 Okay, before we start we'll play a game called name the animal Where does this eyeball come from? Mike you'll know No, it's related. It's a it's a cephalopod, but it is It's a cuttlefish Not edible It lacks Cornia has a Christian lens and the nerve fiber actually leaves the red nerve from the back but Not relevant to this discussion But interesting Yeah, I actually took this picture in Borneo before he ran away They're pretty temperamental animals so my case is a pretty Difficult Manifestation of a common problem This is an adolescent a 17 year old Asian Girl who was referred for iraitous. She complained of a three-year history of floaters loss of vision of both eyes and She was recently admitted to uni for Suicidal ideation. She did not read the Spain flashes. She did have some floaters She has a history of depression anorexia Anodonia suicidal ideation auditory hallucination so major depressive disorder with Psychotic feature features Otherwise family history and social history unremarkable. She's a first-generation immigrant She's on the motor geeking and prototyping Except for the above her review systems was negative On presentation. She was 2400 and 2300 the normal IRB one plus cell in the anterior chamber two plus victory cell one plus victory's haze In fear vitreous hemorrhage in the right eye with multiple areas of very phlebitis model discadema and cystoid macular Dima and Kind of a similar picture in the left eye Massive cystoid macular Dima in both eyes explaining her loss of vision. Have you look at the angiogram that this diffuse? leakage from the from the arterials vanuels and capillaries with a Lot of leakage from the nerve as well seen in the late stage here with end of this dark darkening of the Watershed areas. This is what we call a kind of a foreign like appearance and leakage was described by Janet Davis So this is an Intermediate uveitis is it inflammatory or infectious? It's important to rule that out and there's a very strong component of retinal vasculitis is retinal vasculitis the primary problem it seems more like Intermediate uveitis is a primary problem checked her for Systemic issues DB was negative syphilis testing was negative ace and lysozyme HIV viral hepatitis looked for some of the labs that may be associated with Retinal vasculitis found them to be negative and so our final diagnosis was intermediate uveitis of The paris planitis variety with significant systroid macular edema Vascular leakage new vascularization and Victorious hemorrhage and we really don't know how long this had been going for because she'd been admitted she'd been suicidal She'd had symptoms for three or four years So in consultation with the patient psychiatrist, which is important when you start patients on steroids we started her on prednisone and Concurrently because this was likely a chronic issue Started her on steroids bearing immune immunomodulation with Michael Fenley at one gram twice daily unfortunately on steroids she Did report improvement in her symptoms, but she did Start to have greater suicidal ideation aggression towards a peers family and Had some auditory hallucinations again So steroids were quickly withdrawn down to 20 milligrams and Intervitual steroids were injected into both eyes with incomplete resolution of CME in both eyes At that time no steroid associated oculohypertension was noted the dose of celsep was increased to 1500 twice a day, which is your maximum dose Three months on celsep and after intervitual steroids you can see she still has a lot of macular edema with maybe some improvement in leakage, but Let me pick on a resident again Dina there you are What do you see this different about this and you're going specifically in the right eye exactly so that's actually a new vascularization and In intermediate uveitis you can have new vascularization for two reasons number one because there's a lot of peripheral non perfusion which is common and secondly because Vegaf is an acute phase Reagent and can in fact be found in elevated levels when there's a lot of information Therefore you can end up with new vascularization of the disc or elsewhere And this can often be your source of vitreous hemorrhage in this case. There was some vitreous hemorrhage in fearly and both That is not shown in the pictures So therefore laser was performed through areas of retinal non perfusion in the right eye We started at a limium ab humera with improvement in CME But not complete resolution three months after starting humera she 40 milligrams every two weeks two months after intravitual steroid in both eyes This is the first time in her entire treatment course that the CME mostly went away her vision is now 2100 likely limited by Kind of these areas of Ellipsoid zone loss in both eyes as a result of chronic cystoid molecular demon Still has areas of New vascularization such slightly more consolidated and three months later She comes in with dense viscous hemorrhage in the right eye more than the left vision has now decreased to 20 400 in the left and counting fingers at three feet in the right so you can see hints of My killer Dima In both eyes quite quite quite a lot of my killer Dima, but the view is limited by the vitreous hemorrhage So we finally bit the bullet did a partial of a dractomy with augmentation of the peripheral laser and Implanted a flucid alone a satanide Implant red cert in the right eye and performed a similar procedure in the left eye her vision stabilized to 2060 in both eyes resolute version of CME and Vision is limited by my killer atrophy So summary this is an 18 now 18 year old actually nauseous 20, but Then 17 18 year old girl with severe bilateral intermediate UVA is complicated by massive CME vitreous hemorrhage She was unable to tolerate steroid Suicidal ideation so Vitreous intermediate UVA is can present with varying degrees of severity's manifestations can include vitreous cell in his Retinal vasculitis is a pretty common feature CME is the most common cause of vision loss of Irreversible vision loss in these patients cataract glaucoma and optic nerve edema retinal non perfusion with neovascularization in the retinal periphery and I Sorry, retinal leave at non-properate non perfusion can cause you know on the optic nerve or elsewhere Vitreous hemorrhage in six to twenty eight percent as well as epiretinal membrane Late findings do include psychotic membranes tractional or regmetogenous retinal detachment hypotony and tithes Marisa I'll and myself have found that there are kind of two main Presentations of intermediate UVA just they could be that indolent quiet kind, which you may not have to treat But in children especially sometimes you are faced with these really really bad intermediate UVA just cases with bad Traction at the ciliary body psychotic membranes and they present early with hypotony and they present early with these vitreous membranes those require more severe a more Aggressive treatment as Al alluded to and as Chris will talk about as well there We do you utilize a step ladder approach to treatment You can start with steroids. They may be oral injectable subdenons or intra vitrile immunomodulatory therapy You should not be shy about starting this especially in chronic disease chronic disease that requires chronic treatment and Anti metabolized T cell inhibitors biologics and cytotoxics may all be used although cytotoxics have Kind of gone out of favor with the advent of rituximab and other such biologics Surgical intervention may be utilized sparingly in patients with intermediate uveitis Retrectomy has been shown to in some cases even bring about some degree of remission Be it drug-free or otherwise Retrectomy in conjunction with cryotherapy to the snowbank or to the paris plana inferiorly as well as laser may also Be shown to bring about some degree of remission in some cases Steroid implants have been used and should be used sparingly for intermediate uveitis. They have in the must study Which was a national I Institute funded randomized clinical trial comparing systemic steroid with immunosuppressive treatment with reticent implant at Three years showed that the visual acuity was not significantly different in the two groups the Redisert versus immunomodulation group However, this is not a benign treatment Cataract surgery occurs in in almost a hundred percent of patients to be honest 61% end up with elevated IOP the three-year data shows elevated IOP higher than 70% and Over 35% required incisional glaucoma surgery not everybody can be treated with systemic steroids in a meta-analysis 935 patients The rate of psychiatric complaints on steroids anything from anxiety agitation to psychosis is 27.6% with 5.7% being severe and these are in group patients with hallucinations and and suicidal ideation There's no particular age group predilection or dose dependence for these side effects with steroids. There's no significant association with pre-existing Mental illness. I find that hard to fathom, but this is what this paper showed Minimal but statistically significant increased risk in women on steroids of severe steroid associated psychiatric side effects therapeutic vitrectomy can be utilized with Good efficacy in patients with intermediate UVA just indications to include media opacity vitreous hemorrhage Inflammatory control the removal of antigenic material from within the eye can Can decrease the amount of inflammation in the eye? It can be performed in conjunction with cataract surgery and we have a case series so far of 42 patients But many more patients are being added to that database by Chris Conraddy as we speak hopefully and and really there is There seems to be good evidence to support the fact that this is a safe and effective way To manage intermediate UVA just in conjunction with immunomodulatory therapy and with good patient selection Vitrectomy can be utilized for the removal of epiretinal membranes, which do develop in patients with IU Chronic CME can be treated with vitrectomy and internal limiting membrane feeling hypotony To remove cyclitic membranes either endoscopically or otherwise wrecked retinal detachments do occur Especially with peripheral traction in patients with intermediate UVA just and lastly the implantation of sustained release steroids Redisert which is the most commonly used and now Injectable version your geek which is a non-biodegradable All right be happy to answer any questions. Yes, so I remember that said he came out and Associated that there wasn't associated with underlying conditions, but you know My experience having raised five teenagers is that the majority of teenagers are borderline crazy at some point during that experience Maybe I'll all a hundred percent including my own experience as a teenager and then also having been on You know high Systemic doses personally with reactive asthma at two points in my life that stuff can drive almost anybody crazy Oh, absolutely, even if you're not overtly you say I think a hundred percent of people There are a few I hear will tell you that that I mean there are lots of things in there that just absolutely Can drive you bonkers. So you add the two together I can't help but imagine that systemic steroids and teenagers is is fraught with a lot of potential Psychiatric it certainly can be and you should be ready to withdraw steroids I had a patient in in San Francisco where I was steroids who was ready to jump off a bridge Because he felt he could fly I think steroids should be used with caution Al I was just gonna say that you know, I mean it would use effectively I think that you know fairly safely in fact, we have a study of pediatric patients in which we used steroids and immunomodulatory Stewards as bridging therapy immunomodulatory therapy had zero side effects We're able to get every one of those patients almost every one of those patients 90% of them off steroids So I mean, you know, it's it's very useful and important in selected patients to you know, really quality Is a big thing there to use it as short a period of time getting them off relatively rapidly. I think so So, you know, it's we arbitrarily talking about it for about three month Starting at high-dose and then tapering fairly rapidly in general if you start with one milligram a kilogram So in an adult typically 60 then you're at risk for a lot of psychiatric complaints And if ask them across with the hip osteoporosis Steroid myopathy, etc. But once you drop below 30 those risks start to go down in general with with chronic disease, you never treat steroid monotherapy is a not going to be effective and B is going to be fraught with a lot of Side effects that you don't want to deal with So really early institution of steroids bearing immunomodulatory therapy is key We tell patients the only thing that works today is steroids. So we start the immunomodulatory therapy It's at least, you know, six weeks eight weeks The seven-year results of the must trial You know showed that actually systemic therapy with the immunomodulation and steroids were actually Significantly more efficacious this with, you know, six-line improvement delta visual theory. That's brought with problems itself You know, so it's it really the bottom line is that therapy is to be individualized