Back again!

[Nikorusama]

Hi mike and the rest of the gang.
My Uveitis is back again. I went back to the clinic as I recognised the symptoms, although for me the first thing to notice was the slightly blurred vision, in my right eye, same as last time. Then I realised that my pupil wasn't dilating correctly but at that point didn't have any pain or redness. When I got to the hospital they confirmed there was inflammation and put on pred forte 6 times daily. Unfortunately I suspected right from the start that I already had it in the back of my eye, due to the blurred vision but the doctors could see or measure anything so dismissed it. 2-4 weeks later my eye sight worsened and because I work with microscopes I could tell I had active inflammation (I can see the shadow down the microscope). I could also tell that I had a cystiod macular oedema again. Upon the next visit I told them and this time they could detect what I was saying and have upped my pred forte dose to once and hour. I'm also on acular which is a NSAI 4 times a day, maxitrol (steroid ointment) during the night and timilol because I am a steriod responder. Last time it took almost 10 months to recover from the sub tenons triamcinolone injection (I had high pressure all the while). I asked the doctor what the next step is if these topical medications do not work, and apparently I will be getting oral steroids next. I am moving to Japan in 5 weeks! The reoccurrence happened at the most inconvenient time. I previously had all blood work done and I had ACE, CRP, full blood count, U&E, syphilis, serology, toxo serology and HLA-B27 were all negative. No cause could be found. They have arranged for a non urgent appointment to have a chest X-ray but I am not worried about them finding anything abnormal as I have no chest symptoms and surely the blood work would show something if there was an underlying cause. However it does make me wonder if it is common to have idiopathic intermediate uveitis with cystiod macular oedema or is there usually a cause?

Also is it normal to feel some pain that feels like it's at the back of my eye? I know there shouldn't be associated pain but last time and this time I felt the same sort of pain. It's not unbearable or anything, just rather noticeable. Sometimes I think it is me imagining it though.

I'm also just a bit fed up that it is back again. I tried contacting doctors in Tokyo for when I get over there but so far no luck.

[Mike Bartolatz]

Japan

Koki Aoki, MD
Shiroishi-Ku Tel: 81 11 864-4656
Hondori 6, Kita 2-1 FAX: 81 11 864-2344
Sapporo, 003
Email: aokimd@mail.rainbow.ne.jp

Hajime Inomata MD
Department of Ophthalmology Tel: 81-92-641-1151
Faculty of Medicine FAX: 81-92-633-4045
Kyushu University
Fukuoka 812
Email: inomata@eye.med.kyushu-u.ac.jp

Satoshi Kotake MD
Department of Ophthalmology
Hokkaido University School of Medicine
Kita-15, Nishi-7, Kita-ku
Sapporo 060-8638
Tel: 81-11-716-1161 Ext. 5944
FAX: 81-11-736-0952
Email: skotake@med.hokudai.ac.jp

Manabu Mochizuki MD
Dept. of Ophthalmology & Visual Science Tel: 81-3-5803-5296
Tokyo Medical & Dental University FAX: 81-3-5803-0145
1-5-45 Yushima, Bunkyo-ku
Tokyo 113-8519
Email: m.manabu.oph@tmd.ac.jp

Annabelle A. Okada, MD
Assistant Professor of Ophthalmology
Kyorin Eye Center
Kyorin University School of Medicine
6-20-2 Shinkawa, Mitaka
Tokyo 181-8611
Tel: 81-422-47-5111 Fax: 81-422-71-6836
Email: aokada@po.iijnit.or.jp

Shigeaka Ohno, MD
Dept. of Ophthalmology & Visual Science Tel: 81-11-716-1161
Hokkaido University FAX: 81-11-736-0952
Graduate School of Medicine
Kita-15, Nishi-7, Kita-Ku3-9
Sapporo 060-8638
Email: sohno@med.hokudai.ac.jp

Masahiko Usui, MD
Tokyo Medical University Tel: 81-333426111
Department of Ophthalmology FAX: 81-3-33469170,
6-7-1 Nishinjuku Shinjuku 81-3-33428430
Tokyo
Email: sopthal@tkk.att.ne.jp

here are the specialists in Japan. uncontrolled intermediate uveitis has the vision robbing consequence of cystoid macular edema. often epiretinal membranes grow over this area causing additional distortion.
you need more than steroids to treat this. often surgery to remove the vitreous and to seal off the pars plana region where the exudative process is going on is needed to stop the recurrent nature of the beast. this is done with endolaser or cryotherapy - freezing of the area with the exudate, then a corticosteroid sparing approach to treatment is implemented with DMARD drugs like methotrexate, Cellcept or Imuran alone or in combination with drugs like Cyclosporine or TNF A Blocking drugs Remicade or Humira.

do a medline search on the specialists for literature to see which ones deal with pan uveitis and intermediate uveitis since you have anterior chamber inflammation along with the intermediate stuff going on.
and which ones use a steroid sparing approach for these things.

like you I have a history of both anterior and intermediate uveitis with CME, ERM's, optic neuritis and glaucoma damage from steroids used back in the dark ages of uveitis treatment before there were other options available to prevent vision loss before it occurs in the manner described above.

the pred forte will not treat the intermediate uveitis. it will only penetrate to the iris so it is not treating the IU. a better choice of NSAID would be Bromfenac for the CME or an Avastin injection into the vitreous. they can also inject SHORT ACTING steroid with the subtenons injections for intermediate uveitis or posterior uveitis. insist on this as it may become necessary to do so again. the oral steroid can also increase Intra Ocular pressure so get it checked frequently, timolol can also cause uveitis so explore other pressure lowering drops.

my best to you!
mike