MEDICAL ED NG UC UI AT A CONTINUING TIN IO CON N MEDICAL EDUCATION PUBLICATION CME ISSUE 25 Intermediate Uveitis: Etiology, Diagnosis, and Treatment LANA M. RIFKIN, MD Intermediate uveitis can be associated with a variety of infectious causes as well as systemic autoimmune diseases, most commonly multiple sclerosis and sarcoidosis. Treatment is aimed at the cause of the disease, if identi ed, and at the in ammation, with the goal of preventing vision loss and deleterious sequelae. Steroids are the rst-line treatment for non-infectious intermediate uveitis, but patients with recurrent or chronic disease should transition to steroid-sparing therapies as soon as possible. FIGURE 1 Fundus photograph showing snowball opacities and vascular sheathing, indicative of vasculitis in a patient with multiple sclerosis. (Republished from: Ozdal PC, Berker N, Tugal-Tutkun I. Pars Planitis: Epidemiology, Intermediate uveitis (IU) can have severe consequences for clinical characteristics, management and visual prognosis. J Ophthalmic Vis Res. 2015 vision if left untreated and can be associated with life-threat- Oct-Dec;10(4):469-80.) ening conditions. Recognizing and appropriately treating IU is therefore of utmost importace. IU is uveitis in which the major ASSOCIATION OF IU WITH OTHER DISEASES site of infl ammation is the vitreous.1 Th e ciliary body and More than 50% of IU cases are idiopathic6,9 and only the peripheral retina may be involved, but anterior segment approximately 4% of cases are associated with an infectious cells and chorioretinal infl ammation are usually minimal or etiology such as syphilis10 (Treponema pallidum), tuberculosis absent.1 Th e term pars plantitis refers to idiopathic IU and is (Mycobacteria tuberculosis) and, less frequently, Lyme disease only used when no infectious or systemic cause can be found.1,2 (Borrelia burgdorferi) or cat scratch fever (Bartonella henselae). Th e prevalence of IU has been reported as 5.9 per 100,000 Viral etiologies of intermediate uveitis include Herpes simplex individuals, with an incidence of 1.4 per 100,000 people per virus, varicella zoster virus, and Epstein-Barr virus. year.1,3 IU constitutes anywhere from 6.1 to 17.6% of all uve- itis cases.4,5 In one study, nearly two-thirds of patients were female,6 but in general, no consistent diff erences in frequency See INSIDE for: between genders have been reported.1,7 Although IU can aff ect Dry AMD Pathobiology: Role for Antiinfl ammatory all ages, it is most frequently diagnosed when patients are in Therapies? by Priyatham S. Mettu, MD their 20s to 40s, with a mean age of approximately 35 years.1,6,8 To obtain CME credit for this activity, go to http://cme.ufl .edu/ed/self-study/toai/ Supported byTopics an unrestricted in OCULAR educational ANTIINFLAMMATORIES grant from Shire. 1 Non-infectious IU is more common TOPICS IN OCULAR ANTIINFLAMMATORIES, ISSUE 25 and is oft en associated with systemic au- STATEMENT OF NEED (JavaScript™ and Java™ enabled). For Mac® users: Mac OS® toimmune disease. Approximately 25% of The control of ocular infl ammation is a critical aspect of X 10.4 (Tiger®) or newer; Safari™ 3.0 or newer, Mozilla® medical and surgical ophthalmic practice. Despite their Firefox® 2.0 or newer; (JavaScript™ and Java™ enabled). patients with systemic sarcoidosis and 3% side eff ects, antiinfl ammatory drugs are used to treat a Internet connection required: Cable modem, DSL, or to 27% of patients with multiple sclerosis very wide range of conditions throughout the eye, from better. ocular surface disease and allergic conjunctivitis to poste- (MS) may develop IU at some point in rior segment conditions. Use of antiinfl ammatory agents DATE OF ORIGINAL RELEASE December 2018. Ap- their lifetime. Conversely, 2% to 10% of is also critical in ocular surgery, contributing greatly to proved for a period of 12 months. patient comfort and positive outcomes. patients with IU will develop sarcoidosis, ACCREDITATION STATEMENT The ocular antiinfl ammatory landscape is changing as This activity has been planned and implemented in ac- and 8% to 15% of patients with IU will research reveals more about the role of infl ammation in cordance with the accreditation requirements and poli- 1 a range of ocular conditions and as new antiinfl ammatory develop MS. In children younger than 7 cies of the Accreditation Council for Continuing Medical agents enter the market.1,2 Twenty years ago, for example, Education (ACCME) through the joint providership of the years of age, approximately 30% of IU cas- the idea of using a topical corticosteroid to treat dry eye University of Florida College of Medicine and Candeo and/or allergic conjunctivitis was viewed with alarm; Clinical/Science Communications, LLC. The University of es are associated with juvenile idiopathic today, it is accepted practice. 10 Florida College of Medicine is accredited by the ACCME arthritis. Other systemic disorders Although corticosteroids and nonsteroidal antiinfl am- to provide continuing medical education for physicians. potentially associated with IU include matory drugs (NSAIDs) have been the mainstays of the ocular anti-infl ammatory armamentarium, a number of CREDIT DESIGNATION STATEMENT tubulointerstitial nephritis uveitis syn- new agents with novel mechanisms of action (and new The University of Florida College of Medicine designates 11 ocular drug delivery systems) have come to market or are this enduring material for a maximum of 1 AMA PRA drome (TINU), Behçet’s disease, Vogt- 3,4 being made ready for market. Cate gory 1 Credit™. Physicians should claim only the Koyanagi-Harada disease, lupus, infl am- As indications expand and change, and as new drugs, credit commensurate with the extent of their participa- matory bowel disease, and HLA-B27 syn- formulations, and delivery systems become available, tion in the activity. 1,6,12 clinicians require up-to-date protocols for drug selec- dromes. Malignancies, including lym- tion and use. Such protocols are also needed for routine EDITORIAL BOARD/FACULTY ADVISORS phoma, can also be associated with IU.2 (but nevertheless off -label) uses of corticosteroids and Marguerite B. McDonald, MD, FACS, practices at NSAIDs because important diff erences in effi cacy, safety, Ophthalmic Consultants of Long Island, and is a clinical and tolerability exist between these classes and among professor of ophthalmology at the New York University SIGNS AND SYMPTOMS formulations within each of these classes.5,6 School of Medicine. She is also an adjunct clinical profes- By putting the latest published evidence into the context sor of ophthalmology at Tulane University Health Sciences A patient with IU will commonly of current clinical practice, Topics in Ocular Antiinfl amma- Center. Dr. McDonald is a consultant for Allergan, Alcon, present with gradual onset of blurred vi- tories equips ophthalmologists to maintain competen- Bausch + Lomb, BlephEx, FOCUS Laboratories, Shire, and J&J Vision. 2,13 cies and narrow gaps between their actual and optimal sion and fl oaters, and unlike anterior infl ammation management practices, across the range Victor L. Perez, MD, is a professor of ophthalmology at uveitis, will not typically experience red- of clinical situations in which current and novel ocular the Duke University School of Medicine. He is also the 2 antiinfl ammatories may be used. director of Duke Eye Center’s Ocular Immunology Center ness, pain, or photophobia. Young pa- and Ocular Surface Program. Dr. Perez is a consultant for tients with a complaint of fl oaters should REFERENCES Allergan, Shire, EyeGate, and TopiVert. He is also a stock 1. Song JS, Hyon JY, Lee D, et al. Current practice pattern shareholder for EyeGate. be carefully examined for signs of IU. for dry eye patients in South Korea: a multicenter study. Matthew J. Gray, MD, is an assistant professor in the On examination, predominant site Korean Journal of Ophthalmology. 2014;28(2):115-21. Department of Ophthalmology at the University of 2. Ciulla TA, Harris A, McIntyre N, Jonescu-Cuypers C. Treat- Florida College of Medicine. He states that in the past 12 of infl ammation in intermediate uve- ment of diabetic macular edema with sustained-release months, he has not had a fi nancial relationship with any itis will be in the vitreous, which will glucocorticoids: intravitreal triamcinolone acetonide, commercial organization that produces, markets, resells, dexamethasone implant, and fl uocinolone acetonide or distributes healthcare goods or services consumed by present with vitritis—characterized by implant. Expert Opin Pharmacother. 2014;15(7):953-9. or used on patients relevant to this manuscript. “snowballs,” which are aggregates of 3. Maya JR, Sadiq MA, Zapata LJ, et al. Emerging therapies Priyatham S. Mettu, MD, is a fellowship-trained medical 2 for noninfectious uveitis: what may be coming to the retina specialist and clinician-scientist and is assistant infl ammatory cells. Exudates on the clinics. J Ophthalmol. 2014;2014:310329. professor of ophthalmology at Duke University School pars plana are termed “snowbanks” 4. Sheppard JD, Torkildsen GL, Lonsdale JD, et al, and of Medicine, in Durham, NC. He states that in the past 12 the OPUS-1 Study Group. Lifi tegrast ophthalmic solu- months, he has not had a fi nancial relationship with any and are the hallmark of pars planitis. tion 5.0% for treatment of dry eye disease: results commercial organization that produces, markets, resells, Neovascularization and vasculitis may of the OPUS-1 phase 3 study. Ophthalmology. 2014 or distributes healthcare goods or services consumed by Feb;121(2):475-83. 7 or used on patients relevant to this manuscript. also be present (Figure 1). In some cases, 5. Fong R, Leitritz M, Siou-Mermet R, Erb T. Loteprednol Lana M. Rifkin, MD, is a uveitis specialist at Ophthalmic inflammation—usually mild—can etabonate gel 0.5% for postoperative pain and infl am- Consultants of Boston and is the director of uveitis and 2 mation after cataract surgery: results of a multicenter immunology at New England Eye Center and assistant be seen in the anterior segment with trial.