Intermediate Uveitis: Spotlight on Symptoms, Signs, and Potential Complications

Summary

This educational video by Dr. Amrit delves into intermediate uveitis (UVITIS), a type of eye inflammation. It explains the classification of UVITIS based on the affected part of the uveal tract, the chronic and insidious nature of intermediate UVITIS, and its relapsing course. The lecture also covers the history, causes, symptoms, and signs of the condition, including the presence of snowballs and snow banking in the vitreous. It highlights the importance of scleral depression in examination and the potential complications, such as macular edema and retinal detachment, providing a comprehensive overview for medical professionals.

Takeaways

• 😀 The script is a lecture by Dr. Amrit on intermediate uveitis (UVitis), a type of eye inflammation.
• 🔍 Uveitis can be classified into three types based on the part of the uveal tract affected: anterior, intermediate, and posterior.
• 🏥 The International Uveitis Study Group (IUSG) and the Standardization of Uveitis Nomenclature (SUN) Group have established criteria for classifying uveitis.
• 📚 Intermediate uveitis is characterized by chronic inflammation with an insidious onset, primarily affecting the vitreous and the intermediate part of the eye.
• 👨‍⚕️ The lecture discusses the historical development of the understanding of intermediate uveitis and the various terms used to describe it.
• 🧬 Intermediate uveitis can be idiopathic or associated with systemic disorders, with a significant portion of cases having no identifiable cause.
• 👶 The condition is particularly relevant in pediatric populations, where it accounts for a large percentage of uveitis cases.
• 🌐 Causes of intermediate uveitis include both infective and noninfective etiologies, such as tuberculosis, syphilis, and sarcoidosis.
• 👁️ Symptoms of intermediate uveitis include insidious onset of blurred vision and floaters, often without significant pain or photophobia.
• 🔬 Clinical signs of the condition include the presence of snowballs and snow banking, which are indicative of severe inflammation.
• 💡 The lecture emphasizes the importance of scleral depression in examination to detect peripheral signs of intermediate uveitis.

Q & A

What are the three types of UVEITs based on the inflammation part of the uveal tract?

The three types of UVEITs are anterior, intermediate, and posterior. Anterior UVEIT affects the iris and ciliary body, intermediate UVEIT primarily affects the area near the anterior vitreous, and posterior UVEIT affects the retina and choroid.

What is the definition of intermediate UVEIT according to the SUN Working Group?

The SUN Working Group defines intermediate UVEIT as a disease where the major site of inflammation is the vitreous, with minimal to no anterior segment or chorioretinal inflammatory signs.

Who first described what was likely intermediate UVEIT, and what term did they use?

Fuchs first described what was likely intermediate UVEIT in 198, using the term 'chronic cyclitis' to describe the inflammation of the ciliary body.

What term did Charles Sheehan use to describe the clinical description of intermediate UVEIT?

Charles Sheehan used the term 'intermediate UVEIT' to describe the clinical condition, and he also mentioned peripheral vascular abnormalities and exudation along the pars plana.

What is the difference between intermediate UVEIT and pars planitis according to the SUN Group?

According to the SUN Group, the difference lies in the cause of the inflammation. Intermediate UVEIT can be idiopathic or associated with systemic disorders, while pars planitis specifically refers to idiopathic inflammation with snow banking and snowball formation.

What percentage of all uveitis cases are intermediate UVEIT, and what is its significance in the pediatric population?

Intermediate UVEIT accounts for 15% of all uveitis cases. In the pediatric population, it is the second most common type of uveitis, accounting for up to about 25% of cases.

What are the common symptoms of intermediate UVEIT?

Common symptoms of intermediate UVEIT include insidious onset of blurred vision, usually accompanied by vitreous floaters, and very mild to almost no pain, photophobia, or redness.

What are the major infective causes of intermediate UVEIT?

The major infective causes of intermediate UVEIT include tuberculosis, syphilis, Lyme disease, cat scratch fever, toxocariasis, and HTLV-1 infection.

What is the significance of snow balls and snow banking in intermediate UVEIT?

Snow balls and snow banking are signs of severe inflammation in intermediate UVEIT. Snow balls are focal collections of inflammatory cells and exudates in the peripheral retina, while snow banking is the formation of fibrovascular exudative plaque-like material in the pars plana region or peripheral retina.

What is the importance of scleral depression in examining intermediate UVEIT?

Scleral depression is important in examining intermediate UVEIT to observe and detect snow balls and snow banking, which are usually present in the peripheral part of the retina around the pars plana and pars plana region.

What are the possible complications of intermediate UVEIT?

Possible complications of intermediate UVEIT include cystoid macular edema, cataract, hypotony, optic neuritis, peripheral vasculitis, neovascularization, retinoschisis, and retinal detachment.

Outlines

00:00

👨‍⚕️ Introduction to Intermediate Uveitis

Dr. Amrit introduces the topic of intermediate uveitis, a type of eye inflammation, and explains its classification based on the affected part of the uveal tract. The lecture focuses on the chronic, insidious nature of intermediate uveitis and its relapsing course, affecting the intermediate part of the uvea. Historical perspectives are provided, with the first description by Fuchs in 1988 and further developments by Charles Sheehan and Welch in the 1960s. The International Uveitis Study Group's (IUSG) 1987 definition of intermediate uveitis as an inflammatory syndrome mainly involving the anterior vitreous is highlighted.

05:00

🔍 Understanding Intermediate Uveitis: Definitions and Differences

This section delves into the definitions provided by the IUSG and the SUN Group, emphasizing the primary site of inflammation in intermediate uveitis as the vitreous. The distinction between intermediate uveitis and pars planitis is clarified, with the latter being idiopathic with snow banking and snowball formation. The prevalence of intermediate uveitis in children and its causes, which can be infective or non-infective, are discussed. Infective causes include tuberculosis, syphilis, and other diseases, while non-infective causes involve conditions like sarcoidosis and multiple sclerosis.

10:01

👁️‍🗨 Symptoms and Signs of Intermediate Uveitis

The symptoms of intermediate uveitis are outlined, with an insidious onset of blurred vision and floaters being common. The absence of pain, photophobia, and redness helps differentiate it from anterior uveitis. The presence of vitreous cells, particularly in the anterior vitreous, and the potential development of a membrane leading to severe vitreous haze are discussed. The grading of vitreous haze by the NEI is explained, with a focus on the clinical signs and the importance of scleral depression in examining patients with intermediate uveitis.

15:03

🌨️ Snowballs and Snow Banking in Intermediate Uveitis

The presence of snowballs, which are focal collections of inflammatory cells in the peripheral retina, and snow banking, which is exudative material forming a fibrovascular plaque-like material, are described. The importance of snow banking as an indicator of severe inflammation is emphasized. Histological examination reveals the composition of snow banks, including vitreous strands, blood vessels, fibrous tissue, and inflammatory cells. The role of scleral depression in detecting snowballs and snow banking is highlighted, as well as the potential for neovascularization in these areas.

20:04

🚑 Complications and Clinical Nuggets in Intermediate Uveitis

The complications of intermediate uveitis, including cytoid macular edema, cataract, hypotony, and raised intraocular pressure, are discussed. The development of neovascularization, particularly in areas of snow banking and on the optic nerve head, is highlighted as a significant issue. The potential for retinal detachment due to traction from fibrovascular bands or breaks in the retina is also covered. The importance of recognizing the signs of peripheral vasculitis and its association with multiple sclerosis in the superior quadrant of the retina is emphasized.

25:05

🛑 Advanced Complications of Intermediate Uveitis

This section covers advanced complications such as optic neuritis, peripheral vasculitis, and the development of a vasoproliferative tumor. The presence of optic disc edema and neovascularization of the disc in pediatric patients is noted. The discussion of retinoschisis, a split within the layers of the retina, and the various types of retinal detachments that can occur due to the chronic inflammation and traction in intermediate uveitis are included. The potential for a cyclitic membrane to form and cause cerebrospinal fluid shutdown, leading to hypotony, is also mentioned.

30:07

🏥 Anterior Segment Inflammation in Intermediate Uveitis

Although intermediate uveitis is primarily a vitreous inflammation, some patients may develop granulomatous anterior uveitis with mutton-fat keratic precipitates, particularly in conditions like multiple sclerosis, Lyme disease, sarcoidosis, and tuberculosis. The video concludes with an invitation to the next lecture, where the causes of intermediate uveitis will be dissected in detail.

35:08

📺 Joining the Insight Ophthalmology Membership

The script concludes with instructions on how to join the Insight Ophthalmology YouTube membership, outlining the steps to subscribe to the channel, access the join button, and select the appropriate membership level. The video also addresses potential issues users might face when attempting to join, such as not being logged in or YouTube memberships being unavailable in certain countries.

Keywords

💡Intermediate Uveitis (UVITIS)

Intermediate uveitis, also known as pars planitis, is a type of inflammation that affects the intermediate part of the uveal tract, which includes the vitreous body, the peripheral retina, and the ciliary body. In the video, intermediate uveitis is the main theme, discussed in detail with respect to its classification, symptoms, and treatment. It is characterized by symptoms such as floaters and blurred vision, and it is important in the context of the video as it is the condition being lectured about.

💡Inflammation

Inflammation is a biological response to harmful stimuli and is a key aspect of the immune system. In the video, inflammation is central to understanding intermediate uveitis, as the condition is an inflammatory syndrome. The script describes how inflammation can be chronic and insidious, affecting the intermediate part of the uvea, and how it can lead to complications such as cystoid macular edema.

💡Vitreous Haze

Vitreous haze refers to the opacity of the vitreous body due to inflammation, which can obstruct the view of the retina. The video script mentions the grading of vitreous haze, which is crucial for assessing the severity of intermediate uveitis. The grading is used to monitor the condition and the response to treatment.

💡Snowballs

Snowballs are white or yellowish lesions that form in the vitreous due to the accumulation of inflammatory cells and exudates. In the script, snowballs are a significant sign of intermediate uveitis, and their morphology can indicate whether the inflammation is active or inactive. They are often observed in the inferior part of the vitreous and are an important diagnostic feature.

💡Snow Banking

Snow banking is the term used to describe the accumulation of exudative material along the pars plana, appearing as a gray-white fibrovascular exudative plaque. In the video, snow banking is highlighted as an important clinical sign that indicates severe inflammation and is often found in the inferior quadrant of the eye.

💡Cystoid Macular Edema (CME)

Cystoid macular edema is a condition where fluid accumulates in the macula, leading to blurred vision. In the context of the video, CME is a common complication of intermediate uveitis and is a significant cause of vision impairment. The script explains that the presence of CME does not necessarily correlate with the severity of the vitritis.

💡Cyclitic Membrane

A cyclitic membrane is a fibrous tissue that can form over the ciliary body and extend into the vitreous, often as a result of chronic inflammation. In the video, the formation of a cyclitic membrane is discussed as a possible complication of intermediate uveitis, which can lead to ciliary body shutdown and hypotony.

💡Neovascularization

Neovascularization refers to the abnormal growth of new blood vessels, which can occur in areas of inflammation in intermediate uveitis. The script mentions that neovascularization can develop in the region of the pars plana and on the optic nerve head, and it can lead to complications such as vitreous hemorrhage and tractional retinal detachment.

💡Retinal Detachment

Retinal detachment is a serious complication where the retina separates from the retinal pigment epithelium, leading to vision loss. In the video, different types of retinal detachment, including exudative, tractional, and rhegmatogenous, are discussed as potential complications of intermediate uveitis.

💡Multiple Sclerosis

Multiple sclerosis is a chronic disease that affects the central nervous system, and in the video, it is mentioned as a systemic condition that can be associated with intermediate uveitis. The script highlights that peripheral vasculitis in the superior hemisphere of the retina can be indicative of multiple sclerosis.

Highlights

Introduction to intermediate uveitis (UVIT) and its classification based on the part of the uveal tract affected.

Explanation of the terms 'chronic,' 'insidious,' 'relapsing,' and 'intermediate part of the uvea' in the context of intermediate UVIT.

Historical perspective on the first description of what was likely intermediate UVIT by Fuchs in 198, and the term 'chronic cyclitis'.

Charles Sheehan's clinical description of intermediate UVIT and identification of peripheral vascular abnormalities.

Introduction of the term 'pars planitis' by Welch in 1960 and its association with intermediate UVIT.

The confusion in terminology for intermediate UVIT in literature and the adoption of the term by the International Uveitis Study Group in 1987.

Sun Working Group's definition of intermediate UVIT as a disease with the major site of inflammation being the vitreous.

Difference between intermediate UVIT and pars planitis, particularly the idiopathic nature and presence of snow banking and snowballs in the latter.

Prevalence of intermediate UVIT in pediatric population and its significance as the second most common uveitis in children.

Causes of intermediate UVIT, including both infective causes like tuberculosis, syphilis, and non-infective causes such as sarcoidosis and multiple sclerosis.

Importance of scleral depression in examining intermediate UVIT for detecting snow banking and snowballs.

Significance of snow banking as an indicator of severe inflammation and its implications for treatment.

Clinical signs of intermediate UVIT, including the presence of inflammatory cells in the anterior vitreous and the formation of a cyclitic membrane.

Grading of vitreous haze by the SUN Group, based on the classification by the National Eye Institute in 1985.

Differentiation between active and inactive snowballs in intermediate UVIT and their implications for monitoring inflammation.

Complications of intermediate UVIT, such as cystoid macular edema, cataract, hypotony, and optic neuritis.

Discussion on the presence of peripheral vasculitis and periphlebitis in intermediate UVIT and their significance.

Neovascularization in intermediate UVIT and its potential to cause vitreous hemorrhage and tractional retinal detachment.

Retinosis, a split within the layers of the retina, as a complication of intermediate UVIT due to chronic inflammation.

Development of vasoproliferative tumors in intermediate UVIT due to chronic inflammatory insult and angiogenesis.

Involvement of the anterior segment in intermediate UVIT and the presence of granulomatous anterior uveitis in specific cases.

Transcripts

hello citizens who is

that I'm captain snowball I hear one of

you needs my help yes yes Captain

snowball we all need your help so hello

and welcome to Insight oftalmology this

is Dr Amrit welcoming you to another

lecture today we are studying

intermediate UV itis now quite simply

the UV ittis can actually be classified

into three types according to this

diagram based on the inflammation based

on the part of the Uval tract that is

affected by the inflammation the sun

workking group that is the

standardization for UTIs nomenclature

group basically classified UTIs

anatomically into anterior if the

anterior part of the ubial tract is

affected that means the iris and the

celery body then it called uh it as

intermediate UTIs if the primary site of

inflammation is near the anterior witus

that is just behind the lens then it

said that we have a posterior uiis if

the retina and the choid is affected and

then of course we have a pan UTIs in

which the anterior chamber the vitus and

the retina choid all of them are

actually affected so I explained this to

you in detail in the first video of the

Uvis course okay so now here as we are

discussing in the intermediate UTIs it

is very important for you to remember

certain terms which are related to

intermediate

UTIs so at this point I would like to

drive in this message that intermediate

uias is basically a chronic Insidious

onset inflammation of the intermediate

part of the uvia okay so the terms are

very important it's a chronic

inflammation it has an Insidious onset

and it affects the intermediate part of

the uvia and it has a relapsing nature

okay so it keeps on recording so all

these four words please remember them

chronic Insidious and relapsing and

affecting the intermediate part of the

UVA now let us understand some of the

history of intermediate UTIs so the

first description of what probably was

intermediate UTIs but was not named

intermediate UTIs was first given by

fuches in

198 at that time the term that he used

for intermediate uvi was actually

chronic cyclitis that is the

inflammation of the celer body

considering that the celer body is also

actually situated basically the

posterior part of the CER body which is

the parts planner is situated in the

intermediate zone of the Uval tra it was

Charles sheepen who gave the clinical

description of intermediate UTIs and

further uh expanded the description okay

apart from that he also said that there

are peripheral vascular abnormalities

and exudation along the parts planner

which is the posterior part of the

celery body in intermediate UTIs later

on Welch came in 1960 and he and along

with his associates coined the term pars

plantis okay so so there are all various

terms which are actually which were used

in the literature for intermediate UTIs

so some people called it just vtis

considering that the anterior part of

the vitus and gradually the entire vitus

is basically getting involved they

called it vtis then some of them

actually prefer to call it peripheral

exudative retinitis based on the fact

that some of the exudates are actually

present along the pars plan and along

this peripheral part of the retina near

the AAS Sera then some prefer to call it

cyclo cororo retinitis that means

inflammation of the celar body with the

intermediate part of the choid and the

peripheral retina some called it chronic

post ior cyclitis again considering the

posterior part that is a parts planner

and then some prefer to call it

peripheral ubio retinitis right so there

is so much confusion to what term to use

for intermediate UTIs so what exactly is

intermediate

UTIs so basically in 1987 it was uh the

international UTIs study group that is

the iusg which finally adopted the

correct term that is intermediate UTIs

as a part of of its anatomical

classification scheme for the

intraocular inflammation so this iusc

that is international utic Society group

it basically defined the intermediate

UTIs as an inflammatory syndrome mainly

involving the anterior witus okay so

somewhere here it will involve the

anterior

witus peripheral retina that is here the

drawn in orange color and the cery body

basically the parts PL

so these three parts according to the

iusg group basically were affected in

intermediate UTIs and apart from that

there should be minimal to no anterior

segment or Coro retinal inflammatory

signs so what they mean to say is that

the inflammation should be restricted in

the intermediate part of the eye and

there should be very minimal

inflammation in the anterior segment or

if prefer uh if possible no anterior

segment inflammation and there should be

no posterior segment inflammation also

like the chor retinal inflammatory signs

that we see in posterior UTIs so I hope

that it's clear so what about Sun Group

the Sun Group the standardization of

uiic nomenclature working group

basically however defined intermediate

UTIs as a disease where the major site

of inflammation is actually the witus

okay so this is uh very basic points

which can sometimes be asked in mcqs

that's why I'm focusing on them

so according to Sun Group the vitus is

the major site of inflammation now at

the same time Sun Group also gave a term

that is par plantis so obviously now

it's very confusing now what is

intermediate UTIs what is parlantis so

they both seem to be similar right so

however there is a slight difference

between intermediate UTIs and the par

planitis so let us see what is it now

intermediate UTIs basically can be

idiopathic or it can be associated with

some systemic disorder now so much that

at least half of the cases of

intermediate UTIs are actually

idiopathic and the remaining can be

associated with a systemic disease now

according to the Sun Group if you

actually have the inflammation which is

idiopathic that means it is not

associated with any systemic disorder or

it is not associated with any infection

and along with that you have signs of

past planitis that is snow banking and

snowball formation so our captain

snowball is going to teach us what

exactly is snow Banking and snowball in

a while so basically in past plantis the

inflammation is idiopathic with with

snowballs and snow banking formation and

that is the difference between

intermediate UTIs and P planitis so if

you have an idopathic inflammation that

is referred to as the P planitis whereas

if you have a particular cause of

inflammation like uh the presence of

infection or presence of some systemic

disorder then that is known as the

intermediate

UTIs now another important Point

regarding the intermediate UTIs and

children now 15% of all the utic cases

are actually intermediate UTIs however

when we come to the Pediatric population

although the incidence of UTIs in

children is very very low the

intermediate UTIs account for up to

about 25% of the cases and as a matter

of fact it is actually the second most

common UV ittis that you see in

pediatric

population so now let us discuss what

causes intermediate UTIs okay so here we

have this nice flowchart describing the

ethology and the differentials of the

intermediate

UTIs boss I can't tell the anyone is

well you got to really look at it to

understand it exactly so we really need

to look at it to understand it so

intermediate UTIs causes can be actually

classified into infective causes and the

non-infective causes or the systemic

causes so the under the infective causes

the major infections that can cause

intermediate UTIs are

tuberculosis syphilis limes disease cat

scratch fever toxocariasis and

htlv1 infection now so the most common

in the end IC areas of course is

tuberculosis and then we have this

emerging infection now which is syphilis

so syphilis can actually syphilis is

basically a great masquerader it can

actually present as inflammation in any

part of the UA okay so this can also

cause intermediate UTIs when we talk

about limes disease it is basically seen

in endemic areas okay where you have

more chances of a tick bite then we have

cat scratch fever and toxocariasis not

so common and then we have human T cell

lymphoma virus type 1 which is basically

localized in areas of Japan right so

then we have noninfective causes of the

intermediate UTIs where I want you to

remember the first two uh sorry the

first three causes right so we have

sarcoidosis then we have multiple

sclerosis and inflammatory bowel disease

like Crohn's disease and the ulcerative

colitis and of course we have the

Whipples disease now again what if we

want to

further simplify this eological

classification then if you have to

remember the most common causes of

infective or sorry the most common

causes of intermediate UTIs that you see

in the clinic so the top three ones will

be number one undifferentiated

intermediate UTIs that means you don't

really know the cause of intermediate

UTIs the second one would be sarcoid

multiple sclerosis and tuberculosis as a

matter of fact in endemic areas like the

South Asian countries tuberculosis

actually can come on the second number

as

well so again do you remember this it's

a chronic in serious onset of

inflammation in the intermediate part of

the UVA and now we know according to the

iusg that is the international uaic

Society group the intermediate part of

UIA according to that according to them

is the anterior wies the peripheral

retina and the CER body basically the

Parts planner and of course the Sun

Group says that the site of inflammation

is basically in the witus now this is so

important that whenever you see a case

coming with an acute onset you have to

suppose for example a case comes to you

or a patient comes to you saying that he

has dimin of vision and floaters for two

days okay the onset was two days back

that means that it's an acute onset and

on examination you find there is dense

vtis so you're basically dealing with a

case that has developed dense vitritis

right away in two days so that means

you're not dealing with intermediate

UTIs because the onset of intermediate

UTIs is quite chronic and ins serious so

I hope that is

clear moving on let us now discuss some

important symptoms and signs of

intermediate UTIs so what are some

important common symptoms that the

patient presents to to us when they have

intermediate UTIs so the first Common

symptom is an Insidious onset of blurred

vision and most of the time it will be

accompanied by the presence of witous

floaters okay so blurred vision and V

slauter are very important symptoms of

intermediate UTIs now one important

point to note is that there's usually

very mild to almost no pain and

photophobia there will be a mild redness

of ey so why important is because pain

photophobia and redness are basically

signs of the anterior segment

inflammation and you see them in cases

of anterior

UTIs so here's a tip whenever there's an

Insidious onset of blood Vision

accompanied by witus floaters without

any pain photophobia or redness it

always suggests a possible diagnosis of

intermediate UTIs so always suspect

intermediate UTIs in cases that come to

you and the presence that present to you

with an Insidious onset of blood Vision

along with Vitus floaters apart from

that when you actually do their visual

Equity you will find that uh basically

the cause of reduction in the visual

equity in these patients is because of

the dense vitritis number one and number

two it can be because of the presence of

cystoid macular edema that is one of the

complication of the inflammation that

happens in inter mediate Uvis okay so

don't get confused although here the

side of inflammation is in the

intermediate part that means in the

witus in the P plan and the peripheral

retina you because of this inflammation

and because of the inflammatory uh

product there can be exudation in the

posterior part that means in the macular

area and that is one complication of the

intermediate UTIs that is cytoid macular

edema so disease is really chronic

basically because of long duration of

inflammation patients basically develop

the cytoid macular edema it can actually

last as long as 15 years the disease can

last as long as 15 years and the final

visual Equity that the patient is going

to have is basically going to depend on

how well are you managing this macular

disease in case of intermediate UTIs now

what about the laterality of the disease

is the intermediate uvi is unilateral or

is it bilateral Now by bilateral

involvement is seen in about 70 to 80%

of the patients at the time of

presentation however if you have a

patient who has or in patients who have

unilateral disease approximately

onethird of them are ultimately going to

have a bilateral

involvement so now with this Captain

snowball let us discuss some important

signs in intermediate

UTIs so definitely we are dealing with

inflammation so you will see

inflammatory cells in the anterior Vitus

phase okay so Vitus cells predominantly

are present in the anterior Vitus phase

and anterior Vitus phas is just the is

basically the part of the vitus which is

situated just behind the lens right so

you have the predominance of the cells

in the anterior Vitus phase also known

as the hyloid and that is the reason why

it was also known as

highlighs now in severe cases you might

note that the vitus cells will basically

start condensing and lead to membrane

form

and then when that happens it leads to

severe witous Haze as well so at this

time at this juncture let us just

discuss the grading of Vitus ha which is

given by the newsen blat 1985 that that

is the national Eye Institute so it is

very important for you to remember that

the Sun Group has just adopted this

witus G witus Haze grading which was

originally given by the national Eye

Institute okay so according to this uh

NS blat grading we have vus Haze graded

as uh nil Trace minimal mild moderate

marked and severe okay see this with the

help of the uh photographic

representation which was given by the

national Eye Institute so you can see

that in the first picture you're able to

see these Tri so these Tri are basically

of the nerve fiber lay so if you're able

to see the nerve fiber lay clearly it

means that there is no witus haast then

in score 0.5 you can still see those STS

of nerve fiber layer but they're quite

hazy right compared to the first picture

now in the again in the third grade as

you can see here in the score one okay

you can see the optic dis we can see the

wessels but the nerve fiber layers are

not seen now that means this at this

point you can give it a score of score

one then you have score two where the

vessels and the disc will now start

becoming hazy in score three the vessels

have disappeared you can just see the

optic disc and in score four all the

structures have disappeared and you can

just see a hazy

media now coming to the next important

sign of intermediate tutis and that is

the presence of snow ball so you can see

these whitish focal collections in the

peripheral part of the retina so those

are nothing but they are the focal

collections of of inflammatory cells and

exites and they're usually numerous

quite uh quite numerous in the inferior

part of the vitus right so these focal

collection of inflammatory cells and

xrates basically as you can again see

over here these are known as the

Snowballs

okay so there's a way you can

differentiate between the active

snowballs and inactive snowballs so

active snowall means when the infection

or when the inflammation is basically

active that means you have active

inflammation going going on the

Snowballs basically will have different

morphology that means they will show

very fluffy and fuzzy margins quite

similar to what you see in this diagram

so you can see the margins are not very

well made out so they are fuzzy and the

Snowballs will be quite larger in size

and they will be surrounded by the witus

cells which indicates that there is

active inflammation going on okay

whereas after some

time the Snowballs will basically become

inactive and their morphology will

basically change so now their margins

will become well defined they will

become shrunken or contracted and their

size would be smaller however as a

matter of fact do not decide treatment

based on the Snowballs okay snowballs

really take a long long time to go away

you have to rely on other tests to

monitor inflammation and response to

treatment so don't think that now the

Snowballs have contracted and so the

inflammation has gone away so let me

just stop the treatment and also the

other way around that means suppose you

have given treatment the vitritis has

resolved and there are no leaks on the

FFA which we we will be discussing in a

while but you still see those snowballs

so don't just continue your treatment

just uh based on the morphology of

snowballs okay that is what I mean to

say coming to the third important sign

in intermediate UTIs and that is the

presence of snow banking so basically

all of this is actually exudative

material which is coming out because of

the

along with the fiog proliferation so you

have fibrous tissue G tissue and a lot

of exudative material in the Snowballs

and snow banking so when that exudates

basically the gray when they form this

gray whitish fibrovascular exudative

plaque like material okay on the pars

plan near the region of pars Plana or in

the peripheral retina then that is known

as snow banking okay now the snow

banking basically is most commonly found

found in the inferior quadrant also you

can have uh it in about 180° quadrant or

sometimes it can also extend to 360

degre so that is your snow

banking so why is snow banking important

a very important clinical nugget

regarding snow banking is that whenever

you see snow banking it basically

indicates that there is severe

inflammation going on and your treatment

also should cater to that severe

inflammation so basically let us discuss

about the histology of snow banking so

what exactly those snowbanks consist of

so this histology was actually studied

on enucleated ice and what they found

was on histological examination that

snow Banks basically consist of witous

strands that is collapsed witus along

with that some blood vessels are present

fibr tissue including the fibrous asides

and along with that you will have

scattered inflammatory cells and

predominantly lymphocytes okay

apart from that what was seen was that

the peripheral veins in the retina

basically near the snow banking area

they actually showed lymphocytic

enveloping their um walls which is

called lymphocytic cuffing and

infiltration again a sign of

inflammation now we have seen that the

snow Banks basically have vascular

component as well and the vascular

component of the snowbank in the

enucleated eyes when they were observed

was actually seen uh it actually looked

to be continuous it seemed to be

continuous with the retina in those

cases okay so and moreover only mild

inflammation was noted in the choid and

the celery body and that suggested that

the inflammatory process in intermediate

uvi is primarily involves the witus base

the peripheral retina and not just the

UIA so that is quite a paradox that

although it is called intermediate UTIs

the inflammation is not just coming from

the Uval tissue which is present in the

intermediate zone of the eye we have

involvement of the vitus base and we

have involvement of the peripheral

retina as well so it's quite logical if

you think in that way that Vitus is

basically the vitus does not consist of

any vascular component right so all

those exudates and inflammatory cells

from where are they going to come

they're going to come from the celer

body that is the par Plana and of course

PPL is not that vascular and they're

going to come from the per

retina so that is important

another uh thing to know is that the

Snowballs that we talked about that are

present in the inferior part of the

retina they also are basically giant

nucleated cells multinucleated cells and

the epitheloid cells again these cells

will be coming from the retina

right so moving on this also brings us

to an important clinical nugget the

importance of scal depression in

intermediate UTIs so the snow Banking

and the snowballs they're usually

present in the peripheral part of the

retina that basically around the area of

oraser and pars planner right so in

order to observe and order to detect the

snow Banking and snow depression the

snow Banking and snowball sorry it's

very important for us to carry out a

proper indirect opthalmoscope with

scleral depression okay so as you can

see in these pictures so you can see

these spikes okay so all these are

nothing but this is your oras serator so

on this end you have the pars planner

and over here is your Rea right so this

is the retina peripher retina continuing

ending as orosa and from here you have

the CER body starting which is your

parts planner again this is the oraser

that white structure with the spikes and

this is the retina and on this side you

have the pars planner so obviously you

need to know good indentation okay to

understand and to to detect these

snowballs and snow banking however

sometimes what happens is that the snow

banking might be present quite high up

not just on the par planner but it can

be present quite high up in the retina

so in those cases you might be able to

see them without even um without doing

an indentation and in those cases

another important tip is that you can

ask the patient to look down when you're

carrying out your indirect opthalmoscope

so when the patient looks down the

inferior part of the retina basically

comes to your

view another important clinical point is

that whenever you see a snow bank in

case of intermediate UTIs it is very

important for you to carefully observe

that area for the presence of

neovascularization okay so what happens

is that because of chronic inflammation

this part the peripheral part where the

inflammation is there will be capillary

non-perfusion areas that means retina

will become isic over a period of time

and there will be growth both of new

vessels in the region of the pars

planner and these new vessels can be

detected on a good clinical examination

so these new vessels are definitely

dangerous wherever they are new vessels

we know that they can bleed just like in

diabetic retinopathy here also they can

bleed and they can actually act as a

source of potential witous Hemorrhage

okay so that is one important

Point coming to another important sign

in intermediate UTIs is the presence of

peripheral vasculitis and peripheral

uh pertis okay so it's very important

for us to know that it is the

intermediate UTIs it is the peripheral

part of the retina which is basically

affected and here since the peripheral

part of retina definitely has vessels in

it so those vessels can also be involved

in inflammation and when those are

involved in inflammation it is called

vasculitis that is inflammation itis

means inflammation so vasculitis is

inflammation of the vessels right so you

can have peripheral vessels getting

affected by inflammation which is called

peripheral vasculitis and because the

veins are getting affected more compared

to the arteries it is called per fitis

okay so fitis means referring to weights

now these veins are basically going to

get affected as they will develop this

perivascular cuffing and sometimes

because of the inflammation the

inflammation can actually compress these

veins and cause occlusion so you have

something a picture similar to that what

you see in case of um your vein

occlusions so you will have occlusive

vasculitis and in The Chronic cases what

happens is that you will just see

whitening in the uh whitening of the

vessel's wall as you can see over here

basically that whitening of the vessel

wall is known as the vascular sheathing

right so perivascular cuffing is that

when you see a column of blood uh within

the vessel and surrounding that you will

see white wall and the white wall of the

The Vessel will look quite active

because it is actively exuding it is uh

releasing those exudates from it and

then when it gets blocked after a period

of time what happens is that the blood

column will be totally um gone and you

just have a white vessel over there so

that is called a sclerosed vessel okay

and when that perivascular cuffing is

not very active when there are no other

signs of inflammation then that white

vessel wall is known as sheathing Okay

so I hope that is clear now another

important clinical point that I want you

to know is that in cases of peripheral

vasculitis in case of intermediate UTIs

the vasculitis is basically in most of

the cases it is present in the inferior

quadrant however there is a particular

disease where you're going to see this

vasculitis in the superior hemisphere of

the retina and that disease is multiple

sclerosis okay so always remember

whenever you see

vasculitis specifically peripheral

vasculitis in the upper part of the

retina or in the superior quadrant

always suspect multiple sclerosis right

so we already discussed about the

neovascularization we know that neov

vascularization can actually develop in

the areas of the snow Banking and it can

also develop on the optic nerve head

obviously if it develops in the optic

nerve head it indicates that there's a

lot of inflammation there's a lot of

ishia that is going on okay and when you

control the inflammation the uh it is

seen that the new vascularization on dis

basically starts resolving okay so these

vessels definitely wherever there are

new vessels there is a danger that they

can bleed sometimes they can have

fibrous proliferation along with the

vessel so those fibrovascular bands can

develop so they can cause traction on

the retina and as there's traction on

the retina you can have brakes

developing on the retina and through

those brakes the fluid which is present

the witus can enter in the subretinal

space so what will happen the neuros

sensor retinal will get detached from

the RP because of the fluid and that is

called as a retinal detachment now this

retinal detachment if it occurs because

of the traction it called tractional

retinal detachment if it develops

because of the presence of a um break in

the retina and the fluid seeping through

that break then that is known as a

regenus retinal detachment okay so of

course sometimes what can happen is that

this inflammatory EX Ates can basically

form a membrane right behind the lens

and that membrane can actually extend

into the can extend on top of the parts

planner as well and that membrane is

known as the cyclitic membrane right so

when we talk about the

neovascularization specifically the

vitus hemorrage one more point you

should remember is that Vitus Hemorrhage

in intermediate UTIs is more common in

pediatric population right now

this is what I was talking about there

can be peripheral vasculitis

particularly the peripheral peripher

abius now because of that diffus and

sometimes peripheral sometime diffused

periph bitis can also be seen so what I

mean to say is that if you go ahead and

do an FFA that's fundus floresent

angiography you're going to see these

vessels okay hyper floracing on FFA that

means that they're actively leaking and

they form a pattern which is called as

the ferns

pattern

right so the sper pattern is not very

specific to bit's disease as most of us

think it can be seen in any disorder

which is leading to capillaritis or

fitis right so you can have this

diffused fitis so whenever this diffused

fitis obviously there will be a

breakdown of the blood ocular barrier

and there will be release of these

inflammatory cells cyto kindes and

inflammatory mediators and all of them

are going to basically settled down and

it is usually seen that the inferior the

snow Banking and Snowboard walls are

more common in inferior quadrant and the

reason could be because of the

gravity another important sign that you

see in intermediate UTIs is the presence

of optic dis edema and this optic disc

swelling is particularly common in case

of younger younger patients and in case

of pediatric population uh and as a

matter of fact dis edema can be seen in

about 50% of the children with

intermediate UTIs of course you can also

see neovascularization of the dis as I

talked about okay now this

neovascularization basically indicates

that is that there is severe retinal

esmia and you can go ahead and do a

panretinal laser photocoagulation in

these

cases now here let us discuss the

complications of intermediate UTIs as

well so here the complications that

you're going to see as signs will be the

presence of cytoid macular edema okay so

as we told as I told you that the C

cause of dimin of vision in intermediate

UTIs is actually cytoid macular edema

and sometimes dense vitritis as well and

the CME or CID macular edema occurs in

up to about half% of the patient and it

is a major cause of impaired Vision so

on a slit lamp examination you're going

to see that the fal reflex is absent and

you will see an altered appearance of

the macular area and when you go ahead

and do an OC you're going to see this

presence of cystic spaces on the optical

coherence tomography

test now important clinical point over

here is that the amount of cytoid

macular edema it does not correlate with

the amount of inflammation of vitritis

so sometimes you might have very severe

vitritis but the patient will not have

cytoid macular edema and sometimes you

will have almost no vitritis but the

patient will still be having cytoid

macular edema so that is what I want to

tell you that the CME does not correlate

with the amount of inflammation or

writis now another complication that you

see in intermediate UTIs is the presence

of cataract so this cataract can

actually develop because of chronic

inflammation that goes on with

intermediate UTIs as I told you that the

disease can actually last for a decade

as well so that inflammation can lead to

Cataract and sometimes the treatment

that we gave in intermediate UTIs so uh

let me tell you that in UTIs basically

the treatment is steroid right apart

from um imuno supressant however we

don't give that in case of infectious

disorders so basically here the

treatment is steroids and we know that

steroids can also lead to cataract

formation so cataract can be a

complication either because of the

steroid treatment or because of the

inflammation itself so you can have an

anterior capsular cataract or a

posterior subcapsular cataract or even a

posterior polar cataract in these

patients however the posterior

subcapsular cataract is the most common

lenticular OPAC acity now another uh

complication that you can see is the

hypotony so hypotony is basically

decreased intraocular pressure so what

happens is because of the chronic

inflammation and we know that

inflammation usually causes destruction

fibrosis so because the chronic

inflammation you can have formation of

the cyclitic membrane this membrane can

grow over the celer body and it can

actually cause this uh atrophy of the

celer body processes and ultimately the

celer body stops working and that is

called celery shutdown we know that the

celery body has a very important role in

the formation of Aquis humor right and

if the Aquis is not being produced

because of selary body atrophy

definitely there will be a reduction in

the intraocular pressure and therefore

this is one complication that you see in

case of intermediate

UTIs apart from that sometimes you can

also have a raised intraocular pressure

again this can actually happen because

of the inflammation that inflam cells

going goes on to actually block your

tabular meshwork and as they block the

tabular meshwork your aquous drainage is

impaired leading to an increase in the

intraocular pressure apart from that

steroid also can lead to glucoma or

increase intraocular pressure right so

these two are complications pertaining

to the intraocular pressure in the

eye so what about optic neuritis now as

we discussed that in pediatric

intermediate UTIs we do find this edema

quite commonly but if you see optic

neuritis along with the drop of vision

pale dis and you also have some Superior

vasculitis of course so you can actually

suspect multiple sclerosis as the cause

of intermediate UTIs so I hope that

point is

clear then of course we have other

complications that we discuss in signs

as well so periphal vasculitis

periphlebitis can also be a complication

new vessels is definitely a

complication another complication that

you can see in intermediate UTIs is the

presence of retinosis now retinoschisis

is nothing but it is basically a split

within the layers of the retina okay so

when the retina separates from the RP

that is called retinal detachment

whereas when there's a split within the

retina itself within the layers of the

neurosensory ETA then that is known as

retinosis now in some cases of

intermediate UTIs if it is not treated

well or if the inflammation is not

controlled it can lead to chronic

inflammation and we know that there is

peripheral vascular leakage because of

that vasculitis component that we

discussed just now right so that there

will be persistent capillary leakage in

the periphery apart from that there is

peripheral esmia low grade Vitus

inflammation going on the vitus in that

area is going to shrink and is going to

cause traction okay and that will the

traction is going to lead to development

of the split within the layers of retina

leading to shes so here you can see this

was given in this paper on the FFA you

can see there is this leakage in the

periphery and because of this leakage

because of the new vessels because of

the traction coming from the retina you

from the vus you can see this retina has

actually split and there is this

development of the shic cavities within

the retina leading to retino shis okay

so as you control this capillary leakage

the sh cavities are actually going to

collapse and the retina is going to come

back to its normal

morphology of course we can also have

retinal detachment and what type of

retinal detachment do we see in

intermediate UTIs the answer is all

three types so you can have exudative

retinal detachment because we know there

is so much exudation going on in

intermediate UTIs in the periphery so

you can have exoda Detachment you can

have tractional Detachment because of

those new vessels because of the

fibrovascular proliferation the the

periphery because the snow banking what

can happen is you can have traction

bands those traction bands can pull on

the retina and separated from the

underlying retinal pigment epithelia and

that is called tractional R and because

of the traction sometimes you can

develop a hole in the retina or a break

in the retina and the witus can actually

seep into it leading to a development of

a renous retinal detachment right now

another important

complication of the intermediate UTIs is

basically the development of a Vaso

proliferative tumor so you can see this

uh yellowish structure over here this

yellowish structure is not as yellow you

can see this reddish color things in it

so that is your vascular proliferative

tumor it is basically a mix of vascular

component that can be seen as the red

blood vessels on it and it also has a

fibrous component that is the Gile

component which is seen in the yellow

color right so this vasor proliferative

tumor basically occurs because of the

chronic inflammatory

insult in the intermediate UTIs there is

chronic inflammation and therefore there

will be a breakdown of the blood retinal

barrier there will be uncontrolled

release of the cyto kindes and therefore

there also be angiogenesis that is going

to occur and because of that there will

be uncontrolled proliferation of the

fibrous tissue and the angiogenesis in

the periphery leading to sometimes

development of a wept or a Vaso

proliferate

tumor right so those were the important

signs that you see in the intermediate

zone of the intermediate UTIs now what

about the anterior segment inflammation

in intermediate UTIs right so you might

be thinking that I told you that there

is no inter there's no anti segment

inflammation in case of in case of

intermediate UTIs right that's right in

intermediate UTIs predominantly you are

going to see the vitous cells okay the

vitous inflammation is going to be much

more than the anterior segment

inflammation however there are some

specific patients that are going to

develop granulomatis anterior UTIs along

with intermediate UTIs and sometimes you

will also see the presence of mutton fat

ktic precipitates and this is seen in

case of multiple sosis pediatric

intermediate UTIs limes disease sarcoid

and tuberculosis so again a high e point

for you guys right so in our next video

we shall talk about the diagnosis of

intermediate UTIs and how you can

actually dissect all these causes that

we discussed of the intermediate uvit

one by one so this was our captain

snowball and he's also going to help us

dissect the causes of intermediate UTIs

in the next video one by one so that's

all for today I hope you liked it thank

you and have a nice

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