-: Roadmap for intermediate uveitis.
In this video,
I'll present a practical approach
for management of intermediate uveitis case.
First, start by following a standard approach
for history taking, includes present history,
past ocular history, past medical history.
Then, conduct a rapid initiate review of all systems,
followed by family history,
social history,
medication,
allergies, and drug contraindication.
One of the very useful strategies in uveitis history
is U-turn strategy.
This means that we can return
to take a specific detailed history
relevant to differential diagnosis after examination
of the patient.
The second step
is extensive systematic detailed examination,
starting by general examination,
followed by lid, conjunctiva, cornea, anterior chamber,
iris, lens, intraocular pressure, and baseline gonioscopy,
in addition to dilated fundus examination.
On dilated fundus examination,
signs of intermediate uveitis include vitritis,
like left eye in this photo,
and left eye here also.
Dense vitritis in this photo.
Snowballs, which is highly characteristic
for intermediate uveitis.
Snowbanking
in this arrow.
And here is a video showing inferior snowbanking
which was recorded through super-field lens.
And associated peripheral retinal vasculitis like here.
During the examination of patient
with an intermediate uveitis,
don't forget detailed iris examination for iris nodule,
peripheral transillumination, or heterochromia.
Re-examine if posterior subcapsular cataract
with vitreous opacities in young patient.
Re-examine for possible Fuchs heterochromic uveitis
as it is non-neoplastic masquerade for intermediate uveitis.
Look for any retinal lesion or vascular sheathing
in fundus examination.
Look all the way down as much as you can
to look for snowballs, snowbanking, and retinoschisis,
like this retinoschisis in this image.
The third step is investigation.
We may not investigate in case of known systemic disease
causing intermediate uveitis such as sarcoidosis
or multiple sclerosis.
The recommended investigation protocol
include metabolic panel, full blood count, U&E and LFT,
infective screening, syphilis serology for everyone,
QuantiFERON test in endemic area
or if there is a known contact with tuberculosis patient,
Lyme serum antibody titer.
This indicated in specific condition
because of low positive predictive value.
It should be reserved for patients
with an exposure history, systemic finding for Lyme disease,
and steroid resistant in the absence of systemic finding
or travel to endemic area.
Chest x-ray to exclude tuberculosis or sarcoidosis.
Inflammatory causes and markers, ESR, C-reactive protein,
and ACE.
There is a common agreement among uveitis specialists
that MRI head should be requested
in case of presence of neurological symptoms,
suspected intraocular lymphoma,
or before initiating anti-TNF treatment.
Then, we move to ocular imaging.
First, ultra-wide fundus photo.
It's really helpful for objective assessment
of posterior segment signs,
especially peripheral retinal vasculitis monitoring.
Also, it may be helpful in case of limited view
due to posterior synechiae.
OCT macula is useful in diagnosis and monitoring
of cystoid macular edema and epiretinal membrane.
OCT disc is a helpful tool as an objective tool
for assessment of disc swelling and monitoring the response
to treatment like here in this example,
showing the improvement of disc swelling
during the course of treatment.
Fundus fluorescein angiography
may show disc leakage, diffuse peripheral venous leakage,
vessel staining, as shown in this image
before treatment.
Also, it can show capillary dropout.
Here is the same patient after treatment.
We can see complete resolution of leakage
and staining.
Finally, ultrasound may be useful in case of small pupil
or media opacity.