RAWNY is fortunate to have two uveitis specialists on staff; Dr. Arjun Sood and Dr. Angela Bessette. In addition to their fellowship in vitreoretinal surgery and medical retina respectively, both physicians completed secondary, prestigious fellowships in ocular inflammatory disease. Ocular inflammatory disease encompasses a wide spectrum of conditions, which can occur as a response to an infection, autoimmune disorders, injury or trauma. Uveitis is the most common form of inflammatory eye diseases and may be classified based on the location and cause of the inflammation:
- Anterior uveitis: Inflammation of the iris and/or ciliary body.
- Intermediate uveitis: Inflammation of the ciliary body and vitreous
- Posterior uveitis: Inflammation of the choroid and/or retina.
- Panuveitis: Inflammation of all parts of the uvea (structures of the eye beneath the white of the eye)
If left untreated, severe complications and vision loss can occur. One complication of uveitis is the accumulation of fluid in the macula, called Uveitic Macular Edema (UME). UME is defined by the accumulation of fluid in the retinal layers or the subretinal space, most often seen in cases of posterior uveitis, panuveitis, and intermediate uveitis. UME is diagnosed through slit lamp examination often combined with ophthalmic imaging including HD-OCT and fluorescein angiography.
Dr. Arjun Sood was recently featured in the American Society of Retina Specialists publication Retina Times Winter 2024 issue, as a panelist for a conversation on Uveitic Macular Edema.
How do you approach imaging in UME?
Arjun Sood: I rely primarily on 2 tools. First, optical coherence tomography (OCT) provides an excellent view of the macula’s structural anatomy and can easily identify intraretinal fluid and subretinal fluid. Second, I utilize ultra-widefield fluorescein angiography (FA) to see what’s causing the macular edema seen on OCT, and to identify peripheral leakage.
RAWNY is fortunate to employ an ultra-widefield (UWF) diagnostic camera, which is able to capture 82% or 200⁰ of the retina in a single image. This late photo from a fluorescein angiogram (FA), captured on the Optos California, shows a uveitic eye with vascular inflammation far outside the traditional field of view. This diagram shows how, with traditional fields of view, far peripheral changes can often go undetected. UWF FA and indocyanine green angiography (ICGA), in combination with HD-OCT imaging to monitor UME and other macular changes, have become a crucial tools in the assessment, diagnosis, and treatment of uveitis.
Early intervention and treatment of UME is critical, which typically initially starts with the administration of steroids to help reduce the inflammation. Steroids can be given as oral medications, topical drops, or intravitreal injections/implants. After the delivery of steroids, the treatment plan may be modified with the help of other medications depending upon the response of the patient.
What treatment algorithms do you utilize for steroids when addressing macular edema?
Arjun Sood: I first get an appropriate workup, rule out an infection, and evaluate whether there are any underlying systemic autoimmune conditions. If there is significant uveitic activity in addition to the UME, I will start with oral steroids and assess the treatment response. In eyes that are largely quiet aside from the UME, I often treat or supplement with local corticosteroids. Also—for local steroid injections, you want to steer away from trying to “catch up” with the inflammation. You want to be proactive, not reactive. It is inadequate to repeatedly wait for a recurrence of edema and then treat with a local steroid. Once you establish that pattern of chronicity and recurrence, I think you need to ask yourself, “Am I doing systemic treatment or long-term fluocinolone acetonide implant?”
The article goes on to discuss management techniques and processes, surgical intervention, complex cases and more. To read the rest of the article, refer to Retina Times Winter 2024 issue.
Dr. Sood is board-certified diplomate of the American Board of Ophthalmology and a member of the American Academy of Ophthalmology, American Uveitis Society, American Society of Retina Specialists and International Ocular Inflammation Society. Dr. Sood has a special interest in complex retinal detachment, uveitis, macular hole, epiretinal membrane, secondary intraocular lens, macular degeneration, diabetic retinopathy, vein occlusion, and intraoperative OCT. He remains academically active as a participant in over 30 clinical trials, co-authored numerous publications and book chapters, and has lectured at national and international meetings. Dr. Sood is currently accepting new patients.
