Agenda

Patient profile Clinical course

Discussion---pars planitis

Patient Profile
54y/o Female, married, housewife HTN(+) SBP 150mmHg, regular OPD f/u DM(-), Trauma(-),OPTH OP(-), Allergies(-) presbyopia, wears glasses
C.C.: blurred vision, floaters (OS) for 1 week (mostly temporal side)

BCVA IOP (mmHg)

Cornea

PE 0.8+ 1.25 -1.25X85 17

OD clear clear Mild NS 30% Normal

OS

0.4 +2.25 - 1.5 X100 15

clear Deep, cell +++ Mild NS snow ball on peripheral 40% Disc leakage

Anterior chamber
Lens Vitreous cavity C/D FAG

Fundus OD

Fundus OS

Fundus OS

11/09 FAG OD

11/09 FAG OS

11/09 FAG OS

Assessment
Panuvietis (OS) with snowball FAG showed disc leakage

r/o intermediate uveitis, cause to be determined

D/D
Intraocular lymphoma TB, sarcoidosis Multiple sclerosis Infection: -lymes disease
-toxoplasmosis; toxocariasis - fungal infection -syphilis -HTLV-1 -EBV -cat-scratch disease

Exam
WBC 10800 CRP: wnl HLA B27(-) ANA(-) TPHA(-) CXR : normal Brain CT: normal R/O: TB, sarcoidosis, MS, syphilis, intraocular lymphoma

Less likely: Lymes disease, toxoplasmosis, toxocariasis, HTLV-1,cat-scratch disease, fungal infection

Plan
Favored pars planitis, subset of intermediate uveitis (IU) Tx: prednisolone acetate 1% 1drop Q2H prednisolone 30mg BID PO

12/09 Fundus OS

2011/1/20 OCT

Clinical Course
2010/11/05 - -Blurred vision + floaters : panuveitis - VA(OS): 0.4 - FAG: disc leakage - HLA-B27, ANA, CRP, TPHA, CXR, Brain CT 11/09~17 - - VA: 0.2 -Prednisolone 30mg BID + Prednisolone acetate 1% 1drop Q2H 11/18 - -VA: 0.2; AC: cell 2+; less vitritis 2011/1/20 - -VA: 0.4 ; AC: clear; mild vitritis - OCT: no macular edema 2/17 - -VA: 0.7 regular OPD f/u
Tapering down prednisolone

Discussion
pars planitis

Uveitis
Definition: an inflammation of the uveal tract Classification: 1. Anterior 2. Intermediate(4~8%) 3. Posterior 4. Panuveitis

Ref: http://www.eyedoctorsforyou.com/eyedoctors/uveitis3.html

Intermediate uveitis
Inflammation in the anterior vitreous, ciliary body and the peripheral retina Etiology: unknown; associated infection or systemic diseases Subgroup: pars planitis (idiopathic IU; 69.1%)

Epidemiology: 5~40 y/o, 70~90% bilateral

Ref. Trans Am Acad Ophthalmol Otolaryngol 77:760, 1973 Smith RE. et. al.

Presentations
Gradual onset of blurred vision Floaters Vitritis Vitreous snowballs/snowbanking Periphlebitis

Ref. Indian J Ophthalmol. 2010 JanFeb; 58(1): 2127. Intermediate uveitis B Manohar Babu et. al.

Diagnosis
History & clinical findings Characteristics: vitreous is the most severely inflamed part snowbank in the inferior vitreous base cystoid macular edema

Ref. 1. Kanski Clinical ophthalmology---Uveitis 2. Duanes Ophthalmology 2006 edition, Ch 43 Intermediate Uveitis, Lippincott Williams &Wilkins

D/D
Intraocular lymphoma TB, sarcoidosis(22.6%) Multiple sclerosis Infection: -lymes disease(0.6%)
-toxoplasmosis; toxocariasis - fungal infection -syphilis -HTLV-1 -EBV -cat-scratch disease

Intraocular lymphoma
1. primary CNS lymphoma (PCNSL) 2. metastatic systemic lymphoma Mean age: 63.6 y/o, F>M S/S: painless vision loss, photophobia, red eye, and floaters, refractory uveitis

Diagnosis: B-scan ultrasonography, brain CT, lumbar puncture, biopsy

Intraocular lymphoma

Multiple sclerosis
Inflammatory and demyelinating disease of the CNS More in northern Europe, F>M, 20 to 50 y/o S/S: sensory loss spinal cord symptoms cerebellar symptoms optic neuritis cognitive impairment Diagnosis: MRI, lumbar puncture, McDonald criteria

Ocular TB Primary ocular TB: conjunctiva, cornea, sclera

Secondary ocular TB(hematogenous): uveitis S/S: pulmonary symptoms, choroiditis, panuveitis, chronic iridocyclitis Diagnosis: CXR, PPD

Sarcoidosis
Usually before 50 y/o, peaks in 3rd decade; more and severe in black Americans S/S: nodules in multiple organs(esp. lung), vitritis, periphlebitis, retrobulbar optic neuritis Diagnosis: clinical findings, CXR, PET scan, biopsy

Ref: N Engl J Med 2007; 357:2153-2165 Sarcoidosis Michael C.Iannuzzi, M.D. et al.

Lymes disease
Transmission: Borrelia burgdorferi; tick U.S., Europe, Australia S/S: fever, headache, fatigue, erythema migrans, muscle pain, arthritis, uveitis, optic neuritis Diagnosis: exposure history, antibody(ELISA)

Ref: Centers for Disease Control and Prevention www.cdc.gov/lyme

Ocular Toxoplasmosis
Transmission: Toxoplasma gondii; cat Congential(most) & Acquired(much less); 1/3 ~1/2 of population S/S: flu-like illness, necrotizing retinochoroiditis, focal retinitis, papillitis Diagnosis: PCR, antibody histopathology
Ref: HANDBOOK of Ocular Diswasw Management Jobson Publishing L.L.C.

Ocular larva migrans

Transmission: Toxocara canis; dog, cat, fox S/S: leukokoria, vision loss, anterior uveitis, vitritis Diagnosis: history, PCR, ELISA, serological test

Ref: 1. the EyePathologist Duke University Medical Center 2. bouldersnaturalanimal.com

Syphilis
Transmission: Treponema pallidum; STD, vertical transmission S/S: chancres, diffuse mucocutaneous rash, altered mental status, uveitis, choroiditis Diagnosis: history, VDRL, TPHA

Cat-scratch disease
Transmission: Bartonella Henselae; flea U.S., Europe, Australia, Africa S/S: adenopathy(100%), flu-like illness, splenomegaly, granulomatous conjunctivitis, focal chorioretinitis Diagnosis: cat contact, lymph node biopsy, serum titer

Others
HTLV-1: history of injection drug use, multiple sexual partners, blood transfusion, PCR, ELISA EBV: high prevalence worldwide

Fungal infection: history, immunocompromised, intravenous drug abuser

Complications
Cystoid macular edema(28~50%) Cataract(15%~20%) Retinal detachment(3~22%)

Vitreous hemorrhage(6~28%)
Secondary glaucoma(15%)

Visual loss
Ref. Course and complications of intermediate uveitis. Acta Ophthalmol Scand 75:82, 1997

Treatment
Step 1: periocular steroid Step 2: oral corticosteroids Step 3: systemic immunomodulatory therapy Step 4: peripheral ablation+ cryotherapy/indirect laser photocoagulation Step 5: PPV and peripheral laser photocoagulation, along with immunomodulatory therapy
Ref. 1. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel American Journal of Ophthalmology , October 2000 2. Indian J Ophthalmol. 2010 JanFeb; 58(1): 2127. Intermediate uveitis B Manohar Babu et. al.

Prognosis
The presence of a pars plana exudate was associated with more severe vitreous disease and increased incidence of cystoid macular edema. Snowbank is a sign of progression Permanent spontaneous resolution of the disease is uncommon. (chronically active/intermittent exacerbation)

When properly treated, at least two thirds of patients can maintain a visual acuity of 20/40 or better.
Ref. 1. Am J Ophthalmol 1987 May 15; 103(5) :669-71. 2. Intermediate Uveitis Robert H Janigian Jr, MD et al.

Reference
1. 2. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel American Journal of Ophthalmology Volume 130, Issue 4 , October 2000 Indian J Ophthalmol. 2010 JanFeb; 58(1): 2127. Intermediate uveitis B Manohar Babu et. al. Course and complications of intermediate uveitis. Acta Ophthalmol Scand 75:82, 1997 Trans Am Acad Ophthalmol Otolaryngol 77:760, 1973 Smith RE. et. al. Duanes Ophthalmology 2006 edtion, Lippincott Williams &Wilkins Am J Ophthalmol 1987 May 15; 103(5) :669-71. Intermediate Uveitis Robert H Janigian Jr, MD et al. Centers for Disease Control and Prevention

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Thank you for your attention!