CHOROIDITIS

From Big Medical Encyclopedia

HORIOIDYT (chorioiditis; lat. chorioidea a choroid of an eye - f--itis; a synonym a back uveitis) — an inflammation of an idiovascular cover of an eye.

The isolated inflammation of an idiovascular cover of an eye (horioidea) meets seldom, more often in patol. process is involved a retina and there is a chorioretinitis, or retinokhorioidit (see the Retinitis).

Etiology and pathogeny. In development of inflammatory diseases of a horioidea (see the Choroid of an eye) the main role belongs to an infection — tubercular, toksoplaz-mozny, streptococcal, staphylococcal, virus, syphilitic, brucellous, etc. The structure and functions of a horioidea create the conditions promoting a delay in it the bacteria brought with a blood flow, viruses, protozoa, helminths and other activators, and also toxins.

In a pathogeny of a choroiditis the main role is played by immune responses. Morfol. the changes defining a wedge, a picture of a choroiditis are a consequence of receipt in an eye of antigens and cell-bound immune complexes. The extra-eye centers of an infection are sources of antigens. Emergence of a choroiditis can provoke overcooling of an organism, acute and chronic inf. diseases, injury of an eye. In a pathogeny of a choroiditis the microbic allergy (see) which is shown a giperergichesky inflammation has a certain value. At the same time activators can play a role of a releaser, and the inflammation develops as autoimmune process.

Classification. Allocate endogenous and exogenous choroidites. Most often meet endogenous, among to-rykh distinguish tubercular, virus, toksoplaz-mozny, streptococcal, brucellous and other choroidites. Exogenous choroidites develop as a result of involvement in inflammatory process of a horioidea at traumatic iridocyclites (see) and diseases of a cornea (see).

On the nature of defeat choroidites divide on focal and diffusion. At a focal choroiditis the inflammatory centers (focuses) can be single (isolated) and multiple (scattered, or disseminated, a choroiditis). Depending on localization of inflammatory infiltrate choroidites divide on central, at to-rykh infiltrate is located in the central (macular) region (a spot, T.) eyeground (see), peripapillary, characterized by development of infiltrate around an optic disk, equatorial with infiltrate in a zone of the equator of an eye, peripheral, at to-rykh infiltrate it is localized in peripheral departments of an eyeground, near the gear line.

Pathological anatomy. Pato-morfol. changes at nonspecific inflammatory processes in horioidy are same. At a focal choroiditis in a choroid find the limited infiltrate consisting of the lymphoid elements which are located around expanded vessels. Infilt.Rat occupies all thickness of a horioidea more often. At a diffusion choroiditis inflammatory infiltrate consists of lymphocytes, epithelioid, sometimes colossal cells. All these elements diffuzno extend on fabric of a horioidea, squeezing vascular textures.

The inflammation of a horioidea causes patol. changes in a retina, to-rye are shown first of all by destruction of a layer of a pigmental epithelium, and also edematization and hemorrhages.

In the course of treatment inflammatory infiltrate in horioidy can resolve. More often cellular elements of infiltrate are replaced with fibroblasts and connective tissue fibers, forming a layer of cicatricial fabric. In a neogenic hem the remains of the changed large vessels of a horioidea remain; on the periphery of a hem proliferation of a pigmental epithelium of a retina is noted.

At a tubercular choroiditis character morfol. changes depends on a stage of development of tubercular process (see Tuberculosis extra pulmonary, tuberculosis of eyes). At primary tuberculosis the inflammation in horioidy proceeds on exudative type. Diffusion lymphoid infiltration with existence of epithelial cells and colossal cells of Pirogov — Langkhansa is observed. At secondary tuberculosis the productive type of an inflammation with formation of typical tubercular granulomas with a caseous necrosis prevails. During the progressing of process merge of granulomas and formation of the large konglobirovan-ny center — a tubercle is noted.

Clinical picture. Patients with a choroiditis have no pain and visual frustration therefore quite often it is revealed only at an oftalmoskopiya (see). During the involvement in process of departments of a retina (chorioretinitis), adjacent to the choroidal center, there are vision disorders. When the chorioretinal center is located in the field of the central departments of an eyeground, falloff of sight, distortion of the considered objects is noted (see the Metamorphopsia), the patient feels flashes and blinkings (see Photopsias). At defeat of peripheral departments of an eyeground twilight sight decreases (see Gemeralopiya), «the flying front sights» are sometimes observed. Limited defects under review — the scotomas (see) corresponding to the location of the centers come to light.

The inflammatory centers in horioi-dy, revealed at an oftalmoskopiya, can be single or multiple, have various size and the form, but more often happen roundish. The size of the centers from V2 to I1/2 of diameter of an optic disk, smaller or very large centers are seldom observed.

At an active inflammation on an eyeground the grayish or yellowish centers with indistinct contours are visible (tsvetn. the tab., Art. 48, fig. 1 and, b), pro-mining (pressing) in a vitreous (see); vessels of a retina are located over them, without being interrupted.

During this period in connection with defeat of vessels hemorrhages in horioideyu, a retina and a vitreous are possible. Progressing of a disease and distribution of process on surrounding fabrics lead to development of opacification of a retina in the field of the center; at the same time small vessels of a retina are invisible. In some cases opacifications in back department of a vitreous develop.

Under influence to lay down. influences the chorioretinal center is flattened, becomes transparent, gets more accurate contours. On border of the center pigmentation in the form of small points appears. More often on site than the center small and average vessels of a horioidea disappear; horioideya becomes thinner, it is appeared through by a sclera. At an oftalmoskopiya on a red background of an eyeground the white center with large vessels of a horioidea and pigmental glybka is visible. Sharp borders and pigmentation of the center demonstrate transition of an active inflammation to a stage of an atrophy of a horioidea (tsvetn. tab., Art. 48, fig. 2).

At an arrangement of the chorioretinal center about an optic disk distribution of an inflammation on an optic nerve is possible. In such cases under review there is characteristic scotoma merging from physiological; at an oftalmoskopichesky research the stushevannost of borders of an optic nerve is defined. The iye-ripapillyarny chorioretinitis called by also okolososochkovy neuroretinitis of Janszen, a yukstapa-pillyarny retinokhorioidit of Janszen, a circinate retinitis (see) develops.

Described a wedge, manifestations of a choroiditis are not characteristic of a disease of any certain etiology and can be revealed at virus, streptococcal and other choroidites.

At tubercular defeat of a horioidea (tsvetn. the tab., Art. 48, fig. 3) meet such wedge, forms as miliary, disseminated, focal more often (with the central and okolososochkovy localization of focus) a choroiditis, a tubercle of an em of a horioidea, a diffusion choroiditis (see the Retinitis; Tuberculosis is extra pulmonary, tuberculosis of eyes). The diffusion tubercular choroiditis is observed at young age against the background of chronically current primary tuberculosis. At this form on an eyeground the extensive site of yellowish or grayish color passing into surrounding fabrics is found. Inflammatory process in horioidy is followed by the expressed reaction of a retina and a vitreous, comes to the end with an atrophy of a horioidea.

At a toxoplasmosis the focal choroiditis, as a rule, develops, at an inborn toxoplasmosis — preferential central focal choroiditis (see the Retinitis, the Toxoplasmosis).

At the choroiditis caused by inborn syphilis the characteristic picture of an eyeground is observed (see tsvetn. the tab. to St. Eyeground, t. 6, Art. 96 — 97, fig. 56 and 57).

At the acquired syphilis the diffusion choroiditis develops, as a rule, (see the Retinitis).

Current of a choroiditis more often chronic with a recurrence.

Complications. The choroiditis is complicated by secondary dystrophy of a retina (see), exudative amotio of a retina, neuritis with transition to a secondary atrophy of an optic nerve, extensive vitreous hemorrhages with the subsequent shvartoobrazovaniye. Hemorrhages in horioideyu and a retina can lead to formation of rough connective tissue hems and formation of a neovascular membrane that is followed by falloff of visual functions.

The diagnosis is made on the basis of results of a straight line and return oftalmoskopiya (see), and also a fluorescent angiography of an eyeground (see. Fluorescent angiography). These methods allow to establish a stage of a disease that is of great importance for treatment and the forecast. Clarification of an etiology of a choroiditis is often accompanied by great difficulties (approximately in 30% of cases the etiology remains obscure) and demands comprehensive examination of the patient (see an Eye, methods of a research; Inspection of the patient, ophthalmologic). In a crust, time are eurysynusic immunol. diagnostic methods, they include serological tests, identification of a sensitization and polysensitization to various antigens, definition of immunoglobulins in blood serum, a tear, intraocular liquid, identification of focal reaction in an eye in response to administration of allergens.

Differential diagnosis is carried out with an outside exudative retinopathy (see the Retinopathy), a nevus (see) and an initial stage of a melanoma (see) horioide. Unlike a choroiditis vascular changes in a retina — micro and macroaneurisms, arterial shunts revealed at a fluorescent angiography of an eyeground are characteristic of an outside exudative retinopathy. The nevus of a horioidea at an oftalmoskopichesky research of an eyeground decides as the flat site of flaky or gray and flaky color on a clear boundary, the retina over it is not changed; sight at a nevus of a horioidea does not suffer.

The melanoma of a horioidea in an initial stage at an oftalmoskopichesky research has an appearance of a compact node with a clear boundary. During the progressing of a tumor unilateral secondary glaucoma can develop that is not observed at a choroiditis. The diagnosis is specified by means of ultrasonic and radio isotope methods of a research (see. Radio iso-fenny diagnosis, Ultrasonic diagnosis).

Treatment is directed to elimination of a basic disease, including to stopping of inflammatory process, prevention of a recurrence and complications, recovery of visual functions is carried out. Include the pathogenetic, specific and nonspecific hyposensibilizing means, symptomatic means, physiotherapeutic and physical methods of influence (a lazerkoagulya-tion, cryocautery) in a medical complex.

Specific desensitization is carried out for the purpose of decrease in sensitivity of sensibilized tissues of eye at tubercular, toksoplazmozny, virus, staphylococcal and streptococcal choroidites, etc. Antigen is entered in small doses repeatedly. Specific desensitization is a perspective method of treatment, promotes prevention of a recurrence. Nonspecific desensitization is shown at chorioretinites at all stages of treatment — in the period of an active inflammation, at a recurrence, and also for prevention of an aggravation. For this purpose use antihistaminic drugs (Dimedrol, supras-gin, tavegil, Pipolphenum, diazoliya, etc.).

The important place in treatment of choroidites is taken by antibacterial therapy, to-ruyu carry out according to an etiology of process and for sanitation of the centers of an infection in an organism. At an unspecified etiology of a choroiditis use antibiotics of a broad spectrum of activity. Corticosteroids (dexamethasone, before-nizo l it, a cortisone, Triamcinolonum, a hydrocortisone, triamsikol, etc.) apply in a complex with other pharmaceuticals in the period of an active inflammation or at a recurrence. Immunodepressive means are also shown at an active inflammation and in the period of an aggravation. Appoint Mercaptopurinum, an imuran, a methotrexate, ftoruratsit, Cyclophosphanum in combination with corticosteroids. Antibiotics, corticosteroids, cytostatics enter intramusculary, inside, retrobulbarno, suprakhorioidalno, by means of an electrophoresis. Widely apply redoxons, Vkh, B6, B12 at all stages of treatment of chorioretinites.

For a rassasyvaniye of exudate and hemorrhages in horioidy, a retina, a vitreous use enzymes (trypsin, fibrinolysin whether - Dazu, papain, lecozimum, Streptodecasum), to-rye enter intramusculary, retrobulbarno, by means of an electrophoresis.

Cryocautery of a horioidea is shown at secondary dystrophies after the postponed choroiditis for prevention of amotio of a retina. Retinas make Lazerkoagulyation at hemorrhagic chorioretinites and for prevention of amotio of a retina.

At an active inflammation and a recurrence of a disease treatment is carried out in a hospital, then it is out-patient. The resort therapy can be carried out in sanatoria of the general type, at tubercular chorioretinites — in specialized sanatoria.

The forecast depends on an etiology of a choroiditis, its prevalence and localization. The total blindness is observed seldom, preferential ggr development of complications — post-nevriticheskoy atrophies of an optic nerve, exudative amotio of a retina.

Prevention of a choroiditis consists in timely diagnosis and treatment of acute and chronic infectious diseases.

Bibliography: Arkhangelsk!?. H.

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O. B. Chentsova; E. G. Yeliseyev (tsvetn. fig.).

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