What are the diagnostic steps and treatment options for uveitis?

Diagnostic Approach and Treatment Options for Uveitis

The diagnosis of uveitis requires a systematic approach including anatomical classification, etiology determination, and appropriate monitoring, followed by targeted treatment with topical or systemic therapy depending on the location and severity of inflammation.

Diagnostic Steps for Uveitis

1. Anatomical Classification

• Anterior uveitis: Inflammation of iris and ciliary body (41-60% of cases) 1
• Intermediate uveitis: Inflammation of pars plana and peripheral retina (9-15% of cases) 1
• Posterior uveitis: Inflammation of choroid and/or retina (17-23% of cases) 1
• Panuveitis: Inflammation of all uveal layers (7-32% of cases) 1

2. Clinical Evaluation

• Slit lamp examination: To assess anterior chamber cells and flare
  • Grade 1+ anterior chamber cells = 6-15 cells per field in a 1-mm × 1-mm slit beam 2
  • Look for keratic precipitates, synechiae, and inflammatory membranes
• Fundus examination: To evaluate vitreous haze, chorioretinal lesions, and retinal vascular lesions
• Visual acuity assessment: Critical parameter for monitoring disease activity 2

3. Diagnostic Testing

• Serologic screening for syphilis: Appropriate in all forms of uveitis 3
• Targeted investigations based on anatomical classification:
  • Anterior uveitis: HLA-B27 testing (especially for unilateral acute non-granulomatous cases) 3
  • Chronic uveitis: Serum angiotensin-converting enzyme, interferon-gamma release assay, chest CT 3
  • Intermediate/posterior uveitis: Brain MRI, anterior chamber tap with IL-10 analysis (patients >40 years) 3
  • Rule out masquerade syndromes: Consider diagnostic vitrectomy if malignancy suspected 2

4. Imaging

• Optical Coherence Tomography (OCT): Essential for evaluating macular edema 4
• MRI: Can detect uveal tract enhancement in active inflammation 5
• Ultrasound (B-scan): Useful for evaluating posterior segment when media opacity is present 5

Treatment Options

1. Anterior Uveitis

• First-line therapy: Topical corticosteroids (prednisolone acetate 1%) 1, 6
  • Dosing: Initially may require >1-2 drops/day, but should be tapered to minimize complications 2
  • Caution: Long-term use increases risk of glaucoma, cataracts, and delayed wound healing 7
• Mydriatics: To prevent synechiae formation and relieve ciliary spasm 6

2. Intermediate, Posterior, and Panuveitis

• Mild intermediate uveitis: May be monitored without initial treatment 1
• Moderate to severe cases: Require systemic therapy 1

  • First-line systemic therapy: Non-biologic DMARDs 2, 1

    • Methotrexate (achieves remission in ~52% of cases) 1
    • Mycophenolate mofetil (controls inflammation in ~71% of cases) 1
    • Other options: Leflunomide, cyclosporine 2, 4

  • Second-line therapy: Biologic agents 2, 4, 1

    • Monoclonal TNF inhibitors: Adalimumab, infliximab 4
    • Consider when DMARDs fail to control inflammation
    • Adalimumab extends time to treatment failure (24 vs 13 weeks with placebo) 1
    • Infliximab dosing: 5mg/kg IV at weeks 0,2,6, then every 4 weeks 4
    • Dose escalation (up to 15-20mg/kg) may be considered for inadequate response 4
    • Alternative biologics: Abatacept, tocilizumab for TNF inhibitor failures 4

3. Infectious Uveitis

• Requires systemic antimicrobial treatment specific to the identified pathogen 1
• May require adjunctive corticosteroids depending on severity and specific microorganism 1

Monitoring Protocol

• During topical steroid taper: Ophthalmologic monitoring within 1 month after each change 2
• On stable therapy: Ophthalmologic monitoring no less frequently than every 3 months 2
• When changing systemic therapy: Ophthalmologic monitoring within 2 months 2, 4
• Assessment parameters: Visual acuity, anterior chamber cells, vitreous haze, OCT findings 2, 4

Important Considerations

• Topical steroid complications: Elevated intraocular pressure, glaucoma, cataracts, delayed wound healing, and increased risk of fungal/viral infections 7
• Treatment failure indicators: 2-step increase in inflammation level, lack of 2-step decrease, or inability to achieve inactive disease despite therapy 2
• Treatment goal: Suppress inflammation and achieve inactive disease state while minimizing corticosteroid exposure 1
• Systemic therapy threshold: Consider adding or changing systemic therapy if topical steroids are required for >3 months to maintain control 2

Special Situations

• For patients with inadequate response to standard TNF inhibitor dosing, escalate dose/frequency before switching to another agent 4
• Consider adding methotrexate to TNF inhibitors to enhance efficacy and prevent antibody formation 4
• Evaluate for treatment nonadherence, infections, or masquerade syndromes in any patient with inadequate response to therapy 2