The uvea and vitreous body

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1 The uvea and vitreous body

2 Development of the eye Primary vitreous Mesenchymal invasion Secondary vitreous From the retina: tertiary vitreous Mesenchymal cells: uvea, cornea stroma, slera

Vascular tunic =Uvea vascular pigmented layer Iris: Protects retina from excesive light Layers: Pigment epithelium +stroma melanocytes- eye colour Muscles: Sphincter pupillae parasymp. oculomotor n.

3 Vascular tunic =Uvea vascular pigmented layer Iris: Protects retina from excesive light Layers: Pigment epithelium +stroma melanocytes- eye colour Muscles: Sphincter pupillae parasymp. oculomotor n. (III) Dilatator pupillae symp. - cervical ggl., choroid plex. Pupil margin: close to the lens! (adhesions) Ciliary body: Aqueous humour production (proc. ciliares) Accommodation (m. ciliaris) Choroid: Melanocytes (lamina fusca dark layer) Stroma Choriocapillary nourishment and oxygen supply of the outer retinal layers (receptors!) The blood flow through the choroid is the highest in the entire body.

Vitreous body Optically clear gel - supports the retina 98% water 2% collagen, hyaluronic acid Anatomy: Posterior hyaloid membrane loose attachment with the retina ----anatomical vitreo-retinal

4 Vitreous body Optically clear gel - supports the retina 98% water 2% collagen, hyaluronic acid Anatomy: Posterior hyaloid membrane loose attachment with the retina ----anatomical vitreo-retinal attachments: papilla vitreous basis (at the ora serrata) posterior surface of the lens ---- abnormal vitreo-retinal attachments: (vitreo)retinal degenerations Cloquet s canal (invisible): remnant of the primary vitreous (a. hyaloidea)

5 Examination methods Slit lamp Iris, pupil, anterior vitreous Ophthalmoscopy Posterior vitreous Retina, choroid FLAG (iris-retina), ICG (indocyanin green) angiography (choroid) Gonioscopy, 3 mirror lens (+indentation) Iris root, ciliary body Ultrasound Vitreous, chorioretinal layer Ultrasound biomicroscopy: Ciliary body OCT

6 Diseases Uvea Vitreous (Tumors) Rubeosis iridis Developmental anomalies Hereditary diseases Degenerations Inflammations Posterior vitreous detachment Vitreous haemorrhage Vitrectomy

7 Uveal tract developmental anomalies, hereditary disorders Iris coloboma always inferior -Arteficial coloboma: superior Choroideal coloboma inferior Albinism cutan oculocutan

Uveal tract developmental anomalies, hereditary disorders Gyrate atrophy of

-Arginin restricted diet Chorioideremia -X- linked Recessive -Progressive

is preserved for a long time -Myopia -CHM gene -1.

8 Uveal tract developmental anomalies, hereditary disorders Gyrate atrophy of the choroid -Autosomal Recessive -OAT (ornithin amintrasferase gene) -Arginin restricted diet Chorioideremia -X- linked Recessive -Progressive PE and choroideal atrophy -Visual field loss, ERG disorders -Macular area is preserved for a long time -Myopia -CHM gene -1. phase gene therapy trial (UK) Aniridia: PAX6 gene glaucoma, cataract iris tinted intraocular or contact lens

9 Uveal tract -degenerations Degenerative myopia (above -10D ) Myopic fundus changes Peripapillary and posterior choroid atrophy Choroid neovascularisation (macula) myopic maculopathy intravitreal antivegf therapy

Uveal tract - inflammations Anterior uveitis iritis iridocyclitis Intermediate uveitis pars planitis Posterior uveitis choroiditis chorioretinitis Etiology: 1.

10 Uveal tract - inflammations Anterior uveitis iritis iridocyclitis Intermediate uveitis pars planitis Posterior uveitis choroiditis chorioretinitis Etiology: 1. Autoimmun diseases: HLAB27- JRA, Bechterew, Behcet, sarcoidosis, Wegener granulomatosis, Crohn s disease, colitis ulcerosa 2. Infections: parasites: Toxocara, toxoplasma, bacteria: Syphilis, Borrelia, mycobacterium, Yersinia, Brucella viral: HSV, VZV, CMV, HIV 3. Unknown: 25%

Iridocyclitis Signs: Red eye - Ciliary injection Iris vessels

(Tyndall phenomenon) Precipitates on the corneal endothelium

Complications: posterior synechia (attachment of te pupil margin

11 Iridocyclitis Signs: Red eye - Ciliary injection Iris vessels become permeable: Cells and protein in the anterior chamber (Tyndall phenomenon) Precipitates on the corneal endothelium Hypopyon Complaints: Dull pain Photophobia, tearing Small pupil Complications: posterior synechia (attachment of te pupil margin to the lens) cataract glaucoma (open closed angle) Treatment: Steroids(eyedrops, subconjunctival inj.) pupil dilatation (mydriatics) search for etiology (ENT, dentist, immunology, serology, chest xray)

Pars planitis Complaints: floaters Signs: Snow

ball Etiology: Toxocara, toxoplasma, sarcoidosis

cystoid macula oedema Treatment : Steroids

12 Pars planitis Complaints: floaters Signs: Snow banking Pecipitates in the anterior vitreous Snow ball Etiology: Toxocara, toxoplasma, sarcoidosis more common Complications: Vitreous bleeding, cystoid macula oedema Treatment : Steroids (parabulbar, systemic) Kryoapplication Laser Search for etiology

Chorioretinitis, choroiditis Multifocal focal Acute inveterated Signs: depend on macular involvement and extent of lesions decreased visual acuity visual field defects vitritis - (cells in the

13 Chorioretinitis, choroiditis Multifocal focal Acute inveterated Signs: depend on macular involvement and extent of lesions decreased visual acuity visual field defects vitritis - (cells in the vitreous floaters) Etiology: like anterior and intermediate uveitis Monofocal: toxocara, toxoplasma Multifocal white dot syndromes autoimmune, viral, bacterial Treatment: steroids (parabulbar, systemic, intravitreal implants) immunosuppressive therapy specific therapy depending on etiology

14 Sympathetic ophthalmia Very rare Blindness of one eye (phthisis bulbi), often after injury Release of lens and retinal antigens Autoimmun panuveitis in the other (functioning) eye Severe granulomatous uveitis Treatment: immediate removal (enucleation) of the blind eye Systemic steroid (or other immunosuppressive) therapy Phacogenic uveitis Release of lens proteins into the anterior chamber or vitreous (injuries, operations, hypermature cataract) autoimmun uveitis - steroids, lens removal

Rubeosis iridis Neovascularisation in the iris stroma normally no visible vessels on the iris Always a sign of retinal hypoxia retinal blood vessel occlusion proliferative diabetic retinopathy

15 Rubeosis iridis Neovascularisation in the iris stroma normally no visible vessels on the iris Always a sign of retinal hypoxia retinal blood vessel occlusion proliferative diabetic retinopathy retinal vasculitis Neovascularisation in the iridocorneal angle: secondary angle closure glaucoma Treatment: panretinal or sector laser photocoagulation secondary glaucoma: cyclokryopexy cyclophotocoagulation severe pain: evisceration, enucleation

16 Vitreous body developmental Persistent hyaloid artery Usually asymptomatic anomalies Persistent hyperplastic primary vitreous (PHPV) very rare leucocoria (white pupil) in newborns differential diagnosis: congenital cataract, retinoblastoma US, MRI

usually asymptomatic, sometimes floaters Amyloidosis similar

17 Vitreous body - degenerations Asteroid hyalosis (scintillatio nivea) above 50y cholesterin, calcium containing deposits usually asymptomatic, sometimes floaters Amyloidosis similar in appearance to asteroid hyalosis hereditary, bilateral younger age

Vitreoretinal degenerations (dystrophies) Wagner

adhesions Myopia, retinal detachment Stickler s

maxilla, cleft or high palate, hyperextensible

18 Vitreoretinal degenerations (dystrophies) Wagner s disease: versican gene abnormal vitreortinal adhesions Myopia, retinal detachment Stickler s syndrome: mutations in collagens 2, 9, 11, flat maxilla, cleft or high palate, hyperextensible joints deafness retinal degenerations, breaks, detachment

Posterior vitreous detachment Vitreous gel

collapse detachment of posterior vitreous

vitreous haemorrhage floaters, sometimes visual

retinal detachment (rhegmatogenous) - can be

19 Posterior vitreous detachment Vitreous gel liquefies in older patients floaters Vitreous collapse detachment of posterior vitreous membrane Weiss ring patient sees smoke ring vitreous haemorrhage floaters, sometimes visual loss retinal traction - flashes retinal break - retinal detachment (rhegmatogenous) - can be prevented with laser macular traction distorted vision macular hole decreased VA

Vitreous haemorrhage Signs Etiology (Large) floaters, visual loss

diabetic retinopathy retinal blood vessel occlusion retinal vasculitis

(subarachnoideal haemorhage) Ultrasound: examination of the retina If

20 Vitreous haemorrhage Signs Etiology (Large) floaters, visual loss posterior vitreous detachment retinal neovascularisation proliferative diabetic retinopathy retinal blood vessel occlusion retinal vasculitis age related macular degeneration trauma Terson s syndrome (subarachnoideal haemorhage) Ultrasound: examination of the retina If no reabsorption in 3 months: vitrectomy in the case of retinal detachment: immediate vitrectomy

recidivating endophthalmitis) Complaints: pain red eye + purulent discharge decreased visual acuity

21 Vitreous body - inflammations Vitritis reactive inflammation accompanying chorioretinitis Endophthalmitis Infectious agent gets into the vitreous cavity injury operations hematogenic spread (bilateral, recidivating endophthalmitis) Complaints: pain red eye + purulent discharge decreased visual acuity Signs: hypopyon corneal opacities vitreal haze Treatment: antibiotics (intravitreal), antimycotics, antivirals vitrectomy

22 Vitrectomy Introduction of devices through the pars plana (3.5-4 mm from the limbus): cutter (aspiration, cut) light infusion scissors, forceps, cannulas endolaser endodiathermy membrane peeling retinotomy

Vitrectomy Intraoperative stabilisation of the

must be removed at the end of the operation Vireous

air gas (SF 6, C 3 F 8 ) reabsorbs by itself

23 Vitrectomy Intraoperative stabilisation of the retina: perfluoro-dekalin ( heavy liquid ) toxic, must be removed at the end of the operation Vireous replacement: saline (BSS balanced salt solution) air gas (SF 6, C 3 F 8 ) reabsorbs by itself positioning of the patient Silicon oil removal with another operation

24 Thank you for your attention

Ophthalmology. Juliette Stenz, MD

Ophthalmology. Juliette Stenz, MD Ophthalmology Juliette Stenz, MD Required Slide Disclosures NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS TO REPORT Required Slide At the end of this session, students will be able to: 1.