Uveitis Lecture Notes PDF

Uveal tissue Includes : 1) Iris...

Uveal tissue Includes : 1) Iris Uveitis 2) Choroid 3) Ciliary body. #inflammation in Any of them is Called Uveitis this also include retina iad it's vessels ‫ اضفت بعض النقاط الي مب‬، ‫همه من الدكتور موجوده من الدفع السابقه‬‫حظات ا‬‫ا‬ ‫يدات الي محذوفه هالسنه مع التجميعات اخر شي‬‫موجوده العام ونبهت على الس‬ The uvea is the vascular Batch B 42 layer of the eye and Notes by QUMED41 will be in RED dr. Alzuhairy + QUMED41 prof. Almohaimeed comprises the iris, ciliary body and choroids Lecture notes team QUMED38 Uveitis, by strict definition BATCH -A- implies an inflammation of the uveal tract. But also applies on the retina and Notes will be inside the yellow box its vessels inflammation. CLASSIFICATION OF UVEITIS Anterior uveitis The presentation of uveitis is important but the detailed investigations is hard to know in this stage Subdivided into: 1. Iritis eht hcihw ni 1. Anatomical yliramirp noitammalfni Anterior, intermediate, posterior and panuveitis siri eht sevlovni 2. Pathological All parts involved Granulomatous versus nongranulomatous uveitis 2. Iridocyclitis hcihw ni 5 eht dna siri eht htob 3. Clinical era ydob yrailic Idiopathic versus secondary to systemic diseases devlovni We can mix between the classifications like : They are very common and sometimes can be Anterior granulomatous Idiopathic uveitis missed if not diagnosed properly or use one of them, like: Anterior uveitis e t  Posterior uveitis Intermediate uveitis Here will be inflammation of the vitreous and during examination we can see the vitreous cells come over the anterior chamber It involves the fundus posterior to the vitreous base is defined as 1. Retinitis with the primary focus in the retina inflammation 2. Choroiditis with the primary focus in the choroids predominantly involving the pars plana 00 3. Vasculitis which may involve veins, arteries or both the peripheral retina and the vitreous. Pars Plana = part of ciliary body Acute anterior uveitis 00 Acute anterior uveitis Acute anterior uveitis is the most common form of uveitis. It is characterized by sudden onset 3. External examination shows ciliary injection around the limbus and duration of 3 months or less. e Is 1. Presentation is typically with sudden onset of unilateral pain, photophobia and redness 2 2. Visual acuity is usually good at presentation except in eyes with severe hypopyon Uni Ciliary injections (Typical for uveitis) Ciliary injections (Typical for uveitis) 4 + 5 are the main/must Acute anterior uveitis Acute anterior uveitis important sign We have to be very careful to examine hypopyon bc 4. Aqueous cells indicate disease activity and sometimes it’s minimal to see _Is their number reflects disease severity Prognosis and progression 5. Aqueous flare reflects the presence of protein due to a breakdown of the blood–aqueous barrier Slit lamp exam light Shadow enters through the window is representing an aqueous flare Slit lamp exam anterior chamber. I 6. Hypopyon is a feature of intense inflammation in which cells settle in the inferior part of the ‫ھﻨﺎ أوﺿﺢ‬ Anterior chamber with aqueous cells y you can count them "good luck with that " Ant.reflex of the cornea #As reminder: Posterior synechiae is adhesion of iris to the Ant.capsule of the lens Anterior synechiae is adhesion of the iris to the cornea Acute anterior uveitis Acute anterior uveitis Management: topical steroid 7. Posterior synechiae may develop quickly Prevention: mydriatic agents  Duration. With appropriate therapy the so inflammation tends to completely resolve within 5– 6 weeks.  The prognosis is usually very good. Complications and poor visual prognosis are related to delayed or inadequate management. PdThe majority of cases the cause is idiopathic Fr The most common cause of anterior uveitis in ADULT is idiopathic iridocyclitis Prognosis is excellent, thanks to steroids which is the main treatment here. Entire Posterior synechiae Except if there is complications like cataract or glaucoma  Chronic anterior uveitis Chronic anterior uveitis mild ‫ا)لتهاب غالبًا‬ ‫ بمضاعفات زي‬3‫رضى يجون متأخر او يكونون داخل‬C‫غالبًا ا‬ Unlike Acute, chronic is usually there is no pain or Redness I glucoma / post. Synechia/ catarct 1. Presentation is often insidious and many Chronic anterior uveitis is less common than the acute type and is characterized by persistent patients are asymptomatic until the inflammation that relapses, in less than 3 months, development of complications such as after discontinuation of treatment. I cataract or band keratopathy. e 2. External examination usually shows a white eye Bilateral involvement is more common than in ___ AAU. 3. Aqueous cells vary in number according to iti disease activity but even patients with re Acute Ant.uveitis usually Unilateral Chronic Ant.uveitis usually Bilateral gfap.se numerous cells may have no symptoms. 4. Aqueous flare To defferntiate between Acute and Chronic Acute : Pain & Redness so Chronic : No Pain & No redness (White eye ) Chronic anterior uveitis Chronic anterior uveitis Most important sign for chronic case D 6. Dilated iris vessels 5. Keratic precipitates (KP) are clusters of 7. Iris nodules: Busacca nodules involve the iris stromae e cellular deposits on the corneal endothelium sets 8. Posterior synechiae composed of epithelioid cells, lymphocytes 9. The prognosis is guarded because of e —> shut down of ciliary body(‫>— ) تبدأ ما تفرز‬ and polymorphs —> inflammation g hypotony hypotony g e.gg complications such as cataract, glaucoma and Dilated iris vessels Keratic Preciptates (KP) Posterior synechiae (Severe)  Posterior uveitis 00 Ciliary flush Posterior uveitis includes retinitis, choroiditis Posterior synechiae and retinal vasculitis Pars plana Presentation varies according to the location 1 of the inflammation. For example a patient with a peripheral lesion may complain of floaters whereas a patient with a lesion Hypopyon involving the macula will predominantly complain of impaired central vision 0 KPs Carful that KP is a hallmark for chronic b We see these signs In Anterior uveitis either "Acute" or "chronic" Posterior uveitis Posterior uveitis Retinitis may be focal, multifocal, or diffuse. Choroiditis may also be focal, multifocal, or diffuse. Active choroiditis is characterized by a round, Ʃ Active lesions are characterized by whitish retinal opacities with indistinct borders due to yellow nodule Focal retinitis surrounding oedema Whitish retinal opacity Yellow Retinitis = Whitish opacity Choroditis = Yellow Nodule  Posterior uveitis Juvenile idiopathic arthritis chronic acute uveitis ‫يكون معاه‬ Vasculitis may occur as a primary condition or as a Juvenile idiopathic arthritis secondary phenomenon adjacent to a focus of retinitis. (JIA) is an inflammatory arthritis of at least 6 weeks' duration occurring before BV‫ ماشي مع ال‬lesion‫ال‬ the age of 16 years when all other causes, such as infection, metabolic Vasculitis is a key pathogenetic componentVasculitis is a key pathogenetic component disorders or neoplasms have been excluded. Females are affected more commonly by a ratio of 3:2. 59541 Inflamed blood vessel (Vasculitis) One of JIA presentation is Uveitis Juvenile idiopathic Ankylosing spondylitis A examine them JIA is by far the most arthritis They do not complain so u have to Ankylosing spondylitis (AS) is characterized by inflammation, 2 common disease associated calcification and finally ossification with childhood anterior uveitis. of ligaments and capsules of joints 7 Inflammation is chronice and with resultant bony ankylosis of the asymptomatic and detected axial skeleton. It typically affects on routine slit-lamp males, of whom 90% are HLA-B27 0 positive ‫ با)ختبار‬5 examination ‫كثير يجي‬ 0 for Both eyes are affected in Acute anterior uveitis ( AAU) occurs 70% in about 25% of patients with AS The eye is usually white even and is typically unilateral, recurrent in the presence of severe and associated with a higher uveitis incidence of posterior synechiae bilateal Ant unfiteral  cyclosporine Behcet syndrome Behcet syndrome Autoimmune disease acute or chronic uveitis ‫ممكن يكون معاه‬ Behçet syndrome (BS) is an Retinitis idiopathic, multisystem disease characterized by recurrent Retinal vasculitis episodes of orogenital ulceration and vasculitis Ocular inflammation is the presenting manifestation in about 10% of cases. Sterile hypopyon AAU, which frequently associated with a transient #Characterized by : recurrent aphthous oral mobile hypopyon ulcers, genital ulceration and uveitis. Retinal vasculitis (occlusive ) Multifocal whitish opacities represent Retinitis #Vasculitis is a key pathogenetic component AAU = Acute Anterior Uveitis Not present in this year Not present in this year Toxoplasmosis Toxoplasmosis is caused by Toxoplasma gondii, an Mp Toxoplasma retinitis obligate intracellular protozoa Clinical features The diagnosis of toxoplasma retinitis is based on a compatible fundus lesion and positive serology for toxoplasma antibodies. Presentation is with unilateral sudden onset of floaters, visual loss and photophobia  Toxoplasma retinitis Herpes simplex anterior uveitis posterior uveitis ‫ ويعمل‬unilat ‫غالبًا‬ Signs Anterior uveitis, which may occur with or without active corneal disease. Black lesions(hyperpigmented) is typical for toxoplasmosis Iris atrophy ‫بعدها بسوي‬ Trophy Corneal sensation test —> diminshed Iris atrophy is typical for herpes simplex anterior uveitis "Posterior synechiae" is also present. It's prominent when we give medications to induce mydriasis. Not present in this year Bacterial uveitis Bacterial uveitis Very important to know Tuberculous uveitis Tuberculosis (TB) is a chronic 3 Syphilis Syphilis is caused by the infection caused by the tubercle bacillus spirochaete bacterium Tuberculous uveitis may be Treponema pallidum difficult to diagnose because AAU occurs in about 4% of it may occur in patients patients with secondary without systemic manifestations of TB Anterior chronic uveitis, is the most frequent feature.With choroditis syphilis and is bilateral in 50%. 0 Chorioretinitis is often Choroiditis Yellow nodule multifocal and bilateral Multiple old and active chorioditis almost choroditis which indicates previous attacks of syphilis I Not present in this year Not present in this year Bacterial uveitis Miscellaneous anterior uveitis blurry vision ‫غالبًا يسبب‬ 4 ‫رضى يجونك بمضاعفات زي القلوكوما او كاتاركت‬C‫ا‬ Hx of ‫! حليب نياق‬ Fuchs uveitis syndrome ‫الحالة ما تستجيب لستيرويد‬ Brucellosis Anterior uveitis + Multifocal choroiditis  Fuchs uveitis syndrome (FUS) is a chronic uveitis entity Brucellosis is caused by the Gram-negative which is usually unilateral. bacteria Brucella melitensis or Brucella  It has an insidious onset, abortus. occurs mostly in the 3rd–4th Uveitis usually characterized by chronic decades and affects both sexes equally. anterior uveitis, multifocal choroiditis,  It is frequently misdiagnosed to and over-treated.  It causes heterochromia (difference in iris colour iris atrophy‫ و‬floaters ‫البدايات يشكي من‬ between the two eyes), a corneal sensation ‫ هو‬herpes 3‫الفرق بينه وب‬ cataract, and glaucoma. Not present in this year Miscellaneous anterior Special investigations uveitis 1. Tuberculin skin tests 2. Serological tests for syphilis: Lens-induced uveitis a. Venereal Disease Research Laboratory Lens-induced uveitis is triggered by an immune (VDRL) response to lens proteins following rupture of b. The fluorescent treponemal antibody the lens capsule, which may be due to trauma to absorption test (FTA-ABS) or incomplete cataract extraction 3. Serological tests for toxoplasmosis: a. Immunofluorescent antibody test b. Haemagglutination test c. ELISA Special investigations Treatment According to the cause 1. HLA tissue typing 1. Mydriatics: Cyclopentolate (0.5% and 1%) a. B27 Spondyloarthropathies, particularly 2. Topical steroids: usually for long time, so observe ankylosing spondylitis for complication b. B51 Behçet syndrome 3. Periocular steroid injection ( posterior sub-Tenon 2. Imaging steroid injection) such as triamcinolone a. Fluorescein angiography (FA) Retinitis & choroiditis acetonide (Kenalog) b. Optical coherence tomography (OCT) 4. Systemic steroids: 1–2 mg/kg/day 3. Radiology 5. Antimetabolites: such as Methotrexate (as a a. Chest X-ray steroid-sparing agent). Posterior resistant uveitis b. Sacroiliac joint X-ray is helpful in the 6. Cyclosporine: is the drug of choice for Behçet diagnosis of a spondyloarthropathy in the syndrome, and may also be used in other presence of symptoms of low back pain conditions, namely intermediate uveitis. and uveitis. To Previous MCQs Generally, we treat by: Chalazion can cause all of the following complications except ? 1- Mydriatics(Cyclopentolate) to keep the pupil dilated, preventing post. synechiae. Ptosis Anterior uveitis + It Irregular astigmatism 2-Steroids : Orbital cellulitis Mild cases = Topical Moderate = Periocular steroid injection Which of the following is the commonest form of uveitis ? Severe = Systemic Steroids Anterior acute uveitis Anterior chronic uveitis Posterior acute uveitis Posterior chronic uveitis management of uveitis What is the most common cause of anterior uveitis in children ? Thank you Idiopathic juvenile arthritis Which of the following is a feature of herpetic anterior uveitis ? Hyphema Decreased corneal sensation Iris atrophy Hypopyon 17y male with left eye pain and photophobia, he had history of lower back pain. What is the most likely sign Is will be seen during the examination ? E Follicle Hypopyon Aqueous flare and cell Hyphema All correct about JIA except : more common in female acute uveitis and symptomatic most common disease of childhood anterior uveitis it’s bilateral A 23 years old man presented to ophthalmology clinic with bilateral non- granulomatous anterior uveitis. History revealed low back pain with flexion deformity of the back. What is the most useful investigation for this condition ? Sign In which disease Pic Ciliary injection Typical for uveitis HLA - 27 OCT Which of the following is not a characteristic of anterior uveitis ? Aqueous cell more cells = more severe uveitis KP Nodule Horner trantas dots Aqueous flare Presence of protein due to breakdown of blood-aqueous barrier Which of the following conditions not associated with HLA-B27 ? Posterior synechiae “adhesion of iris Anterior uveitis crohn’s disease with anterior lens capsule” Arthritis Bechet syndrome Keratic precipitates Anterior uveitis Which of the following is a sign of posterior uveitis ? Dilated iris vessels Chronic anterior uveitis KP Nodules Vasculitis Hypopyon Whitish retinal opacities Posterior uveitis “retinitis” Which of the following is characteristic manifestation of anterior uveitis ? Yellow choroidal nodule Posterior uveitis “choroiditis” purulent discharge Aqueous cells Iridodonesis Symblepharon Retinal Vasculitis Posterior uveitis All of the following are parts of uvea except ? Black pigmented lesion Typical for toxoplasmosis retintis Pars plicata Pars plana Choroid Schwalbe’s line ‫تجميعات‬ Iris atrophy with posterior synechiae Herpes simplex anterior uveitis Multiple old and active choroiditis, Bacterial uveitis “syphilis” which indicates previous attacks of ‫ﻣﺎ أﺗوﻗﻊ ﻓﯾﮫ ﺷﻲء ﺧﺎص ﺑﺎﻟﺳﻔﻠس ﺗﺣدﯾدا‬ syphilis (: ‫ﺑس ھذا ﻣوﺿﻌﮭﺎ ﺑﺎﻟﻣﺣﺎﺿرة‬ Heterochromia Fuchs uveitis syndrome Uveitis lecture BY: AHMED ALMUZAINI QUMED38 – Batch A  : Objectives Manifestaton of diferent ocular tumor Ocular Tumor The most common ocular tumor in adults. The most common ocular tumor in children. The basic treatment optons for them. Qumed 42 batch B notes with red Dr. Nayef Alswaina, MD Good luck Associate professor Ophthalmology consultant orbit details with orbit lecture but you have to differentiate bt the Intraconal and extraconal lesions : Subclassifications : Orbital between the extraocular muscles and contain the optic nerve T Orbital tumors. Intraconal compartement: Eyelid and skin tumors. 1- Optc nerve glioma. E Conjunctval tumors. 2- Optc nerve hemangioma. Uveal tumors. 3- Optc nerve meningioma. Retnal tumors. 4- Cavernous hemangioma I Extraconal compartement: - - S 1- Lacrimal gland tumors. S - S S 2- Rhabdomyosarcoma. 3- Orbital dermoid & Outside the extraocular muscles and contain the lacrimal gland ; Orbital dermoid W ; Orbital dermoid Benign tumor and it’s size increases with age superior temporal swelling > In general considered choristomas Dermoid and epidermoid cysts are examples of choristomas. Choristoma is a benign tumor consistng of histologically normal cells occurring in an abnormal locaton. Dermoid cysts consist of keratnized epithelium and adnexal structures such as hair follicles, >>normal histological tissues but in sweat glands, and sebaceous glands. Slowly enlarge with age, non tender mass how it’s formed ? so abnormal place ↓ As two suture lines of the skull close during embryonic development, dermal or epidermal elements may be pinched of and form cysts. These cysts occur adjacent to the suture line. displacement of the globe superior temporal swelling / * ↑ V :Eyelid tumors Complications:- - Displacement of globe. main complication >> causes proptosis Basal cell carcinoma. Most common malignant tumor of the eyelid - Inflammation in adjacent tissues, if the cyst leaks or ruptures. T Causing astigmatism Squamous cell carcinoma. - Neurologic complications if the cyst compresses optic nerve or cranial nerve Cutaneous melanoma. Sebaceous cell carcinoma ( most aggressive and life threatening conditon ) :Treatment options Observaton( small , asymptomatc) Refracton Surgical excision ( Main treatment opton)  Basal cell carcinoma( BCC) In lower eyelid V Basal cell carcinoma( BCC) Basal Cell Carcinoma (BCC) is a malignant epidermal carcinoma. BCC is the most common eyelid malignancy, accountng for over 90% of malignant eyelid neoplasms. More than 50% of BCCs of the eyelid initally occur on the lower lid. One of the known risk factors of BCC is intense exposure to ultraviolet radiaton And HIV , HPV infection ↑ Elderly patents. Like truck drivers Locally aggressive. rarely metastasize Presentaton: Rodent ulcer 2 -Distorton of eyelid architecture or eyelid malpositon -Presence of skin ulceraton &Rodent ulcer Telangiectasias & -Madarosis (loss of eyelashes) * -Telangiectasias Madarosis = loss of Eyelashes Management : surgical excision+ free margin. Remove all the tumor 29.Conjunctival tumors Conjunctval nevus. Conjunctval melanoma. Conjunctval squamous cell carcinoma. :Conjunctival nevus Z Benign tumor On the surface of the conjuctiva * Brown color Enlarge with aging -  Conjunctival squamous cell carcinoma :Conjunctival nevus. (SCC) Large feeding BV * Benign, noncancerous growth. The most common lesion that occurs on the surface of the eye. It is usually a discrete lesion on the conjunctva (the clear [lm over the eye) and can range from dark brown to yellow color, and many tmes will contain clear cystc components. May darken or lighten with tme. The best inital management for a small, typical - conjunctval nevus is periodic observaton with # photographs. to If growth is documented, local excision of the lesion Gelatinous material At limbal area and Adherent to the underlying tissue should be considered. UNLIKE the Nevus which is located in the surface of g observation conjuctiva. Conjunctival squamous cell carcinoma (SCC) : Conjunctival SCC features & Important = very malignant can cause loss of vision and metastasis * Squamous cell carcinoma of the conjunctva is the end-stage of a spectrum of disease referred to as ocular surface squamous neoplasia (OSSN). Presentaton: OSSN is a malignant disease of the eyes that can lead to loss of vision and, in - Limbal vascularized conjunctval severe cases, death. mass E - large feeding vessels The main risk factors for both are exposure to solar ultraviolet radiaton - adherent to the underlying outdoors, HIV/AIDS, human papilloma virus. Tissues. 8 The limbal epithelial cells appear to be the progenitors of this disease -pterygium-like mass. But don’t have Management: -Topical chemotherapeutc agents (Interferon-α2b, mitomycin C …) > For few weeks then do the surgical removal after that use the topical chemo - - Surgical Excision again to prevent recurrence Lottery : Uveal tumors The most common is the uveal melanoma. The most common site is the choroid. ;Choroidal melanoma Could be pigmented or not ,but usually pigmented b Choroidal melanoma can arise from a pre- existng disease like, choroidal nevus, melanocytoma. Or as a de novo. Or it can be secondary from cutaneous melanoma. 7 -Subretinal mass as the retinal blood vessels above the mass a 83 ;Choroidal melanoma Important ; Features *Usually located near the optic disk n While in children Orange The most common adult ocular malignancy. (Retinoblastoma) Pigmented large subretnal mass. 85% of the uveal melanoma. With blurry margins. In the sixth decade of life. Old people beyond 6th decade With subretnal fuid. Presented either asymptomatc or with vision disturbance if it is around the macula. t Choroidal melanoma is one of the causes of Risk factors: Family Hx, Xeroderma Pigmentosa, dysplastc Neavus Syndrome, uveal Exudative retinal detachment : nevus. Fluid builds up behind the retina Metastatc haematogenous spread to the liver and occasionally to the lungs, bone, skin and brain. *Thickness is over 2 mm. Most common site so do: 1-Abdominal US 2-Liver enzymes To exclude metastasis. : Investigation Once it reaches the mass the reflectivity will decrease after the mass it will go back up Ultra sound: If HIGH consider metastasis and others Low-moderate A-scan: Shows a low- moderate internal refectvity. B- scan : É Shows a thick, solid ocular wall mass. With a characterstc mushroom shaped mass. It breaks Bruch’s membrane and appears as mushroom shape s Differentiate choroidal nevus from. Histopathologic features Very important Formed of 3 types of cells: ‫ قبل‬MCQ ‫جاي عليه‬ :melanoma As it is difficult to differentiate especially at the beginning Spindle cell ( 45 % ) Melanoma features compare to nevus: Either it is (( A )) or (( B )) Thickness over 2 mm; Good prognosis in relatve to the other subtypes. Fluid ( presence of subretna fuid) Epitheliod subtype ( 5 % ) Symptomatc Blurry vision, floaters Poor prognosis Presence of orange pigment Mixed type ( 40 % ) Margin is irregular and within 3 mm of the optc disc Poor prognosis. Drusen absent. 6 Small yellowish pigmentation present in nevus :38 ‫دفعة‬ Drusen : is a small yellowish lipid materials deposit under retina which is absent here and present in choridal nevus.  : Management 1st : Retinoblastoma BV are within the mass in contrast to choroidal melanoma 6 Rule out metastasis; liver enzymes, Ultrasound , chest radiography. + Bone imaging Very Observaton. For small tumors. And can’t differentiate with nevus Radiaton : for intermediate tumors. Small and there is melanoma sign Enucleaton: for large tumors Enucleation ( eyeball removal ) Exenteraton: for orbital melanoma. Exenteration ( eyeball + orbital removal ): for orbital melanoma + choroidal melanoma extending behind the eye to the orbit : Retinoblastoma Presentation Most common primary, malignant, intraocular tumor of childhood (1:20,000) Leukocoria ( most common ). 60% of cases are unilateral, and the remaining 40% are bilateral. Squint 2nd most common presentation No sexual predilecton Loos of vision Usually presents before age of 3 years. Uveits-like. Predisposing gene (RB 1) on 13q14 l Proptosis and orbital cellulits. For large masses 13914 We need to do (red reflex and fundus exam) to R/O retinoblastoma  :Fundus Exam : Investigations presents with one or multple nodular, A & B scan US white or cream colored masses. Ultrasound will help de[ne tumor height and thickness as well as to con[rm associated ofen associated with increased retnal detachment and calci[caton. vascularizaton. -MRI Most likely retinoblastoma ofen shows vitreous seeding, which causes Optc nerve involvement vitreous haze and opacites u G As the prognosis depends on it one of the tumor signs : tumor cells floating inside the vitreous Orbital Eyelid Conjunctival Uveal Retinal : Prognosis Orbital dermoid BCC Most common Conjunctival naevus most common lesion that occurs on the surface of the eye. MC site is Choroid Choroidal melanoma Retinoblastoma Most common primary, malignant, intraocular (extraconal | cutaneous The most common adult ocular Benign, noncancerous growth tumour of childhood cholistoma) malignant tumor. malignancy 60% unilateral Locally aggressive. If optic nerve is not involved the survival and superior temporal lower lid -A discrete lesion dark brown to yellow color -asymptomatic or vision disturbance if 40% bilateral treatment rates will be high and verse versa These cysts occur adjacent With rodent contain clear cystic components. around the macula. M=F Spread thorough the optc nerve. to the suture line ttt: Metastatic hematogenous spread to before age of 3 years Complication: ulcer In general the prognosis depends on the optc nerve involvement. -Displacement of RF: initial observation with photographs. the liver (RPE 1) on 13q14 If grows →local excision. A-scan: Presentation: Treatment includes : thermal, chemotherapy, enucleaton. the glope exposure to SUN Shows a low- moderate internal Leukocoria ( most common ). -Inflammation (UV) reflectivity. Squint thermal laser to shrink it For large tumors -Compression to ELDERLY B- scan Loos of vision optic/cranial nerve “truck driver” Conjunctival SCC solid ocular wall mass. With a Uveitis-like. Proptosis and orbital cellulitis. end-stage of OSSN characterstic mushroom shaped mass. ttt: From limbal epithelial cells Spindle cell → GOOD Fundus Exam: -Observation( small Locally aggressive. One/multiple nodular, RF: Epitheliod/ MIXED → POOR white/cream masses with , asymptomatic) Rarely 38 ‫دفعة‬ metastasize solar ultraviolets, HIV, HPV. Melanoma features: increased vascularization, -Refraction vitreous seeding, which causes Thickness > 2 mm, Fluid, Symptomatic, -Surgical excision ( ttt: pterygium-like gelatinous mass orange pigment, Irregular Margin and vitreous haze and opacities A & B scan US: Main treatment surgical excision+ with large vascular feeding within 3 mm of the optic disc, Drusen associated retinal option) free margin. ttt: absent. detachment and ttt: calcification. Topical chemotherapeutic → -MRI :Optic nerve involvement Surgical Excision First rule out Mets Locally aggressive “POOR” Small: observation Spread thorough the optic nerve Intermediate: radiation ttt: :38 ‫ملخص من دفعة‬ Large: Enucleation Small: thermal, chemotherapy orbital melanoma: Exenteration Large: enucleation  ( ‫تجميعات ) تأكدوا من الحلول‬ A- Basal cell carcinoma. - The most important risk factor for orbital cellulitis is: B- Cutaneous melanoma. A- Ethmoid sinusitis. C- Sebaceous cell carcinoma. B- Dental extraction. D- Squamous cell carcinoma. C- Preseptal cellulitis. D- Surgery. 31- A 5 years old boy presented with slowly progressive painless proptosis and visual loss. Imaging studies confirmed the diagnosis of optic nerve glioma. Which -regarding blow-out fracture of the orbital floor, which of the following is NOT true: of the following is the likely associated condition in this patient? a. a step on the orbital rim is often palpable A- Turner syndrome. b. diplopia may occur B- Neurofibromatosis type-1. c. decreased sensation at the tip of the nose is common C- Tuberous sclerosis. d. surgical emphysema is recognized feature D- Von Hippie Lindau syndrome. e. tear-drop sign on coronal CT scan is characteristic 34- Which of the following is “poor” prognostic feature of a malignant choroidal Patient has trauma to his eye and develop retrobulbar hematoma. What is the first thing to do? melanoma? Lateral canthotomy or cantholysis A- Epithelioid cell type. B- Spindle B cell type. Patient get trauma to his eye and develop hyphaema. Which of these vessels is commonly affected? C- Mixed type. A. Post cillary vessels D- Spindle A cell type. B. Isis major C. Conjunctival vessels 36- A 30 years old patient is presented with unilateral pulsating proptosis. What is the most probable diagnosis? A- Thyroid eye disease. B- Orbital cellulitis. 14.- Ocular tumors Dr. Alswaina C- Optic nerve glioma. D- Carotid cavernous fistula. What is the most common eyelid Tumor? a. Squamous cell carcinoma. 42- Repeated fundus examination of a 57 years old patient revealed a progressive b. Basal cell carcinoma. small pigmented para central sub retinal mass. Which of the following is the C. Sebaceous cell carcinoma. diagnostic investigation of this patient’s condition? d. Cutanous melanoma. A- Visual evoked potential. B- Electro-retinogram. Repeated funds examination of a 57 years old patient revealed a progressive small pigmented para C- Electro-oculogram. central sub retinal mass. Which of the following is the diagnostic investigation of this patient's condition? D- Ophthalmic ultrasound. a. Ophthalmic ultrasound b. Visual evoked potential C. Electro-retinogram d. Electro-oculogram Child come with loss of vision and white puble. C.T show classification what is most likely diagnosis? 1. cataract A 5 years old boy presented with slowly progressive painless proptosis and visual loss. Imaging 2. retinopalstoma not sure studies confirmed the diagnosis of optic nerve glioma. Which of the following is the likely associated 3. rhabdomyosarcoma condition in this patient? 4. Glaucoma a. Von Hippie Lindau syndrome b. Turner syndrome All the following are risk factors for scc except C. Neurofibromatosis type-l 1. HSV d. Tuberous sclerosis 2. ultraviolet 3. HPV Which of the following is "poor" prognostic feature of a malignant choroidal melanoma? 4. AIDS/HIV a. Spindle B cell type - A 7 years old child presented with rapidly progressive unilateral proptosis and displacement of the globe b. Posterior location inferiorly. What is the most likely diagnosis? C. Small-sized tumor A- Optic glioma. d. Epithelioid cell type B- Retinoblastoma. C- Rhabdomyosarcoma. (NOT SURE) 22- A 64 years old man truck driver for 30 years is presented with painless ulcerative and irregular lesion in D- Cavernous hemangioma. his left lower eyelid. What is the most probable diagnosis? * * , ,..., , , Q1: Describe the picture? A: Limbal vascularized conjunctival mass, with Feeding vessels. Q1: Diagnosis? Q2: Diagnosis? A: Orbital Dermoid. A: Conjunctival SCC. Q2: What’s its origin and where do it usually develop? Q3: Risk factors? A: Normal ectodermal tissue in an abnormal location, usually adjacent to suture line. A: 1. Exposure to sun light. 2.HIV 3.HPV 4.Allergic conjunctivitis. Q3: Treatment? Q4: Treatment? A: Observation and refraction. if big or visual loss: surgical excision. A: Excision + local chemotherapy (MMC). MOST COMMON MALIGNANT SKIN TUMOR MOST COMMON ADULT OCULAR MALIGNANCY.. ,.,. Q1: Describe the picture? Q1: Diagnosis? A: Pigmented large subretinal mass with blurry margins and subretinal fluid. A: Basal cell carcinoma. Q2: Diagnosis? Q1: Treatment? A: Choroidal melanoma. A: Surgical excision with free margin. Q3: Pre-existing lesions that can develop this condition? A: 1.Choroidal nevus 2.Melanocytoma. 3. Secondary from cutaneous melanoma. Q4: Risk factors? A: Family Hx, Xeroderma Pigmentosa, dysplastic Neavus Syndrome, uveal nevus. MOST COMMON ADULT OCULAR MALIGNANCY MOST COMMON PRIMARY CHILDHOOD MALIGNANCY A Scan B Scan Q5: Interpretation of A & B Scans? ,. , 3 , ,.. , ,. ,, , A-Scan: Low-moderate internal reflectivity. B-Scan: Thick, solid ocular wall mass with mushroom shape. Q1: Diagnosis? Q6: Prognosis? A: Retinoblastoma. A: Spindle shape has a good prognosis, Mixed type has the poorest. Q1: Treatment? Q7: Treatment? A: Thermal, Radiation, enucleation + chemotherapy. A: R/O Metastasis. Q1: Prognosis? If small: Observation. If big: Radiation + Enucleation or Exenteration(if extend to orbit). A: poor if involves optic nerve. Q1: Diagnosis? A: Conjunctival Nevus.