Medication Summary
In acute anterior uveitis, topical corticosteroids and a cycloplegic agent should be started immediately, unless an infectious etiology is suspected. If the eye is not adequately responding to topical therapy within a week to 10 days or if the disease is very severe, the addition of either oral corticosteroids or a periocular injection of corticosteroids to the treatment regimen may be necessary as long as no systemic contraindications or evidence of infection is present. The injection of long-acting steroids may be contraindicated in a known steroid responder or in a patient with an already elevated IOP.
Tapering of steroid therapy is guided by the clinical response on follow-up examination. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) tend to be of little or no benefit in the treatment of iritis.
Immunomodulatory and immunosuppressive medications may be useful in patients who are unresponsive to corticosteroids, in patients with chronic uveitis, or in patients who develop adverse effects of corticosteroid therapy.
A number of agents have been used, including methotrexate, azathioprine, cyclosporin A, mycophenolate mofetil, cyclophosphamide, and chlorambucil. Myelosuppression and secondary infection are among the most common adverse effects of these agents.
TNF-alpha inhibitors may be useful in patients with the seronegative spondyloarthropathies, including AS. TNF-alpha inhibitors that are available include infliximab, etanercept, and adalimumab. Reports suggest that infliximab is effective in reducing the number of flares of anterior uveitis in patients with ankylosing spondylitis. Adalimumab may also be effective, but there is evidence that etanercept is not. [13]
An internist or a rheumatologist should be involved in the management of patients treated with immunomodulatory agents.
Corticosteroids
Class Summary
These are the mainstays of therapy for iritis and help to stabilize the blood-aqueous barrier.
Prednisolone acetate 1% (Pred Forte, Econopred)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.
Prednisone (Deltasone)
Can be used if topical therapy inadequate to treat iritis. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.
Cycloplegics
Class Summary
These agents help prevent or break posterior synechiae and reduce ciliary body–induced pain.
Cyclopentolate HCl 1% (Cyclogyl)
Prevents spasm of ciliary muscle and iris sphincter. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min.
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Fine keratic precipitates in a patient with ankylosing spondylitis–associated acute anterior uveitis.
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Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
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Acute anterior uveitis with plasmoid aqueous and hypopyon in a patient with ulcerative colitis.
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Fuchs heterochromic iridocyclitis with cataract and iris heterochromia.
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Iris atrophy in a patient with herpes simplex virus–associated anterior uveitis.
