INTERMEDIATE UVEITIS

Dr Mita Joshi

Intermediate uveitis

• Also known as pars planitis ,cyclitis, peripheral uveitis, basal uveoretinitis

• Intriguing disease

• Enigma in ophthalmology

Anatomy

• Pars plana• Flat extension from ciliary processes to ora

serrata• 3.5 -4 mm

Etiology

• Incidence in population 1 in 15,000• 8 – 22% of uveitis• Almost equal sex ratio• Young patient ,23 – 28 years• Bi modal 2 nd 5 th decade

• Associated with Sarcoidosis,Multiple Sclerosis,Lyme disease,peripheral Toxocariasis,Syphillis,Tuberculosis,Primary Sjogren syndrome,infection with human T cell lymphoma virus

• Unknown cause : pars planitis 85-90% cases

Pathogenesis

• Not well understood• Autoimmune reactions against

vitreous ,peripheral retina, ciliary body.• HLA DR 15 ,subtype HLA DR 2 associated with

MS

Clinical Features

• Blurring of vision• Floaters• Central vision impaired after complications set

in• Redness, photophobia, discomfort in children

Clinical Features

• Visual acuity• Anterior segment spill over

uveitis• Early : cell ,flare ,keratic

precipitates• Late : posterior sub

capsular cataract : posterior synechiae : band keratopathy

Clinical Features

• Fundus

• Snowball• Snowmen• Snowbanking

Clinical Features

• Inferior peripheral retinal phlebitis• Venous sheathing• Cystoid macular edema• Chronic/refractory in 10% cases

Complications

• Neovascularisation in 5-10% of cases• Vitreous hemorrhage• Tractional/rhegmatogenous detachment• Retinal angiomas• Retinal detachment 10% cases of pars planitis• Epiretinal membrane• Vitreous opacity

Investigations

• FFA diffuse peripheral venular leakage, CME• UBM peripheral exudates membranes over

pars plana• VDRL syphillis• Serum ACE ,chest X ray, Lyme antibody titer

Histopathology

• Vitreous condensation• Cellular infiltration of

vitreous base• Macrophages,

lymphocytes ,few plasma cells

• Peripheral lymphocytic cuffing of venules

• Loose fibrovascular membrane over pars plana

Progression

• 10% self limited ,benign• 30% smouldering course• 60% prolonged without exacerbations• Burns out after 5-15 years • Long term visual prognosis good if CME

controlled

Complications

• Cataract• Glaucoma• Cystoid macular edema• Retinal neovascularisation• Vitreous haemorrhage• Retinal detachment

Differential diagnosis

• Syphillis• Lyme disease• Sarcoidosis• Intermediate uveitis with MS• Toxocariasis• Primary CNS lymphoma• Fuchs heterochromic iridocyclitis

Treatment

• Directed towards cause• Anti-inflammatory therapy• Visual acuity 20/40 or worse• Presence of CME,extensive peripheral

neovascularisaton,extensive vasculitis,complain of severe floaters

FOUR STEP APPROACH

• Outlined by Kaplan

STEP ONE

• Periocular steroids• Depot preparations• Subtenons• Triamcinolone/methylprednisolone• Repeat every 2-3 weeks till four injections• Complications

STEP ONE

• Systemic corticosteroids• 1-1.5 mg/kg body weight• Gradual taper every 2-4 weeks

• Intravitreal triamcinolone in refractory cases• Inf temp with caution

• Randomized comparison of systemic anti-inflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial.

• In each treatment group, mean visual acuity improved over 24 months, with neither approach superior to a degree detectable with the study's power. Therefore, the specific advantages and disadvantages identified should dictate selection between the alternative treatments in consideration of individual patients' particular circumstances. Systemic therapy with aggressive use of corticosteroid-sparing immunosuppression was well tolerated, suggesting that this approach is reasonably safe for local and systemic inflammatory disorders.

STEP TWO

• Peripheral ablation of pars plana snowbank• Cryotherapy eliminates source of

inflammation and neovascularisation• Complications

• Indirect laser photocoagulation• Equally effective

STEP THREE

• Pars plana vitrectomy with induction of PVD and peripheral laser

• Benefits doubtful• Intravitreal implants fluocinolone acetonide :

retisert

STEP FOUR

• SYSTEMIC IMMUNOMODULATING AGENTS• Methotrexate,cyclosporine,tacrolimus• Azathioprine,cyclophosphamide

• Infliximab anti TNF monoclonal antibody• Daclizumab interleukin-2 receptor blocking

antibody• Interferon β in intermediate uveitis with MS

• MULTIPLE SCLEROSIS• 5- 20 % of patients of MS have intermediate

uveitis• 15 % of patients of intermediate uveitis may

develop MS

THANK YOU

Presentation is with the insidious onset of blurred vision often accompanied by vitreous floaters. The initial symptoms are usually unilateral, but the condition is typically bilateral and often asymmetrical. Careful examination of the apparently normal eye may reveal minor abnormalities of the peripheral retina, such as vascular sheathing or localized vitreous condensations.

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Anterior uveitis