Fungal Uveitis

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    Dr. Anumeha

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    Pathogenesis:

    Caused by Histoplasma capsulatum

    By inhalation of infective mycelia or spores withdust particles

    POHS represents an immunologic mediatedresponse in individuals previously exposed to

    fungus

    Inc prevalence of HLA-B7 and HLA-DR2

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    Key features are:

    Occurs From area, endemic for histoplasmosis Whites

    20-50 years of age

    Fundus picture:

    Multiple peripheral atrophic scars

    Macular disciform scar

    Peripapillary choroidal scars

    Linear peripheral streak lesions Lack of aqueous and vitreous inflammation

    HLA-B7-and HLA-DR2-positive patients

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    Multiple peripheral atrophic scars

    vary in number, shape, size, and pattern are at the level of the outer retina(retinal pigment

    epitheliuminner choroid)

    usually 0.2 to 0.7 DD in size

    mostly nonpigmented, but central pigmentclumps, peripheral pigmentation, or diffusepigmentation may be seen

    occur bilaterally usually remains unchanged through out life

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    Peripheral atrophic scar

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    Peripapillary choroidal scars and macular scars

    Peripapillary scars raisessuspicion of disciformmaculopathy also

    FAngio of inactive scars shows loss of pigmentepithelium and choriocapillaris in the area of thescar.

    neovascularization with asymptomatic leakage isseen occasionally.

    Hemorrhagic peripapillary choroidalneovascularization may also occur, with permanentloss of central vision if spread to the macula occurs

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    Peripapillary scars with associated choroidal neovascularization extending into the macul

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    Peripheral linear streak lesions

    variable length, width, and pigmentation in the equatorial region and oriented parallel to

    the ora serrata

    result from loss of choriocapillaris and retinal

    pigment epithelium and appear to represent alinear aggregation of peripheral atrophichistoplasmosis spot

    The linear distribution at the equator is because

    anterior and the posterior choroids are suppliedseparately and the watershed zone is at theequator

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    Linear peripheral streak lesion

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    Macular choroidal neovascularization

    Brings the patient to the ophthalmologist

    Symptoms: Metamorphopsia blurred vision, or

    loss of central vision

    Fundus shows: Rarely, choroidal neovascularization can occur

    in the macula without a prior scar or pigmentarychange.

    These macular lesions can also cause RD butmost are hemorrhagic lesions. It is usually 1 disc diameter or less in size and is

    greenish gray in color.

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    D/d:

    o Granulomatous disease of the fundus:

    Tuberculosis Sarcoidosis

    Coccidioidomycosis

    Cryptococcosis

    o Multifocal choroiditis with panuveitis

    o High myopia

    o Punctate inner choroidopathy

    o Birdshot chorioretinopathy

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    Diagnosis:

    Histoplasmin skin test: clinically helpful

    lasts lifetimeocular lesion may

    reactivate aft this

    Serological tests:Complement fixation is quantity test

    Antibodies are present up to2- 5 yrs aft infec

    Chest Xray: Calcifications seen of previous infec FFA

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    Prognosis: If untreated choroidal neovascular membranes in the

    macula result in a final visual acuity

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    T/t

    Laser photocoagulation of choroidalneovascularization

    it is effective when the extent of the new vesselsis well defined and does not extend beneath the

    foveaboth argon and krypton laser are used

    Corticosteroids may be beneficial if new vesselsare beneath the fovea

    Surgical removal of subfovealneovascularization is still experimental.

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    FFA showing leakage with foveal involvement

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    After t/t with laser photocoagulation closure of choroidal neovascular membrane

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    Caused by candida albicans

    Occurs in three main groups: IV drug addicts

    Pts with long term indwelling catheters

    Immunocompromised pts

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    C/f

    Gradual u/l blurring of vision

    Floaters

    Signs:

    Focal or multifocal chorioditis

    Small,round, white slightly elevated lesions withindistinct borders

    Enlargement of lesions and extension intovitreous making cotton ball colonies

    Chronic endoph

    Retinal necrosis and RD

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    Multifocal candida retinitis with cotton ball vitreous colonies

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    D/D of Candida Endophthalmitis

    Endogenous bacterial endophthalmitis

    Toxoplasmin retinochoroiditis

    Primary intraocular lymphoma Cytomegalovirus retinitis

    Syphilitic chorioretinitis

    Aspergillus endophthalmitis

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    Treatment

    Oral 5-flucytosine 150 mg daily

    +

    Ketoconazole 200-400mg daily for 3weeks

    In resistant cases IV amphoterecin-B in5%dextrose

    Pars plana vitrectomy: in endop cases

    Intravitreal inj of ampho is also given.

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    Caused by cryptococcus neoformans (encapsulatedcyst)

    Present in soil contaminated with pigeon droppings

    Mode of transmission is inhalation

    Occurs in cell mediated immune dysfunction and aids pts

    Histologically, there is usually acute and granulomatousinflammation

    S/s

    Meningitis assoc manifes-most common

    Papilloedema

    Optic neuropathy

    Ophthalmoplegia

    Ptosis

    6th N palsy

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    Earliest clinical manifestation is multifocalchorioretinitis

    Lesions vary in size, and there may beoverlying retinitis and vitritis

    In severe cases,

    vascular sheathing,

    mutton fat keratic precipitates, orendophthalmitis can occur

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    multifocal necrotizing lesions of the retina.

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    T/t

    IV amphotericin B or

    oral fluconazole and oral 5-flucytosine

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    Caused by mold aspergillus

    Found in decaying veg matter

    Infection by inhalation of spores

    In immuno-compromised host::

    abuse intravenous drugs,

    alcoholic patients

    organ transplant recipients

    patients on chemotherapy formalignancy

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    Presentation rapid onset of pain and visual loss.

    yellowish infiltrate: in the macula beginning in the choroid

    and subretinal space. retinal vascular occlusion and full-thickness retinal

    necrosis.

    Intraretinal hemorrhages usually occur.

    dense vitritis varying degrees of cell in AC,

    flare

    hypopyon

    The macular lesions heals to form a central atrophicscar.

    In severe infection, subretinal abscess andendophthalmitis occurs

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    T/T

    systemic treatment with intravenousamphotericin B

    intravitreal injection of 510 g of

    amphotericin B.may be reinjected weekly

    Intravitreal corticosteroids may be used

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