Intermediate Uveitis
Transcript of Intermediate Uveitis
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INTERMEDIATE UVEITIS
Dr Mita Joshi
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Intermediate uveitis
• Also known as pars planitis ,cyclitis, peripheral uveitis, basal uveoretinitis
• Intriguing disease
• Enigma in ophthalmology
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Anatomy
• Pars plana• Flat extension from ciliary processes to ora
serrata• 3.5 -4 mm
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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
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• 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
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Pathogenesis
• Not well understood• Autoimmune reactions against
vitreous ,peripheral retina, ciliary body.• HLA DR 15 ,subtype HLA DR 2 associated with
MS
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Clinical Features
• Blurring of vision• Floaters• Central vision impaired after complications set
in• Redness, photophobia, discomfort in children
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Clinical Features
• Visual acuity• Anterior segment spill over
uveitis• Early : cell ,flare ,keratic
precipitates• Late : posterior sub
capsular cataract : posterior synechiae : band keratopathy
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Clinical Features
• Fundus
• Snowball• Snowmen• Snowbanking
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Clinical Features
• Inferior peripheral retinal phlebitis• Venous sheathing• Cystoid macular edema• Chronic/refractory in 10% cases
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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
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Investigations
• FFA diffuse peripheral venular leakage, CME• UBM peripheral exudates membranes over
pars plana• VDRL syphillis• Serum ACE ,chest X ray, Lyme antibody titer
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Histopathology
• Vitreous condensation• Cellular infiltration of
vitreous base• Macrophages,
lymphocytes ,few plasma cells
• Peripheral lymphocytic cuffing of venules
• Loose fibrovascular membrane over pars plana
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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
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Complications
• Cataract• Glaucoma• Cystoid macular edema• Retinal neovascularisation• Vitreous haemorrhage• Retinal detachment
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Differential diagnosis
• Syphillis• Lyme disease• Sarcoidosis• Intermediate uveitis with MS• Toxocariasis• Primary CNS lymphoma• Fuchs heterochromic iridocyclitis
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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
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FOUR STEP APPROACH
• Outlined by Kaplan
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STEP ONE
• Periocular steroids• Depot preparations• Subtenons• Triamcinolone/methylprednisolone• Repeat every 2-3 weeks till four injections• Complications
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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
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• Randomized comparison of systemic anti-inflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial.
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• 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.
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STEP TWO
• Peripheral ablation of pars plana snowbank• Cryotherapy eliminates source of
inflammation and neovascularisation• Complications
• Indirect laser photocoagulation• Equally effective
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STEP THREE
• Pars plana vitrectomy with induction of PVD and peripheral laser
• Benefits doubtful• Intravitreal implants fluocinolone acetonide :
retisert
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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
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• MULTIPLE SCLEROSIS• 5- 20 % of patients of MS have intermediate
uveitis• 15 % of patients of intermediate uveitis may
develop MS
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THANK YOU
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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.
2
Anterior uveitis