general treatment principles of uveitis
- • Infectious causes should be treated accordingly.
- • Anterior uveitis:
- • Mydriatic and cycloplegic agents are commonly used to alleviate pain and prevent synechiae.
- • Topical corticosteroids are the hallmark of therapy (limited/no efficacy in posterior disease).
- • Oral corticosteroids are uncommonly required for isolated anterior uveitis.
- • Uveitis in any segment:
- • Periocular or intravitreal corticosteroids may be useful for more severe cases or when posterior disease is prominent.
- • Oral corticosteroids are commonly effective; in severe cases, doses of 1 mg/kg may be required.
- • When systemic corticosteroids lead to an inadequate response, intolerance, or inability to taper, steroid-sparing immunosuppressive therapy may be required.
- • Immunosuppressive agents that have demonstrated efficacy in uveitis include methotrexate, azathioprine, mycophenolate mofetil, leflunomide, calcineurin inhibitors, cyclophosphamide, anti-TNF therapy (monoclonals > etanercept), and rituximab.
- • Adalimumab has demonstrated efficacy in noninfectious intermediate, posterior, and panuveitis in several randomized controlled trials and is approved by Food and Drug Administration for this indication.
- • Disease-specific considerations:
- • Methotrexate plus adalimumab has been shown to be more effective than methotrexate alone for JIA-associated uveitis.
- • Anti-TNF therapy (monoclonal antibodies, not etanercept) has been found particularly beneficial in patients with uveitis due to Behçet’s disease, sarcoidosis, and HLA-B27-associated AAU.
- • Rituximab may be an alternative to cyclophosphamide in ANCA-associated vasculitis with uveitis and other forms of ocular inflammation.
There is a balance between the use of systemic and local corticosteroids. All forms of corticosteroids (when used chronically) will lead to cataract, and some patients will develop corticosteroid-induced intraocular pressure rise. However, it is important to note that uncontrolled uveitis can cause cataract and elevated intraocular pressure (uveitic glaucoma) as well. The choice of local versus systemic corticosteroids is based on patient tolerance, risk factors, and the potential for side effects.
