Intermediate uveitis
Introduction
Introduction to intermediate uveitis Intermediateuveitis is a group of inflammatory and proliferative diseases that primarily involve the flat portion of the ciliary body, the basement of the vitreous, the peripheral retina, and the choroid, typically manifesting as a snow-like lesion of the flat portion of the ciliary body. basic knowledge Sickness ratio: 0.05% Susceptible people: no specific population Mode of infection: non-infectious Complications: cataracts, vitreous hemorrhage, optic disc edema, retinopathy, cystoid macular edema, retinal detachment, hemangioma, optic atrophy, retinitis pigmentosa, glaucoma
Cause
Cause of intermediate uveitis
(1) Causes of the disease
The cause of the disease is not fully understood. It has been found that some infectious factors and diseases are related to their occurrence, but in most patients, the cause is not found and the systemic disease cannot be determined.
(two) pathogenesis
There are various theories about its pathogenesis.
1. The infection theory suggests that some low-virulence, unusual bacterial infections can cause the disease.
2. Allergic theory Some infection factors or allergic reactions to allergic substances may cause this disease. The cause may be mainly caused by type III or type IV allergic reactions.
3. Autoimmune theory is the most important theory at present. The autoimmune response to retinal S antigen, photoreceptor vitamin A-binding protein and type II collagen may cause this disease. For the analysis of patients' vitreous cells, T lymphocytes account for all 11% to 95% of vitreous cells, of which 5% to 75% are CD4 T cells, and there are still more macrophages in the vitreous, but B lymphocytes are rare. This result indicates that the central uveitis is mainly caused by T cells. Caused, and helper T cells play a major role,
4. Angiography Some vascular abnormalities, especially retinal vasculitis, perivascular inflammation and lymphocytic infiltration of the peripheral retina may lead to the occurrence of uvitis.
Prevention
Intermediate uveitis prevention
Complication
Intermediate uveitis complications Complications cataracts vitreous hemorrhage edema retinopathy macular cystic edema retinal detachment angioma optic atrophy retinitis pigmentosa glaucoma
Common complications of intermediate uveitis include macular degeneration, complicated cataract, retinal neovascular membrane, vitreous hemorrhage, optic disc edema, and proliferative vitreoretinopathy.
1. The most common macular degeneration of uveitis in the macular area is cystoid macular edema. In addition, pseudo-macular hole, retinal vitreous interface syndrome, premacular glial fibrosis, macular hole and so on.
Although the mechanism of macular cystic edema in such patients is not fully understood, it has been identified as the most important cause of the decline in visual acuity. For example, cystoid macular edema lasts for several months and will lead to irreversible vision loss.
2. Complicated cataract complicated with cataract is a common complication of intermediate uveitis, the incidence rate is 31% to 58.8%, which is not only related to chronic inflammation, but also related to long-term use of glucocorticoid eye drops. This type of complicated cataract mainly manifests as opacity of the posterior capsule of the lens, and the progress is generally slow, but the child is prone to full turbidity. The incidence of complicated cataract is closely related to the course of the disease. The longer the course of the disease, the higher the incidence. The reported duration of disease was 4 to 15 years, the incidence of cataract was 52%, 73% in 16 to 20 years, and 100% in 21 years or more.
3. Retinal neovascular membrane In patients with intermediate uveitis, the incidence of retinal neovascularization is 5% to 15%, which can occur in the peripheral part, posterior pole and optic disc, but is most common in the peripheral part, related to retinal neovascularization The mechanism of occurrence is not fully understood. At present, there are roughly the following viewpoints: 1 Inflammation itself stimulates the formation of new blood vessels. 2 vascular changes cause retinal ischemia, and produce diffuse substances that cause neovascularization, thereby inducing new blood vessels. 3 The lesion located in the flat part of the ciliary body can pull the peripheral retina, rupture the inner limiting membrane and promote the formation of new blood vessels.
Felder divided the peripheral retinal neovascular membrane into four phases: stage I, with snow-like lesions on the flat part of the ciliary body and the serrated edge. In stage II, there are new blood vessels in the snow-like lesions. The blood vessels usually originate from the anterior part and extend backwards to reach the serrated margin. In stage III, neovascularization increases and aneurysmal-like changes occur. In stage IV, neovascular membrane contraction occurs. Secondary retinal detachment may be associated with intraretinal or vitreous hemorrhage and exudation. This staging method generally reflects the occurrence, development and final consequences of peripheral retinal neovascularization, and has certain significance for guiding treatment.
4. Retinal detachment The incidence of uveal inflammation and retinal detachment reported by different authors is very different, but the middle uvitis complicated with retinal detachment is quite rare, and the retinal detachment complicated by uveal inflammation can be expressed as exudative retina. Detachment, retinal detachment and rhegmatogenous retinal detachment due to traction of vitreous fibrous tissue. Retinal detachment may occur on one side or on both sides, but the severity of inflammation is often different in both eyes, so the unilateral retina Detachment is more common.
5. The volume of blood in the glass volume of blood glass is low, 1.8% to 9%. The bleeding can be derived from the retinal vein. It can also be derived from retinal neovascularization. In the case of inflammation, the retinal vitreous often adheres to the blood vessel, and the vitreous wrinkles When the time is reduced, it can cause tearing of the retinal vein and cause bleeding; the retinal, optic disc and vitreous and other new blood vessels are more brittle, and they are prone to bleeding.
6. Other intermediate uveitis can cause optic disc edema, retinal edema around the optic disc, optic atrophy, retinal palpebral fissure, retinal hemorrhage, retinitis pigmentosa-like changes, banded corneal degeneration, secondary glaucoma, iris reddening, eyeball atrophy , uveal exudation and other complications.
Symptom
Symptoms of middle uveal inflammation Common symptoms Insomnia in the eyes of the eyes are non-lesional... Monocular anterior vaginal ciliary congestion, cystoid macular edema, retinal edema
1. Most of the symptoms of uveitis are concealed. It is often difficult for patients to determine the exact time of onset. Some patients may have no clinical symptoms. They are found in ophthalmologic examinations, but more patients complain of dark shadows. Obscuration, temporary myopia, generally no redness, eye pain, photophobia, tearing and other irritating symptoms, but in children and very few adult patients, early onset of the disease may appear red eyes, eye pain and other symptoms similar to acute anterior uveitis The patient's visual acuity is more than 0.5, but significant visual loss may occur in the occurrence of cystoid macular edema and other complications. In the case of acute vitreous hemorrhage and retinal detachment, sudden severe visual loss may occur.
2. Signs
(1) Inflammation of the anterior segment of the eye: Some patients may have no signs in the anterior segment of the eye, but most patients have mild to moderate anterior segment inflammatory response. Occasionally, patients with initial onset can see more severe anterior segment reaction and ciliary Congestion, a large number of KP, obvious anterior chamber flash and a large number of anterior chamber inflammatory cells.
Most patients have no ciliary congestion, but often KP, this KP is mostly medium size, sheep fat, but also dusty, anterior chamber flash ( ~), cells ( ~ ), post-iris adhesions are more common, iris Pre-adhesion is less common, and there may be gelatinous or punctate deposits similar to the fat-like KP in the corner of the anterior chamber. Adhesion of the anterior chamber, especially columnar adhesions may occur. It is reported that acute corneal endotheliitis may occur in individual patients. For peripheral corneal edema, KP is linearly distributed at the junction of the edema cornea and the normal cornea, suggesting that uvitis may have a similar pathogenesis to the transplant response. In addition, banded corneal degeneration may occur in children.
(2) Vitreous and ciliary body flat lesions: Vitreous changes are one of the common and important manifestations of uveal inflammation, mainly characterized by vitreous inflammatory cells, agglomerated snowball turbidity, ciliary body flats and The base of the vitreous body extends to the vitreous lesion of the vitreous cavity, the vitreous degeneration, posterior detachment, hemorrhage, and proliferative vitreoretinopathy that occurs later.
Vitreous inflammatory cells ( ), sometimes inflammatory exudation is very serious, making the entire fundus difficult to see, vitreous globular turbidity is one of the typical signs of intermediate uveitis, a dense round white turbid small group, often posted Attached to the posterior vitreous membrane, close to but not in contact with the retina, the point-like shadow cast on the retina can be seen when examined by a three-sided mirror.
A snowbank-like change (snowbank) is a proliferative lesion that occurs in the flat part of the ciliary body. It is white or yellowish white and extends into the vitreous cavity. It can be seen through the enlarged pupil when the lesion is obvious. "Posterior hypopyon", when the lesion is small, can be observed by three-sided mirror to determine the lesion, such as the patient has post-iris adhesion, when the pupil is difficult to enlarge, the lesion can be confirmed by in vivo ultrasound microscopy, such The lesion is unique to uveal inflammation, with a prevalence of 40% to 100%. The location of the snow-like lesion can be limited to the lower ciliary body flat or to the serrated margin. In recurrent patients, the lesion It often extends symmetrically from both sides to the flat part of the upper ciliary body, and a few may involve the entire flat part of the ciliary body. The snow-like lesion may be single or multiple, and the latter often has one major lesion. Other lesions are distributed in a satellite shape. Snow-like lesions generally show sharp front edges, irregular trailing edges, and often thickened or formed finger-like protrusions that protrude into the vitreous. Those with snow-like lesions are prone to macular sac. Edema, the incidence of cystoid macular edema found under ophthalmoscopy is much lower than that confirmed by fluorescein fundus angiography, although cystoid macular edema can also be seen in many other types of uveitis, but in the middle Uveitis
Retinal vasculitis and perivascular inflammation are a common change in intermediate uveitis. It is more common in people with a higher incidence. Some people even think that it is of great value in the diagnosis of uvitis, and it is not easy to be seen in peripheral fundus lesions. In the case of the case (the following vitreous is severely turbid), the diagnosis of cystitis edema can be roughly made for cystoid edema which cannot be explained by other reasons. Up to 21% to 80%, veins are more susceptible than arteries, perivascular inflammation is more common than vasculitis, vascular changes occur in the peripheral part, but can also occur in the posterior pole, even involving the optic disc blood vessels, blood vessel changes can be Plaque, may also involve the whole process of the blood vessels, retinal vasculitis and perivascular inflammation may occur near the retinal oozing, the snow levee has a prominent and smooth appearance when inflammation occurs, the atrophy occurs when the inflammation subsides, flat and dry form .
(3) Retinal changes: Intermediate uveitis can cause a variety of retinopathy, such as cystoid macular edema, diffuse retinal edema, retinal vasculitis and perivascular inflammation, retinal oozing, hemorrhage, neovascularization, proliferative retinopathy, Retinal detachment, etc., cystoid macular edema is a common manifestation of this disease. Diffuse retinal edema is a common manifestation of severe intermediate uveitis, which can occur in the posterior pole. This result indicates that there is a wide range of intermediate uveitis. Retinal microvascular involvement.
(4) optic disc changes: optic disc edema and inflammation is a common change in active intermediate uveitis, but if there is no obvious cystoid edema, optic disc edema and inflammation generally cause severe vision loss, the center of the retina at the optic disc Vasculitis and perivascular inflammation can also occur in blood vessels, and new blood vessels can still appear in the optic disc.
(5) choroidal lesions: related to choroidal lesions, the results observed by different authors are quite different, some people think that the choroid is usually not involved or only slightly affected, but it has also been found that 75% of patients with choroidal lesions, showing peripheral choroid Atrophy and pigmentation, choroidal neovascularization, choroidal detachment, etc. can also be found.
Examine
Examination of intermediate uveitis
Serological examination, elevated serum angiotensin-converting enzyme levels, strongly suggesting sarcoma-like disease; elevated serum lysozyme levels can be found in sarcoma-like diseases, tuberculosis and other granulomatous diseases, specific antibody detection for the determination of Lyme disease, syphilis, Cat scratches and injuries can be very helpful, and the above laboratory tests can be used to rule out other diseases of the eye.
1. X-ray examination of chest X-ray examination revealed pulmonary infiltrates, fibrosis, cavity formation, miliary lesions, suggesting the possibility of tuberculosis; hilar lymphadenopathy, plaque or nodular pulmonary interstitial Infiltration or other changes suggest sarcoma-like disease, and ankle and spine X-ray findings are helpful in the diagnosis of ankylosing spondylitis, Reiter syndrome, and inflammatory bowel disease.
2. Gallium scan and chest CT examination For patients with elevated serum angiotensin-converting enzyme and no abnormal chest X-ray examination, chest CT examination may be considered, and lacrimal gallium scan and whole body gallium scan may be performed to determine or exclude Sarcomatoid disease.
3. Fluorescein fundus angiography fluorescein fundus angiography can show the extent of retinitis and retinal capillaries without perfusion, although otoscopy can sometimes find cystoid edema, but fluorescein fundus angiography can be more accurate Judging whether there is such a lesion, you can find a lot of clinically undetectable cystoid macular edema (Figure 6). The middle uveitis is often accompanied by subretinal retinal vasculitis. This vasculitis is sometimes under ophthalmoscopy or It is difficult to see under the three-sided microscope, but fluorescein fundus angiography can see vascular leakage and blood vessel wall staining. Although retinal vasculitis can occur in the middle uveitis caused by various causes and various systemic diseases, Behcet's disease, intermediate uvitis caused by sarcoma-like disease, retinal vasculitis is a prominent clinical manifestation.
4. Ultrasound examination Ultrasound examination of patients with severe vitreous opacity can be found in retinal detachment, posterior scleritis, ocular granulomatous granuloma, intraocular tumors, etc., to help determine the diagnosis and differential diagnosis, ultrasound biomicroscopy It is of great value to determine the snow-like changes in the flat part of the ciliary body, exudation, edema and infiltration of inflammatory cells in the vitreous.
Diagnosis
Diagnosis and identification of intermediate uveitis
Diagnostic criteria
The diagnosis of intermediate uveitis is mainly based on clinical manifestations, especially according to the vitreous inflammatory cells more than the anterior chamber inflammatory cells, typical snowball opacity in the vitreous, characteristic snow-like lesions, with cystoid macular edema, retinal vasculitis Clinical features such as perivascular inflammation, in general, as long as these lesions are noted, the diagnosis is not difficult, but the problem is that uveal uvitis is the same as anterior uveitis, posterior uveitis, and uveitis. A large type of classification, which can itself be caused by a variety of causes or systemic diseases, so it is not enough to make a diagnosis of intermediate uveitis. It should also be based on the characteristics of the eye and the accompanying body. Sexual lesions, inquire about the medical history in detail, do the necessary laboratory tests and related examinations, and further clarify what causes the patient's suffering and the intermediate uveitis caused by the disease. Only then can the doctor know what to expect and give The patient is treated correctly. It is worth noting that the majority of patients with Chinese uveitis are difficult to determine the cause and potential Disease, but that does not mean we do not need to find the cause or underlying disease, on the contrary, if they can rule out these causes and diseases (ie, identified as idiopathic intermediate uveitis), the treatment also of great help.
Differential diagnosis
The differential diagnosis of intermediate uveitis includes two aspects: one is to identify the many causes and systemic diseases that cause uveitis, especially to determine whether it is caused by infectious factors, so the cause of the cause Anti-infective treatment. The other is to identify some diseases of non-intermedial uveitis. Because uveitis can cause lesions from the anterior segment to the fundus, patients with different signs should be considered for differentiation with different diseases. Discuss the differential diagnosis of several diseases.
1. Multiple sclerosis associated with uveitis Multiple sclerosis is a progressive recurrence and remission of the nervous system demyelinating disease, which can cause optic neuritis, retinal vasculitis, perivascular inflammation, chronic anterior uveal There are many types of inflammation and intermediate uveitis. The incidence of intermediate uveitis in these patients is 3.3% to 26.9%. This kind of ocular inflammation itself is not specific, so it is difficult to diagnose multiple sclerosis based on ocular inflammation. Although uveitis can occasionally occur before neurological diseases, in most patients, neurological lesions appear before uveitis, patients have or have had dizziness, ataxia, vision loss, sensory disturbance, weakness, sphincter function Disorders, etc., suggest the possibility of multiple sclerosis. For these patients, a neurologist should be consulted and a magnetic resonance examination should be performed to confirm the diagnosis.
2. Sarcoma-like uveitis sarcoma is a multi-system chronic granulomatous disease whose etiology is not fully understood. It mainly causes uveitis in the eye. Carcinosarcoma is common in black people. Rarely, this disease causes anterior uveitis, can also cause posterior uveitis, intermediate uveitis and total uveitis. Uveitis often occurs after systemic disease, systemic lesions, especially skin lesions (nodular erythema) , frostbite-like lupus, maculopapular and granulomatous nodules, hilar lymphadenopathy, superficial lymphadenopathy, etc. are very helpful for diagnosis, especially elevated serum angiotensin-converting enzyme levels are of great value for diagnosis.
3. Lyme disease associated with Lyme disease Lyme disease is a borreliosis caused by sputum, manifested as a multi-system inflammatory lesion, the patient is usually in the forest area, has a history of bite injury, manifested as migratory erythema, Migratory arthritis, may be associated with cranial nerve palsy and peripheral neuropathy, chronic meningitis, myocarditis, pericarditis, arrhythmia and other systemic diseases, usually cause granulomatous iritis in the eye, iridocyclitis, middle Uveitis, diffuse choroiditis, optic neuritis, exudative retinal detachment, etc., the above systemic lesions strongly suggest Borrelia burgdorferi infection, serological tests, especially the use of enzyme-linked immunosorbent assay (ELISA) to find specific antibodies help For diagnosis, but because the production of antibodies takes a certain time, it is not always possible to find specific antibodies in the early stage of the disease. The application of early antibiotics can also affect the production of antibodies, resulting in false negative results. Such tests can also produce false positive results. In addition to the above methods, indirect immunofluorescence assay, immunoblotting, polymerase chain reaction (PCR) determination of specific DNA and other technologies help The diagnosis of this disease.
4. syphilitic uveitis syphilis is a systemic disease caused by Treponema pallidum, mainly in the eyes of anterior uveitis, intermediate uveitis, posterior uveitis, total uveitis, chorioretinitis, Retinal vasculitis, etc., monocular or binocular involvement, the disease often has typical skin lesions, such as primary diarrhea, secondary syphilis rash or papule scaly, late syphilis nodules or syphilis, non-treponema pallidum antigen serum test (such as STD laboratory tests, rapid plasma pheresin test) and Treponema pallidum antigen test (such as fluorescent spirochete antibody absorption test, Treponema pallidum coagulation test, Treponema pallidum fluorescein labeled antibody double staining test) and other tests are important for diagnosis Value, but should pay attention to false positive or false negative results when judging the results.
5. Human T-lymphotropic virus (HTLV) caused by human T lymphocyte virus type I has type 3, of which type I is associated with adult T cell leukemia, so it is called human T cell leukemia. Virus type I, this virus can cause granulomatous anterior uveitis, intermediate uveitis, posterior uveitis, total uveitis, retinal vein inflammation, retinal choroiditis, etc., the virus caused by uveitis More common in Japan, there is no report in this aspect in China. Although this type of uveal inflammation is typically characterized by vitreous globular opacity, cystoid macular edema and retinal vasculitis, there is generally no snow levee-like change. The emergence of serum-specific antibodies is important for diagnosis.
6. Cat scratch injury Cat scratch injury is a disease caused by Bartonella, conjunctivitis, neuroretinitis and uvitis in the eyes, lymph nodes, blood vessels detected in the blood, appear in serum A specific antibody to the Bartonella can be used to determine the diagnosis.
7. Behcet's disease uveitis Behcet's disease can cause intermediate uveitis, but it is more caused by acute non-granulomatous anterior uveitis, total uveitis, retinitis and retinal vasculitis, and it is caused by The middle uveitis is rarely manifested in this type alone, often with obvious retinitis or retinal vasculitis and anterior segment reaction. In addition, patients are often accompanied by recurrent oral ulcers, pleomorphic skin lesions, genital ulcers, Arthritis, nervous system involvement, etc., according to these performances is generally not difficult to make a correct diagnosis.
8. Fuchs syndrome Fuchs syndrome can cause intermediate uveitis, vitreous globular opacity, peripheral retinal vasculitis or retinal choroidal lesions, but these patients often have typical anterior segmental lesions, such as diffuse distribution or central corneal area Distribution of star KP, iris depigmentation, Koeppe nodules, complicated cataracts, etc., but these patients generally do not have cystoid edema, posterior pole retinal vasculitis and perivascular inflammation, so the diagnosis is generally not difficult.
9. Camel syndrome caused by intraocular lymphoma Intraocular lymphoma can cause anterior uveitis, intermediate uveitis, retinitis and choroiditis, more common in the elderly, but can also occur in children, this disease Can cause severe anterior segment inflammation, even anterior chamber empyema, large cell mass in the vitreous, choroid or retinal infiltration, but more common is non-specific reaction, this inflammatory response to glucocorticoids Insensitive to immunosuppressive drugs, some patients may have neurological diseases, lymphadenopathy, cerebrospinal fluid examination, brain magnetic resonance examination and vitreous biopsy are important for diagnosis.
