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 antiinflammatory 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 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.

2 Anterior uveitis