Non Necrotizing Herpetic Retinopathies NNHR

This entity was reported recently 10 . Molecular analysis applied to ocular fluids confirmed the presence of herpes virus DNA in patients presenting with different forms of chronic and atypical posterior uveitis, such as Beh et's disease, retinal vasculitis and birdshot retino-choroidopathy. Non-necrotizing retinopathies associated with haemorrhages have been described (Fig. 10.7). The disease is usually bilateral. It is important to emphasize that all patients with NNHR are corticoresistant or...

Acute Macular Neuroretinopathy AMN

Acute macular neuroretinopathy (AMN) is a rare chorioretinopathy affecting young adults mono- or bilaterally, producing disturbing symptoms of photopsia and often occurring after a flu-like illness like many of the other PIC-CPs 72 . Visual loss is variable and fundus changes are characterized by large macular orange-brown plaques (Fig. 14.7). Fluorescein an-giography shows early choroidal hypofluores-cence or can be unremarkable. The visual field can show a central scotoma. The photopsias,...

In Immune Mediated Dry Eye Disease

The starting point of immune mediated inflammation in the conjunctiva, similar to events in the lacrimal gland in Sjogren's syndrome, may lie in an alteration of the epithelial cells. In the case of the conjunctiva, this is caused by destructions that are observed in all kinds of dry eye due to mechanical abrasion via increased Fig. 6.6. Common mechanisms in immune mediated dry eye disease. Different types of dry eye disease share an immune modulated inflammatory process that can similarly...

Eye Associated Lymphoid Tissue EALT

There has been considerable controversy about the occurrence and normality of lymphoid cells at the ocular surface and appendage. Recent results in whole mounts of complete normal human ocular tissues have shown that lymphoid cells are a normal tissue constituent and in fact form a continuous mucosa-associated lymphoid tissue in the lacrimal gland, conjunctiva and lacrimal drainage system, termed eye-associated lymphoid tissue (EALT) 22, 23, 25, 28 (Fig. 6.2). Fig. 6.2. Eye-associated lymphoid...

To Dry Eye Disease Sjogrens Syndrome

The lacrimal gland is an associated gland of the ocular surface that functionally and embryolog-ically constitutes an integral part of the ocular surface. Similarly, from the viewpoint of mucosal immunology, it is an integral part of the ocular mucosal immune system (EALT) 23 together with the conjunctiva-associated lymphoid tissue (CALT) and the lacrimal drainage-associated lymphoid tissue (LDALT). It contains similar cell populations of T- and B-lymphocytes and DC 64 . T-cell-mediated...

Serpiginous Choroiditis

Serpiginous choroiditis is a progressive recurrent primary inflammatory choriocapillaropa-thy that leads to non-reversible destruction of the chorioretina and is situated at the malignant end of the spectrum of PICCPs 59 . It is also called geographical or helicoid choro-idopathy 60, 61 and affects more elderly patients in addition to the young healthy adult age group traditionally affected by the other PIC-CPs. In India, however, patients are of the same young adult age group as all other...

Basic Functions of MALT

MALT modulates between inflammatory immune protection and immune tolerance (Fig. 6.3). There was a historic misunderstanding of the function and significance of lym-phoid cells at least at the ocular surface because they were usually considered an indication for an inflammatory infiltration of the mucosa. Consequently lymphocytes and plasma cells were frequently termed inflammatory cells. In contrast to this term, lymphoid cells have important functions for the preservation of the tissue...

Vitreous Tap Vitrectomy

Vitreous fluid analysis has to be considered in both inflammatory conditions that do not respond to treatment and in masquerade syndromes. Diagnostic vitrectomy can be associated with therapeutic vitrectomy, especially with a hazy vitreous. This procedure is more complicated than ACP,but provides a larger amount of material for analysis. It is mostly performed in the operating room using a surgical microscope with subtenon or peribulbar anesthesia. During three-port vitrectomy, 0.5-1 ml of...

To Dry Eye Disease Non Sjogrens Dry

Inflammatory affections in dry eye disease are not only found in the lacrimal gland. Even in the clinically inflammation free and primary tear deficient non-Sjogren's dry eye an elevation of inflammatory cytokines (ILia, IL6, IL8, TNFa) is found in the tear film and inside the tissue of the conjunctiva 48 . The ability of conjunctival epithelial cells to release inflammatory cy-tokines has been reported 12 . This indicates a shift of the cellular immune response into the direction of an...

Practical Attitude in Primary Inflammatory Choriocapillaropathies PICCP

As a first step the characteristic ICGA patterns for primary inflammatory choriocapillaro-pathies (PICCP) should be identified and the FA signs should be recorded to stage the severity of the involvement (strong versus mild choriocapillaris ischaemia). Before the diagnosis of PIC-CP is retained, an infectious cause, a neoplastic process or a systemic vasculitis causing choroi- dal ischaemia has to be excluded. The two most frequent infectious causes that can mimic a PICCP are syphilitic and...

Summary for the Clinician

The recent finding of NOD2 associated with a rare familial granulomatous disease has been promising, although so far has not been found to be associated with other granulomatous uveitides Finding TNF associated polymorphisms provides hope that further research will provide a means to predict who will respond best to specific therapeutic agents Inflammation is involved in the pathogenesis of many ocular diseases, not only those thought to be due to primarily to autoimmunity or infection. Such...

Acute Retinal Necrosis ARN

In 1971 Urayama and associates reported the first six cases of presumed viral retinal necrosis and called it unilateral acute uveitis with retinal periarteritis and detachment 60 . The disease is known in Japan as Kirisawa uveitis. Bilateral forms were described later by Western authors. Fisher et al. used the term acute retinal necrosis for the first time in 1982 18 . Later studies confirmed the role of VZV and HSV in the pathogenesis of ARN. In 1994, Holland and the American Uveitis Society...

Diagnostic Procedures

Diagnostic testing of vitreous specimens needs to be carefully planned prior to surgery. Separate specimens need to be collected in appropriate transport containers for each diagnostic test. In general, undiluted vitreous is preferred for cytology, viral culture, polymerase chain reaction (PCR), and antibody determinations. Diluted vitreous wash can be used for flow cytom-etry and DNA gene rearrangement studies and filtered for bacterial and fungal cultures. Vitreous cells and bacterial or...

Lacrimal Functional Unit

Tear flow is reflexively regulated by the lacrimal functional unit (Fig. 2.1). The lacrimal functional unit comprises the ocular surface, including the cornea, conjunctiva, and meibomian glands, the main and accessory lacrimal glands, and the neural network that connects them 33, 41 . Its overall purpose is to maintain corneal clarity and the quality of the image projected onto the retina. Corneal clarity depends, in turn, on the integrity of the tear film and the health of the ocular surface....

Experimental Viral Uveitis

Viral eye diseases are common and are associated with different well-known forms of uveitis. Different animal and cellular models have been used to study herpetic ocular infections 7i, i6 . However, experimental models and clinical observations support the notion of an infectious, especially a viral, aetiology in different autoimmune conditions. One of the major characteristics of herpetic ocular infections is the dual occurrence of a replicative lytic reaction followed or accompanied by...

Fluorescein Angiography Indocyanine Green Angiography

In 1989, Atmaca 5 demonstrated in her study that in 6.3 of BD patients who had otherwise no visual loss and no abnormal findings on fundus examination fluorescein angiography (FA) disclosed incipient fundus changes, like discrete fluorescein leakage from the retinal capillaries. Mostly, in patients with recurrent ocular BD, FA demonstrated occlusion and marked dilatation of the retinal capillaries 156 . In patients with active ocular BD, FA discloses diffuse fluorescein leakage from the retinal...

Cytomegalovirus Retinitis

CMV is one of the most puzzling members of the Herpesviridae family. Ocular involvement has been reported during congenital infection and in patients with acquired immunodeficiency syndrome (AIDS) 34 . Primary infection during pregnancy is the major cause of in-trauterine infection in developed countries, with a mortality rate of 20 and a risk of retinitis in 15 of children. Before the use of highly active antiretroviral therapy (HAART) in AIDS patients, CMV disease was the major cause of...

History Ocular Symptoms

The clinical presentation of scleritis depends upon the anatomic site involved and the extent of inflammation. Patients often seek medical attention for severe, deep, boring pain that can be localized to the eye or generalized (66 ), radiating along the trigeminal nerve distribution to the brow, temple, sinuses, and or jaw 43, 45 . Pain is usually only temporarily relieved with analgesics and can be associated with malaise and weight loss, leading to misdiagnoses such as sinusitis, migraines,...

In Inflammatory Choriocapillaropathies

Indocyanine green angiographic signs in inflammatory choriocapillaropathies have been well determined and have contributed to the recognition of the common mechanism involved and to the regrouping of these entities formerly classified under the term of white dot syndromes. The following ICGA signs need to be looked for 1. The hallmark sign of inflammatory chorio-capillaropathy is patchy or geographic ICGA hypofluorescent areas of variable sizes present in the early, intermediate and late...

Secondary Inflammatory Choriocapillaropathy

As usual in inflammatory disorders, the inflammation is not strictly limited to the primary site of involvement but can also touch adjacent structures. For example severe retinitis caused by Toxoplasma gondii usually extends to the choriocapillaris, causing secondary inflammatory choriocapillaropathy 13 . Likewise severe stromal disease can cause inflammation at the level of the choriocapillaris and beyond to the retinal pigmentary epithelium and to the retina as in Vogt-Koyanagi-Harada...

Acute Idiopathic Blind Spot Enlargement AIBSE

Acute idiopathic blind spot enlargement AIBSE was described in 1988 in a report including seven patients that presented a peripapillary scotoma producing symptomatic enlargement of the blind spot objectively identified by visual field testing. They were all young patients aged from 25 to 39 years with a 5 2 female predominance and 2 7 patients had previous episodes 29 . Visual acuity, colour vision, pupillary responses, funduscopy and fluorescein angiogra-phy were all normal. The only...

Anterior Uveitis

No codified treatment has been used on clinical trials. Topical antiviral therapy is of little benefit during viral anterior uveitis and keratou-veitis. Acyclovir and valacyclovir are active on herpes simplex and varicella zoster virus but inactive on other herpes viruses. Oral administration of antivirals is proposed in the majority of cases. In immunocompetent patients, treatment of herpes zoster ophthalmicus in the first 3 days is able to reduce the occurrence of keratouveitis and uveitis...

Indications for PPV in Uveitis

Accepted Indications Urgent indications - Rhegmatogenous retinal detachment - Visually significant vitreous opacities despite adequate treatment with cor-ticosteroids or immunosuppressive therapy - Vitreomacular traction associated with macular oedema - Non-clearing vitreous haemorrhage - Visually significant epiretinal membranes - In combination with other ocular procedures pars plana lensectomy, placement of GDD - For diagnosis of infections or intraocular lymphoma Relative or Controversial...