TITLE

bull Intrermediate Uveitis

bull Dr Md Mominul Islam

bull Fellow (Vitreo-Retina)

bull Ispahani Islamia Eye Institute And Hospital Dhaka

bull Bangladesh

INTRODUCTION

bull According to Standardized UveitisNomenclature Working Group

ldquoIntraocular inflammation in which the primary site is the vitreous but commonly involves the

peripheral retina as wellrdquo

EPIDEMIOLOGY AND DEMOGRAPHY

Prevalence 40 per 100thinsp000 persons 33 per 100thinsp000 persons

Incidence 15 per 100thinsp000 person-years 208 per 100thinsp000 persons

At any age (average 31 years more in younger)No gender and racial predilection

Thorne and colleagues- more common in women (664)

Dev Ophthalmol 2010 47136-147

PRESENTATION amp CLINICAL FINDINGS

bull Typically bilateral (745ndash80 bilateral)

bull Asymmetric unilaterally

bull Blurry vision and floaters

bull Pain

bull Redness

bull photophobia

Anterior vitreous cells

Diffuse vitreous haze

Snowballs

Snowbanks

Peripheral vasculitis

manifested by

perivascular sheathing

Differential diagnosis of intermediate uveitis

Infectious

bull Lyme disease

bull Syphilis

bull Toxocariasis

bull Toxoplasmosis

bull Tuberculosis

Immune

bull Idiopathic (nearly 70)

bull Pars planitis (36)

bull Sarcoidosis (222)

bull Multiple sclerosis (8)

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

INTRODUCTION

bull According to Standardized UveitisNomenclature Working Group

ldquoIntraocular inflammation in which the primary site is the vitreous but commonly involves the

peripheral retina as wellrdquo

EPIDEMIOLOGY AND DEMOGRAPHY

Prevalence 40 per 100thinsp000 persons 33 per 100thinsp000 persons

Incidence 15 per 100thinsp000 person-years 208 per 100thinsp000 persons

At any age (average 31 years more in younger)No gender and racial predilection

Thorne and colleagues- more common in women (664)

Dev Ophthalmol 2010 47136-147

PRESENTATION amp CLINICAL FINDINGS

bull Typically bilateral (745ndash80 bilateral)

bull Asymmetric unilaterally

bull Blurry vision and floaters

bull Pain

bull Redness

bull photophobia

Anterior vitreous cells

Diffuse vitreous haze

Snowballs

Snowbanks

Peripheral vasculitis

manifested by

perivascular sheathing

Differential diagnosis of intermediate uveitis

Infectious

bull Lyme disease

bull Syphilis

bull Toxocariasis

bull Toxoplasmosis

bull Tuberculosis

Immune

bull Idiopathic (nearly 70)

bull Pars planitis (36)

bull Sarcoidosis (222)

bull Multiple sclerosis (8)

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

EPIDEMIOLOGY AND DEMOGRAPHY

Prevalence 40 per 100thinsp000 persons 33 per 100thinsp000 persons

Incidence 15 per 100thinsp000 person-years 208 per 100thinsp000 persons

At any age (average 31 years more in younger)No gender and racial predilection

Thorne and colleagues- more common in women (664)

Dev Ophthalmol 2010 47136-147

PRESENTATION amp CLINICAL FINDINGS

bull Typically bilateral (745ndash80 bilateral)

bull Asymmetric unilaterally

bull Blurry vision and floaters

bull Pain

bull Redness

bull photophobia

Anterior vitreous cells

Diffuse vitreous haze

Snowballs

Snowbanks

Peripheral vasculitis

manifested by

perivascular sheathing

Differential diagnosis of intermediate uveitis

Infectious

bull Lyme disease

bull Syphilis

bull Toxocariasis

bull Toxoplasmosis

bull Tuberculosis

Immune

bull Idiopathic (nearly 70)

bull Pars planitis (36)

bull Sarcoidosis (222)

bull Multiple sclerosis (8)

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

PRESENTATION amp CLINICAL FINDINGS

bull Typically bilateral (745ndash80 bilateral)

bull Asymmetric unilaterally

bull Blurry vision and floaters

bull Pain

bull Redness

bull photophobia

Anterior vitreous cells

Diffuse vitreous haze

Snowballs

Snowbanks

Peripheral vasculitis

manifested by

perivascular sheathing

Differential diagnosis of intermediate uveitis

Infectious

bull Lyme disease

bull Syphilis

bull Toxocariasis

bull Toxoplasmosis

bull Tuberculosis

Immune

bull Idiopathic (nearly 70)

bull Pars planitis (36)

bull Sarcoidosis (222)

bull Multiple sclerosis (8)

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Differential diagnosis of intermediate uveitis

Infectious

bull Lyme disease

bull Syphilis

bull Toxocariasis

bull Toxoplasmosis

bull Tuberculosis

Immune

bull Idiopathic (nearly 70)

bull Pars planitis (36)

bull Sarcoidosis (222)

bull Multiple sclerosis (8)

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Masquerade

bull Lymphoma (usually B-cell NHL)

bull Leukemia

bull Amyloidosis

bull Neoplasms

bull IrvinendashGass syndrome

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Treatment

Unilateral disease

ActiveCMEInactiveminimally with smolding CME

Topcal corticosteroid and NSAIDs

Good respons

Posterior subtenonkenalog

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

after 3-4 weeks

Good response

Frequent 3 per year

PSTK

Minimum response

PSTK 1st

Good response

Repeat PSTKIVTA

When active

Flucinolone acetonide Implant Dexamethason intravitreal insert

NoMinimum

PSTKIVTA 2nd

Snowbank + Snowbank -

Cryotherapy Vitrectomy

If recurrence Systemic corticosteroid

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Bilateral diseases

Prednisone 1 mgkgday

Good response

After 2 weeks at maximum doseTaper by 10mgweek until 20mg

Then 15 mg Thentaper by 25 mg increments

Minimum effective dose lt 5 mg daily

Prednisone

Minimum effective dose lt 5 mg daily

Prednisone

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Prednisone 1 mgkgday

MinimumNo response

Good response

Mithotraxate 15-25 mg weekly +Folic acid 1 mg daily

Minimum effective dose lt 5 mg daily Prednisone

MinimumNo response

Azathioprine 50-250 mg PO DailyMycophenolate mofetil 500-

1500mg PO BID

Cytotoxicagent or T cell

inhbitor

Biologic (TNF ndashalpha or IL-2)

MinimumNo

response

Consider vitrectomy

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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

Ophthalmology 1999 Jan106(1)111-8

Methotrexate treatment for sarcoidosisassociated 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 inflammationGalor 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

bull Therapeutic

a No responsive to standard medical therapy

bull Diagnostic

a Specimen sent for cytopathological evaluation andor flow cytometry

Herpetic viral infection

Toxoplasma

Intraocular lymphoma

CLINICAL COURSE

Patients with Intermediate Uveitis

Visual outcomes often ndash Favorable

Mean visual acuity after 10 years of follow up-2030

75 maintained VA or ndash 2040 or better

One third maintained VA ndash Normal without treatment

COMPLCATIONS

bull Vision loss due to CME ndash 412 over 15 years amp 457

Uveitic Glaucoma

Retinal detachment

Vitreous haemorrhage

Cataracts ndash 342

Epiretinal membrane 444

Band Keratopathy

CLINICAL COURSE

Patients with Intermediate Uveitis

Visual outcomes often ndash Favorable

Mean visual acuity after 10 years of follow up-2030

75 maintained VA or ndash 2040 or better

One third maintained VA ndash Normal without treatment

COMPLCATIONS

bull Vision loss due to CME ndash 412 over 15 years amp 457

Uveitic Glaucoma

Retinal detachment

Vitreous haemorrhage

Cataracts ndash 342

Epiretinal membrane 444

Band Keratopathy

COMPLCATIONS

bull Vision loss due to CME ndash 412 over 15 years amp 457

Uveitic Glaucoma

Retinal detachment

Vitreous haemorrhage

Cataracts ndash 342

Epiretinal membrane 444

Band Keratopathy