From Chronic Care to Zebras: Clinical Pearls in Uveitis
SEATTLE — Uveitis expert Nisha Acharya, MD, shared three clinical pearls on the condition at the American Society of Retina Specialists (ASRS) 2023 Annual Meeting.
“Chronic or recurrent uveitis requires chronic treatment,” said Acharya, who is the Elizabeth C. Proctor distinguished professor of ophthalmology at the Proctor Foundation in the Department of Ophthalmology at the University of California at San Francisco.
Repeated steroid shots may be acceptable for acute uveitis or infrequent recurrences of uveitis. However, chronic or frequently recurrent forms of uveitis, such as birdshot chorioretinopathy, Behcet’s disease, and ophthalmia, tend to be severe, progress over decades, and impair vision. As a result, they require long-term treatment.
Pointing to a case of progressive panuveitis that led to foveal scarring, she said: “With this pattern of intermittent treatment, you’ll have lesions pop up, which is really dangerous. What if this happens right in the fovea and knocks out vision? Even if we don’t see macular edema, there’s subclinical inflammation going on in the choroid pretty much all the time. So intermittent therapy is not a way of addressing that.”
Acharya listed corticosteroids available as sustained-release implants that address the deficiencies of short-acting steroid injections. These include dexamethasone (Ozurdex), fluocinolone acetonide (Iluvien, Retisert, Yutiq), and triamcinolone acetonide (I-vation). She added that the use of implants for long-term treatment was supported by the results of the MERIT trial, which found better outcomes with implants than with other approaches after 7 years.
According to Acharya, long-term therapy is particularly important for patients with uveitic macular edema, the primary cause of vision loss from uveitis, because it has been found to persist for 2 years in 40% of patients. Regional corticosteroids are the standard of care for these patients, she said, adding that intravitreal triamcinolone was found to be superior to periocular triamcinolone in the POINT trial.
Systemic immunosuppressants are another option for treating chronic disease, but Acharya noted that adalimumab is the only such agent approved for uveitis. However, she noted, before initiating adalimumab for patients with intermittent uveitis, an MRI of the brain is required to rule out multiple sclerosis because immunosuppressive therapy can worsen demyelination.
Consider the ‘Zebras‘
Her second clinical pearl advised considering less-common diagnoses. “If someone’s not responding well, think infection,” Acharya said, before reviewing two treatment-resistant cases of uveitis — one of ocular syphilis and another of post-surgical atypical mycobacterial infection.
Genetic sequencing can play a key role in certain cases, she added, illustrating the utility of this approach by reviewing a case in which floaters and progressive vision loss developed after cataract and glaucoma surgeries. After traditional tests produced negative results, metagenomic deep sequencing led to a diagnosis of Whipple’s disease, although the patient reported no gastrointestinal symptoms.
Another case was that of a 37-year-old patient who had intermittent uveitis for 8 years and developed vitritis despite treatment. After immunosuppression was found to worsen the condition and metagenomic sequencing for pathogens produced negative results, the patient was diagnosed with monoclonal B-cell lymphoma.
“Vitreoretinal lymphoma is a diagnosis that’s hard to make,” Acharya said, adding that in this case, a less-common but known mutation was found that routine, directed polymerase chain reaction testing would not have detected.
Incorporate Multimodal Imaging
Her third clinical pearl for assessing patients with uveitis focused on the increasing importance of multimodal imaging, which may be crucial for detecting interocular inflammation associated with pegcetacoplan treatment or cancer that has metastasized to the eye.
Acharya encouraged ophthalmologists to work with a rheumatologist or specialist in uveitis to better manage long-term immunosuppression. Although many rheumatologists are reluctant to care for patients with inflammation that affects only the eyes, she said, they are more likely to help if you build a relationship with them and emphasize the risk of blindness.
ASRS 2023 Annual Meeting. Presented July 28, 2023.
A former staff reporter for Cardio magazine and contributor to MD Magazine’s vision disease coverage, Ellen Kurek earned her bachelor’s degree from Swarthmore College, where she covered mental health issues for the campus newspaper and researched learning and memory neurophysiology. She earned her nonfiction writing certificate from the University of Washington, where she studied with writing coach and former Seattle Times reporter Jim Molnar.
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