Expert Opinion: Effective Management of Noninfectious Uveitis
Uveitis — inflammation of the pigmented vascular layer of the eye — is a medical emergency responsible for up to 20% of cases of blindness.1
Management varies markedly in clinical practice and only 25% of surveyed physicians follow available guidelines' recommendations; for example, patients are frequently administered maintenance doses of corticosteroids far exceeding the recommended maximum of ≤10mg per day.3
Diagnosis and treatment therefore should be multidisciplinary and involve uveitis experts.2 Effective clinical management of noninfectious or autoimmune uveitis may involve a rheumatologist and an ophthalmologist, and hinges on determining the anatomical location of ocular inflammation, exclusion of potential infectious etiologies (including tuberculosis and HIV), and assessing which medications a patient is already taking at the time of diagnosis.2,4-7 Examination of the eyes reveals the anatomic extent of inflammation and any optic nerve involvement.2
Part of the challenge of effective management of noninfectious uveitis is that it is not really a single disease, but a constellation of many different ones.2,7
“It varies in terms of etiology and whether it's in the front, middle, or back of the eye—or all three,” said James Rosenbaum, MD, Chief of the Uveitis Clinic and director of inflammatory research at Oregon Health & Science University (OHSU) in Portland, OR. “Therapy is very much tailored to the cause, location, and individual patient. There are a lot of variables.”
There might be as many as 85 different etiologies for uveitis, noted C. Stephen Foster, MD, FACS, FACR, founder and president of the Ocular Immunology and Uveitis Foundation in Waltham, MA. Autoimmune eye inflammation can result from underlying, systemic autoimmune disease or it may be localized.3
“Autoimmune uveitis is a diagnosis of exclusion,” said J. Fernando Arevalo, MD, Professor of Ophthalmology at Johns Hopkins's Wilmer Eye Institute and Chairman of the Department of Ophthalmology at Hopkins Bayview Medical Center in Baltimore, MD. He uses chest x-ray or CT and lab tests for tuberculosis, syphilis, and HIV, as well as blood and urine cultures, to exclude infectious uveitis.
For most patients with noninfectious uveitis and anterior eye involvement, topical corticosteroids are a typical front-line treatment, Dr. Rosenbaum said. “There is also a role for injected corticosteroid,” he added.
Corticosteroid eye drops were first used for uveitis in 1950 and prednisone and other glucocorticoid eye drops remain a mainstay of treatment today. Corticosteroids are usually effective, experts agree. Dr. Arevalo estimates that perhaps 30% of patients with noninfectious uveitis do not respond to corticosteroids alone.
But particularly at higher corticosteroid doses and with systemic therapy, serious side effects can become a problem over time, and can involve numerous major organ systems.2-4
“The limiting factor is not ineffectiveness but rather the complications caused by monotherapy,” Dr. Foster explained. “The recognition of the inevitable side effect of cataract with chronic therapy, and in some cases, glaucoma” led to a search for alternatives to corticosteroid monotherapy.
Corticosteroid dose and duration “must be tailored to the patient,” Dr. Foster emphasized. He does not recommend initiating corticosteroid therapy at low doses with the expectation of subsequently escalating the dose. Instead, therapy should begin at high doses of corticosteroids, and then tapered—sometimes sharply—depending on clinical response.4
For patients with recurring anterior uveitis, Dr. Foster recommends evaluation of the patient's HLA-B27 status, IgG anti-treponemal antibody and other lab studies.