Although the initial events leading to uveitis are not always clear, the eventual loss of vision has always been ascribed to the ocular tissue damage caused by the amplification of the inflammatory processes. [30 – 32]
Topical steroids are often the first-line as inhibitory agents in the treatment of uveitis.
Uveitis treatments primarily try to eliminate inflammation, alleviate pain, prevent further tissue damage, and reduce vision loss.
Treatments depend on the type of uveitis a patient displays.
Anterior Uveitis can be Chronic:
Regardless of the presentation, the treatment is with Uveitis eye drops are mostly in the form of steroid therapy as the first option for treating patients with non-infectious uveitis because it can suppress the hallmark inflammation.
Many doctors agree that treating the eye aggressively and early can help avoid complications and vison loss. Treating hourly with Pred Forte or every 2 hours with Durezol (difluprednate).
Dr Glenn Jaffe at Duke University starts with the anterior uveitis and says: “I treat aggressively in the beginning, it makes it easier for me to get the patient off the drops, as opposed to treating less aggressively and prolonging the treatment duration. I begin to taper the treatment once the anterior chamber is quiet.”
Local therapy options include a posterior sub-Tenon’s steroid injection or intravitreal steroids. However, I usually start with a posterior sub-Tenon’s injection. I can always go to an intravitreal injection later, if needed. As retinal specialists, we are almost programmed to treat people with intravitreal injections, but with a uveitis patient you can often achieve the treatment you need with a periocular steroid injection, which has the advantages of less risk for endophthalmitis and/or an increase in intraocular pressure. Having said that, though, if the inflammation is severe, or if the patient doesn’t respond to a periocular steroid injection, I’d use an intravitreal steroid.” For the intravitreal steroid route, Dr. Glenn Jaffe says that, at this point in the therapy, he prefers either an intravitreal injection of triamcinolone acetonide (1 mg in 0.1 ml) or a short-acting sustained drug delivery system such as Ozurdex (dexamethasone implant), which lasts six weeks to three months.
At a certain point, however, steroids will have to be ceased, and continued inflammation suppression is achieved by steroid-sparing therapy.
Some practice guidelines suggest that immunosuppressive therapy may be appropriate as the first therapeutic option in some cases of uveitis, including sympathetic ophthalmia, Vogt-Koyanagi-Harada disease and Behçet’s disease with retinal vasculitis, and in some rheumatologic disorders, such as Wegener’s granulomatosis, Behçet’s disease or polyarteritis nodosa, which affects the posterior segment.
However, immunosuppressive therapy requires close and careful follow-up, and there are systemic concerns that general ophthalmologists may not be aware of. For that reason, referral to a uveitis specialist may be warranted.
Referral may also be called for if the disease course is particularly violent, if it affects the retina, or if uveitis recurs every time the steroid is tapered down or eliminated. Dr. C. Stephen Foster (a leading specialist) suggested referral after 6 months of steroid use and that the timing of the referral can be of critical importance.
“Delayed referral is too common, and a change in practice patterns is going to be necessary if we are going to have any significant hope of reducing the prevalence of blindness secondary to uveitis,” Dr. Foster said. “Too often, the uveitis specialist gets the referral, gets the case, after sufficient damage has been done that precludes the patient ever seeing well again.”