Options

I'm reminded of the Gomez song "... that's okay, at least I've got options".

As of yesterday I now officially have options back on the table. I went to Albuquerque to see a new uveitis specialist who only moved to the area late last year. The last actual specialist I saw was over in Dallas, Texas. Not that my regular quack doesn't know what he's doing, but he's a vitreo-retinal specialist and I'm his only uveitis patient.

So anyway, up till now I've been getting local treatment for my symptoms. Mostly that means some sort of steroid in my eyeball to control inflammation and bring down the cystoid macular edema (swelling in the central part of the retina). The doc in Dallas suggested immuno-suppressant treatment, which I eventually went on, but my local doc is unwilling to manage that. His consistent suggestion has been vitrectomy (surgically removing the vitreous jelly from the eye). So both I and my rheumatologist are getting frustrated with having no guidance. Until recently my best option for input was another trip to Texas.

That has all changed! The new uveitis specialist in Albuquerque (at UNM Hospital) is really good. She laid a bunch of options out for me, rather than just focusing on one. So here's a quick summary, split into groups:

Local:
- More ozurdex implants to control the swelling. I need these every three to four months currently.
- A retisert implant. Downside is that I'd probably need some kind of device put in my eye to help manage the pressure, since this is another steroid option and I 'respond' to steroids (i.e. my intra-ocular pressure shoots up). Brightside: lasts well over a year, can cause cataracts, except not in me since I already had one lens replaced and my other eye will be done soon.

Surgical:
- Vitrectomy. I don't like the idea of this since it's a 50/50 shot in the dark. One thing they usually do with this procedure though is laser the inside of the eye (in my case it'd be the pars plana) to help reduce the chance of inflammation.
- Cryotherapy. This sounds super-cool [/pun]. They freeze the pars plana from the outside, so it's non-invasive surgery. It has the same effect as lasering the inside, like they'd do in a vitrectomy, except there's no surgical removal of anything. The only downside is the local anesthesia, which is my "favourite": retro-bulbar injection!

Systemic:
There are a ton of options here.
Currently I'm subjecting myself to Methotrexate, which is used to treat various nasty things like rheumatoid arthritis and leukemia. It's been doing exactly squat for me. Well, it has taught me to inject myself on a weekly basis, which I'm sure is a useful life skill.
- Increase the methotrexate. I'm on a lowish dose right now, and I'm tolerating it well. So increasing the dose is a first step before thinking about anything else.
- CellCept. Apparently a much more potent drug that works in a similar way to the methotrexate. It's a twice daily thing, rather than weekly injections, but could work. Same issues as my current regimen, which means regular blood testing to check on my liver function.
- Other drugs. The only name I remember here is cyclosporin, but there were two other "categories" of drugs that could be considered. I also recall "T-cell inhibitors" being discussed, but I can't remember whether cyclosporin was one of those. Regardless (I can google that later), there are other systemic options that the doctor is happy to manage herself, which is a massive change for me.

I was also amused by the eye test where they checked for my best-corrected vision. They managed to correct my left eye so that I could read the giant E on the top line. Very exciting.

So my plan:
- Schedule another ozurdex implant for my left eye and then schedule cataract surgery.
- Go see my rheumatologist and double my dose of methotrexate.
- Review situation in a couple of months. If there's no clear improvement from the methotrexate then we'll try CellCept.
- Cryotherapy. Despite the retro-bulbar injection, this seems like a low-risk option for improving things. It might be on the cards later this year.

Mostly I'm glad to know that I've got options. I wasn't that hopeful about seeing the new doctor, but it turned out great. All I have left to worry about this weekend is a trail half-marathon that I'm running up at ~8500ft.