Presentation on theme: "Macular Invovement in Posterior Uveitis"— Presentation transcript:
1Macular Invovement in Posterior Uveitis بسم الله الرحمن الرحيمMacular Invovement in Posterior UveitisF. Kianersi M.D 1386 / 8 / 3
2Posterior Uveitis is one of the vision threatening diseases especially when the Macula is involved. Several Posterior Uveitic entities involve the Macula, which can either be:Infectious orNon-Infectious.
8Most often is Congenital. Toxoplasmic Retinochoroiditis is Unilateral in 72 to 83% of the cases.Ocular Toxoplasmosis occurs from activation of cysts deposited in or near the Retina.
9Congenital Toxoplasmosis Most commonly acquired during the 3th Trimester of Pregnancy.Infants are usually asymptomatic.
10Peripheral Retinochoroidal scars are the most common ocular finding occurring in 82% of the patients.However, Toxoplasma has a strong predilection for the Posterior Pole, particularly the Macular region.
11Typical Congenital Toxoplasmic Retinochoroiditis Macular Cicatricial Lesion, consisting in: Radial Deposition of Pigment around a Central Necrotic Zone.
12Recurrent lesions frequently develop at the borders of the old Toxoplasma scars, so called Satellite lesions.
13A Yellowish White or Grey Exudative lesion is seen with ill defined borders because of surrounding area of Retinal Edema.Adjacent Choroiditis, Retinal Vasculitis, Hemorrhage and Vitritis may be seen.
14An Active lesion accompanied by a severe Vitreous Inflammatory reaction will have the classic “Headlight in the Fog" appearance.
15Healed Scar typically has well defined borders with Central Retinochoroidal Atrophy and peripheral RPE hyperplasia.
24TreatmentDespite recent advances, an ideal combination that destroys the Tissue Cysts and prevents recurrence has not been found.Current therapies are targeted mainly at the Active disease.
25A combination of the following drugs are used: Pyrimethamine:Loading dose: 100 mg (1st day), followed by 25 mg once daily.Sulfadiazine:4 Gr daily divided in every 6 hours.For 4 to 6 weeks.These two drugs work synergistically against the Tachyzoite form of T gondii.
26Other drugs used in various combinations include: Clindamycin:mg/dose every 6-8 hours, maximum dose: 1.8 gm/day.Trimethoprim + Sulphamethoxazol (Co-Trimoxazole):160 mg/800 mg (one tablet) twice daily.Spiramycin:2 gr/day in two divided doses.Azithromycin:Loading dose 1 G (1st day), followed by 500 mg once daily for 3 weeks.
27Oral CorticosteroidsOral corticosteroids must be initiated at least 24 hours after starting anti parasitic drugs.
28Therapy regimens used during Pregnancy: Spiramycin:2 gr/day in two divided doses.Treatment of the Mother reduces the likelihood of Congenital transmission.
29Standard regimen for newborns Pyrimethamine + Sulfadiazine + Folinic acid
30ManagementFolinic acid for decreasing the likelihood of Leukopenia and Trombocytopenia.Weekly exam of CBC and PLT.
31Surgical Treatment Pars Plana Vitrectomy: to remove Vitreous Opacities, orto relieve the persistent Vitreo-Retinal traction.Scleral Buckling:in cases complicated with Retinal Detachment.
32PrognosisIn cases where Optic Nerve or Macula is spared from the active disease Prognosis remains Good.
39Clinical FeaturesGranuloma in the Peripheral Retina and Vitreous.
40Clinical Features Granuloma in the Peripheral Retina and Vitreous. Posterior Pole Granuloma.
41Clinical Features Granuloma in the Peripheral Retina and Vitreous. Posterior Pole Granuloma.Chronic Endophthalmitis.
42Posterior Pole Toxocariasis Whitish or Grayish-White in Colour
43size of Posterior Pole Toxocariasis Less than One Disk DiameterInvolvement of the Entire Macular Region
44Location of Posterior Pole Toxocariasis JuxtapapillarySubfoveal Location
45DiagnosisThe diagnosis of Ocular Toxocariasis is based on Clinical findings and the serological correlations.
46TreatmentMedical treatment is directed toward the inflammatory response that produces Structural Damage and decreased vision.This includes initial treatment with Topical or Systemic Steroids.Antihelminthic therapy for Ocular Toxocariasis do not alter natural course of the disease.
49Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE - AMPPE) Sudden,Painless Loss of Vision,usually Bilateral.A flu-like prodrome consisting of Fever, Malaise and Headache precedes most cases of AMPEE.
50Fundus ExaminationMultiple Round, Circumscribed, Flat, Yellow White Sub-Retinal lesions involving the RPE.
51Fluorescein Angiography Early films:Hypo-Fluorescence in Inflamed areas secondary to RPE cell Edema, Leukocyte Infiltration, and Capillary Nonperfusion.
52Fluorescein Angiography Late films:Hyperfluorescence due to leakage from the Choriocapillaris through damaged RPE cells.
53As these lesions resolve over several weeks, vision improves in most cases to slightly less than initial acuity.
55Management Neurologic and Systemic Evaluation. Macular involvement in AMPPE needs treatment with Systemic Steroids.Prompt use of Systemic Steroids rapidly resolves inflammation, and may result in a better visual prognosis.
63Serpiginous Choroiditis Bilateral Inflammatory Disorder.Grayish-White lesions at RPE or Choroidal level.
64Serpiginous Choroiditis Usually occurs in the Peripapillary region and progresses in a Helicoid or Serpiginous manner toward the Macula.Acute lesions occur at the edge of the Chronic lesion.Recurrences are common.
65Serpiginous Choroiditis Chronic lesions show Pigmentary changes.