruch’s memb
-‘Double circulation’-simultaneous visibility of choroidal & ret Vs in melanomas that hav perforated bruch’s memb

9. USG
* A-scan-location of mass
             -Ant surf spike-double peaked-1st peak-Ant ret surf
                                                             -2nd peak-Ant surf of mass
             -Jagged post surf spike-scleral infiltrtn
             -Increase in tum thickness by 0.5mm suggests tum growth
Diagnostic triad-low reflectivity
                         -solid consistency with no after-movt
                         -vascularity with fast spontaneous vertical spike motion

  • B-scan-Dome shaped mass
              -mushroom if breaks BM
              -strong sound attenuation
              -acoustic hollowing[ quiet zone] choroidal melanoma


10.Radioactive P32 uptake test
Principle- Malignant cells b/o their higher metabolic activity will incorporate & utilize more of radioactive element than nml cells
-Used only once per pt
-C/I-preg
     -childn
     -polycythemia vera

11.CT Scan-
    * well-circumscribed lesion
    *hyperdense
    *extends into vitreous
    *extrascleral extn
     *size & extent of lesion

12.Colour coded Doppler
13.Carcinoembryonic antigen-increased in metastatic tum but not in prim choroidal tum
14.FNAB-C/I ed unless diag is clearly establd by other ancilliary test

T/T-
  1. PHOTOCOAGULATION-
IND-
  1. Small active tum located > 3mm from foveola,not overhanging disc margin
  2. Active juxtapapillary tum 2-3mm thick located sup,inf or nasal to disc

TECH-
  • 2 confluent rows around tum margin
  • Spot 200-500µ
  • Power-500-1000mW
  • Time-0.5-1sec

COMPLICATION-
  • sudden intraret/subret h’age
  • Bruch’s memb perforation with melanin release

2.RADIOTHERAPY-
Gold radon seeds,co-60 plaques,Ru-196,radon gas encapsulated in gold,I-125,iridium-192
IND-
1.small melanomas which are growing or show activity
2.med & large tum with some salvageable vision
3.only useful eye

C/I→ 10mm thickness
    →15mm dia
    • Enucleation shud be done
TECH-
  1. Episcleral plaque RT-
35000cGy- tum base
800-10,000 cGy –apex
2. Charged particle RT-
  _Proton beam/Helium ion method
  -Beam encompasses the lesion plus 1.5mm of nml fundus
3. External beam RT

3.LOCAL RESECTION-
Penetrating partial sclerouveoretinovitrectomy [SURV]
OR partial lamellar sclerouveactomy

IND-
1.Ciliochoroidal melanoma < 4 clock hours of pars plicata
2.Choroidal mel < 15mm dia, centered near equator & growing

COMPLICATIONS-
  1. Blding
  2. cataract
  3. ant seg ischaemia
  4. Pre-ret /subret fibrosis
  5. expulsive h’age
  6. CME
  7. RD

  1. ENUCLEATION-
IND-
1.Tum producing visual loss,but is too large for local resection/RT.
2.Total RD/sec glauc
3.Tum invading ON

  1. ORBITAL EXENTERATION-
IND-
  1. Extensive EO inv
  2. No sys metastasis
  3. Orbital recurrence after enucleation

COMPLICATIONS-
  1. Blding
  2. # ethmoid bone
  3. PO inf
  4. sloughing of skin graft

   POOR PROGNOSIS-
  1. Big size
  2. Anteriorly situated
  3. EO inv

                  COLOBOMA [J-07]-case

DEF- Developmental imperfect closure of the foetal fissure

Coloboma→Typical
                →Atypical

Typical- coloboma in inferonasal dirn
           -Genesis-overgrowth of inner layer of optic cup→eversion of lips of fetal fissure→obstrn of natural union bet the lips→failure of dev of retina & other struc

Typical C→. Complete
               →Incomplete

Complete-extends from pupil to ON
                 -Sector shaped defect occupying 1/8th of the circumference of ret & choroids,Cb & iris & causing a corresponding indentation of the lens where the zonules are missing.

Incomplete-When it stops short of ON or iris.

Typical col of iris-Pear shaped pupil
                           -Broad base towards pupil
                           -Extends upto CB

Atypical coloboma of iris-Foetal fissure closes before iris forms
                                       -occurs at any meridian
- - - - - - - - - - - - - ---- - - - -  - - - - - - - - - - - - - - - -  - - - - - - - - - -

HETEROCHROMIA IRIDUM-
Two irides show diff in colour

HETEROCHROMIA IRIDIS-
Part of the same iris shows diff in colour.

Heterochromia iridum may be –
HYPOCHROMIC-
1.Congenital
2.Horner’s [ IMP]
3.fuch’s uveitis [IMP]
4.Glaucomatocyclitic crisis
5.Amelanotic tum of iris
6.iris atrophy

HYPERCHROMIC-
  1. Retained IO FB [siderosis][IMP]
  2. Malignant melanoma of iris
  3. Haemosiderosis [foll hyphaema]
  4. Latanoprost

IRIDODONESIS-
  1. Aphakia
  2. Subluxated / dislocated lens
  3. buphthalmos

PHTHISIS BULBI
ATROPHIC BULBI
Irregular shape
Quadrilateral
Foll-penetrating inj,panophthalm,endophthlm
Foll-iridocyclitis,absolute glaucoma
Ocular struc cannot be distinguished
Can be distinguished
Calcification/malignancy may be +nt
No such chance



                    STEROIDS
ACTIONS-
Reduce inflamn by-
  • Decreasing capillary permeability
  • Limiting exud
  • Inhibiting NVs & granulation formn

ROUTES OF ADMINISTRATION-
1.Topical-
*  Dexamethasone acetate 0.1%
*   Betamethasone 0.1%
*   Prednisolone acetate 1%

2.Periocular inj-
Adv over topical-
-Therapeutic conc behind lens
-Water sol drugs incapable of penetrating the cor can enter trans-sclerally
-longlasting effect with depot prep [triamcinolone acetonide,methylpred acetate]

A] Ant subtenon’s-
-1ml steroid drawn up into a 2ml syringe
-ask pt to look away from the site of inj
Grasp the conj & tenon’s capsule with a non-toothed forcep
-with the bevel away from the globe,needle is passed thru conj & tenon’s
-0.5ml inj

B] Post-sub-tenon
-1.5ml is drawn into a 2ml syr with 26 G needle
-Ask the pt to look inferonasally wen inj is being given superotemporally
-Bulbar conj is penetrated with the tip of the needle,bevel towards the globe,along the contour of the globe with wide side to side motions & limbus is watched
-Movt of limbus means that sclera is engaged
-When the needle has been advanced up to the hub & cannot be inserted any further,inj 1ml

3] Intra-vitreal-Triamcinolone acetonide [2mg in 0.5ml]
                      -For resistant uveitic chronic CME

4] Systemic-
  Oral-T prednisolone 1mg/kg in tapering dose

  PULSED STEROID
  -This is high dose intra-venous steroid T/T
  -T- cells are affected to a greater extent than B- cells with a relatively greater depletion of helper / inducer sub-population
- Concn of lymphocytes returns to nml after 48 hrs
- A pulse steroid possibly resets an aberrant immune response by the simultaneous inhibition of the proliferating zone & temporary removal of recirculating T-cells from the bld &eye.
-Dose- 250mg QID [ 1gm] daily for 3 days-IV methyl pred f/b
          1mg/kg oral pred for 11days
-Ind- ocular- 1. Optic neuritis
                    2. Symp oph
                    3. VKH
                    4. TED
                    5. Pseudotum
                    6. Scleritis
Non-ocular-graft rejection-renal
5] Sustained release steroid implant-currently posurdex implant containing dexamethasone is under clinical trial.DOA-6wks

INDICATIONS OF STEROIDS-
  1. Sterile ocular inflamn-
1] Disciform keratitis
2] episcleritis
3] scleritis
4] uveitis
5] optic neuritis

  1. Allergic-
1] phlycten
2] VKC
3]allergic blepharoconjunctivitis

  1. Post-oper
1] cat
2]KP
3] vitrectomy
4] trab

  1. misc-endo exophthalmos
           -pseudotum
           -temporal arteritis
           -post-herpetic neuralgia

COMPLICATIONS-
A] LOCAL-
1] risk of superinfection
2]steroid induced glaucoma
3]steroid induced cat
4] delayed wound healing
5]corneal melting [d/t increased collagenase activity]
6]transient ptosis
7]transient myopia
8] mydriasis
9] papilloedema

B]SYSTEMIC
1] peptic ulcer
2] cushingoid facies
3] severity of diab
4] osteoporosis
5] electrolyte imbalance
6]mental changes
7] benign ICT
INTRAVITREAL STEROIDS-
IND-
  1. DR
  2. DME
  3. venous occlusions
  4. CME
  5. PVR
  6. endophthalmitis
Dose- 2mg/0.1ml

            IMMUNOSUPPRESSIVE AGENTS [D-02,j-07]-read from notes
A]  ANTIMETABOLITES-
1  AZATHIOPRINE-
*  Purine analogue
* Pro-drug of 6 mercaptopurine
*  affects the synthesis of nucleic acid & proteins
* Selective toxicity to T-helper/ inducer cells
IND-  Behcet’s
    • SLE
    • VKH
    • Pars planitis
    • Sympathetic oph
DOSE-  1-3mg/kg/day OD orally
S/E-1. BM suppression
  1. GI disturb
  2. Hepatotoxicity
  3. Neutropenia
  4. Sev nausea & vomiting
  5. Infections
  6. Stomatitis

Monitoring-1] Hematological parameters weekly for 1 mo,bimonthly for 3 mo & monthly thereafter
2]Ser transaminase & bilirubin

C/I- Preg & lactation

2.  METHOTREXATE-
*  Folic acid antagonist
*  Inhibits dihydrofolate reductase
* Both T & B cells are suppressed
*  Folinic acid is given concurrently
IND-1. Steroid resistant uveitis
  1. Retinal vasculitis
  2. Sympathetic oph
  3. Cyclitis
  4. Necrotizing scleritis
  5. Iridocyclitis asstd with JRA
DOSE- 7.5-25mg single dose once wkly
S/E-1.BM toxicity.
  1. GI sym
  2. Pulmonary fibrosis
  1. Hepatotoxicity
  2. Pneumonitis
  3. Stomatitis
10.Ocular-photophobia,tearing & irritatn

C/I-Preg ,lact,children
Monitor-
1. LFT every 6-8 wks
2. liver biopsy after an accumulative dose of 1.5gm is reached
3. Chest X-ray

3. MYCOPHENOLATE MOFETIL
DOSE- 1gm BD
S/E- 1. BM Tx
  1. GI dist

B] T-CELL INHIBITORS
CYCLOSPORIN-
IND- 1. Behcet’s
        2. Parsplanitis
       3.  VKH syn
         4. Birdshot retinochoroidopathy
         5. Sympathetic oph
         6. Retinal vasculitis
DOSE-2-5mg/kg/d
S/E-1. HT
      2.  Nephrotoxicity
      3. Hirsutism
       4. Hepatotxicity
       5. Gingival hyperplasia

TACROLIMUS-
DOSE- 0.05-0.15mg/kg/d
S/E-1. Hyperglycaemia
  1. neurotoxicity

CYCLOPHOSPHAMIDE-
  • nitrogen mustard
  • Interferes with cross-linking of cellular DNA→ Inhibits proliferation & replication of cells
  • Suppresses only T- suppresser cell activity & enhances cellular immunity
  • IND-Symp oph
          -Parsplanitis
          -Behcet’s
          -PAN
          -Weg gran
        
*  DOSE- 1-2mg/kg  before meal
C/I- Preg & lact
    -cautious in child
*  S/E-
1.myelosuppression
2. Sterility
3.Hemorrhagic cystitis
4. Risk of infection & neoplasia
5. Bladder fibrosis & carcinoma
6. Dry eyes
7. Rise in IOP

Monitor-Blood count
            -Urine analysis

CHLORAMBUCIL-
  • Nitrogen mustard
  • Slowest acting & least toxic of all nitrogen mustards
  • Highly carcinogenic
  • IND- Behcet [ DOC]
          -Sym oph
          -JRA
*  Dose- 2mg /day oral→ Increase 2mg/day every week
*  S/E-
1. Myelosuppression
2. sterility
3.alopecia
4.pulmonary fibrosis
5. seizures

C/I-preg & lact
Cautious in child

CYCLOSPORIN-
  • Affects T-cell mediated responses & selectively inhibits T helper cell activation
  • Inhibits interleukin 2-4 ,TNF & gamma interferon
  • Available as a white crystalline powder,insoluble in aqueous.so dissolved in castor oil or olive oil with ethanol
  • Dose- 5mg/kg`.Must be diluted with milk or orange juice before using orally
  • Stored below 30deg C Do not refrigerate
  • C/I preg & lact
  • Caution in child & epilepsy
  • IND-
  1. Behcet
  2. sym op
  3. Birdshot retinochoroidopathy
  4. Parsplanitis

5-FLUORORACIL-
*  Pyrimidine analogue
* Inhibits thymidilate synthetase & cell div
* Antiproliferative
IND-
Glauc filtering surg
DOSE-
-S/C  0.5ml of 10mg/ml
-cellolose sponge-50mg/ml
S/E-
  1. Cor  epith defect
  2. Wound leak
6.MITOMYCIN –C
MOA- Inhibits DNA ,cellular RNA & protein synthesis
IND-
  1. Filtering surg -0.2mg/ml
  2. pterygium excision-0.02% BD for 5 days
S/E
  1. Scleral necrosis
  2. hypotony
  3. shallow AC
  4. Choroidal detachment

   BROMOCRIPTINE-
Ind- Ant uveitis
Dose- 2.5mg 4 times /day oral
S/E- postural hypotension

COLCHICINE-
Ind- Behcet
Dose- 0.5-0.6 mg 2-3 times/ day oral
S/E- BM suppression

DAPSONE-
Ind-Cicatricial pemphigoid
Dose- 25-50mg 2-3 times /day oral
S/E- Haemolytic anaemia
          UVEITIS  IN JUVENILE RHEUMATOID ARTHRITIS
  • Childhood arthritis [< 16 years]
  • 3 mo duration
  • 3 types-

SYSTEMIC ONSET JRA[STILL’S DIS]
PAUCIARTICULAR JRA
POLYARTICUALR JRA
Systemic features
   +
Mild / -
     -nt
uveitis
Very rare
uncommon
Very common
RF
      -
         -
             -
ANA
      -
          +
             +
Joints
Rare
         > 5
           < 4

Uveitis-
  • Chronic
  • Unilat/BL
  • Band keratopathy
  • Fine KPs
  • Flare & cells
  • Posterior synechiae
  • Cataract [Rx-lensectomy & ant Vtomy]
  • Glaucoma
Joints inv- knee→ wrist→ ankle

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