Diagnosis & Treatment
Prior to initiation of treatment, a serologic work-up is needed to identify an etiology and rule out infectious causes of the ocular inflammation. The tests ordered vary by clinical exam findings, provider and region, but uveitis specialists universally agree both a non-treponemal (RPR, VDRL) and a treponemal test (FTA-Abs, T. pallidum IgG, MHA-TP) are required to rule out syphilis.
Most immunosuppressive agents are used off label, given there is only one FDA-approved medication for non-infectious intermediate & posterior uveitis, & panuveitis—adalimumab.
Additional testing based on clinical picture can include a computed tomography scan of the chest without contrast if there is a high suspicion for sarcoidosis or Lyme titers in patients with a history of travel to areas where Lyme disease
is endemic.
In patients with anterior uveitis or intermediate uveitis, a positive HLA-B27 test can give prognostic information, because the inflammation is more likely to be chronic or recurrent. Most acute episodes of anterior uveitis last six weeks and, on average, recur once a year.11
Treatment is based on the anatomic location of the inflammation and the chronicity.
Acute anterior uveitis is treated with corticosteroid drops, including prednisolone acetate 1% or difluprednate 0.05%, starting at four times per day or fewer with minimal inflammation or hourly dosing when fibrin and hypopyon are present in the anterior chamber. Cycloplegic drops—such as cyclopentolate 1%, which can be used up to three times per day, or daily atropine 1%—are added to break posterior synechiae, which are abnormal adhesions between the iris and lens.
If chronic anterior uveitis cannot be controlled with three or fewer drops a day of prednisolone acetate 1% or if complications develop, systemic treatment with corticosteroids is warranted.12 Concurrently, a steroid-sparing immunosuppressive agent is started to minimize the long-term side effects associated with steroid monotherapy.13
This approach is also used to treat panuveitis, posterior uveitis and intermediate uveitis with secondary complications, including retinal neovascularization, macular edema or vision loss due to vitreous haze.
Most immunosuppressive agents are used off label, given there is only one medication approved by the U.S. Food & Drug Administration (FDA) for non-infectious intermediate and posterior uveitis, and panuveitis—adalimumab.
The American Uveitis Society has published recommendations on the use of anti-metabolite and biologic agents for ocular inflammatory disorders.14 However, treatment needs to be individualized based on patient comorbidities, age, pregnancy status and the side effect profile of each drug.
The second treatment approach is local therapy, using periocular or intraocular steroid injections. The FDA has approved several intraocular implants for the treatment of non-infectious intermediate and posterior uveitis, and panuveitis.
Options for short-term inflammation control include the 0.7 mg dexamethasone intravitreal implant (Ozurdex; Allergan) and the 0.18 mg fluocinolone acetonide intravitreal implant (Yutiq; EyePoint).
Long-term control can be achieved using the 0.59 mg fluocinolone acetonide anchored implant (Retisert; Bausch and Lomb) in lieu of immunosuppression.
An additional periocular treatment for macular edema is the injection of triamcinolone acetonide (Kenalog-40) into the sub-tenon space or into the vitreous cavity (Triesence; Alcon).
Local therapy spares the systemic side effects of immunosuppressive agents and oral corticosteroids, but it has been associated with the development of elevated intraocular pressure and cataracts. The Multicenter Uveitis Steroid Treatment (MUST) trial showed that seven years after implantation of the 0.59 mg fluocinolone acetonide-anchored implant, 45% of patients underwent glaucoma filtering surgery, and 90% received cataract surgery.15
