Intermediate uveitis

Your immune system is designed to fight off infection (bacteria, viruses and parasites) and get rid of abnormal cells such as cancer cells. This is a complex mechanism of checks and balances but sometimes, despite all the checks, it starts to think that part of your body is not yourself. Rheumatoid arthritis and uveitis are two examples of these mechanisms going haywire.

Uveitis is the inflammation of the coats the eye. We classify this condition by according to the following characteristics:

• The symptoms
• The cause (when it can be identified, often a past infection)
• The type of inflammation (granulomatous or not)
• The location inside the eye: uveitis is broadly classified into anterior, intermediate, posterior and panuveitis based on the anatomical involvement of the eye.

In the case of intermediate uveitis, it is mainly the location that determines the name, though the location also gives an idea of how the inflammation behaves over time. A uveitis specialist will refer to a condition as being intermediate uveitis when the inflammation is primarily located in the vitreous and peripheral retina.

Intermediate uveitis can be associated with, or be the ocular manifestation of some other diseases such as sarcoidosis, multiple sclerosis, inflammatory bowel disease, Lyme disease or amyloidosis (among others). It is the role of the uveitis specialist to rule out other causes and select the appropriate treatment. A subtype of intermediate uveitis, which we discuss under another heading, is pars planitis.

Symptoms and clinical manifestations

Most patients experience blurred vision and/or floaters and will complain of loss of contrast sensitivity (objects are less well defined and loose their sparkle). Pain and light sensitivity are rare. Early on, the vision is only moderately affected usually due to the presence of fluid in the macular area (cystoid macular edema). Vitritis (cells in the vitreous) and leakage from the retinal vessels (not present in normal non inflamed eyes) are the main manifestations.

Untreated, vision loss may get worse and may lead to permanent loss of function.

Being examined for the first time

An eye exam in uveitis takes time. You should expect on your first visit to stay for one or more hours. Initially we will review your medical history, so please bring with you a summary of your past medical history or your complete dossier if you have it. The following information will be very important for us:

• Images taken of your eyes in the past (these can be also sent ahead of time by E- mail, or bring them along on a CD).
• Names and dosages of medications you have taken in the past (in particular corticosteroids and immunosuppressive agents).

After a complete medical history, your eyes will be examined starting with a careful measurement of your vision, reading vision and possibly contrast sensitivity. After a careful examination of the outside layers of the eye for present and past signs of inflammation, the eyes will be dilated to allow a detailed exam of the inside of your eyes - vitreous and retina.

Often other tests are required which may include OCT, angiography, autofluorescence among others. The exact type and nature of these ophthalmic exams will be determined during your first visit. We will do our best to perform all the exams you need during this visit

Many uveitis patients also require blood tests (these can be done at a local laboratory), CT scan, MRIs and other radiologic. Although this might not be your case, the necessity of this test will be explained in detailed with you during this first visit but in general, these tests might help to establish a diagnosis, rule out other causes and help determine the best treatment for your specific condition.

Treatment

After ruling out causes of uveitis that can mimic intermediate uveitis, you will initially be treated with corticosteroids. Steroids usually work well to restore vision and control the inflammation, but we can only use these for a short period of time.

If the treatment with corticosteroids does not completely resolve or at least reduce, the eye inflammation within the first 3 months, we often add additional immunosuppressive agents to limit the dose of steroids required or to get a better response.

Because the disease is often not as severe in the two eyes, we can use local treatments to reduce the oral dose of medication to a minimum.

Surgery is rarely needed at an early stage, but it may be required to prevent structural damage from becoming permanent.

Since each individual case is different and requires a tailored approach, a more detailed description of the treatment is only possible after a uveitis specialist has examined you.

New developments in intermediate uveitis

MIOS is committed to improve the care for patients suffering from this autoimmune disease. For years, Prof de Smet has studied the mechanisms of inflammation as a way to better understand the natural course of uveitis. Today, we are especially interested in the diagnosis and treatment of this condition.

Specifically in intermediate uveitis, we are exploring the use of a standardized reading chart that appears to be more sensitive to detect subtle changes in vision not detected on standard distance vision charts.

We are also assessing the use of a 9-point vitreous haze scale in patients with posterior (including intermediate) uveitis.

Finally, we are also participating in a clinical trial with patients with intermediate uveitis. In this trial patients with steroid treatment who still have a significant amount of cells or flare in the vitreous cavity. In this trial are treated with an anti-inflammatory IL-6 antibody (Sarilumab) . This trial is a phase II trial for patients with intermediate and posterior uveitis. If you wish to know more, please send a message by e-mail to research@retina-uveitis.eu or call our research coordinator at (+41-21-566-1862) and we will be happy to discuss the protocol and its inclusion/exclusion criteria with you.