IRIDOCYCLITIS (iridocyclitis; Greek iris, irid[os] a rainbow + kyklos a circle, an eye + - itis) — an inflammation of an iris and a ciliary body. The isolated inflammation of an iris (iritis) or a ciliary body (cyclitis) meets seldom. Frequency of simultaneous defeat of an iris and ciliary body is caused by a community of their blood supply and an innervation.
Modern achievements of an oftalmoimmunologiya promoted development of etiopatogenetichesky classification endogenous And., on a cut the following its forms are allocated: 1) infectious And., developing in connection with the general infectious diseases of an organism; 2) infectious and allergic And., caused hron, a bacterial sensitization; 3) autoimmune And., arising at general diseases; 4) And. at other patol, conditions of an organism.
at the heart of emergence And. hl lie. obr. general diseases of an organism (endogenous And.). And. can be also a complication of inflammatory diseases of a cornea or the getting damages of an eyeglobe (exogenous And.). Endogenous And. arise owing to a hematogenous drift of the causative agent of tuberculosis, syphilis, a brucellosis, and also staphylococcus, a streptococcus, various viruses or their antigens, cell-bound immune complexes in fabric of an iris and ciliary body. At children etiol, the children's infections postponed vnutriutrobno and also in the first months and years of life can play a role.
Specific weight of various infections in development And. it is not identical. Most often And. earlier it was connected with a tuberculosis infection, however decrease in frequency tubercular is noted And. from 45% to 25 — 27%. The second place on frequency is taken herpetic And. (3 — 3,8%). The role of syphilis, brucellosis, a toxoplasmosis, a hay fever is insignificant (1 — 2%). At 17,7% of patients And. arise because of the infection which is localized in almonds, carious teeth, paranasal sinuses etc. at 15,5% — at general diseases (rheumatism, a pseudorheumatism, collagenoses).
Development of an oftalmoimmunologiya led a pathogeny to recognition of the leading role of immune mechanisms in a pathogeny And.
Features of a structure of an iris and the ciliary body consisting of numerous vascular loops with sharp expansion of a gleam and delay of a blood flow create favorable conditions for fixing in them pathogenic microorganisms at various infections.
The inflammatory process in an iris and a ciliary body arising under the influence of «releaser», most often a microbe or a virus is followed, on the one hand, by their pathogenic action on tissue of an eye, and with another — immunol, the reactions developing in an organism. Damage of tissues of eye is followed by release of biologically active agents — serotonin, a histamine, prostaglandins and various mediators of cellular immunity — limfotsitotoksin, the factor inhibiting migration of macrophages, blastogenic, hemotoksichesky factors etc.
By pilot studies on animals it is shown that at penetration of a microbe or a virus into an eye there is their migration in peripheral bodies of an immunogenesis — limf, nodes, a spleen and formation of cellular and humoral immunity. Immunol. reactions finally define character of a current and an outcome And. various etiology.
Fluorescent angiography (see) irises at experimental immupogenny And. reveals increase in permeability of a blood-ocular barrier with an exit of a flyuorestsein in an anterior chamber.
During the modeling of infektsionnoallergichesky and autoimmune PI. at animals it is established that one general sensitization — microbic or fabric — is not enough for development And. Crucial importance has repeated administration of antigen in an eye.
In a pathogeny infectious and allergic And. the great value gets action of the provocative factors of surrounding or internal environment leading to repeated intake of antigens in an eye from the extraocular centers of an infection from the person. Provocative factors are cooling, an injury, endocrine and neurohumoral shifts in an organism, visual overloads, fluctuations meteorol. conditions and other stressful situations.
Features morfol, pictures I. various etiology formed the basis to Woods (A. Woods, 1956) for their division on granulematozny and negranulematozny.
Granulematoznye I. develop generally at some infections and are characterized by education in an iris and in a ciliary body of the granulomas consisting of lymphoid, epithelial and colossal cells and the centers of a necrosis.
Morfol, a picture of a negranulematozny inflammation is characteristic of infectious and allergic and autoimmune I. Otmechayetsya hypostasis, fibrinous exudation of an iris and a ciliary body, polynuclear, plasmatic or their lymphoid infiltration with the phenomena of disturbance of microcirculation and fibrinoid swelling, a hyalinosis of a vascular wall. Gistokhim, methods of a research allow to reveal the metachromasia of a vascular wall indicating accumulation of acid mucopolysaccharides.
Tubercular And. are shown or in the form of a diffusion proliferative inflammation of an iris and a ciliary body and infiltration by lymphocytes, macrophagic elements, epithelial and colossal cells, or in the form of small nodular educations — a tubercle. The tubercular granuloma can extend to a back surface of a cornea, a sclera, a vitreous, an idiovascular cover (horioide)) and a retina.
At syphilitic And. focal or diffusion infiltration from lymphocytes and plasmocytes and expressed endo-and perivasculites is noted.
Due to the broad use of specific antibacterial therapy and corticosteroids it is noted pathomorphism (see) infectious And., what complicates differential morfol, diagnosis And. various etiology.
And. occur at any age, but a thicket at persons from 20 to 40 years. At women are usually observed infectious And., and at men And. are often combined with arthritises. At advanced age, as a rule, meet And. at a spondylarthritis, gout and diabetes. At children And. preferential develops in the senior age groups, and the streptococcal and staphylococcal sensitization connected with hron, tonsillitis in 28% of observations — a rheumatoid arthritis is the main reason. Main symptoms And. — eye pain, dacryagogue, a photophobia, expansion of perilimbalny vessels (a pericorneal injection), emergence of precipitated calcium superphosphates on a back surface of a cornea, discoloration and the drawing of an iris, narrowing of a pupil (tsvetn. fig. 4), formation of back commissures — synechias, an opacity of the vitreous body, change of intraocular pressure and decrease in sight.
The pericorneal injection of vessels arising in the form of a cyanochroic nimbus around a cornea is caused by expansion of regional looped network of front tsiliarny vessels. In hard cases there is a mixed injection, conjunctival joins tsiliarny.
Discoloration and the drawing of an iris is connected with strengthening of a krovenapolneniye of its vessels, an exit of uniform elements of blood at the expense of a hyperpermeability of capillaries and formation of exudate — serous, fibrinous or fibrinoznognoyny. Treatment by serous liquid and cellular infiltration of fabric of an iris increase its volume and promote narrowing of a pupil (tsvetn. fig. 5 and 6).
The Infiltrirovanny edematous iris concerns a surface of a crystalline lens that in the presence of exudate leads to formation of synechias between an iris and the front capsule of a crystalline lens. The iris can be soldered throughout a pupil, forming a circular synechia — seclusio pupillae. At an adverse current And. exudate can close completely a pupil, and the subsequent development of connecting fabric leads to fusion of a pupil (seclusio and occlusio pupillae). Perhaps plane spayaniye of an iris, at Krom its back surface grows together with a crystalline lens.
The union and fusion of a pupil breaks outflow of intraocular liquid from the back camera in a lobby, at the same time a peripheral part of an iris of the eye is pushed aside forward, and its pupillary part soldered to a crystalline lens remains motionless, and the anterior chamber becomes uneven. The iris in such state is called bombirovanny (iris bombe). Frequent sign And. emergence on a back surface of a cornea of precipitated calcium superphosphates — the deposits consisting of the one-nuclear cells which are stuck together among themselves by fibrin, quite often containing kernels of a uveal pigment is. At a rassasyvaniye of cells pigmental kernels can is long remain on a back surface of a cornea. Precipitated calcium superphosphates can be small in the form of points of gray or brown color or large shapeless, a grease look. They are localized preferential in the lower half of a cornea, smaller — from above, large — below. Their emergence is connected with increase in permeability of capillaries of front tsiliarny shoots. If in moisture of an anterior chamber purulent cells drop out, then, settling at the bottom of it, they form accumulation of pus in the form of a half moon or a strip with horizontal level — hypopyon (see). At the hit in moisture of an anterior chamber of an eye of blood caused by the increased vascular permeability or a rupture of a vessel of an iris at the bottom of an anterior chamber accumulation of blood is formed — hyphema (see).
Inflammatory process in a ciliary body (cyclitis) causes opacification vitreous (see). At serous character of exudate opacification insignificant, at loss of fibrin it happens more intensive, to existence of floating flakes. Upon transition of an inflammation to a flat part of a ciliary body so-called peripheral develops uveitis (see).
At acute And. and especially a cyclitis the pain syndrome happens sharply expressed, especially at night, and also during the pressing on an eyeglobe.
Intraocular pressure (see) at And. most often it is not changed, but at the acute beginning of an inflammation with the expressed exudation build-up of pressure due to blockade of outflow tracts cellular elements, kernels of a pigment, edematous trabeculas of a corner of an anterior chamber is possible. At oppression of secretion of intraocular liquid pressure can be lowered. Secondary glaucoma develops at an union and fusion of a pupil that is followed by disturbance of outflow of intraocular liquid.
At tubercular And. a typiform of defeat — focal processes with development in an iris and a ciliary body of tubercles or granulomas (tsvetn. fig. 7). However such forms in modern conditions meet seldom. Are more often observed inertly current plastic And. with availability of grease precipitated calcium superphosphates, exudate, tendency to development of synechias and plane unions of an iris and a crystalline lens. Also acute serous forms of tubercular I.
Klinik influenzal meet And. in each flu epidemic has the features, but influenzal And. always proceed sharply.
Common features herpetic And. the torpid current, serous or serofibrinous exudate, large gray or whitish-gray precipitated calcium superphosphates, massive imposings on a back surface of a cornea, a tendency to increase in intraocular pressure is.
For infectious and allergic And. the acute current is characteristic, is frequent with a favorable outcome. Autoimmune And. are characterized by a recurrent current and their outcomes are less favorable.
Current And. can be acute and chronic and depends on an etiology, weight of process, age of the patient and a condition of an organism. Duration acute And. makes 4 — 6 weeks. Bilateral hron, process with frequent development of the complicated cataract and secondary glaucoma is, as a rule, observed at infectious And.
Complications — secondary glaucoma (see), complicated cataract (see), distribution of inflammatory process on a cornea, a sclera, back departments of a vascular path, a retina, an atrophy of an eyeglobe after heavy fibrinous and plastic And. with development amotio of a retina (see).
the Diagnosis is established on the basis of comprehensive clinical laboratory examination of patients and consultations of specialists of various profile.
Differential diagnosis at And. carry out with conjunctivitis and a bad attack of glaucoma (tsvetn. fig. 3). In an initial stage And. the pericorneal injection of vessels can be accepted mistakenly for conjunctival that can lead to the wrong treatment, development of synechias and other complications.
Main distinctions And. and a bad attack of glaucoma are presented in the table.
Table. Differential diagnosis of an acute iridocyclitis and bad attack of glaucoma
Serol, reactions (Wassermann reaction, RSK) to syphilis, Toxoplasmosis, histoplasmosis, a brucellosis have only relative value, indicating the general of contamination of an organism. The greatest diagnostic value has a method of identification of focal reaction in an eye in response to hypodermic or intradermal introduction of specific antigens — tuberculine, a toksoplazmin, staphylococcal and streptococcal allergen.
In diagnosis virus And. the immunofluorescent research of a buccal swab of a conjunctiva — a method of fluorescent antibodies is applied. The most reliable diagnostic value has definition of specific anti-virus antibodies in moisture of an anterior chamber. For diagnosis herpetic And. the method of identification of focal reaction in an eye in response to repeated intradermal introduction of a herpetic polyvalent vaccine is used, and also luminescent it is gray l. the method based on detection of a viral antigen in tissues of an eye after intradermal administration of herpetic antigen.
At identification of a bacterial and fabric sensitization apply serol, reactions and intracutaneous tests with microbic antigens and uveopigmentny antigen. This method of microprecipitation gained the greatest distribution. For the purpose of identification of a cellular sensitization to antigens of tuberculosis, toxoplasmosis, staphylococcus, streptococcus and virus of herpes in vitro methods are used blastotransformation of lymphocytes (see), braking of migration of leukocytes of blood and a leykotsitoliz (see. Leukolysis ).
For assessment immunol, reactivity of an organism definition of immunoglobulins G, M and A in the lacrimal liquid and in serum is of particular importance.
First aid at And. consists in a mydriasis (for prevention of unions of an iris with a crystalline lens) and removal of a pain syndrome. Apply atropine, analgetics to this purpose.
Treatment And. it is carried out in a complex, with inclusion of the funds influencing a source of an infection and a sensitization for immune mechanisms of an organism and on inflammatory process in an iris and a ciliary body.
Antibacterial drugs are used generally at infectious and infectious and allergic And. Antibiotics are appointed inside in the standard doses on average during 2 — 3 weeks. The exception is made tubercular And., which treatment by specific antibacterial therapy is carried out is longer depending on weight of their current. Effectively topical treatment by antibacterial drugs in the form of subconjunctival and retrobulbar injections and method of an electrophoresis.
The general nonspecific desensibilizing therapy — salicylates, Butadionum, Rheopyrinum, the drugs of calcium, antihistamines, substances strengthening a vascular wall, and corticosteroids. Butadionum applied on 0,15 g 4 times a day during 2 — 3 weeks is most effective. Calcium chloride l enter intravenously in the form of 10% of solution on 5 — 10 ml (15 — 20 injections on a course) or in 10% solution on 1 table. 3 times a day. From antihistamines appoint Dimedrol on 0,05 g 2 times a day during 2 weeks.
Ascorutinum is applied on 1 tablet by 3 times a day within 1 — 1,5 month.
Corticosteroids apply locally in the form of instillations, injections under a conjunctiva of an eyeglobe and retrobulbarno. At the same time the greatest concentration of steroids in an eye is created and their general impact on an organism decreases. In drops appoint a hydrocortisone of 0,5 — 1% solution or Prednisolonum, and in injections under a conjunctiva — a hydrocortisone or Dexasonum.
Inside corticosteroids use generally at infektsionnoallergichesky and autoimmune And. Daily dose of Prednisolonum of 25 — 30 mg, dexamethasone of 2,5 — 3,0 mg, Polcortolonum (Triamcinolonum) of 4 — 6 mg. Drugs are appointed in the decreasing doses, lowering each 5 days Prednisolonum by 2,5 mg, dexamethasone — by 0,25 mg and Polcortolonum — by 0,5 mg. Treatment by corticosteroids is carried out against the background of administration of drugs of calcium chloride, potassium chloride and redoxon.
At steroidorezistentny forms I. apply immunodepressants from group of tsitostatik — Cyclophosphanum at the rate of 1,5 — 3,0 mg on 1 kg of weight of the patient within 1 — 1,5 month under control of quantity of leukocytes.
In a stage of subsiding of the inflammatory phenomena for the purpose of a rassasyvaniye at And. apply fermental therapy — trypsin, a lidaza and papain. Trypsin is entered intramusculary on 5 — 10 mg into 1 — 2 ml of isotonic solution of sodium chloride. Lidaza is entered intramusculary on 32 — 64 UE (conventional units), 15 — 25 injections, by means of an electrophoresis on 16 — 32 UE.
For treatment And. apply also physiotherapeutic methods: electrophoresis, diathermy, UVCh, ultrasound and fonoforez.
The roentgenotherapy is used in combination with other methods of treatment for removal of a pain syndrome, and also for achievement of antiinflammatory and immunodepressive effect. Radiation is carried out by beams of average rigidity: at acute processes appoint 15 r, at hron, a current — 30 r, totally 180 — 200 rubles.
At tubercular And. at the first stage of treatment use drugs of the 1st row: streptomycin on 1 million. Piece a day (on a course on average 40 — 50 million. Piece), PASK on 9 — 12 g a day and Tubazidum on 0,3 g 3 times a day or Ftivazidum on 0,5 g 2 times a day. Duration of a course — 6 — 12 and more months depending on weight of process and effect of treatment. From drugs of the 2nd row apply Etioniamidum on 0,25 g 3 times a day, Cycloserinum on 0,25 g 2 times a day. Prolonged continuous treatment with appointment at the same time not less than 2 drugs is recommended. An effective remedy is tuberculinotherapies.
At herpetic And. the best effect is gained at the combined use of drugs of interferon with means of an immunotherapy (donor plasma, gamma-globulin). Leukocytic human interferon with activity of 150 — 500 PIECES/ml is more preferable to enter podkonjyunktivalno 0,3 — 0,5 ml, from 3 to 20 injections on a course of treatment. Interferon is applied also in drops (in a conjunctival sac) by 2 — 6 times a day. At infectious and allergic And., connected with a focal infection, carrying out sanitation of an oral cavity, opening of adnexal bosoms of a nose at existence - in them pus, a tonsilectomy is necessary at hron, tonsillitis.
At some complications And. — in a vitreous — operational treatment is shown to secondary glaucoma, the complicated cataract, amotio of a retina, a shvartoobrazovaniya.
In most cases acute And. at timely and full treatment the forecast favorable. At hron. And. with a recurrent current, followed by development of various complications, visual functions considerably decrease.
Separate forms of an iridocyclitis
Traumatic iridocyclitis develops after the getting wounds, a contusion of an eyeglobe, burns, helcomas, and also intraocular operations. It complicates apprx. 60% of all getting wounds. Develops owing to implementation of an exogenous infection, chemical reaction at hit of foreign bodys, the expressed processes of proliferation and a shvartoobrazovaniye, emergence of autoimmune reactions. Heavy complication traumatic And. development of a sympathetic inflammation and bilateral fakogenny I.
Klinik traumatic is And. it is characterized by the same signs of an inflammation, as endogenous I. Vyrazhennost of the inflammatory phenomena at traumatic And. can be various. At easy forms I. the inflammatory phenomena gradually abate and disappear in 10 — 15 days. At the severe forms proceeding with the phenomena of exudation and proliferation, a current And. can be long and there is a danger of development of a sympathetic inflammation.
Fakogenny iridocyclitis develops in the main ambassador of the getting wounds or operations connected with damage of a crystalline lens. In rare instances internal causes can be of it an origin.
In differential diagnosis traumatic and fakogenny And. a certain value has disturbance of an integrity of the capsule of a crystalline lens and existence on a back surface of a cornea large friable precipitated calcium superphosphates of white color (so-called lenticular precipitated calcium superphosphates). In certain cases arises bilateral fakogenny And., which on a wedge, to a picture, a current and an outcome differs from a sympathetic inflammation. In a pathogeny fakogenny And. development of a sensitization to lenticular protein is of great importance. In this regard extraction of a traumatic cataract or removal of the remains of lenticular substance is a necessary condition for successful treatment fakogenny And.
Sympathetic iridocyclitis has the autoimmune nature therefore special value in its prevention has timely and correct treatment by corticosteroids traumatic And., proceeding with autoimmune reactions (see. Sympathetic ophthalmia ).
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O. B. Chentsova.