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Necrose retiniana aguda e porn

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Necrose retiniana aguda e porn

  1. 1. * Julia Souza Dominguez Sotelino R3 de Oftalmologia Setor de Retina HBDF
  2. 2. *1- DEFINIÇÃO*É uma rara e devastadora retinite necrosante que afeta tipicamente indivíduos saudáveis de todas as idades.2- FISIOPATOLOGIA* Causada por Vírus Varicela Zóster (VZV) – indivíduos mais velhos* Herpes Simples Vírus (HSV) I e II – menor frequência, pacientes jovens
  3. 3. *3- EPIDEMIOLOGIA* Mais comum em homens 2:1* Bilateral em 33% dos casos e envolvimento do segundo olho ocorre nas primeiras 6 semanas* Imunossuprimidos podem apresentar NRA com evolução fulminante e bilateral
  4. 4. *4- CLÍNICA* Dor* Hiperemia ocular* BAV progressivaBiomicroscopia:* RCA significativa* Precipitados ceráticos granulomatosos* Vitreíte
  5. 5. *4- CLÍNICAFundo de Olho:* Focos de retinite necrosante periférica, com tendência a confluírem centripetamente.* Progressão da necrose para toda a espessura retiniana* Vasculite e hemorragias* Pólo posterior é poupado* Neurite
  6. 6. *
  7. 7. *
  8. 8. *5- DIAGNÓSTICO Critérios Essenciais Critérios que dão suporte ao diagnóstico1 ou mais focos de necrose retiniana periférica, Neuropatia ópticacom margens bem demarcadasProgressão rápida na ausência de TTO EscleriteExtensão circunferencial das lesões DorVasculopatia oclusiva e envolvimento arteriolarVitreíte e RCA* Outras síndromes causadas por vírus da família Herpesviridae que não preencham esses critérios, devem ser incluídas no grupo das retinopatias herpéticas necrosantes
  9. 9. *5- DIAGNÓSTICO* Hemograma completo* FTA-ABS* Sorologia para toxoplasmose, CMV* Radiografia de tórax* Teste para HIV* Paracentese da CA para PCR de herpes simples e VZV* TC de órbita ou US modo B para pesquisar aumento do NO* TC ou RM de crânio (encefalite, sífilis terciária)
  10. 10. *6- DIAGNÓSTICO DIFERENCIAL* Retinopatia Herpética* Retinite por CMV* PORN* Sífilis* Toxoplasmose* Doença de Behçet* Endoftalmite fúngica ou bacteriana* Linfoma de células grandes
  11. 11. * NRA CMV ToxoplasmoseHemorragias Incomuns Significativas AusentesretinianasVitreíte Significativa Mínima SignificativaDor Significativa Ausente ModeradaEstado imune Saudável Imunocomprometido Qualquer umAspecto Lesões bem Necrose retiniana “Farol na demarcadas de granular associadas a neblina”com vitreíte aparência quase hemorragias ao longo densa e bordas lisas homogênea e mesma das arcadas idade vasculares retinianas (brushfire)
  12. 12. *6- TRATAMENTO* Aciclovir IV (10 mg/kg/dia a cada 8 horas) por 10 a 14 dias* Seguido de aciclovir oral (800 mg 5 vezes/dia) por 6 a 14 semanas* Ganciclovir intravítreo: reduz progressão da lesão e o risco de DR* Ácido acetilsalicílico(500 mg/dia)- reduzir a vasculopatia oclusiva* Costicóide sistêmico(prednisona 40-60 mg/dia) após 24 a 48hs do inicio do aciclovir – para casos graves principalmente com envolvimento do NO* Colírios de corticóide e cicloplégico/midriático para RCA
  13. 13. *6- TRATAMENTO* Fotocoagulação a laser cercando a margem posterior das lesões para profilaxia de DR
  14. 14. *7- PROGNÓSTICO* Lesões necróticas progridem rapidamente quando não tratadas.* O tratamento adequado acelera a resolução das lesões retinianas agudas e reduz o risco de envolvimento do segundo olho, mas não previne o DR.* Lesões agudas resolvem-se em 6 a 12 semanas – retina necrótica transparente com bordos hiperpigmentados* Prognóstico sombrio: 60% evoluem com BAV devido ao DR, neurópatia óptica isquêmica e perifeblite oclusiva
  15. 15. *1- DEFINIÇÃO*É uma necrose retiniana que ocorre predominantemente em pacientes imunossuprimidos principalmente na AIDS* CD4 em torno de 24/uL* É uma condição rara porém devastadora2- FISIOPATOLOGIA* Causada por Vírus Varicela Zóster (VZV)
  16. 16. 3- CLÍNICA* Perda visual rapidamente progressiva* Infiltrados retinianos branco-amarelados e multifocais* Acometimento macular precoce* Apenas nos estágios iniciais a infecção é limitada à retina externa* Rápida confluência e necrose de toda a espessura da retina* Uveíte anterior e vitreíte mínimas* DR em 70% dos casos
  17. 17. 4- DIAGNÓSTICO* Clínico* É confirmado com exame de PCR para DNA do vírus varicela zóster a partir de uma amostra do vítreo5- TRATAMENTO* Associação de ganciclovir EV com ou sem foscarnete* Ganciclovir ou foscarnete intravítreo* Demarcação profilática por laser para diminuir o risco de DR
  18. 18. 6- PROGNÓSTICO* Pouca resposta ao tratamento* Péssimo prognóstico visual* Cegueira: Por necrose macular ou DR* Resultados das cirurgias vítreo-retiniana são muito ruins
  19. 19. NRA PORNEstado imune Saudáveis ImunossuprimidosClínica RCA + Uveíte e vitreíte mínimas Precipitado granulomatoso Acometimento macular Vitreíte precoce Polo posterior é poupadoEtiologia VZV e VHS VZVTratamento Aciclovir IV Ganciclovir IV
  20. 20. *KANSKI, J.J. Oftalmologia clínica: Uma abordagem sistemática. Sexta Ed. Rio de Janeiro: Elsevier, 2008. 478 p.*ORÉFICE, F; SANTOS, D.V.V; ORÉFICE, J.L. Uveítes: Série Oftalmologia Brasileira. Ed. Rio de Janeiro: Cultura Médica, 2011. 243 p.*EHLERS, J.P; SHAH, C.P. Manual de doenças oculares do Wills Eye Hospital. Ed. Porto Alegre: Artmed, 2009. 367 p.

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