UPFRONT

A Pox on Uveitis

Peter K. Kaiser, MD

Yesterday a patient who works in a local ophthalmologist’s office came to my clinic for a second opinion. This patient had been to numerous retina doctors who all had no idea what was causing the patient’s uveitis.

In my clinic, like I am sure in yours, patients like this will take a lot of time. They always come with a phonebook collection of lab tests, chart notes, letters, and imaging tests that must be sifted through to decide the next course of action. My AMD, RVO, and postop patients will not be happy, I think to myself.

Uveitis has always been among the more difficult areas of retina to master. Case conferences are usually sprinkled with weird uveitis cases, as opposed to how to operate on a macular pucker. We all know what to do with a pucker; uveitis is an entirely different beast. Many diseases look very different but have the same cause. I can remember one meeting at which five straight “unknown” cases turned out to be syphilis.

Part of the problem is how little we know about the pathogenesis or even the correct pathophysiology of the various disorders. Take for example the “white dot syndromes.” This continuum consists of a myriad of different phenotypical presentations lumped under one heading. As our ability to elucidate the true causes of these diseases improves, we will undoubtedly better define these syndromes.

I have no doubt that many of them are actually one disease with different phenotypes. Whether the root cause is inflammatory or infectious remains to be seen. When I trained, we would order an array of lab tests to see if we could by luck find the cause. Not much has changed nowadays. Infectious etiologies are much easier to find since we can do PCR and often find the bug or virus — not so with the noninfectious etiologies.

The other part of uveitis that makes us all cringe is that the cases are inherently more complicated and often times very difficult to manage. Making mistakes in the order, timing, or type of treatment can often lead to blinding consequences. We all like things we can inject or operate on to fix, but that is not what works. Instead, a thoughtful stepwise approach is required that often requires cooperation with your local rheumatologist.

The one area of uveitis that has not changed much in years is the management. Since very little can beat steroids, the field has remained stagnant for a very long time. That is not to say that clinical trials have not been done — just that beating or even being noninferior to steroids is a very difficult task. But with the advent of new targets and delivery techniques, several new and promising drugs are in clinical trials and are hopefully about to get approved.

In this issue, Emmett Cunningham discusses the ever-expanding clinical research in this exciting field. This article a must read since we have a new drug about to be released that may help us treat our patients better. At the very least, the diagnosis and management of noninfectious uveitis will be front and center over the next year in lectures and CME programs. It will be a fun ride.

As for my patient, I think it is multiple sclerosis, but I need to rule out syphilis first...