What is the initial treatment for uveitis?

Initial Treatment for Uveitis

Topical corticosteroids are the first-line treatment for uveitis, specifically prednisolone acetate 1% drops, which should be used as initial therapy to control inflammation. 1

Classification and Initial Assessment

Uveitis is classified based on anatomical location:

• Anterior uveitis (41-60% of cases): Affects iris and ciliary body
• Intermediate uveitis (9-15%): Affects pars plana and peripheral retina
• Posterior uveitis (17-23%): Involves choroid and/or retina
• Panuveitis (7-32%): Involves all uveal layers 2

Treatment Algorithm

Step 1: Topical Corticosteroids

• First-line therapy: Prednisolone acetate 1% topical drops 1
• Preferred over difluprednate due to better corneal penetration and lower risk of corticosteroid-induced complications 1
• Dosing: Initially frequent administration (every 1-2 hours) followed by tapering as inflammation comes under control
• Goal: Control inflammation as rapidly as possible to prevent permanent tissue damage 3

Step 2: Assess Response (2-6 weeks)

• Regular monitoring by ophthalmologist is essential
• If patient continues to require 1-2 drops/day of prednisolone acetate 1% for ≥3 months, consider systemic therapy 1

Step 3: Systemic Therapy (if needed)

1. First systemic agent: Methotrexate 4

   • Recommended when topical therapy is insufficient or when prolonged topical steroid use poses risk of complications (cataracts, glaucoma) 1

2. Biologic agents (if methotrexate is ineffective):

   • Monoclonal TNF inhibitors are preferred 4
   • Adalimumab is FDA-approved for non-infectious intermediate, posterior, and panuveitis 5
   • Infliximab is an alternative TNF inhibitor 1, 4
   • Etanercept should NOT be used for uveitis treatment 1

Special Considerations

Risk Factors for Complications

• Topical glucocorticoid use at ≥2 drops/day increases risk of intraocular pressure elevation 1
• Long-term topical steroid use (>3 months) increases risk of cataracts and glaucoma 1
• Poor prognostic factors that may warrant earlier systemic therapy include:
  • Male gender
  • Posterior synechiae
  • Band keratopathy, glaucoma, or cataract
  • Poor initial vision
  • Macular edema 1

Common Pitfalls to Avoid

1. Delayed treatment: Untreated uveitis can lead to cataracts, glaucoma, macular edema, retinal detachment, and vision loss 2
2. Prolonged topical steroid monotherapy: Limit to ≤3 months if possible 1
3. Inadequate monitoring: Regular ophthalmologic follow-up is essential to assess treatment response and adjust therapy 4
4. Failure to exclude infectious causes: Always rule out infectious etiologies before starting corticosteroid therapy 3
5. Overreliance on systemic corticosteroids: These should be used only as short-term bridging therapy in selected complicated cases 1

Treatment Outcomes

The primary goal of treatment is to induce and maintain remission while minimizing corticosteroid use to reduce adverse effects 2. Early and appropriate treatment can significantly improve visual outcomes and prevent complications 2. For posterior uveitis, first-line therapy with disease-modifying antirheumatic drugs such as methotrexate achieves remission in approximately 52% of patients 2.