Physical

• On ocular examination, the ophthalmologist encounters vitritis that ranges in severity. The absence of cellular activity in the vitreous precludes the diagnosis of active intermediate uveitis.
• The presenting visual acuity is often reduced to 20/40 (mild visual loss) due to mild vitritis and CME.
• Anterior segment inflammation is infrequent and more commonly associated with pediatric intermediate uveitis. On occasion, patients with MS develop granulomatous anterior uveitis with characteristic mutton keratic precipitates.
• Aggregates of inflammatory cells may appear in the inferior vitreous as white or yellow tufts termed vitreous snowballs. A snowbank, the requisite finding in pars planitis, may be seen as a grayish yellow exudate along the inferior ora serrata, frequently extending over the pars plana. Not all patients with intermediate uveitis manifest snowbanks.
  • In severe cases, the exudates may coalesce across the entire periphery for 360°, albeit rarely.
  • Scleral depression is usually required to appreciate snowbanks, but, sometimes, they can be seen with the eye infraducted using an indirect ophthalmoscope without the 20 D-lens.
  • In fact, snowbanks may be fibroglial masses and not a true protein exudate (see Histologic Findings).
• Peripheral retinal vascular abnormalities are not uncommon but may become obscured by the dense vitritis.
  • Sheathing or obliteration of small venules may be noted. This finding may appear months or years after initial presentation.
  • Less often, a periarteritis or a combined perivasculitis is present with exudates.
  • Peripheral retinal neovascularization can occur as a result of ischemia, causing vitreous hemorrhages; this occurs more commonly in children.
  • The neovascularization can evolve into a vascular cyclitic membrane in the rare patient, exercising traction on the ciliary body and leading to hypotony and phthisis bulbi.
• CME may be seen. Severe macular edema can be appreciated clinically. Angiographic study or optical coherence tomography is often necessary for a definitive diagnosis, especially if the edema is subtle or if the media are hazy. Some patients with angiographic CME may present with 20/20 acuity.
  • Estimates of the incidence of macular edema vary.
  • Most early reports have noted this complication in 28-50% of cases.
• Optic nerve edema is not uncommon, especially in pediatric cases where the disk is edematous at least half of the time. In a retrospective study, optic disk edema was found in 71% of patients with onset of the disease before age 16 years.
• In the anterior segment, late findings include anterior and posterior synechiae, band keratopathy, cataracts, and glaucoma.
  • The glaucoma may be related to both the uveitis and/or corticosteroid use.
  • The incidence of cataract formation, most often a posterior subcapsular opacity, has been reported in approximately 15-20% of cases and may not be independent to the use of steroids for treatment.
• The late complications of intermediate uveitis are important to recognize early.
  • A combination of vitreous hemorrhage and vitreous fibrosis can cause traction on the peripheral retina and lead to retinal detachment. Studies vary widely in the frequency of this late complication, ranging from 3-22%. Some detachments may become complete, leading to a phthisical eye.
  • Chronic CME may cause moderate-to-severe vision loss. Treating CME, regardless of how good the vision may be, is therefore imperative.
  • Peripheral retinal neovascularization can occur as a result of ischemia, causing vitreous hemorrhages, as discussed above.
  • A vascular cyclitic membrane can exercise traction on the ciliary body and lead to hypotony and phthisis bulbi.

Health Research Sciences MDD-1 and MDD-2 products can be used for Intermediate Uveitis Detection, Screening and Testing