anterior uveitis
Introduction
Introduction to anterior uveitis Anterioritis is a group of inflammatory diseases involving the iris and/or anterior ciliary body. It is clinically manifested in three types, namely iritis, iridocyclitis and anterior ciliary body inflammation. . basic knowledge The proportion of illness: 0.006%-0.008% Susceptible people: no specific population Mode of infection: non-infectious Complications: cataracts, middle uveitis, sympathetic ophthalmia
Cause
Anterior uveitis
(1) Causes of the disease
There are many causes and types of anterior uveitis, such as acute anterior uveitis associated with HLA-B27 antigen, anterior uveitis with systemic disease, anterior uveitis due to systemic infectious disease, local Anterior uveitis caused by infectious diseases, anterior uveitis caused by immune response, anterior uveitis associated with sympathetic and vascular dysfunction, camouflage syndrome caused by intraocular tumors, and idiopathic anterior grapes Membrane and so on.
According to the duration of inflammation, anterior uveitis can be divided into two types, acute and chronic. Acute anterior uveitis is acute and rapidly regressed. Chronic anterior uveitis is occult, sometimes for a long time after the onset of illness. Not perceived by the patient, but some chronic inflammation is caused by acute inflammation. Acute anterior uveitis is significantly different from the cause of chronic anterior uveitis, anterior uveitis associated with HLA-B27 antigen, tonicity Pre- uveitis associated with spondylitis, Behcet's disease anterior uveitis is a common cause and type of acute anterior uveitis (Table 2), while anterior uveitis associated with juvenile chronic arthritis, Fuchs synthesis Zheng and Vogt-Koyanagi Harada disease are common causes and types of chronic anterior uveitis.
(two) pathogenesis
According to the origin of inflammation, anterior uveitis may be inflammation of the primary iridocyclitis, may be an inflammatory response to the lens antigen, may be caused by inflammation of adjacent tissues, or may be an "overflow" of inflammation in the posterior segment of the eye. The results may also be clinical manifestations of non-inflammatory diseases (such as retinoblastoma, intraocular lymphoma, etc.), anterior uveitis may be used as an independent clinical type, or as a total uveitis a part of.
Prevention
Anterior uveitis prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Anterior uveitis complications Complications cataract uvitis sympathetic ophthalmia
1. Complicated cataract complicated with cataract is one of the common complications of anterior uveitis. The mechanism of its occurrence is not fully understood, but it is related to the disorder of lens water caused by changes in aqueous humor during inflammation. The lens secondary to post-iris adhesion Turbidity may be caused by accumulation of toxic metabolites due to local hypoxia and changes in local aqueous flow. Enzymes produced during inflammation (such as phospholipase A and lysosomal enzymes) have been shown in animal experiments. It has a damaging effect on the lens fiber membrane. Inflammatory products such as oxygen free radicals have also been shown to cause lens damage in animal experiments. The immune complex deposited in the lens capsule during inflammation can cause damage and aggravate the vicinity of the lens through the complement cascade. Inflammatory reactions, glucocorticoids used in pre-treatment uveitis can also induce cataracts.
The lens changes secondary to uveitis, first seen in the anterior capsule epithelium, under the equator and posterior capsule, changes in the anterior capsule epithelium are often associated with posterior iris adhesion, pathologically visible focal cell necrosis and nearby proliferating lens on the belt Clinically, it is characterized by focal opacity at the posterior adhesion site. Diffuse anterior subcapsular cataract is rare in clinical practice. It is often associated with severe anterior chamber inflammation, and is often secondary to specific dermatitis or chemical injury. Membrane inflammation, opacity under the equator and posterior capsule of the lens is often associated with inflammation of the posterior sac, often initially manifested as changes in the equator, including retrograde movement of lens epithelial cells and destruction of adjacent cortical fibers, when transitional epithelial cells Posterior capsule cataract occurs when degeneration and proliferation occur. In general, most of the complicated cataract caused by uveitis is opacity of the posterior capsule.
Fuchs syndrome is one of the most common types of cataract in uveitis. The incidence of cataract is as high as 15% to 75%. Most authors report that it is about 50%. The anterior uveitis associated with juvenile chronic arthritis is also It is easy to cause complicated cataract. It is reported that the incidence rate is as high as 40% to 60%. Other uveitis which is prone to complicated cataract also has middle uveitis, idiopathic non-granulomatous anterior uveitis, sarcoma-like disease. Vogt-Koyanagi Harada disease, sympathetic ophthalmia, etc., almost all anterior uveitis can cause concomitant cataract as long as it lasts for a certain period of time and has certain activity.
2. Secondary glaucoma anterior uveitis can cause glaucoma through a variety of mechanisms. In general, glaucoma caused by inflammatory fragments and trabecular meshwork can achieve better results with anti-inflammatory treatment; extensive post-adhesion of iris As a result, peripheral iris laser incision or peripheral iridotomy is often required; anterior iris adhesion, trabecular mesh sclerosis, iris reddening, etc. can be used to induce carbonic anhydrase inhibitors, timolol, adrenaline, etc. Treatment, poor results should be treated surgically; glaucoma-induced glaucoma can gradually return to normal after reduction or withdrawal.
3. Banded corneal degeneration banding corneal degeneration (Figure 6) is prone to occur in patients with chronic anterior uveitis, especially in patients with anterior uveitis associated with juvenile chronic arthritis, its presence often prompts patients Uveitis has been going on for quite some time.
4. Low intraocular pressure and long-term chronic ciliary body atrophy, which can lead to atrophy of the ciliary body, decreased secretion of aqueous humor, and decreased intraocular pressure. In addition, the ciliary membrane caused by inflammation and the ciliary body are pulled. The resulting ciliary body detachment can seriously affect the formation of aqueous humor, causing a significant decrease in intraocular pressure, and severe eyeball atrophy.
Symptom
Anterior uveitis symptoms Common symptoms Flowing ciliary congestion, dehydration, photorespiration, herpes, oral ulcer, cystoid edema, monocular, pre -eye shadow
Acute anterior uveitis
(1) Symptoms: eye pain, red eyes, photophobia, and tearing are common manifestations of acute anterior uveitis, but their severity can vary greatly. In non-granulomatous inflammation, patients often complain of severe eye pain. Photophobia and redness; in granulomatous inflammation, these manifestations are often mild or absent, patients may have blurred vision, generally no significant visual loss, but a large amount of fibrinous exudation or reactive optic disc edema in the anterior chamber Macular edema can cause severe vision loss.
(2) Signs: examination showed obvious ciliary congestion, mixed hyperemia in patients with severe anterior uveitis (Fig. 1), cells above the anterior chamber () and flashing, in general, acute inflammation, before The inflammatory cells in the room tend to be more prominent than the anterior chamber. KP may not be obvious or even absent in the early stage of the disease, but a large amount of dusty KP often appears after 2 days of onset; severe patients may have anterior chamber empyema (Fig. 2). A large amount of fibrinous exudation or even coagulative aqueous humor in water, after a few days, granulomatous inflammation gradually showed signs of granulomatous inflammation, such as sheep fat KP (Figure 3), Busacca nodules, etc., whether it is granulomatous Or non-granulomatous anterior uveitis, can cause post-irisal adhesions (Figure 4), sometimes the adhesion of the iris occurs very quickly, can be formed a few hours after the onset, but the post-adhesion is often not strong at this time, After using the ciliary muscle paralysis agent and the dilating agent, it is easy to be pulled apart, and the post-iris adhesion can be partially opened, which can form pupils of various shapes. Once a strong iris is formed, the drug is difficult to work, and the complete iris is completely effective. Post-adhesion can cause iris bulging, secondary Complications such as glaucoma can cause vision loss or loss. Acute iridocyclitis is often accompanied by a decrease in mild intraocular pressure, but intraocular pressure can also be unaffected, in some types such as herpes simplex virus, herpes zoster virus Uveitis and acute retinal necrosis syndrome, often with elevated intraocular pressure, anterior uveitis generally does not cause changes in the posterior segment of the eye, but in a few patients may have reactive optic disc edema and / or macular cystic edema, these Fundus changes generally subside with the regression of inflammation.
2. Chronic anterior uveitis
(1) Symptoms: Patients with chronic anterior uveitis have no obvious red eyes, eye pain and photophobia, or even no such symptoms at all. Patients may have blurred vision, but no obvious visual loss, or complicated cataract. Secondary glaucoma, banded corneal degeneration, reactive optic discitis, and/or macular cystic edema (Figure 5) showed severe vision loss.
(2) Signs: There is no obvious ciliary congestion in patients. KP can be dusty (non-granulomatous), fat-like (granulomatous) or star-shaped, fresh KP tends to be white, round, and appears Dense, smooth, moist, and old KP appears shrinking, dehydrated, dull, sparse, sometimes frosted glassy appearance, mixed with pigmentation, anterior chamber inflammatory cells are generally less, but anterior chamber flash often compare Significantly, especially in chronic granulomatous anterior uveitis, even in the quiescent period of inflammation, there may be obvious anterior chamber flash, which is caused by the destruction of blood-aqueous barrier function, granulomatous inflammation may occur Iris Koeppe nodules or Busacca nodules, even iris granuloma, iris swelling sometimes has a spongy appearance, chronic anterior uveitis often has post-iris adhesions, resulting in a variety of different shapes of pupils, such as plum-like, pear-shaped, irregular Shape and so on.
Examine
Anterior uveitis examination
Mainly involved in some cases of anterior uveitis, with clinical features as the entry point, targeted HLA antigen typing test.
For some anterior uveitis which is difficult to determine the cause or classification in clinical practice, relevant laboratory tests and auxiliary examinations should be carried out according to some clinical clues. If the patient is found to be an acute recurrent double-eye alternating non-granulomatous anterior grape Membrane inflammation should be performed for HLA-B27 antigen typing, ankle joint filming, etc.; if anterior chamber empyema and polymorphic skin lesions are found, skin allergic reaction test, fluorescein fundus angiography, HLA-B5 antigen should be performed. Or B51 antigen typing and other tests; if the patient is found to have granulomatous anterior uveitis and diarrhea, blood in the stool, etc., endoscopy and biopsy should be performed.
Fluorescein fundus angiography is important for determining cystoid macular edema associated with anterior uveitis and mild edema of the optic disc. Many acute anterior uveitis can cause reactive fundus changes.
Since slit lamp microscopes, ophthalmoscopes, and three-sided mirror examinations are difficult to understand the lesions behind the iris and near the ciliary process, little is known about the changes in the posterior iris and ciliary processes caused by anterior uveitis. In recent years, living organisms The advent of ultrasound microscopy provides a very useful tool for evaluating lesions near the iris and near the ciliary process. This type of examination can be used to detect exudate after the iris in the anterior uveitis, ciliary body edema, exudation, and atrophy. , detachment, mechanical film formation, etc. change.
Diagnosis
Diagnosis and identification of anterior uveitis
Chronic anterior uveitis varies in duration, some may be self-limiting, and some may last for several years. Long-term anterior uveitis may lead to zonal degeneration, complications such as cataract and secondary glaucoma.
1. The diagnosis of uveitis itself is not difficult before the diagnosis step. The difficulty is to determine the cause and diagnosis of what type of anterior uveitis.
2. Attention to systemic diseases A variety of systemic diseases can cause inflammation of the anterior uveal membrane. Asking about the systemic history and familiarity with the extraocular manifestations of these systemic diseases can be very helpful in making a correct diagnosis, such as the presence of oral ulcers. For the diagnosis of Behcet's disease uveitis, uveitis associated with inflammatory bowel disease, uitis with Reiter syndrome, etc.; nodular erythema for sarcoma-like uveitis, Behcet's disease Uveitis, uveitis caused by Lyme disease, and other uveitis are important; vitiligo suggests Vogt-Koyanagi field disease, sympathetic ophthalmia, etc. Arthritis helps to diagnose grapes associated with ankylosing spondylitis Membrane inflammation, uitis associated with Reiter syndrome, uveitis associated with inflammatory bowel disease, uveitis associated with psoriatic arthritis; central nervous system abnormalities can be seen in Vogt-Koyanagi field disease, Behcet disease Uveitis, uygitis caused by Lyme disease, herpes viral uveitis, sarcoma-like uveitis, syphilitic uveitis, uveitis associated with multiple sclerosis, and other types of uveitis.
