Disclosures Intermediate Uveitis: I have no financial disclosures - - PowerPoint PPT Presentation

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Intermediate Uveitis: When and How Do You Treat?

December 2, 2016 UCSF Ophthalmology Update John Gonzales, MD F.I. Proctor Foundation University of California, San Francisco

Disclosures

• I have no financial disclosures

Anatomical location of inflammation

v

Vitreous haze

• NEI system - 20 D lens, indirect ophthalmoscopy

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NEI Vitreous Haze Scale

Trace 1+ 2+ 3+ 4+

Differential Differential Differential

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Supra nuclear palsy Tropical spastic paraparesis

Diagnostic Testing

• Review of systems, past medical history, social

history

• Treponemal antibody
• quantiFERON Gold TB or PPD
• CXR or high-resolution CT chest
• ACE and lysozyme

Pars Planitis

Fibroglial cells Lymphocytes Lymphocytic cuffing of peripheral venules Collapsed vitreous

Intermediate Uveitis & Multiple Sclerosis

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Ocular Features of Multiple Sclerosis

Efferent Findings

New nystagmus Cranial nerve palsies (CN6>CN3>CN4) Heat worsens symptoms

Afferent Findings Intraocular Findings Intraocular Findings

Courtesy Marc Levin, MD Subai &

• Eggenberger. Curr

Opin Ophthalmol 2012;23(6):506-509

Lumbar Puncture? Demyelination is not Uncommon

• Postmortem – demyelination without history
• f neurologic symptoms in 18%
• Radiological Isolated Syndrome (RIS)
• 33% develop clinical signs of MS in 5 years
• Georgi. Schweiz Med Wochenschr 1961;91:605-7

Moore & Okuda. Neurol 2009;73:1714

So When to Neuroimage in IU?

• When MS symptoms/signs present
• When considering advancement to anti-TNF

therapy

Petrushkin et al. Br J Ophthalmol 2015;99(12):1591-1593

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When is Intermediate Uveitis “More” than Intermediate Uveitis? When is IU Perhaps “More” than IU? Complications in Intermediate Uveitis A Stepwise Approach to Immunosuppression

STEROIDS ANTI- METABOLITES T-CELL INHIBITORS ALKYLATING AGENTS BIOLOGICS Inflximab Adalimumab Cyclophsophamide Chlorambucil Cyclosporine Tacrolimus Methotrexate Mycophenolate Azathioprine Drops Injections Systemic

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Anti-TNF therapy in Intermediate Uveitis

• Can play a role in managing intermediate

uveitis

• Image to rule out signs of multiple sclerosis
• MS can be uncovered or made worse with

anti-TNF

Other Options

X X X X X X X X X X X X X

• Detailed history & review of systems
• Consider systemic associations, infections or lymphoma
• Fluorescein angiography identifies vasculitis
• Pars planitis is a subtype of intermediate uveitis
• No “routine” neuroimaging in isolated intermediate

uveitis

• Image when advancing to anti-TNF or neuro

signs/symptoms

Intermediate Uveitis Summary Thank you! ☺