What is the treatment for infectious uveitis?

Treatment of Infectious Uveitis

The treatment of infectious uveitis requires targeted antimicrobial therapy specific to the causative pathogen, combined with anti-inflammatory agents to control inflammation and prevent vision loss. 1 Inappropriate treatment with immunosuppressive therapy alone can be devastating in infectious uveitis cases, making proper identification of the infectious etiology critical.

Diagnostic Approach

Before initiating treatment, essential diagnostic steps include:

• Identification of causative organism through:

  • Clinical presentation assessment (morphology of lesions, laterality)
  • Laboratory testing (serology, PCR, cultures)
  • Imaging techniques (OCT, fluorescein angiography)
  • Ocular fluid sampling when necessary

• Risk factor evaluation:

  • Age and sex of patient
  • Geographic exposures
  • Immunocompromised status
  • Associated systemic symptoms

Treatment Algorithm

1. Antimicrobial Therapy

• Bacterial uveitis: Targeted antibiotics based on suspected or confirmed pathogen

  • Systemic antibiotics for posterior segment involvement
  • Topical antibiotics may be sufficient for anterior segment infections

• Fungal uveitis: Antifungal agents (systemic and potentially intravitreal)

  • May require prolonged treatment course

• Parasitic uveitis: Specific antiparasitic medications

  • Treatment duration determined by organism and clinical response

• Viral uveitis: Antiviral medications (oral or intravenous)

  • Herpes viruses: acyclovir, valacyclovir, famciclovir
  • CMV: ganciclovir, valganciclovir, foscarnet

2. Anti-inflammatory Therapy

• Corticosteroids: Used concurrently with antimicrobial therapy to control inflammation

  • Topical for anterior uveitis
  • Periocular or intravitreal for intermediate/posterior uveitis
  • Systemic for severe or bilateral disease
  • Important: Corticosteroids should only be initiated after appropriate antimicrobial coverage is established 1

• NSAIDs: May be used as adjunctive therapy

  • Help control inflammation and pain
  • Particularly useful when corticosteroids are contraindicated 2

3. Management of Complications

• Elevated intraocular pressure: Anti-glaucoma medications
• Cataract: Surgical intervention when inflammation is controlled
• Macular edema: Topical/periocular/intravitreal steroids, anti-VEGF agents
• Retinal detachment: Surgical intervention

Special Considerations

• Duration of therapy must be sufficient to completely eradicate the infectious agent

• Monitoring for response should include regular assessment of:

  • Visual acuity
  • Inflammatory markers
  • Ocular complications
  • Medication side effects

• Treatment failure may indicate:

  • Incorrect diagnosis
  • Antimicrobial resistance
  • Inadequate drug penetration
  • Concurrent non-infectious inflammatory component

Pitfalls to Avoid

1. Misdiagnosis of infectious vs. non-infectious uveitis: Using immunosuppressants alone in infectious uveitis can worsen the infection and lead to devastating outcomes 1

2. Inadequate antimicrobial coverage: Insufficient dosing or duration can lead to treatment failure and chronic/recurrent disease

3. Premature discontinuation of therapy: Complete eradication of the infectious agent is necessary to prevent recurrence

4. Overlooking systemic manifestations: Many infectious causes of uveitis have systemic involvement requiring comprehensive treatment

5. Delayed treatment: Prompt initiation of appropriate therapy is essential to prevent permanent vision loss

By following this structured approach to the treatment of infectious uveitis, clinicians can optimize outcomes and preserve vision while minimizing complications from both the disease and its treatment.