Iritis and Uveitis Medication

Updated: Aug 08, 2017
  • Author: Monalisa N Muchatuta , MD, MS; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce pain and inflammation with cycloplegics and corticosteroids. Corticosteroid eye drops have been the standard of care for uveitis since the early 1950s. Although evidence to support their use is somewhat sparse, [3, 4] they are the only medications approved by the FDA to treat uveitis. Corticosteroids should be initiated only in conjunction with an ophthalmologist because uveitis is a diagnosis of exclusion, and adverse effects of steroids include increased intraocular pressure, cataract formation, steroid-induced glaucoma, [1] and an increased risk of herpes keratitis, which should be managed by a specialist.

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. [3]

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. [16]

 

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Anticholinergic Agents, Ophthalmic

Class Summary

These agents block nerve impulses to the pupillary sphincter and ciliary muscles, easing pain and photophobia.

Cyclopentolate 0.5-2% (Cyclogyl)

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 setting of severe anterior chamber reaction. For this reason, Cyclogyl 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 agent of choice for uveitis.

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Topical steroids

Class Summary

These agents decrease inflammation. Corticosteroid treatment often is initiated only after consultation with an ophthalmologist.

Prednisolone 1% (Pred Forte, Omnipred)

Strongest steroid of its group and best choice for uveitis. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

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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 is a widely studied but off-label application for these biologic agents. [17, 18]

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.

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