Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment

6 Intraocular Inam m ation 211

A B

C D

Fig . 6.11 Vogt-Koyanagi-Harada syndrome. (A) Individual leaking choroidal vessels (black arrow s) indicating inflamm atory choroidal vasculopathy and patchy hypofluorescent areas (w hite arrow s) were visible in the early-phase indocyanine green videoangiography (ICG-V) in the acute disease. (B) Note m arked decrease in the number of large choroidal vessels (black arrow s) in the early phase ICG-V in the acute disease. (C) Evenly sized hypofluorescent spots are observed in the intermediate phase ICG-V at the acute phase of the disease. (D) Some of the spots are persisting into the late phase. (Courtesy of Leyla Atmaca, MD)

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Behçet Syndrome (Oculo-Oro-Genital Syndrome)

It w as first described by Beh çet as a syn drom e ch aracterized by recurren t oral aph - th ous u lcers, gen ital u lcers, an d uveit is (Fig. 6.12).

Presentation

Major feat u res

Recurren t aph th ou s ulcerat ion of th e oral m ucou s m em bran e

Skin lesion s (er yth em a n odosum –like lesion s), su bcu tan eous th rom boph lebit is, folliculit is (acn elike lesion s), cu t an eou s hyp ersen sit ivit y

Eye lesion s (iridocyclit is, ch orioret in it is, ret in ouveit is) an d a defin ite h istor y of ch orioret in it is or ret in ouveit is

Gen ital u lcers

Minor features

Ar th rit is w ith out deform it y an d an kylosis

Gast roin test in al lesion s ch aracterized by ileocecal u lcers

Epididym it is

Vascular lesion s

CNS sym ptom s

A B

C D

Fig. 6.12 Behçet syndrome. (A) Hypofluorescent spots in the late phase of indocyanine green videoangiography (ICG-V). (B) These spots cannot be seen on fluorescein angiography. Hyperfluorescence due to pigment epithelial changes can be observed.

(C) Hyperfluorescent spots in the late phase of ICG-V. (D) These spots cannot be seen on fluorescein angiography. (Courtesy of Leyla Atmaca, MD)

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Differential Diagnosis

Com plete: Fou r m ajor feat u res

Incom plete: (1) Th ree m ajor feat ures, (2) t w o m ajor an d t w o m in or feat u res, or

(3) t ypical ocu lar sym ptom an d on e m ajor or t w o m in or feat ures

Possible: (1) Tw o m ajor feat ures or (2) on e m ajor an d t w o m in or feat u res

Management

Cor t icosteroids an d oth er im m u n osup pressives h ave been t ried . Em pirical t reat- m en t is given .

Sympathetic Ophthalmia

Presentation

Characterist ic sym ptom s: Pain , ph otoph obia, an d decreased accom m odat ion

Characterist ic signs: In flam ed an d th icken ed uveal t issu e w ith edem atous iris,

disk sw elling, n odu les, papillit is, an d yellow n odu les called Dalen -Fuch s n od - ules

Characterist ic associat ions: vit iligo, poliosis, alopecia

Different ial diagnosis: Vogt Koyan agi Harada, len s-in duced uveit is

Treatment

Steroids via all routes an d im m un osu ppressan ts are in dicated .

Endophthalmitis

Traumatic Endophthalmitis

Bacteria or fungi are in t rodu ced at th e t im e of inju r y in t rau m at ic en doph th alm it is. It can occur in u p to 13%of cases of pen et rat ing globe t rau m a. Th e cau sat ive organ - ism differs from oth er en doph th alm it is w ith gram -p osit ive bacteria accou n t ing for 61.0%cases, gram -n egat ive bacteria for 10.2%of cases, fungi in 8.3%cases, an d polym icrobial in fect ion s in 15.6% cases. Th e m ost com m on gram -posit ive organ - ism s w ere coagu lase-n egat ive Staphylococcus (21.5%) an d Bacillus species (18.5%), follow ed by St reptococcus species (14.8%) an d Staphylococcus aureus (8%).

Presentation

Becau se ocular t raum a gen erally occu rs in a n on sterile environ m en t , m ost inju ring object s are con tam in ated w ith m ult iple in fect ious agen ts. Pat ien t s w ith a larger area of lacerat ion , delay in su rger y, rupt u red len s capsu le, retain ed in t raocular foreign body, n on m et allic foreign body, an d dir t y w ou n d are m ore com m on ly associated w ith post t rau m at ic en doph th alm it is. Th e pat ien t presen t s w ith pain , ph otop h obia, an d decreased vision occurring a variable period, even years, after pen et rat ing ocu lar t raum a. Sign s of in t raocu lar in fect ion are seen .

214 Color Atlas of Ophthalm ology

Management

Early repair of th e injur y is n ecessar y. A retain ed in t raocu lar foreign body m ay requ ire a vit rectom y. If th e risk of en doph th alm it is is greater, con sider t aking an aqu eou s an d vit reous t ap for cu lt ure an d sen sit ivit y. In t ravit real an t ibiot ics such as van com ycin hydroch loride (1 m g in 0.1 m L) an d am ikacin (0.4 m g in 0.1 m L) or ceftazidim e (2.25 m g in 0.1 m L) m ay be given at th e t im e of su rger y along w ith in t racam eral an d in ten sive postop erat ive an t ibiot ics, w h ich are ch anged according to cult u re an d sen sit ivit y report s.

On ce th e in fect ion is con t rolled, steroids m ay be added to decrease th e in flam - m at ion .

Postoperative Endophthalmitis

Any su rgical procedure on th e eye th at disru pts th e in tegrit y of th e globe, h ow ever m in or th e breach m ay be, can lead to postop erat ive en dop h th alm it is, su ch as cat a- ract , glau com a, vit rectom y, an d radial keratotom y. Postoperat ive en doph th alm it is represen ts 70% of in fect ive en doph th alm it is. Th e large m ajorit y of cases follow cataract su rger y, w ith an approxim ate prevalen ce of 0.082 to 0.1%. It can occur secon dar y to periocu lar flora gain ing access in to th e eye du ring su rger y, organ ism s being carried in to th e eye as su rface flu id reflu xes th rough th e w oun d du ring surger y, secon dar y to in t raocu lar len s con t am in at ion if it tou ch es th e ocular surface, or w ith th e use of con tam in ated irrigat ion solut ion s (Fig. 6.13).

Presentation

Th e pat ien t gen erally presen t s w ith pain , redn ess, decreased vision , lid edem a, h azy corn ea, an d hypopyon . Th ree form s of presen tat ion m ay be seen :

Acute form : Usu ally fulm in an t , occurs 2 to 4 days postop, m ost com m on ly du e to S. aureus or st reptococci

Delayed form : Moderately severe, occurs 5 to 7 days postop, due to Staphylococcus epiderm idis, coagu lase-n egat ive cocci, rarely fungi

Chronic form : Occu rs as early as 1 m on th postop, due to Propionibacterium acnes, Staphylococcus epiderm idis, or fungi

Fig. 6.13 Endophthalmitis—conjunctivitis.

6 Intraocular Inam m ation 215

Management

Cer tain m easures, such as 3 days of p reoperat ive prophylact ic an t ibiot ics an d preoperat ive povidon e-iodin e (5%) scr ub, can h elp reduce th e risk of postoperat ive en doph th alm it is (POE). Prim ar y use of preoperat ive topical fou rth -gen erat ion flu oroqu in olon es su ch as m oxifloxacin an d gat ifloxacin is ben eficial an d is bet ter for preven t ing resistan ce.

Th e En dop h th alm it is Vit rectom y St udy w as a m u lt icen ter ran dom ized t rial perform ed at 24 cen ters in th e Un ited St ates (1990 to 1994) to determ in e th e role of in t raven ou s an t ibiot ics in th e m an agem en t of POE an d th e role of in it ial vit rectom y in m an agem en t . Th e st udy con clu ded th at system ic an t ibiot ics w ere of n o ben efit an d th at in it ial vit rectom y w as on ly ben eficial for pat ien t s presen t ing w ith a ver y poor visu al acu it y.

Cu lt u res sh ou ld be t ake n from t h e aqu eou s an d vit re ou s. Th e p ossibilit y of isolat in g an organ ism from t h e vit reou s is 56 to 70%, w h ereas from t h e aqu eou s it is 36 to 40%. In est ablish ed e n d op h t h alm it is, oral or in t rave n ou s an t ibiot ics h ave p oor p e n et rat ion in to t h e vit re ou s cavit y. Hen ce in t ravit real inject ion s are t h e t reat m en t of ch oice. For gram -p osit ive organ ism s, a sin gle d ose of in t ravitreal van com ycin 1 m g in (0 .1 m L) h as ad e qu ate an t ibiot ic con cen t rat ion s for over 1 w eek. Am ikacin (0 .4 m g in 0 .1 m L) an d ceft azid im e (2 .25 m g/0 .1 m L) are effe ct ive again st gram - n egat ive organ ism s. Th u s van com ycin com bin e d w it h am ikacin or ceft azid im e ap p ears to be t h e best com bin at ion for t h e t reat m e n t of POE.

Dose of subconjunct ival ant ibiot ics: Van com ycin (25 m g in 0.5 m L) an d ceftazidim e (100 m g in 0.5 m L) or am ikacin (25 m g in 0.5 m L)

Dose of topical fort ified ant ibiot ics: Van com ycin (50 m g/m L) an d am ikacin (20 m g/m L), altern at ing ever y 1 to 4 h ours

Dose of cort icosteroids: Topical, sub-conju n ct ival inject ion (dexam eth ason e, 6 m g in 0.2 m L), oral (p redn isolon e 30 m g by m ou th t w ice a day for 5 to 10 days), or in t ravit real

Endogenous Endophthalmitis

En dogen ou s en doph th alm it is is gen erally of h em atogen ou s origin an d u su ally affect s adult s w ith predisposing con dit ion s such as diabetes, u rogen it al an d gas- t roin test in al t ract disorders, en docardit is, an d pat ien ts on im m u n osu ppressives or h aving u n dergon e invasive procedures. Th e et iological organ ism m ay be gram - posit ive or n egat ive bacteria or fungi. In th e p ediat ric age grou p, n eon atal in fect ion h as been seen w ith grou p B st reptococcal or Candida albicans.

Presentation

It m ay presen t acutely or as a slow ly progressive con dit ion . Th e p at ien t m ay presen t w ith pain an d decreased visual acu it y. Exam in at ion m ay sh ow a spect rum of clin ical sign s ranging from m in im um sign s of in flam m at ion , hypopyon , vit rit is, Roth spot s, ret in al periph lebit is, to pan oph th alm it is in severe cases. W h ite ch orioret in al in filt rates w ith fluffy w h ite vit reou s opacit ies (“st ring of pearls” appearan ce) m ay be seen in Candida endophthalm it is.

Management

Blood cu lt u res, in t raocu lar cu lt u res obtain ed from both ch am bers, an d cu lt ures from oth er sites su ch as an in dw elling cath eter are taken . Early in t raven ou s an - t ibiot ic th erapy is crucial. Th e pat ien t sh ou ld be w orked up system ically to de-

6 Intraocular Inam m ation 217

Intraocular Foreign Body

A retain ed in t raocu lar foreign body can cau se siderosis, m an ifest ing as a focal low - grade in flam m at ion , cat aract form at ion , or ch ron ic in flam m at ion .

Schw artz-Jampel Syndrome

Rh egm atogen ous ret in al detach m en t m ay be associated w ith an terior ch am ber react ion an d glau com a.

Juvenile Xanthogranuloma

Juven ile xan th ogran ulom a is a rare pediat ric disorder affect ing th e h ist iocytes of th e skin . It m ay som et im es affect th e eye an d can presen t w ith m any differing ocu lar m an ifest at ion s su ch as m asquerade uveit is, h eteroch rom ia, hyph em a, or glaucom a.

Paraneoplastic Syndrome

Tu m or-associated ret in op athy secon dar y to cu tan eous m elan om a or bron ch ial carcin om a m ay som et im es occu r. Su ch pat ien t s m ay h ave bilateral ret in opathy an d loss of vision .

7 Lens and Cataract 219

ficat ion . A sm all am oun t of viscoelast ic can be injected ju st u n der th e rim of th e rh exis all arou n d to form a m ech an ical barrier for flu id from acciden tally en tering th e subcapsular plan e w h ile perform ing hydrodelin eat ion . Because th e n u cleu s after hydrodelin eat ion is ver y sm all, it can be rem oved easily eith er by carou selling (con st an tly rot at ing th e n ucleus to prolong occlusion an d allow m ore effect ive breakdow n of th e cataract) it ou t w ith th e ph aco t ip or by u sing a ch op m an euver. Ph aco ch op is esp ecially h elpfu l in case of associated n uclear sclerosis. If th e cen - t ral plaque w as n ot rem oved at th e t im e of su rger y, it can be tackled by a yit t riu m alu m in u m garn et capsu lotom y postoperat ively.

Sub 1 mm 700-Micrometer Ca ta ra ct Surgery—Micropha konit

Microph akon it or bim an ual ph acoem u lsificat ion th rough t w o 0.7-m m in st ru - m en ts (an irrigat ing ch opper an d a ph aco t ip) can be u sed effect ively to t ackle a posterior polar cat aract . Hydrodelin eat ion can be don e th rough both por ts h ere. An oth er advan t age of th is tech n ique is th at on e can easily rever t to bim an ual vitrectom y in case of vit reou s loss. Th e advan tage of m icroph akon it over ph aco is th at on e h as a closed ch am ber th rough ou t su rger y becau se both th e in cision s are so sm all (Fig. 7.1B).

Subluxated Cataract

Sublu xated cataracts pose a risk of n u cleu s drop du ring cataract su rger y, an d h en ce requ ire sp ecial precau t ion s.

Presentation

Th ere can be a zon u lar deh iscen ce or w eakn ess presen t .

Differential Diagnosis

Colobom a of th e len s. Th ere can be colobom a w ith a su blu xat ion (Fig. 7.2A).

A B

Fig . 7.2 (A) Subluxated colobomatous lens. (B) Aniridia rings being implanted. ([A]

Courtesy of Lincoln L. Freitas)

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Management

Cat aract su rger y in th e presen ce of zon ular w eakn ess or a su blu xated len s is a great ch allenge. In th e past , su rgical in ter ven t ion in th ese cases w as difficu lt , lead - ing to com plicat ion s. Th e u se of an en docapsular flexible polym ethyl m eth acr ylate (PMMA) ring h as ch anged th e su rgical approach to su blu xated cataracts. Im plan ta- t ion of a capsular ten sion ring (CTR) st abilizes a loose len s an d allow s th e surgeon to place th e in t raocu lar len s in th e m ost desirable p lace—th e capsular bag. Th ere are n u m erous oth er advan tages: vit reous h ern iat ion to th e an terior ch am ber is redu ced, a t aut capsu le gives coun tert ract ion to all t ract ion m an euvers m aking th em easier to perform , capsular su ppor t for an “in th e bag” im plan t is obtain ed, an d m ost im por tan tly, th e capsu lar bag m ain t ain s its sh ape, avoiding capsu lar fibrosis syn drom e an d in t raocu lar len s decen t rat ion .

Do n ot use t r ypan blue in sublu xated cataracts because th e tr ypan blue w ill go into th e vit reous cavit y through th e zonular dehiscen ce an d m ake th e w hole vitreous cavit y blue. W h en zonular deh iscence is large in extent or progressive in n at ure, capsular bag shrin kage resulting in in traocular len s decen tration and pseudoph a- kodonesis m ay occur even after a successful surger y w ith a capsular ring. Com plete lu xation of the bag an d its con ten ts has also been reported . For such cases, Cionn i’s m odified design w ith a fixat ion h ook is a good solution . The h ook is kept in th e area of dialysis an d is pulled periph erally using a t ran sscleral fixation sut ure to counteract capsular bag decen trat ion an d tilt . In severe cases, t w o such rings or th e t w o- hooked m odel can be used . An altern ative in cases of severe decentration is to m ake a sm all equatorial capsulorrhexis through w h ich a standard capsular tension ring can be in serted . A scleral sut ure can th en be passed around th e exposed capsular ten sion ring, w h ich is th en used to cen ter th e lens before capsulorrh exis. Peribulbar anesth esia is suitable for creat ion of scleral w indow s an d transscleral sut uring of th e capsular ring or of th e in traocular lens if n ecessar y.

CTRs can also be placed to cover sector iris defects or colobom a. Th ese colobom a sh ields h ave an in tegrated 60to 90-degree sector sh ield to protect again st glare an d m on ocu lar diplopia. More th an on e capsu lar ten sion ring can be used if m ore th an 90 degrees of defect is presen t . Mult isegm en ted colobom a rings are available for an iridia as w ell as for cases w ith large perm an en tly dilated pu pils secon dar y to any cause. In sert ion of t w o of th ese rings so th at th e in terspaces of th e first ring are covered by th e sector sh ields of th e secon d m akes a con t iguous ar t ificial iris possible (Fig. 7.2B).

Miotic Pupil Cataract

A w ell-dilated pu pil is th e gatew ay to a sm ooth , easy, an d rew arding cataract su rger y. Bu t th e su rgeon m ay n ot be lucky en ough to sail sm ooth ly th rough th e w ell-ch arted path of a dilated pu pil each t im e. Som et im es th e door looks n arrow an d un invit ing even for th e best . A m iot ic pu pil is a com m on bugbear th at ever y su rgeon faces at som e t im e.

Presentation

A sm all pu pil affects all steps of ph acoem ulsificat ion , righ t from capsu lorrh exis to in t raocu lar len s in ser t ion . Difficult m an euvering cau ses iris dam age, sph in cter tears, zon u lar dialysis, bleeding, an d so on . Poor exposure th rough a sm all pu pil forces th e surgeon to m ake a sm aller rh exis, adding to th e difficu lt y an d frequen tly