How is uveitis with elevated intraocular pressure (IOP) treated?

Treatment of Uveitis with Elevated Intraocular Pressure

For patients with uveitis and elevated intraocular pressure (IOP), treatment should include topical corticosteroids for inflammation control while simultaneously managing IOP with pressure-lowering medications, with systemic immunomodulatory therapy initiated if topical steroids cannot be tapered below twice daily within 3 months. 1

Initial Management of Uveitis with Elevated IOP

Anti-inflammatory Treatment

• First-line therapy: Prednisolone acetate 1% topical drops
  • Initial dosing: Frequent administration (every 1-2 hours) during acute phase 2
  • Taper as inflammation comes under control
  • Avoid difluprednate due to higher risk of significant IOP elevation (31.5% of patients develop clinically important IOP elevation) 3
  • Children and patients on concurrent systemic corticosteroids are at substantially higher risk of difluprednate-induced IOP elevation 3

IOP Management

• First-line IOP-lowering agents:
  • Prostaglandin analogs (e.g., latanoprost) - safe in uveitis patients without increasing inflammation 4
  • Beta-blockers
  • Alpha-2 agonists
  • Carbonic anhydrase inhibitors
• Latanoprost works by increasing uveoscleral outflow, with IOP reduction starting 3-4 hours after administration and maximum effect after 8-12 hours 5

Monitoring and Treatment Escalation

Monitoring Schedule

• Ophthalmologic monitoring within 1 month after each change in topical glucocorticoid therapy 1
• Regular monitoring no less frequently than every 3 months while on stable therapy 1
• Monitor for:
  • Anterior chamber cell count (using SUN criteria)
  • IOP
  • Development of complications (synechiae, cataract, glaucoma)

Criteria for Treatment Escalation

• Uveitis is considered uncontrolled if:
  • Anterior chamber cells ≥1+ (6-15 cells/field) 1
  • Development of new ocular complications
  • Inability to taper topical steroids to twice daily or less 1

Systemic Therapy Initiation

When to Start Systemic Therapy

• If patient requires topical steroids for ≥3 months 1, 2
• If unable to control inflammation with topical steroids alone
• If developing steroid-induced complications (elevated IOP, cataract)
• If recurrent inflammation occurs with steroid taper

Systemic Therapy Options

1. First-line systemic therapy: Methotrexate

   • Subcutaneous administration preferred over oral for ocular inflammation 2

2. Second-line therapy: TNF inhibitors if inadequate response to methotrexate

   • Adalimumab (preferred)
   • Infliximab (alternative if adalimumab fails)
   • Note: Etanercept should NOT be used for uveitis 2

Special Considerations

Corticosteroid-Induced IOP Elevation

• Corticosteroid-induced IOP elevation (61.1% of cases) is generally easier to control than IOP elevation from other causes 4
• Requires fewer eye drops (mean 2.06 vs 2.52) and less filtration surgery (8.9% vs 22.4%) 4
• For patients with steroid-responsive IOP elevation, consider:
  • Loteprednol or fluorometholone (weaker anti-inflammatory effect but less IOP elevation) 6
  • Intravitreal sustained-release devices for severe cases (Ozurdex has better safety profile than triamcinolone) 7
  • Methotrexate as a steroid-sparing agent 7

Pediatric Patients

• Children have higher risk of steroid-induced IOP elevation 3
• More aggressive monitoring of IOP is needed
• Earlier consideration of systemic therapy may be warranted

Treatment Algorithm

1. Initial phase:

   • Prednisolone acetate 1% drops (frequent dosing)
   • IOP-lowering medication if IOP elevated

2. After 3 months:

   • If still requiring topical steroids >2 drops/day: Add systemic therapy
   • If IOP controlled but inflammation persists: Add methotrexate

3. If inadequate response to methotrexate:

   • Add or switch to adalimumab

4. If inadequate response to adalimumab:

   • Switch to infliximab

Pitfalls to Avoid

• Prolonged topical steroid therapy (>3 months) without systemic immunomodulatory therapy increases risk of cataract and glaucoma 1, 2
• Using difluprednate in high-risk patients (children, those on systemic steroids) 3
• Delaying systemic therapy in patients with recurrent inflammation or steroid-dependent disease
• Avoiding prostaglandin analogs in uveitis patients (they are actually safe and do not increase inflammation) 4

By following this treatment approach, the goal is to control inflammation while minimizing steroid-related complications, particularly elevated IOP, to preserve vision and quality of life for patients with uveitis.