Intermediate uveitis

October 15, 2007

Intermediate uveitis, also variably called chronic cyclitis, peripheral uveitis, vitritis, and pars planitis, denotes inflammation localized primarily to the vitreous cavity and accounts for 10% to 15% of cases of uveitis seen at tertiary referral centers. A panel of authorities discusses their approach to evaluating and treating this common condition. In part one (Ophthalmology Times. Oct. 1, 2007, Pages 40, 42, and 44) of this two-part article, the panelists discussed strategies for diagnosing intermediate uveitis and pars plantis. In part two, here, the discussion concludes with a review of management options.

Keypoints:

In North America and Europe, sarcoidosis and multiple sclerosis are the most commonly identified systemic associations, with much less frequent cases resulting from lymphoma, Behcet's disease, Vogt-Koyanagi-Harada (VKH) disease, syphilis, tuberculosis, Lyme disease, HTLV-1 infection, Whipple's disease, Sjögren's syndrome, and HIV infection. Unilateral presentation, particularly in children, should raise suspicion of toxocariasis and diffuse unilateral subacute neuroretinitis (DUSN). Failure to respond to corticosteroid therapy should suggest the possibility of a masquerade syndrome, such as lymphoma, retinitis pigmentosa, amyloidosis, or multiple myeloma.

We asked a panel of authorities to discuss their approach to evaluating and treating this common condition. In part one (Ophthalmology Times. Oct. 1, 2007, Pages 40, 42, and 44) of this two-part article, the panelists discussed strategies for diagnosing intermediate uveitis and pars planitis. In part two, here, the discussion concludes with a review of management options.

Ralph D. Levinson, MD: My guidelines for treating vitreous inflammation in this disease are much like those for inflammation in any form of uveitis. We have to consider whether it appears to be visually significant, and whether we are dealing with active vitritis and not just some cells in the strands of vitreous that are caught up and will be very slow to resolve, or vitreous condensations that may not respond to therapy. I am fairly aggressive about treating any level of vitreous haze and free cells in the lacunae. The concern here is that this can cause organization of the vitreous with vitreous opacities that may not resolve later with treatment and cause visual problems. Furthermore, it may be a scaffolding for peripheral neovascularization with traction, or even perhaps play a role in traction that leads to retinal tears and retinal detachment (albeit this is, at best, uncommon). It may be that inflammatory changes also can lead to epiretinal membrane formation with tractional changes on the macula, and subsequent macular edema.

Russell W. Read, MD: I treat based on visual compromise and visual needs. If a patient has 20/20 visual acuity, without CME, but with vitreous cell, I would discuss the extent to which the floaters are interfering with the patient's daily life. If the answer is not much, then I observe closely. If the patient is experiencing functional impairment, then I will treat.

Carlos Pavesio, MD: It will depend on visual acuity and symptoms associated with the presence of floaters. Even with good Snellen acuity, many patients are very disturbed by floaters, but in many others, vision will be reduced because of vitritis. In these patients, periocular steroids may work reasonably well. A trial of oral therapy may be necessary in some quite symptomatic cases after no response to periocular therapy. If the vitreous becomes chronically involved, it is less likely to respond to medical therapy, and a vitrectomy becomes the next alternative.