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

12/2/2016 Disclosures Intermediate Uveitis: • I have no financial disclosures When and How Do You Treat? December 2, 2016 UCSF Ophthalmology Update John Gonzales, MD F.I. Proctor Foundation University of California, San Francisco Vitreous haze Anatomical location of inflammation • NEI system - 20 D lens, indirect ophthalmoscopy v 1

12/2/2016 NEI Vitreous Haze Scale Differential 4+ 3+ 1+ 0 2+ Trace Differential Differential 2

12/2/2016 Diagnostic Testing Supra nuclear palsy • Review of systems, past medical history, social history • Treponemal antibody • quantiFERON Gold TB or PPD • CXR or high-resolution CT chest Tropical spastic • ACE and lysozyme paraparesis Pars Planitis Intermediate Uveitis & Multiple Sclerosis Collapsed vitreous Fibroglial cells Lymphocytes Lymphocytic cuffing of peripheral venules 3

12/2/2016 Ocular Features of Multiple Sclerosis Lumbar Puncture? Intraocular Findings Efferent Findings Intraocular Findings Courtesy Marc Levin, MD New nystagmus Cranial nerve palsies (CN6>CN3>CN4) Heat � worsens symptoms Afferent Findings Subai & Eggenberger. Curr Opin Ophthalmol 2012;23(6):506-509 So When to Neuroimage in IU? Demyelination is not Uncommon • When MS symptoms/signs present • Postmortem – demyelination without history • When considering advancement to anti-TNF of neurologic symptoms in 18% therapy • Radiological Isolated Syndrome (RIS) • 33% develop clinical signs of MS in 5 years Georgi. Schweiz Med Wochenschr 1961;91:605-7 Petrushkin et al. Br J Ophthalmol 2015;99(12):1591-1593 Moore & Okuda. Neurol 2009;73:1714 4

12/2/2016 When is IU Perhaps “More” than IU? When is Intermediate Uveitis “More” than Intermediate Uveitis? A Stepwise Approach to Complications in Intermediate Uveitis Immunosuppression Inflximab Adalimumab Cyclophsophamide BIOLOGICS Chlorambucil Cyclosporine ALKYLATING Methotrexate Tacrolimus AGENTS Mycophenolate T-CELL Drops Azathioprine INHIBITORS Injections ANTI- Systemic METABOLITES STEROIDS 5

12/2/2016 Other Options Anti-TNF therapy in Intermediate Uveitis • Can play a role in managing intermediate uveitis • Image to rule out signs of multiple sclerosis X • MS can be uncovered or made worse with X X anti-TNF X X X X X X X X X X Intermediate Uveitis Thank you! Summary • ☺ 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 6