Treatment Options for Uveitis

Treatment Options for Uveitis

Uveitis is an inflammatory disease or process that can occur in one or several different parts of the eye. Inflammation usually appears as swelling, redness or irritation and is the body's normal response to illness, infection, or introduction of harmful and/or toxic stimuli (bacteria, viruses, injury or other disease). Uveitis can occur for unknown reasons (idiopathic), as a single disease state (primary), or as a symptom of another disease or disorder (co-manifestation) that evolves over time.

Different types of uveitis have been described, based on the anatomic location (which structure(s) within the eye are affected), how long the uveitis has been present and the underlying cause of the inflammation. Answering the Where? When? and Why? can help to confirm a diagnosis of uveitis and provide insight into the best treatment and management plan.

What are the treatment goals for all uveitis?

1. Eliminate the inflammation

2. Reduce the pain

3. Prevent any damage to eye structures or tissue

4. Prevent vision loss / restore vision

5. Prevent recurrence

6. Reduce treatment side effects

 

Seeking treatment for uveitis is essential and should not be delayed in order to preserve and restore vision. If left untreated, uveitis can lead to serious complications and permanent vision loss.

What are the different treatments for different types of uveitis?

The cause of inflammation can separate the uveitis into infectious or non-infectious types. Infectious uveitis means that the inflammation causing the symptoms is because there is bacteria or virus or fungus in the eye. Non-infectious uveitis can occur after an eye injury or may be caused by a disease or inflammation occurring elsewhere in the body. The non-infectious type of uveitis is the most common, occurring in more than 90% of cases in the United States. [2]

The most common type of uveitis is acute (short duration) and anterior uveitis. The symptoms of this type and location of uveitis generally respond well to topical corticosteroids (eye drops) and cycloplegic and/or mydriatic medications.

Depending on where the uveitis is located in the eye, eye drops may not be effective. Eye drops do not penetrate structures at the back of the eye very well. Patients with chronic disease (long duration) location in the middle portion of the eye (intermediate uveitis) or back of the eye (posterior uveitis), or entire eye (panuveitis) usually have more serious symptoms and may require more intense treatments.  

Surgery may be recommended to treat types of severe uveitis or deliver long-acting drug delivery devices to the eye.

 

What types of medications are used to treat uveitis and how are they administered?

Due to the seriousness of uveitis, and importance of preserving vision and preventing damage to the eye, treatment needs to begin without delay. Medications are administered in many different ways, depending on where the uveitis is located.

Uveitis treatment is delivered as eye drops, orally administered tablets or capsules, injections of medications or implants into or around the eye, surgically implanted devices or intravenous or intramuscular medications.   

Many people are treated with a combination of treatments, in order to address the inflammation and pain. Prescription eye drops in combination with anti-inflammatory medications are a common initial treatment.

 

The main types of medications used to treat uveitis include:

Steroids/Corticosteroids

For non-infectious uveitis, ophthalmologists usually choose to initially treat with a steroid medication (corticosteroids). Corticosteroids have shown to be very effective in uveitis treatment because they act on the inflammation by disrupting the normal function of the immune system, preventing further release of the cells that cause inflammation.   

Depending on the location of the uveitis, the corticosteroid medication may be given as an eye drop, a pill, by injections of mediactions or implants around or into the eye, , or released into the eye through a surgical implant. Medicines may also be given subcutaneously intramuscularly or intravenously. Dosing depends on the symptoms that are present and the drug being used. Some eye drops may have to be used every hour, while others are used once every two days.

If the uveitis is located toward the middle or back of the eye, (intermediate or posterior uveitis), or if corticosteroid eyedrops have not been effective in managing symptoms, injections may be recommended. Injections may be administered around the outside of the eye (periocular injection) or inside the eye (intraocular injection). Although many people may be uncomfortable with the thought of injections in or around the eye, this treatment can be very effective. Ophthalmologists numb (anesthetize) the eye before the injection to prevent any pain or discomfort.

Corticosteroids when taken orally are  tablets or capsules. This form or corticosteroids is very strong and is usually not recommended unless eye drops or injections have not been effective or are unsuitable for the patient. Oral corticosteroid treatment delivers the drug systemically (through the entire body) and can cause a wide range of side effects. Some people respond after only a few weeks of treatment, while others require ongoing treatment with corticosteroids for months or years. In some cases intravenous steroids may be required.

Common corticosteroids include: prednisolone acetate, prednisolone phosphate, rimexolone, solumedrol and prednisone.

Antibiotics, Antivirals and Antifungals

If an underlying infection is the cause of the uveitis (infectious uveitis), then the infection will also need to be treated. Viruses can be treated with antiviral medication, bacterial infections with antibiotics, and fungal infections can be treated with anti-fungal medication.

Cycloplegics, Mydriatics

Eye drops that enlarge (dilate) the pupil, block nerve impulses, and help to manage pain by temporarily paralyzing the ciliary body (muscle that controls lens shape, an extension of the iris, the colored part of the eye). By calming the ciliary body, pain is reduced, Cycloplegic drops may temporarily cause blurry vision, problems focusing and an unusual sensitivity to light, known as photophobia. Common drops include: homatropine, atropine, cyclopentolate, and mydriacyl.

Immunosuppressants

Usually in pill form, taken orally to reduce irritation and inflammation. Immunosuppressant may be recommended if the inflammation has not responded to corticosteroid treatment or if the side effects of corticosteroid treatment have become too difficult to tolerate. Sometimes immunosuppressants are used to allow the dose of corticosteroids to be reduced. Immunosuppressants control the immune system and disrupt the inflammatory process, but this may make an individual more vulnerable to infection. Immunosuppressants can also negatively affect the functioning of some organs and bodily systems, including lungs, liver, kidneys and bone marrow so regular blood tests to monitor overall health are required.  

Reasons to treat uveitis with immunosuppressants:

• Patient becomes dependent on corticosteroid treatment to prevent disease recurrence and requires continuous systemic corticosteroid treatment.

• Patient is resistant to corticosteroids. This means that they either do not have any response to corticosteroid treatment, or they require very high doses to prevent uveitis recurrence.

• Patients who cannot take oral corticosteroids

• Patients with specific causes of uveitis, such as juvenile idiopathic arthritis associated uveitis, inflammatory bowel disease associated uveitis)

Common immunosuppressants include: methotrexate, mycophtnolate, azathrioprine, cyclosporine and biologics (biologic response modifiers) such as, adalimumab, infliximab, daclizumab, abatacept, and rituximab. Biologics target specific elements of the immune system and can be very effective in uveitis treatment, but may also have serious side effects and may increase the risk of cancer.

Non-steroidal anti-inflammatory drugs (NSAIDs) - Widely used medications used to help reduce irritation and swelling in uveitis. Oral NSAIDs should not be used together with oral corticosteroids due to increased risk of stomach ulcers (gastric ulceration). Common NSAIDS include: diclofenac, ketorolac tromethamine, nepafenac, celecoxib, naproxen, and indomethacin.

 

What kind of surgery is used to treat uveitis?

Surgical procedures may be required to replace the vitreous, the jelly-like fluid inside the eye, or to insert a tiny device into the eye that can slowly release medication to treat the inflammation.  

The surgery to replace the vitreous, is called a vitrectomy. The procedure is performed while the patient is under local or general anesthetic in a hospital or surgical center setting. During the vitrectomy, the affected vitreous is gently suctioned from inside the eye and replaced with an air bubble, gas bubble or replacement liquid/gel. There are risks of complications with vitrectomy, as with any eye surgery. Also, having a vitrectomy increases someone’s risk of developing a cataract in that eye.

Rather than having repeated intraocular injections, some corticosteroids can be delivered using a device surgically implanted in the eye that slowly releases drug into or near the affected structures over time. This treatment has been effective in treating uveitis, however it can cause cataract formation and elevate intraocular pressure. [1]

 

Can I discontinue treatment when symptoms improve?

It is important to continue to take all prescribed medications until advised by an ophthalmologist that it is safe to stop. Many medications require a tapered dose before stopping, meaning the dose should be gradually reduced and not stopped abruptly. Stopping treatment too soon may result in symptoms returning.

Discontinuing oral corticosteroids, when not advised that it is safe to do so by a physician, can cause serious and unpleasant side effects.

 

What are the side effects of uveitis treatment?

Each type of treatment for uveitis can involve different side effects, some restricted only to the eye, while others affect other parts of the body. It is important to speak with your ophthalmologist about all medications you are taking, to ask any questions, and tell them about any concerns you have.

Eye drops may cause temporary blurred vision after use.  

Some treatments may cause the pressure inside the eye (intraocular pressure) to increase, so the ophthalmologist will carefully monitor eye pressure and manage with other treatments if necessary.  

Short term use of oral or intravenous systemic corticosteroids can cause weight gain, increased appetite, insomnia and changes in mood. Longer use of corticosteroids can lead to more serious side effects, including stomach ulcers, osteoporosis and increased risk of infection. Ophthalmologists often prescribe the lowest effective dose in order to minimize negative side effects.

Some of the medications used to treat uveitis can have very serious side effects, therefore follow-up eye examinations and possible blood tests, to monitor over all health, may be required every 1-3 months.

Potential side effects of immunosuppressants can include skin rash, numbness or tingling in different parts of the body, loss of appetite, nausea and vomiting, increased blood pressure, headaches, hair loss and shortness of breath.

 

What type of doctor treats uveitis?

Ophthalmologists (medical doctors that specialize in diseases and disorders of the eye) are the type of specialists that manage and treat people with uveitis. Often, because uveitis is associated with other disorders, the ophthalmologist will collaborate with other physicians, such as primary care physicians or rheumatologists to ensure that the uveitis and any underlying disorders are treated appropriately. Primary care physicians may also assist with some of the monitoring and blood tests that are needed for people undergoing certain types of uveitis treatment (systemic corticosteroids or immunosuppresants). Depending on the part of the eye affected by uveitis, an ophthalmologist specializing in that particular part of the eye (Vitreoretinal specialist for intermediate or posterior uveitis) may take over care of the patient.

 

References:

[1] Jaffe GJ, Lin P, Keenan RT, Ashton P, Skalak C, Stinnett SS. Injectable fluocinolone acetonide long-acting implant for noninfectious intermediate uveitis, posterior uveitis, and panuveitis: two-year results. Ophthalmology. 2016;123(9):1940-1948. https://www.ncbi.nlm.nih.gov/pubmed/27421623

[2] Thorne JE, Suhler E, Skup M, Tari S, Macaulay D, Chao J, Ganguli A. Prevalence of Noninfectious Uveitis in the United States: A Claims-Based Analysis. JAMA Ophthalmol. 2016 Nov 1;134(11):1237-1245. https://www.ncbi.nlm.nih.gov/pubmed/27608193