Uveitis, Anterior, Granulomatous Treatment & Management
- Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD more...
Treatment of inflammation of the anterior segment is discussed below.
Use a long-acting cycloplegic agent, such as cyclopentolate or homatropine, to relieve both pain and photophobia (if present) and to prevent the formation of posterior synechiae. However, this may not always be necessary in chronic disease, especially if the inflammation is well controlled. In any case, allowing for some pupil movement is helpful to prevent posterior synechiae formation in the dilated position.
Topical corticosteroids are the mainstay of therapy and should be used aggressively during the initial phases of therapy.
If the patient poorly complies with topical therapy or if the iritis is not responding to topical corticosteroids, a subconjunctival injection of shorter-acting or depot steroids may be used. Betamethasone (Celestone) is short and intermediate acting and can be used for exacerbations, whereas triamcinolone acetate is longer acting and is used more often for associated cystoid macular edema or vitritis.
Depot steroids should be avoided in cases of uveitis secondary to any suspected infectious process because of their potentially severe adverse effects.
In severe cases of iritis, oral corticosteroids may be added to the treatment regimen (after ruling out the infectious etiology or after under coverage of medication, which treats the infectious etiology).
Prolonged use of systemic corticosteroids is to be avoided. The goal is less than 10 mg of prednisone per day by 6 months. In severe disease or if prolonged corticosteroids are being used, systemic corticosteroid-sparing immunomodulatory agents are used in chronic noninfectious uveitis. If evidence shows involvement of the posterior uvea by noninfectious uveitis, intravitreal steroids can be used via intravitreal injection or insertion of a steroid-eluting delivery system (eg, Retisert, Iluvien, Ozurdex).
Treat increased intraocular pressure as indicated.
Systemic immunomodulating agents
Systemic immunomodulating agents may be used in patients in whom regional or systemic corticosteroids are not responding or in patients who have the potential for steroid side effects. Systemic immunomodulating agents work by selectively blocking steps in the inflammatory and immune cascades. For example, abatacept and alefacept dampen the immune response by interfering with the activation of T cells, while adalimumab, etanercept, and infliximab target the inflammatory mediator TNF-alpha.
Glaucoma surgery can be performed if medical treatment fails to control the intraocular pressure and after quieting the eye from inflammation. In case of cataract, the eye must be free of inflammation at least 3 months before the surgery. A peripheral iridectomy may be indicated for iris bombe; however, if the pupil is not entirely occluded or secluded, an iridectomy can precipitate iris bombe by diverting flow from the small area of the pupil that is not occluded. In that case, if there is an exacerbation of inflammation, the pupil can close as there is no flow and the iridectomy may become occluded as well.
If a specific systemic diagnosis is suspected or is confirmed on the basis of laboratory and/or radiographic investigation, consultation with a subspecialist may be indicated.
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