Intermediate uveitis

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Information about Intermediate uveitis

Published on March 21, 2014

Author: badhon821


TITLE • Intrermediate Uveitis • Dr. Md. Mominul Islam • Fellow (Vitreo-Retina) • Ispahani Islamia Eye Institute And Hospital Dhaka • Bangladesh

INTRODUCTION • According to Standardized Uveitis Nomenclature Working Group “Intraocular inflammation in which the primary site is the vitreous but commonly involves the peripheral retina as well”

EPIDEMIOLOGY AND DEMOGRAPHY Prevalence  4.0 per 100 000 persons  3.3 per 100 000 persons Incidence  1.5 per 100 000 person-years  2.08 per 100 000 persons. At any age (average 31 years , more in younger) No gender and racial predilection Thorne and colleagues- more common in women (66.4%) Dev Ophthalmol 2010; 47:136-147

PRESENTATION & CLINICAL FINDINGS • Typically bilateral (74.5–80% bilateral) • Asymmetric unilaterally • Blurry vision and floaters • Pain • Redness • photophobia Anterior vitreous cells Diffuse vitreous haze Snowballs Snowbanks Peripheral vasculitis manifested by perivascular sheathing

Differential diagnosis of intermediate uveitis Infectious • Lyme disease • Syphilis • Toxocariasis • Toxoplasmosis • Tuberculosis Immune • Idiopathic (nearly 70%) • Pars planitis (36%) • Sarcoidosis (22.2%) • Multiple sclerosis (8%)

Masquerade • Lymphoma (usually B-cell, NHL) • Leukemia • Amyloidosis • Neoplasms • Irvine–Gass syndrome

Treatment Unilateral disease Active/CME Inactive/minimally with smolding CME Topcal corticosteroid and NSAIDs Good respons Posterior subtenon kenalog

after 3-4 weeks Good response Frequent 3 per year PSTK Minimum response PSTK 1st Good response Repeat PSTK/IVTA When active Flucinolone acetonide Implant Dexamethason intravitreal insert No/Minimum PSTK/IVTA 2nd Snowbank + Snowbank - Cryotherapy Vitrectomy If recurrence Systemic corticosteroid

Bilateral diseases Prednisone 1 mg/kg/day Good response After 2 weeks at maximum dose, Taper by 10mg/week until 20mg Then 15 mg Thentaper by 2.5 mg increments Minimum effective dose < 5 mg daily Prednisone Minimum effective dose < 5 mg daily Prednisone

Prednisone 1 mg/kg/day Minimum/No response Good response Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily Minimum effective dose < 5 mg daily Prednisone Minimum/No response Azathioprine 50-250 mg PO Daily Mycophenolate mofetil 500- 1500mg PO BID Cytotoxic agent or T cell inhbitor Biologic (TNF – alpha or IL-2) Minimum /No response Consider vitrectomy

Ophthalmology. 1999 Jan;106(1):111-8. Methotrexate treatment for sarcoidosis associated panuveitis. Dev S, McCallum RM, Jaffe GJ. Source: Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, USA. CONCLUSION: Low-dose MTX is an effective and safe adjunct to treat chronic sarcoid- associated panuveitis

Comparison of antimetabolite drugs as corticosteroid- sparing therapy for noninfectious ocular inflammation. Galor A, Jabs DA, Leder HA, Kedhar SR, Dunn JP, Peters GB 3rd, Thorne JE. Source Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Conclusions These data suggest that the time to control of ocular inflammation is faster with mycophenolate than with methotrexate. Azathioprine therapy has a higher rate of treatment-related side effects compared with the other 2 agents.

VITRECTOMY • Therapeutic : a. No responsive to standard medical therapy • Diagnostic: a. Specimen sent for cytopathological evaluation and/or flow cytometry  Herpetic viral infection  Toxoplasma  Intraocular lymphoma

CLINICAL COURSE Patients with Intermediate Uveitis Visual outcomes often – Favorable Mean visual acuity after 10 years of follow up-20/30  75% maintained V/A or – 20/40 or better One third maintained V/A – Normal without treatment

COMPLCATIONS • Vision loss due to  CME – 41.2% over 15 years & 45.7%  Uveitic Glaucoma  Retinal detachment  Vitreous haemorrhage  Cataracts – 34.2%  Epiretinal membrane 44.4%  Band Keratopathy

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