Medication Summary
In addition to treating the suspected underlying etiology, the goals of pharmacotherapy are to reduce pain and inflammation with cycloplegics and corticosteroids. Corticosteroid eye drops are the standard of care for uveitis, [4, 5] but should only be initiated in conjunction with an ophthalmologist. Specialist management helps to monitor for adverse steroid effects, which may include elevated intraocular pressure, cataract formation, and steroid-induced glaucoma, [1] as well as increased risk for herpes keratitis.
Studies comparing nonsteroidal anti-inflammatory drug (NSAID) eye drops to placebo and corticosteroids have not demonstrated benefit; their use as an alternative to corticosteroids is not supported by evidence. [4]
Potassium-sparing drugs are indicated when chronic steroid use is required to control inflammation. [1] Approximately half of patients with uveitis need more than corticosteroid treatment to prevent vision loss. [26]
Corticosteroid eye drops were the first medication FDA approved to treat non-infectious uveitis but adalimumab (humira) is now an FDA-approved treatment for uveitis. [27, 28]
Anticholinergic Agents, Ophthalmic
Class Summary
These agents block nerve impulses to the pupillary sphincter and ciliary muscles, easing pain and photophobia. They can also aid in prevention of posterior synechiae formation.
Cyclopentolate (AK-Pentolate, Cyclogyl, Cyclomydril)
Induces cycloplegia in 25-75 min and mydriasis in 30-60 min. Effects last as long as 1 d; however, duration may be less in the setting of severe anterior chamber reaction. For this reason, Cyclogyl is less attractive for treating uveitis than homatropine.
Homatropine (Isopto Homatropine, Homatropaire)
Induces cycloplegia in 30-90 min and mydriasis in 10-30 min. Effects last 10-48 h for cycloplegia and 6 h to 4 d for mydriasis, but duration may be less in setting of severe anterior chamber reaction. Homatropine is the anticholinergic agent of choice for uveitis.
Corticosteroids, Ophthalmic
Class Summary
These agents decrease inflammation. Corticosteroid treatment often is initiated only after consultation with an ophthalmologist. The frequency, duration (tapering) and choice of ophthalmic corticosteroid depends on the degree of inflammation. Implants, intravitreal injections, and suprachoroidal injections require trained ophthalmologist to conduct the procedure.
Prednisolone ophthalmic (Econopred Plus, Inflamase Forte, Inflamase Mild)
Strongest steroid of its group and best choice for uveitis. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Triamcinolone suprachoroidal (Xipere)
Suprachoroidal injectable suspension provides more precisely located corticosteroid therapy to the affected posterior areas of the eye. This decreases the area of the eye exposed to corticosteroids thus decreasing the risk of adverse effects. A drug dose reduction is also an advantage, due to the high bioavailability of the drug in the choroid.
Fluocinolone intravitreal implant (Retisert, Yutiq)
The implants are surgically inserted by the ophthalmologist and indicated for chronic, noninfectious uveitis of the posterior segment of the eye. Retisert releases 0.6 mcg/day initially; amount released decreases after the first month to 0.3-0.4 mcg/day over ~30 months. Yutiq releases at a rate of 0.25 mcg/day over ~36 months.
Dexamethasone intravitreal implant (Ozurdex)
The implant is surgically inserted by the ophthalmologist and indicated for chronic, noninfectious uveitis of the posterior segment of the eye.
Difluprednate ophthalmic (Durezol)
Another choice for ophthalmic corticosteroid,Difluprednate 0.05% four times daily has been found to be equivalent to prednisolone acetate 1% eight times daily in anterior uveitis. It has greater tissue penetration compared to other prednisolone derivatives but a higher rate of complications, including increased intraocular pressure. [34]
Tumor Necrosis Factor Blockers
Class Summary
The American Uveitis Society has released expert panel recommendations on the use of tumor necrosis factor alpha (TNF-α) inhibitors in ocular inflammatory disorders, which have been widely studied and shown to have superior efficacy, especially in the treatement of severe disease. [29, 30, 31]
These recommendations include the following considerations:
Use of infliximab or adalimumab early in the treatment of patients with vision-threatening ocular manifestations of Behçet disease.
Use of infliximab or adalimumab as second-line therapy in children with vision-threatening uveitis secondary to juvenile idiopathic arthritis for whom methotrexate therapy is ineffective or not tolerated. Methotrexate, if tolerated, can be combined with infliximab.
Use of infliximab and possibly adalimumab can be used as second-line treatment for patients with vision-threatening chronic uveitis caused by seronegative spondyloarthropathy.
Use of infliximab or adalimumab for vision-threatening corticosteroid-dependent disease in patients for whom first-line therapy has failed.
Use of infliximab or adalimumab before etanercept in treatment of ocular inflammatory disease, or switching of patients using etanercept to either infliximab or adalimumab.
Infliximab (Remicade)
Infliximab is a chimeric IgG1κ monoclonal antibody that binds specifically to the soluble and transmembrane forms of TNF-α and inhibits the binding of TNF-α to its receptors.
Adalimumab (Humira)
Adalimumab is a recombinant human IgG1 monoclonal antibody that is specific for human TNF. It reduces inflammation and inhibits progression of structural damage. In 2016, it was FDA approved for the treatment of uveitis in patients 2 years of age and older. [39]
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Anatomy of the eye.
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Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
Tables
Type |
Primary Site of Inflammation |
Manifestation |
Anterior uveitis |
Anterior chamber |
Iritis/iridocyclitis/anterior cyclitis |
Intermediate uveitis |
Vitreous |
Vitreitis/hyalitis/pars planitis |
Posterior uveitis |
Choroid |
Choroiditis/chorioretinitis/retinochoroiditis/retinitis/neuroretinitis |
Panuveitis |
Anterior chamber, vitreous, and/or choroid |
All of the above |
