Further Outpatient Care
Observe patients every 1-4 weeks during the active phase of the disease, more frequently if CME or severe inflammation is present.
Since corticosteroids can cause glaucoma at any time, it is imperative that patients return for intraocular pressure monitoring at 4-week intervals while using corticosteroids or after periocular injections. Periocular triamcinolone can cause steroid responsive glaucoma many months after an injection.
Consider fluorescein angiography and/or OCT whenever CME is suspected.
Consider reordering any relevant laboratory tests if the clinical situation changes. For example, a patient who initially presents with routine intermediate uveitis and negative findings on workup is found to have multiple choroidal granulomata 14 months later; in this case, unless proven otherwise, consider sarcoidosis (or other granulomatous disease).
Further Inpatient Care
Patients generally are treated on an outpatient basis.
Inpatient & Outpatient Medications
Topical steroids (prednisolone acetate 1%, loteprednol etabonate 0.5%) are used for anterior segment inflammation. Frequency of use depends on severity of inflammation. Possible discrepancy in potency between proprietary Pred Forte 1%, and generic prednisolone acetate 1%, wherein the generic preparation is less potent due to markedly higher suspension particle diameter and resultantly decreased surface exposure and intraocular absorption.
Triamcinolone is given as a periocular injection in the office setting to suppress intraocular inflammation and CME. The most commonly used dose of triamcinolone acetonide is 20 mg. If no response occurs, it can be repeated as soon as 2 weeks after the initial injection. If no improvement occurs after 3 consecutive injections, a different treatment modality must be considered.
Use oral prednisone (0.5-1 mg/kg) in the presence of moderate-to-severe inflammation, especially when it is bilateral. Tapering can be initiated as soon as 2 weeks after treatment was started, according to the clinical response of the patient, and the minimum effective dose controlling the inflammation should be maintained for at least 4 months.
Immunosuppressive agents (ie, methotrexate, cyclosporine, tacrolimus, azathioprine) generally are used as steroid-sparing agents or for severe inflammation that is unresponsive to steroids. Immune-modulating agents (ie, infliximab) can be considered to treat persistent macular edema or to decrease the steroid requirements of selective patients. Consult with a specialist who is familiar with these drugs.
Deterrence/Prevention
Smoking cessation should be strongly encouraged. Thorne et al found a 4-fold increased risk of uveitic CME in smokers with intermediate uveitis. [21]
Complications
Potential complications include the following:
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Cataract
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Glaucoma
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CME
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Vitreous hemorrhage
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Retinal detachment
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Epiretinal membrane
Prognosis
The following may influence prognosis:
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Approximately one half of patients with intermediate uveitis present with a visual acuity of 20/30 or better.
When properly treated, at least two thirds of patients can maintain a visual acuity of 20/40 or better.
According to an early review, greater than one third of patients develop significant vision loss.
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There are many possible levels of chronicity for this form of uveitis; the proportions of patients with each potential end point vary from facility to facility. Early aggressive treatment generally portends a more benign course in appropriately selected patients.
Some patients have mild inflammation that may not lead to significant visual loss or macular edema even without treatment. Despite long-term follow-up care, permanent remission rates are reportedly low. Most cases are long term and loosely classified as mild, moderate, or severe; each has variable and unpredictable responses to treatment, although the severe form tends to be more recalcitrant.
Regardless of the severity of a patient's inflammation, use caution when encouraging patients that their disease will likely "burn out" with time. The disease is typically chronically active or follows a course of intermittent exacerbation punctuated by periods of quiescence. Permanent spontaneous resolution of the disease is uncommon.
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Whether the presence of a pars plana snowbank predicts a worse prognosis is unknown.
Henderly and colleagues found that a snowbank is associated with more severe vitreous inflammation and more frequent and extensive CME. [6]
Patients without this finding tended to have a milder inflammation, less macular edema, better visual acuity, less phlebitis, and fewer snowballs.
These differences were not statistically significant, which may have been in part due to the small sample size.
Some patients with a snowbank had good vision without CME.
Nevertheless, the trends are intriguing and could suggest that a snowbank is a sign of progression along the same disease continuum.
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The prognosis of pediatric patients with intermediate uveitis was considered unfavorable secondary to late presentation in the course of the disease and the inherent difficulties in treating such patients with immunosuppressive agents.
In a cohort of 32 consecutive patients with onset of the disease before age 16 years, an incidence of legal blindness of 12-13% was found after 8 years of follow-up.
According to the same study, 3 of 16 patients showed a complete remission after 3 years of follow-up. The proportion of patients showing complete remission increased to 47% after a follow-up of 5 years.
Another case series of 35 patients suggested that children diagnosed before age 7 years have poorer visual outcomes than those who are diagnosed at an older age. [22]
Patient Education
Since this disease is long term and recurrent, patients must recognize symptoms of a flare-up (ie, floaters, blurred vision, redness, discomfort) early and seek medical attention appropriately.
