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Dr.Vishali Gupta , Dr.Reema Bansal , Dr.Amod Gupta INTRODUCTION Vitritis, or more accurately known as vitreous humor inflammation, is an important clinical entity. It is the most consistent sign of intermediate uveitis (cyclitis) and can also occur in association with certain nonuveitis entities including intraocular lymphoma, trauma, etc. The inflammation could be induced by an infectious agent or trauma, but in majority the underlying mechanisms appear to be autoimmune in nature. The term ‘Intermediate uveitis’ encompasses the inflammation of pars plana that could be of various etiologies including sarcoidosis, tuberculosis, etc. The term ‘pars planitis’ is used when the intermediate uveitis is idiopathic in nature. CLINICAL PRESENTATION Patients complain of floaters or blurry vision. Pain, photophobia and redness are unusual. Children may be more prone to develop anterior segment inflammation including posterior synechiae 1, 2 and band keratopathy 3, 4 Vitritis is the most consistent sign of intermediate uveitis.The vitreous humor cellular reaction has the appearance of “dust” at the slit lamp biomicroscope5.Vitritis may become so dense so as to obscure the retina entirely6,7and cause profound loss of vision. These white cells are present in both the anterior and posterior vitreous (diffuse clouding). Examination of posterior vitreous humor is necessary to evaluate fully the degree of vitritis, as it is usually most prominent posteriorly.Characteristic mobile, round, white, focal vitreous humor opacities, dubbed “oeufs de formi” (ant’s eggs) in French8, can be seen in the inferior peripheral vitreous. They lie close to the retina but are not in contact with it. They are not specific for parsplanitis and may occur with any kind of inflammation of the peripheral fundus or with an extensive and diffuse uveitis9.Later,the vitreous shows degenerative changes with fibre-like cylinderical condensations of coarse vitreous strands10,11. Posterior vitreous detachment is common. The hallmark of pars planitis are the white or yellowishwhite exudates (posterior hypopyon) and collagen bands (snow banks) over the pars plana, with extension into the ora serrata and peripheral retina. They are typically located inferiorly, but may also be found superiorly or divided into multiple foci. Chronicity produces gliosis and collagen deposition similar to that seen in preretinal membranes12,13. DIFFERENTIAL DIAGNOSIS OF VITRITIS Vitritis could be due to infectious or non-infectious etiologies. Certain non –uveitis conditions might present as vitritis and mimick chronic uveitis.These are termed as ‘masquerade syndromes’. Infectious causes 1. Tuberculosis 2. Syphilis 3. Toxoplasmosis 4. Toxocariasis 5. Lyme disease 6. Endogenous endophthalmitis 7. Parasitic infestations e.g.,cysticercosis
Non-infectious causes 1. Sarcoidosis 2. Behcet’s disease 3. Multiple sclerosis 4. Inflammatory bowel disease 5. Fuch’s heterochromic uveitis 6. Collagen vascular disease 7. Eales’ disease
Masquerade syndromes 1. CNS lymphoma 2. Other tumors e.g., Retinoblastoma, malignant melanoma, medullloepithelioma 3. Metastasis from breast, lung or renal carcinomas into the eye 4. Paraneoplastic syndromes Following are some of the common entities:
Autoimmune reactions against vitreous. Cystoid macular edema (CME) is common in pars planitis.06%) patients of uveitis seen between January 1996 and June 2001. 23-26. peripheral uveitis. peripheral retina and pars plana ciliaris. Davis et al found associations with HLA – DR 2 and HLA – DQI28. sarcoidosis in 8(4%) and toxoplasmosis in 1(0. The diagnosis is based on clinical features with a positive tuberculin skin test. peripheral retina and ciliary body have been proposed. or of the iris (NVI) can occur in most severe disease. Vitreous traction may be involved in the generation of CME. subretinal exudation with serous retinal detachment are rare. Retinal traction. Retinal periphlebitis in TB is usually a result of extension from choroidal disease.44 Intermediate Uveitis Journal of the Bombay Ophthalmologists’ Association Vol. it constituted 198 of 1233(16.4%) were idiopathic in nature.Tuberculous uveitis may appear as a chronic granulomatous iridocyclitis.Out of these. There has been no striking sex predilection or familiar tendency. vitritis and pars planitis 15-21. Presence of the characteristic pars plana exudates (snow balls) and snowbanking facilitates diagnosis. intermediate.36 . The diagnosis of intermediate uveitis is made when intraocular inflammation primarily involves the vitreous. and arterioles are rarely involved30. This classification scheme subdivides uveitis into anterior. pulmonary radiographic evidence of TB. 2 Intermediate uveitis is a common type of uveitis in children and young adults. The term intermediate uveitis has been designated by the International Uveitis Study Group for the entities that have been previously called cyclitis.181(91. it is important to rule out following causes: Tuberculosis Tuberculosis may affect any ocular structure. An immune mechanism has been proposed in the pathogenesis of retinal periphlebitis in patients with tuberculin hypersensitivity. It is one of the four major categories of uveitis in the classification scheme proposed by the International Uveitis Study Group14. Toxoplasma Retinochoroiditis Active toxoplasma lesions are round or oval. Eyes with exudates have been considered to be more severely involved29. posterior and panuveitis based on the principal anatomic site of inflammation. Clinical features Patients complain of floaters or blurred vision. adjacent to a pigmented old scar or satellite lesions and are usually in the posterior retina. In our population from North India. Cuffing of retinal vessels with inflammatory cells is a common feature and there is occasionally obliterative vasculitis. characterized by mutton-fat KPs and extensive posterior synechiae. intermediate uveitis represented 4-25% of patients 22. including a wide ring-like lesion near the extreme periphery. Several studies have looked for human leukocyte antigen (HLA) associations in Intermediate Uveitis.Active toxoplasmosis may cause such a heavy vitreal . Vitritis is the most consistent sign of intermediate uveitis. yellowwhite. Pars planitis occurs in patients between the ages of 5-40 years and has a bimodal distribution with a young group in the age range 5-15 years and an older group in the age range 20-40 years. resembling the snowbanking seen in pars planitis 35. peripheral uveitis. being the most common cause of decreased visual acuity31-34. 13 No. These changes are most common in the terminal branches of retinal veins. chronic cyclitis. Peripheral lesions have been described. Aetiology As in any case of uveitis. Papillitis and optic nerve edema are uncommon. NVD or NVE may lead to vitreous hemorrhage and NVI to neovascular glaucoma. The associated iridocyclitis is usually granulomatous. Neovascularisation of the disc (NVD). Epidemiology In a large series from uveitis referral practices. of the retinal periphery (NVE). retinal detachment. tuberculosis was the etiology in 8(4%) cases.5%) case 27. PCR positivity from intraocular fluids and a response to empiric antituberculous therapy. Pathogenesis The pathogenesis of intermediate uveitis largely is unknown.The presence of choroidal tubercles classically suggests hematogenous dissemination. disseminated choroiditis or panuveitis. Cataract is common in protracted pars planitis.
the vitreous and retina are most likely affected46. in some patients. In these patients. and cranial nerve palsies. Unlike pars planitis.A subset of intermediate .Progressive posterior uveitis can lead to disc edema.Chest radiograph. Diffuse or segmental vasculitis may be seen. Syphilis Anterior uveitis is the most common finding of secondary syphilis 40. Endogenous endophthalmitis Endogenuos infections. Vitreous inflammation may be so severe that it obscures view of the fundus and makes clinical diagnoses difficult . producing endogenous endophthalmitis. toxocariasis is a major diagnostic consideration when dealing with unilateral intermediate uveitis 37. cardiac conduction defects. Lyme Disease It may present with unilateral or bilateral uveitis which usually resolves rapidly on treatment with antibiotics.The pathogenesis of uveitis appears to be related to both infectious and immunogenic components.An anterior uveitis is frequent with an associated hypopyon. it can cause intermediate uveitis.It is usually acute in onset in contrast to the insidious onset in intermediate uveitis. The regimen for neurosyphilis provides effective therapy. but only tissue biopsy (transbronchial lung biopsy) confirms it. Intermediate uveitis may precede multiple sclerosis by more than 7 years 50 .most often affecting the posterior pole 42 and juxtapapillary area 43 . Cysticercosis Although any structure within or around the eye can be involved in ocular cysticercosis.Vitritis is usually severe in ocular cysticercosis. The infective element initiates a focal choroiditis.Patients with ocular toxocariasis are usually free of systemic findings. Serology for Borrelia burgdorferi should be performed if suspicion is high based on exposure or review of systems which include erythema migrans like skin rash.Sudden onset and a compatible history are helpful in making a correct diagnosis 45. it produces inflammation and involves all structures of the eye. Behcet’s Disease Characterized mainly by its retinal vascular involvement. serum lysozyme and gallium scans support the diagnosis.There may be “spillover” anterior segment inflammation with small to medium-sized . retinal vasculitis.Multiple sclerosis does not have to be active for intermediate uveitis to be present.Late syphilis may present with anterior or posterior uveitis. syphilitic vitritis may be the initial manifestation of HIV disease. uveal effusion and exudative retinal detachment 44 . Behcet’s disease has usually bilateral ocular involvement with recurrent episodes of uveitis 39 . An isolated vitritis is not characteristic but is significant .The parasite may be present within the vitreous or in the subretinal space 47 . usually as part of a disseminated infection. vitritis. Toxocariasis In chidren. bacterial or fungal.June 2004 reaction that the retinal lesion itself cannot be directly visualized (“headlight in the fog”). mutton-fat KPs in the cornea. with an older age of presentation 38 . vitritis may be the first manifestation of syphilis.Breger suggested an autoimmune disorder directed against an unknown antigen.round white or large. Moreover. 45 Vitritis as the primary manifestation of ocular syphilis in patients with HIV infection: HIV positive patients with syphilis may present with atypically dense vitritis. reach the eye via the bloodstream. When this initial focus of infection extends into the vitreous. common to both eye and myelin nerve sheath 49. History of infected puppies or pica and serological testing (ELISA) for toxocara antigen are extremely helpful. Rarely. retinitis or cyclitis.HLA typing(HLA-B 51).a compatible history and systemic evaluation are helpful. Multiple Sclerosis Patients with multiple sclerosis may develop ocular disease resembling other forms of intermediate uveitis. Retinal periphlebitis and vitritis have been reported to occur in 5-20% of patients of multiple sclerosis 48 . serum ACE levels. Sarcoidosis Sarcoidosis should be suspected in all patients with intermediate uveitis. The characteristic unilateral chronic endophthalmitis with peripheral granuloma and tractional bands extending from the disc to the posterior pole is distinct from intermediate uveitis. sacoid uveitis is slightly more common in females. Posterior uveitis can occur as diffuse or localized choroiditis or chorioretinitis 41 .
there is destruction of photoreceptors 54 which is thought to be immunemediated. acute mylogenous leukemia and juvenile xanthogranuloma can masquerade as uveitis. cytological evaluation of CSF and neuroimaging are necessary for establishing diagnosis. vascular sheathing and RPE disturbances. toxoplasmosis.53 . Other malignant conditions Tumors such as retinoblastoma. Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) is another paraneoplastic disorder simulating as uveitis.46 Journal of the Bombay Ophthalmologists’ Association Vol. Fluorecein angiography is useful for retinal or choroidal pathologies. round. subretinal red patches with or without exudative retinal detachment and vitreous cells can be seen. Atypical vitreous cells and a mass. Multiple stellate keratic precipitates and heterochromia iridis constitute this diagnosis. syphilis). toxocariasis. and TPHA for syphilis. Serological tests (ELISA) may be indicated for toxoplasmosis. malignant melanoma or medulloepithelioma can disseminate into the vitreous and simulate intermediate uveitis. apart from retinoblastoma and medulloepithelioma. Breast. Posterior synechiae preclude the diagnosis. There is no snowbank. 2 uveitis patients may be at a risk for the subsequent development of multiple sclerosis 51. found in association with a systemic malignant process. In suspected cases of endogenous endophthalmitis. detectable by fundoscopy or ultrasonography constitute these diagnosis . raised. many of the masquerade syndromes are malignant processes. Intraocular Lymphoma Vitritis without fundus lesions has been reported with intraocular lymphoma 52. chest radiograph to screen for tuberculosis and sarcoidosis. 13 No. blood culture and urine culture may prove contributory. Multiple. LABORATORY INVESTIGATIONS The diagnosis of intermediate uveitis is clinical. Apart from certain nonmalignant conditions masquerading as uveitis. TREATMENT The goal of the treatment is to ameliorate vision threatening complications secondary to intermediate uveitis like CME. glaucoma and exudative retinal detachment.then the treatment is directed against the particular disorder and a relevant medical consultation is sought for systemic involvement. Diagnostic vitrectomy. Masquerade Syndromes These comprise a group of disorders that occur with intraocular inflammation and are often misdiagnosed as chronic idiopathic uveitis. HIV and Lyme disease. MRI may be required to look for multiple sclerosis. Cranial imaging with lumbar puncture are indicated to rule out large cell lymphoma. erythrocyte sedimentation rate. a tuberculin skin test.Elderly patients presenting with vitreous cells may be indicative of intraocular lymphoma. sarcoidosis. . Aqueous tap and Vitreous biopsy may be required for cytological or microbiological evaluation and Polymerase chain reaction. If a specific cause of intermediate uveitis is diagnosed (such as tuberculosis.This inflammation reflects an improved immune response against cytomegalovirus. Such patients need a complete medical evaluation to detect the primary cancer. Fuch’s Heterochromic cyclitis It can produce a unilateral. lung and renal carcinomas can metastasize to the choroid and produce signs and symptoms of uveitis. chronic. low grade anterior segment inflammation with spillover of the cells into the vitreous cavity.In children. Transient Vitreous Inflammatory Reactions associated with combination antiretroviral therapy in patients with AIDS and Cytomegalovirus Retinitis Patients with AIDS and CMV Retinitis may develop transient intraocular inflammation associated with combination antiretroviral therapy. Routine tests should include a complete blood count to look for WBC abnormalities (as in a malignant masquerade syndrome). Vitreous biopsy may reveal the presence of malignant cells. Vitritis may be significant to cause CME. Paraneoplastic Syndromes: Cancer-associated retinopathy (CAR) may manifest as uveitis. Histologically. subtle CME and capillary nonperfusion. cataract. Visual loss may be explained by optic disc pallor.
Rifampicin (10mg/kg/day). sulphadiazine and corticosteroids with Folic acid supplementation. 57 Penicillin remains the treatment of choice for syphilis . Arch Ophthalmol 64:540-549.Peripheral uveitis:the complication of retinal detachment. uncontrolled cases of vitritis and patients who are intolerant to corticosteroids may require the use of immunosuppressive agents. . Surgical management Pars plana vitrectomy may be indicated for diagnostic as well as therapeutic purpose to remove vitreous antigens and inflammatory cells and mediators. although rare. oral Prednisolone in the dose of 1. But these agents have serious systemic side effects which should be monitored by an experienced physician. cataract. Brockhurst RJ.Schepens CL:Uveitis.IV.started a day before oral corticosteroids and continued for a few days after tapering off steroids for a total period of 6 weeks.The other approach is to use Clindamycin in a dose of 300 mg QID as the sole antimicrobial agent in combination with corticosteroids 56 . depending upon the response .Patients with acive syphilitic uveitis are treated as for neurosyphilis-Penicilllin G Sodium 2-4 million units every 4 hours intravenous for 2 weeks after a negative skin test. Initiation of oral corticosteroid therapy is delayed for 24-48 hours after starting antimicrobial agents to allow adequate blood levels of antimicrobials 55.June 2004 The mainstay of the treatment of intermediate uveitis is periocular corticosteroid injections or oral steroids. ATT. Ethambutol and Pyrazinamide are discontinued after 4 months and patient is maintained on 2 drug-regimen (INH and Rifampicin) for upto a 47 total of 18 months. playing an important role in CME. in our experience. Azathioprine. PROGNOSIS The visual prognosis depends upon status of the macula and vitreous opacification in the early course of the disease. bilateral. Ethambutol (10-15mg/kg/day) and Pyrazinamide (1520mg/kg/day) with Pyridoxine (10mg/day) supplementation. secondary glaucoma and tractional retinal detachment affect the visual outcome in later stages. results in a deposit of the drug closer to the macula. Posterior sub-tenon Triamcinolone Acetonide injection may be given every 6-8 weeks until resolution of CME or return of 20/20 visual acuity. Other specific indications for vitrectomy include intravitreal or subretinal cysticercosis. ATT comprises of Isoniazid (5-10mg/kg/day). Specific causes Cases diagnosed as intraocular tuberculosis are treated with a course of anti-tubercular therapy (4 drug regimen) and oral steroids. reduces the recurrence rate. Oral steroids are tapered over a period of 6-8 weeks. The “classic” antimicrobial therapy for active ocular toxoplasmosis consists of a combination of pyrimethamine.1960. Severe. Methotrexate. ocular toxocariasis for granuloma excision and tractional retinal detachment. Cyclophosphamides. Very severe cases may need Combination therapy (Prednisolone plus immunosuppressives. Giving the injection superotemporally in the sub-Tenon space as far posteriorly and close to the globe as possible.0 mg/kg daily are given and tapered over 6-12 weeks. Chlorambucil and Cyclosporin A have proven to be effective. 2. epiretinal membranes and vitreous hemorrhage. Posterior injection also reduces the risk of intraocular pressure rise. or two or three different immunosuppressives). Topical betamethasone and cycloplegics are given for associated anterior segment inflammation.1968.Wahlen HR:Peripheral posterior segment inflammation. include vitreous opacification.vitreous opacities and edema of the posterior pole:pars planitis. REFERENCES: 1. tractional retinal detachment. Core Vitrectomy with intravitreal antibiotics (antibacterial or anti fungal) along with administration of intravenous antibiotics is recommended for endogenous endophthalmitis. Other indications of vitrectomy. When a series of periocular injections have failed. Welch RB.Maumenee AE. Clindamycin appears to be concentrated in ocular tissue and can penetrate tissue cyst walls. Arch Ophthalmol 80:747-753.All possible complications of corticosteroids should be looked for on follow-ups. Cataract.
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MRI ruled out CNS lymphoma.Vision improved to 6/12. A 50-years old male with severe vitritis OD.2. Fig. A 26-years old male with a “headlight in the fog” appearance OD.Treated with Clindamycin and oral corticosteroids.ELISA was positive for IgM in the vitreous and serum.vision improved from 6/60 to 6/12.cell Lymphoma.3 .Vision improved from 6/36 to 6/6. .Vision was 4/60. Vitreous biopsy revealed B. Fig.Pars plana vitrectomy was done and intravitreal antibiotics given.Routine investigations were normal .June 2004 51 Fig. An 18-years old male with endogenous endophthalmitis OS.Pars plana vitrectomy was done and intravitreal methotrexate given.1.
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