John A. Moran Eye Center Clinical Focus 2021: Advances in Uveitis Care

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Advances in

UVEITIS

CARE

Clinical FOCUS

Moran Eye Center


MOR A N E Y E CE N T E R

July 1, 2019 – June 30, 2020

AT A GLANCE $

Publications:

Grants and Contracts:

Surgeries Performed:

Clinical Trials/ Studies:

180

$8,616,674

7,031

94

RANKINGS

Retina: 16,130 Glaucoma: 14,205 Pediatric: 14,943

Cornea: 17,032

U.S. News & World Report : Best Hospitals for Ophthalmology: 13th Nationwide Ophthalmology Times: No. 11 Nationwide for Best Overall Program No. 9 Nationwide for Best Residency Program No. 12 Nationwide for Best Research Program No. 12 Nationwide for Best Clinical Care Program Doximity: No. 9 Nationwide No. 2 in the West for Residency Education

About the Cover Photo illustration adapted from a color fundus image of sympathetic ophthalmia taken with the Optos California by Chris Keth, CRA, OCT-C.

Other: 10,735

PAT IEN T V ISIT S : 13 5 , 8 2 5

Oculoplastics: 5,588 Uveitis: 4,415

Comprehensive Ophthalmology: 25,023 Low Vision: 175

Neuro-Ophthalmology: 4,176

Optometry: 23,403

RESOURCES FOR PHYSICIANS Refer a Patient 801-213-2001 healthcare.utah.edu/moran/refer-patient.php

Moran CORE Clinical Ophthalmology Resource for Education morancore.utah.edu

For Uveitis Referrals A referral letter and chart notes are required before an appointment can be made. Fax information to 801-213-6972 or visit the referral link above. When a physician has been assigned, a referral coordinator will call the patient to schedule an appointment. This process can take one to three days.

NOVEL Neuro-Ophthalmology Virtual Education Library novel.utah.edu WEBVISION The Organization of the Retina and Visual System webvision.med.utah.edu CME Information medicine.utah.edu/cme


Unparalleled Uveitis Care As ophthalmologists, we know many of our patients tend to view the eyes as separate entities from the other body systems. Nothing could be further from the truth, especially as we work to advance education and treatments for a significant cause of preventable blindness in the United States: uveitis. In uveitis, we see a range of inflammatory diseases manifest in the uvea to produce swelling and threaten sight. The John A. Moran Eye Center’s Uveitis Division took shape in 2003 when I recruited Albert T. Vitale, MD. Akbar Shakoor, MD, and Marissa B. Larochelle, MD, later joined him. Together they comprise the only uveitis division between Colorado and California and are among a small number of fellowship-trained uveitis specialists nationwide. The team provides unparalleled expertise and hope for patients, treating conditions that require long-term, skilled management to increase quality of life in the absence of a cure.

I like to think of our division as a triple threat, leading the field forward on a national scale, training one fellow each year, and working closely with colleagues in rheumatology. Their leadership has been multifaceted, with a host of publications, high-profile clinical trials, new screening protocols, and book chapters. These contributions to advance care have been especially noteworthy over the past year. I hope you’ll take away valuable insight from the case studies and updates featured in this edition of Clinical Focus. Sincerely,

Randall J Olson, MD Professor and Chair, Department of Ophthalmology and Visual Sciences, University of Utah CEO, John A. Moran Eye Center

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Care. Education. Research. A Center of Excellence for Uveitis BY ALBERT T. VITALE, MD

The overarching mission of the Moran Eye Center’s Uveitis Division consists of three parts: to provide state-of-the-art, comprehensive, timely, and compassionate care to patients suffering from uveitis; to serve as leaders in the clinical education of uveitis locally, nationally, and internationally; and to contribute to the field through collaborative and investigator-initiated clinical research.

PATIENT CARE The physicians in our division, Akbar Shakoor, MD, Marissa B. Larochelle, MD, and I, together with our uveitis fellow, provide a prodigious amount of direct patient care, both medical and surgical. Our team treats individuals of all ages suffering from various complex ocular inflammatory and infectious or masquerading neoplastic diseases and their complications. The only program of its kind in the Mountain West, our division is nationally recognized as a regional referral center of excellence, working in collaboration with University of Utah Health rheumatology (adult and pediatric), infectious diseases, and Huntsman Cancer Institute specialists. We endeavor to provide personalized and complete care. Our collective training and experience in uveitis and vitreoretinal diseases and comprehensive ophthalmology and complex cataract surgery is unique. We can provide the most advanced diagnostic modalities and therapeutic approaches, individualized to patients, their specific ocular or systemic disease, or both, and address the potential side effects of treatment. Specifically, these include:  Diagnostic intraocular tissue sampling with molecular analysis. 

From left, Marissa B. Larochelle, MD, Albert T. Vitale, MD, and Akbar Shakoor, MD. —2—

The use of established systemic conventional and newly available biologic steroid-sparing medications.

Appropriate use of primary and adjunctive corticosteroid injections, including sustained-release intravitreal inserts and implants. Visual rehabilitation of the structural ocular complications of uveitis in the anterior and posterior segment employing advanced cataract and vitreoretinal surgical techniques.


EDUCATION

ONGOING U V EIT IS CL INICA L T R I A L S

Our educational mission begins with ophthalmology residents who gain exposure to uveitis through structured rotations on the uveitis and retina services and a unique approach to didactic instruction known as a “flipped classroom format.” Dr. Larochelle is a leader in developing a curriculum for this format, which emphasizes interactive learning.

Vitreous Biopsy Analysis PI: Akbar Shakoor, MD Macular Edema Ranibizumab v. Intravitreal Anti-inflammatory Therapy (MERIT) Trial PI: Albert T. Vitale, MD

Dr. Shakoor established and is the head of Moran’s Association of University Professors of Ophthalmology-accredited uveitis fellowship program, in its fifth year, as well as a six-month international fellowship program. These have become highly competitive and attracted superb fellows who have gone on to excellent academic and private practice positions in uveitis.

Adalimumab vs. Conventional Immunosuppression for Uveitis (ADVISE) Trial PI: Albert T. Vitale, MD

Our team has also served in various leadership roles in national ophthalmology organizations (see list below), including hosting the American Uveitis Society (AUS) Winter Meeting and Uveitis Fellow’s Forum in January 2020. These meetings are central to the AUS national educational mission and are highly popular and widely attended.

Adalimumab in Juvenile Idiopathic Arthritis-Associated Uveitis Stopping Trial (ADJUST) PI: Albert T. Vitale, MD

N AT ION A L L E A DER SHIP R OL E S

Other Machine Learning Algorithm for Electroretinography Sorting

Dr. Vitale: • American Uveitis Society (AUS) Executive Committee • Immediate Past President of AUS • Recent Chair and Co-Chair of the American Academy of Ophthalmology Uveitis Subspecialty Day • Co-Chair of the AUS Winter Meeting in Park City • Chair of the Uveitis Fellow’s Forum (UFF)

PI: Akbar Shakoor, MD

Dr. Shakoor: • AUS Executive Committee UVEITIS FELLOW 2020-21 Wen Fan Hu, MD, PhD, joins the Moran Eye Center as the 2020-2021 Uveitis Fellow following residency at Massachusetts Eye and Ear. She completed her medical and doctorate degrees at Harvard University and undergraduate studies at Yale. Dr. Hu was recently named a 2020-2021 Heed Fellow to support her postgraduate fellowship training and academic pursuits.

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RESEARCH The research activity of the Uveitis Division has involved participation in multiple pivotal randomized controlled trials (RCTs) sponsored by the National Eye Institute (NEI) and industry, as well as investigator-initiated studies, collaborative case series, and reports. As a part of the Multicenter Uveitis Steroid Treatment (MUST) consortium, we have contributed to the important results of the two- and seven-year follow-up studies of the MUST trials. These studies compared the outcomes of systemic treatment with conventional immunomodulatory therapy (IMT) to the local therapy with the fluocinolone acetonide implant for the treatment of noninfectious intermediate, posterior and panuveitis. More recently, we have been vanguard clinics for two NEIsponsored RCTs investigating the safety and efficacy of steroidal and non-steroidal regional and intravitreal therapy for uveitic macular edema (UME), a leading cause of visual impairment. The Periocular and Intravitreal Corticosteroid Trial (POINT) recently compared periocular triamcinolone acetonide (PTA), intravitreal triamcinolone acetonide (ITA), and the intravitreal dexamethasone implant (IDI) as initial therapy for UME. The trial concluded that while all three approaches were effective, both intravitreal therapies were superior to the periocular treatment for reducing UME and improving visual acuity, with similar safety profiles for the intravitreal groups.1 A companion RCT, the Macular Edema Ranibizumab vs. Intravitreal Anti-inflammatory Therapy (MERIT) trial, is exploring the safety and efficacy of IDI to non-steroidal alternatives ranibizumab and methotrexate in eyes with quiescent uveitis. Having been involved in the VISUAL I and II trials sponsored by industry partner AbbVie Inc., which led to the FDA approval of the first biologic agent, adalimumab, for the treatment of noninfectious intermediate, posterior and panuveitis, we are currently enrolling patients in the NEI-sponsored Adalimumab

CITATIONS 1. Thorne JE, et al. Periocular Triamcinolone vs. Intravitreal Triamcinolone vs. Intravitreal Dexamethasone Implant for the Treatment of Uveitic Macular Edema: The PeriOcular vs. INTravitreal Corticosteroids for Uveitic Macular Edema (POINT) Trial. Ophthalmology. 2019 Feb.; 126(2):283-295.

vs. Conventional Immunosuppression for Uveitis (ADVISE) trial. Likewise, we are ready to enroll patients in the Adalimumab in Juvenile Idiopathic Arthritis-Associated Uveitis Stopping Trial (ADJUST), an RCT to study the recurrence rate of ocular inflammation in patients with quiescent, juvenile idiopathic arthritis-associated uveitis. (See a full list of Uveitis Division clinical trials on page 3.) Within our division and in collaboration with other investigators, we have recently published widely on diverse subjects of interest to those in the field of uveitis, including our 13 year-experience with combined phacoemulsification and pars plana vitrectomy for the treatment of cataracts in patients with noninfectious uveitis.2-7 (See a full list of 2020 Uveitis Division publications on page 9.) Our current uveitis fellow and Heed award recipient, Wen Fan Hu, MD, PhD, and Dr. Larochelle are studying the outcomes of uveitic cataract surgery using intraoperative intracameral tPA. Our previous fellow, Inna Stoh, MD, PhD, co-authored a chapter on cataract surgery in uveitis with Dr. Larochelle. Another former fellow, Christopher Conrady, MD, PhD, and myself, in collaboration with Stephen Anesi, MD, and C. Stephen Foster, MD, contributed the most comprehensive chapter on “Pediatric Uveitis” to date for Pediatric Retina, edited by Mary Elizabeth Hartnett, MD, director of Pediatric Retina at Moran. Finally, Katherine Hu, MD, a current ophthalmology resident, and Dr. Larochelle have spearheaded a protocol to institute standard ophthalmic screenings for all pediatric and adult bone marrow, stem cell, or organ transplanted patients for the detection of CMV retinitis ocular infection. (See back cover.) Dr. Vitale directs Moran’s Uveitis Division and specializes in diagnosing and treating uveitis and other infections and inflammatory diseases of the eye. He is co-author of the definitive text on the subject with Dr. C. Stephen Foster, titled “Diagnosis and Treatment of Uveitis.”

Pigment Epitheliopathies. Ocular Immunology and Inflammation. 2020 Feb. 20:1-8. 5. Conrady CD, et al. Checkpoint Inhibitor-Induced Uveitis: A Case Series. Graefes Archive for Clinical and Experimental Ophthalmology. 2018 Jan.;256(1):187-191.

2. Conrady CD, et al. Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients with Noninfectious Uveitis. Journal of VitreoRetinal Diseases. 2020; 4(5):393-400.

6. Conrady CD, Shakoor A. Rituximab-Associated Retinal Occlusive Vasculopathy: A Case Report and Literature Review. Ocular Immunology and Inflammation. 2020 May 18;28 (4):622-625.

3. Conrady CD, et al. Long-Term Visual Outcomes of Endophthalmitis and the Role of Systemic Steroids in Addition to Intravitreal Dexamethasone. BMC Ophthalmology. 2020 May 6;20(1):181.

7. Conrady CD, et al. The First Case of Trypanosoma Cruzi-Associated Retinitis in an Immunocompromised Host Diagnosed with Pan-Organism Polymerase Chain Reaction. Clinical Infectious Diseases. 2018 June 18;67(1):141-143.

4. Kutluturk I, et al. The Clinical Characteristics of Unilateral Placoid

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OUTREACH

Scenes from Myanmar: Dr. Albert T. Vitale, MD, center back row, stands next to Dr. Lynn Hassman, MD, PhD, left, and Dr. Yee Yee Aung, chief of Yangoon Eye Hospital (YEH), and a group of ophthalmology residents during a workshop in early 2020 at YEH. At right, Dr. Vitale examines a patient during the same outreach trip.

Extending Uveitis Care Around the World BY ALBERT T. VITALE, MD

In resource-poor countries such as Myanmar, which has the second-highest number of people living with HIV in Southeast Asia, the rates of cytomegalovirus (CMV) retinitis and associated vision-threatening complications remain unacceptably high. Patients present late with advanced ocular pathology due to delay in diagnosis and limited access to care.

all over the country to provide appropriate and timely care for their patients with ocular complications from HIV/AIDS.

David Heiden, MD, of California Pacific Medical Center, pioneered comprehensive workshops for non-ophthalmologist HIV/AIDS physicians to address this problem. The training includes the use of indirect ophthalmoscopy to diagnose CMV retinitis and other ocular opportunistic infectious diseases. Training workshops, including the safe administration of intravitreal antiviral therapy, have been conducted in Yangon since 2007.

Our most recent workshops were conducted at Yangon Eye Hospital (YEH) with Dr. May Zun Aung Win, director of the Uveitis Service, her colleagues, and residents. The workshops have provided the impetus for an ongoing, sustained institutional relationship between YEH and the Moran Eye Center, initially in the arena of uveitis, with the eventual goal to include other subspecialties in ophthalmology.

Until recently, a variety of non-governmental organizations supported this work; however, over the past several years, there has been a shift in the care of patients with HIV/AIDS to governmental institutions.

Moran’s uveitis outreach care also extends to Pakistan.

Along with past uveitis fellows, I have participated in six such workshops and will have submitted for publication a study to assess the utility of prophylactic argon laser photocoagulation to prevent retinal detachment in patients with CMV retinitis. The methodology and details of CMV screening in these workshops, as described in the peer-reviewed literature, have been highly successful and sustainable, allowing trainees from

Akbar Shakoor, MD, has been a lecturer at the Aga Khan University Medical College and the Layton Rahmatullah Benevolent Trust in Karachi. This work has included an annual Uveitis Lectureship to residents and staff and the development of uveitis curriculum. Of our three superb international uveitis fellows thus far, two have hailed from Pakistan and one from Myanmar. —5—


Medical and Surgical Management of Ocular Inflammatory Disease BY AKBAR SHAKOOR , MD

Ocular inflammatory disease, including uveitis, scleritis, and orbital inflammatory disease, can be acute or chronic, infectious, non-infectious, or present as a masquerade syndrome. Therefore, its management is manifold, and a comprehensive medical and ocular history and targeted laboratory workup are critical to appropriate therapy.

ASSESSMENTS

First, it is important to consider and assess for infectious disease to administer the correct antimicrobial therapy if an infectious process is suspected. Physicians should only consider steroids and other immunomodulatory therapy once ruling out infectious processes.

MEDICAL MANAGEMENT

In the medical management of non-infectious uveitis, corticosteroids play a major role, either by themselves in acute disease, as a bridging therapy in conjunction with corticosteroid-sparing immunomodulatory therapy (IMT),

or in patients on systemic medications. They may be administered topically, regionally (periocular or intravitreal), orally, or intravenously depending on the anatomic location and severity of the uveitis. Avoid long-term exposure to corticosteroids, which can cause a litany of ocular and systemic complications. Topical and locally administered corticosteroids may produce cataracts and induce glaucoma. Systemic administration can cause many side effects, including ocular complications, hypertension, weight gain, diabetes, metabolic syndrome, myopathy, osteoporosis, and avascular necrosis of the hip. To manage chronic ocular inflammatory disease, “cortico­ steroid-sparing” IMT is often used to limit these complications. Immunomodulatory medications may be grouped into conventional agents, which include:  Antimetabolites (methotrexate, mycophenolate mofetil, and azathioprine).  T-cell inhibitors (cyclosporine and tacrolimus).  Cytotoxic medications (cyclophosphamide and chlorambucil).

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Newly emerging biologic response modifiers, including the anti-tumor necrosis factor monoclonal antibodies (infliximab and adalimumab).

Diagnostic vitrectomy and chorioretinal biopsy may be critical in diagnosing infectious uveitis and neoplastic disease, which may masquerade as ocular inflammatory disease that presents atypically or responds unexpectedly to therapy.

Monoclonal antibodies targeting specific proinflammatory cytokines such as rituximab (anti-CD20) and tocilizumab (anti-IL-6). 

A large volume of undiluted vitreous may be obtained using air infusion into a simple vitreous trap system (Figure 1) for a variety of assays. Chorioretinal or sub-retinal aspiration biopsies must be appropriately processed and fixed prior to histopathologic evaluation.

Sustained-release steroid implants are another option to provide prolonged anti-inflammatory therapy and limit systemic corticosteroid exposure. Clinicians may anchor these implants in two ways:  Via sutures to the pars plana, as with the fluocinolone acetonide implant (Retisert, Bausch + Lomb).

In summary, ocular inflammatory disease treatment requires a multimodal approach individualized to each patient following careful disease evaluation and appropriate exclusion of infectious and neoplastic processes.

Injected intravitreally, such as the intravitreal dexamethasone implant (Ozurdex, Allergan) and the fluocinolone acetonide intravitreal implant (Yutiq, EyePoint Pharmaceuticals), shown to be effective in the management of posterior uveitis for up to one to three years after injection. 

Dr. Shakoor specializes in medical and surgical diseases of the retina and vitreous, and the diagnosis and treatment of uveitis and other infectious and inflammatory diseases of the eye. He is director of the Uveitis Fellowship Program.

Although effective, sustained-release implants carry a high risk of corticosteroid-induced cataract formation and glaucoma requiring medical and/or incisional surgery in a high percentage of patients.

Figure 1

SURGICAL MANAGEMENT

Surgical approaches to the management of uveitis may be

therapeutic and diagnostic. Multiple structural complications requiring surgical management occur in uveitis cases, including cataract formation, glaucoma, vitreous hemorrhage and opacity, and epiretinal membrane formation. Surgery should be performed with caution, although with appropriate perioperative planning, anterior and posterior segment surgery can be performed safely and effectively. Therapeutic vitrectomy may be performed with cataract surgery or by itself to clear media opacity, in conjunction with epiretinal membrane peeling, or to address retinal detachment, peripheral retinal non-perfusion, and hypotony. Pars plana vitrectomy may help manage intermediate uveitis by reducing antigen and cytokine load in the eye. In conjunction with cataract surgery, pars plana vitrectomy may reduce the postoperative incidence of posterior capsular opacity, cyclitic membranes, hypotony, and cystoid macular edema. Certainly, in our cohort of patients, a combined surgical approach appeared to be safe and effective in visual rehabilitation in patients with uveitic cataracts. The majority of eyes (64%) achieved vision of 20/40 or better, and 21% achieved complete drug-free remission of inflammatory disease at the one-year follow-up.

A 71-year-old woman received a referral for persistent vitritis after cataract surgery. A surgeon performed a diagnostic vitrectomy, which yielded a large sample of undiluted vitreous. Cytology, flow cytometry, and genetic studies revealed large B-cell lymphoma.

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Combining Cataract and Uveitis Care BY MARISSA B. L AROCHELLE, MD

Cataract surgery in uveitis patients requires special consideration. Both intraocular inflammation and its first-line treatment (steroids) contribute to cataract progression, and cataracts are a main cause of decreased vision in uveitis patients. With careful perioperative planning and management, cataract surgery can be safe and effective in this patient population.

EXAMPLES: 

PERIOPERATIVE PLANNING The most important aspect of successful cataract surgery in a

uveitis patient is control of inflammation in the perioperative period. In general, surgery should only be considered when inflammation has been quiescent for a minimum of three

months, ideally on an anti-inflammatory regimen with or without steroid-sparing immunomodulatory therapy (IMT), on acceptably safe doses of systemic corticosteroids (≤10 mg/daily). Several regimens involving a combination of topical, periocular, and/or systemic steroids exist to control inflammation in the perioperative cataract setting.

Oral prednisone 60 mg daily (or 1 mg/kg/day for patients weighing less than 60 kg) starting two or three days before surgery and tapering over approximately three weeks post- operatively. Initiation of topical steroid (prednisolone acetate 1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) one week before surgery. Use of intravitreal implant (0.7 mg dexamethasone implant – Ozurdex) or subtenon’s injection of triamcinolone before surgery in patients with a history of recurrent macular edema. Pulse dose of intravenous methylprednisolone (ranging from 125-1000 mg) at the time of surgery. Subconjunctival or intracameral triamcinolone at the conclusion of the case.

Structural complications associated with uveitis can affect surgical planning. For example, fluctuating macular edema can alter axial length measurements and intraocular lens (IOL)

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calculations. The presence of band keratopathy can block the visual axis and the surgeon’s view. Removal with chelation

S E L E C T E D P U B L I C AT IO N S 2 0 2 0

should be considered, with adequate time to allow for corneal stabilization before biometry.

INTRAOPERATIVE CONSIDERATIONS Currently, phacoemulsification is the mainstay of cataract surgery for uveitic eyes, with IOL placement in the capsular bag when possible. Uveitic structural complications can pose challenges intraoperatively. Lysis of posterior synechiae or pupillary membranes is often required and can be accomplished with a viscoelastic cannula, Sinskey hook, or micro scissors. The creation of a continuous curvilinear capsulorhexis can be challenging in the case of a fibrotic capsule from chronic inflammation. Capsular hooks or tension rings may be required to stabilize the capsular bag in cases of zonular weakness.

CHILDREN WITH UVEITIS Uveitic cataracts in the pediatric population present a unique challenge. Cataracts occur in approximately 35% of those with juvenile idiopathic arthritis-associated uveitis. Timing of cataract surgery is especially important in children in the amblyopic age range. Post-operative inflammation in children with uveitis can be particularly robust, resulting in fibrin and formation of pupillary membranes. Uveitis is no longer an absolute contraindication to IOL implantation in children, but special attention is required to minimize complications and optimize outcomes. PEARLS  Increase or restart oral antivirals (acyclovir or valacyclovir) before cataract surgery in patients with a history of herpetic ocular disease. 

Treat aggressively with corticosteroids (topical, periocular, or oral) in the perioperative period to prevent severe inflammation. Consider prophylaxis with Bactrim DS before cataract surgery in patients with ocular toxoplasmosis.

Bilateral Placoid Choroiditis in an HIV patient with Cryptococcus Neoformans Meningitis and Disseminated Cryptococcal Disease Larochelle RD, Larochelle MB, Aung YY, Linn T, Heiden D, Vitale AT. Journal of VitreoRetinal Diseases (In Press). July 2020. Single-Nuclei RNA-Seq Provides Comprehensive Transcriptomic Classification of Human Retinal Cell Types Xuesen Cheng, Qingnan Liang, Leah A. Owen, Akbar Shakoor, Albert T. Vitale, Ivana K Kim, Denise J. Morgan, Yumei Li, Margaret M. DeAngelis, Rui Chen. Investigative Ophthalmology & Visual Science. June 2020, Vol.61, 1956. Prevalence of Retinal Diseases and Associated Risk Factors in an African Population from Mwanza, Tanzania Bradley H. Jacobsen, Avni A. Shah, Sahil Aggarwal, Christopher Mwanansao, Molly McFadden, Moussa A. Zouache, Akbar Shakoor. Ophthalmic Surgery, Lasers and Imaging Retina. 2020. Efficacy of Adalimumab in Non-Infectious Uveitis Across Different Etiologies: A Post Hoc Analysis of the VISUAL I and VISUAL II Trials Pauline T. Merrill, Albert T. Vitale, Manfred Zierhut, Hiroshi Goto, Martina Kron, Alexandra P. Song, Sophia Pathai, Eric Fortin. Ocular Immunology and Inflammation. 2020 May 29;1-7. Online ahead of print. Surgery in Uveitis Christopher D. Conrady, Lynn Hassman, Akbar Shakoor. Uveitis. 2020 - Springer; pp 181-198. Long-term Visual Outcomes of Endophthalmitis and the Role of Systemic Steroids in Addition to Intravitreal Dexamethasone Christopher D. Conrady, Richard M. Feist Jr., Albert T. Vitale, Akbar Shakoor. BMC Ophthalmology. 2020; 20:181. Not All That Flickers Is Snow Rachel C. Patel, Albert T. Vitale, Donnell J. Creel, Kathleen B. Digre. Journal of Neuro-Ophthalmology. 23 March 2020. The Clinical Characteristics of Unilateral Placoid Pigment Epitheliopathies Isil Kutluturk, Aniruddha Agarwal, Shiri Shulman, Albert T. Vitale, Maurizio B. Parodi, Christoph D. Conrady, et al. Ocular Immunology and Inflammation. Published online: 20 Feb. 2020.

Avoid multifocal IOLs in patients with uveitis, especially if they have any posterior involvement.

Dr. Larochelle specializes in cataract surgery as well as the diagnosis and management of patients with infectious and inflammatory conditions of the eye.

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NON-PROFIT ORG. U.S. POSTAGE PAID Permit No. 1529 Salt Lake City, Utah

65 Mario Capecchi Drive, Salt Lake City, Utah 84132

Uveitis Clinical Updates screening protocol for CMV retinitis in bone marrow and solid organ transplant patients.

Repeat DFE every 6-8 weeks while viremic until 6-8 weeks after immune system is reconstituted.4

Exam is repeated immediately if visual complaints occur.

1. With initiation of anti-viral therapy as determined by treatment team. 2. CMV disease defined as any CMV organ disease (lung, gastrointestinal, or central nervous system). 3. Patients who develop CMV viremia or disease prior to transplantation should also be referred for screening. 4. As defined by, and in discussion with transplant team. 5. As age and cognitive status allows. 6. Indications for anterior chamber paracentesis include unclear clinical diagnosis (small or atypical lesions) and need for resistance testing or to rule out co-infection.

C OV ID -19 A N D UVEITIS CARE

Cases of suspected  CMV retinitis.

NEW CMV SCREENING PROTOCOL

The timely, systematic ophthalmic examinations were implemented in Fall 2019 to maximize early disease detection and potential interventions to prevent irreversible vision loss in a disease that is largely asymptomatic in early stages. —Katherine Hu, MD

Baseline dilated fundus exam (DFE) with fundus photos within 2 weeks of viremia or disease.

In collaboration with multidisciplinary care teams at Primary Children’s Hospital and University of Utah Health, the Moran Uveitis Division developed a

SCREENING FOR CMV Studies have highlighted a need for a standardized approach to screening for cytomegalovirus (CMV) retinitis in transplant patients, as there are no national ophthalmic screening guidelines for this vulnerable population.

Hematopoietic stem cell and solid organ transplant patients who develop CMV viremia1 or disease.2, 3

Fundus photos including periphery, autofluorescence, fluorescein angiography, visual field testing.5 +/- anterior chamber paracentesis6

There have been no published reports of COVID-19-associated uveitis; however, retinal microvascular changes have been described. Consensus has been evolving as to the optimal management of uveitis patients during the pandemic, especially for those on immunomodulatory therapy (IMT). While there is concern these patients would be at higher risk of severe SARS-CoV-2 infection, literature from multiple subspecialties with large numbers of patients on IMT has not shown this to be the case. Recommendations include continuation of IMT in the absence of known infection, use of local rather than systemic steroids when possible for those at very high risk for severe COVID-19, and a multidisciplinary approach to carefully monitor patients who develop active infection necessitating the discontinuation of IMT. —Marissa B. Larochelle, MD