What is the management for uveitis?

Management of Uveitis

Topical corticosteroids are the first-line treatment for anterior uveitis, while systemic immunosuppression with methotrexate followed by anti-TNF biologics (adalimumab preferred) is recommended for refractory cases or posterior segment involvement. 1

Initial Treatment Approach

Anterior Uveitis

• First-line therapy: Topical corticosteroids (preferably prednisolone acetate 1% or dexamethasone) 1
  • Initial dosing: Every 1-2 hours, then taper as inflammation subsides
  • Goal: Complete resolution of anterior chamber cells
  • Monitor: IOP, cataract formation

Poor Prognostic Factors Requiring Early Systemic Therapy

• Male gender
• Posterior synechiae
• Band keratopathy, glaucoma, or cataract
• Poor initial vision
• Macular edema 1
• Uveitis antedating arthritis 2

Systemic Therapy Algorithm

1. Initiate systemic immunosuppression if:

   • Poor prognostic factors present at first visit 2
   • Topical steroids insufficient after 3 months 2
   • Inflammation reactivates during steroid taper 2
   • Patient requires topical steroids for ≥3 months (to avoid cataract/glaucoma risk) 1

2. First-line systemic therapy: Methotrexate 2, 1

   • Dosing: 15-25 mg weekly (subcutaneous preferred over oral) 1
   • Monitor: Liver function, complete blood count

3. Second-line therapy (if methotrexate ineffective or not tolerated):

   • Anti-TNF biologics 2, 1
   • Preferred order: Adalimumab > Infliximab > Golimumab 2
   • Do not use etanercept for uveitis (strong evidence against its efficacy) 2, 1

4. For refractory cases:

   • Consider switching between anti-TNF agents 2
   • If lack of efficacy, test for antidrug antibodies and drug trough levels 2
   • Alternative options: Tocilizumab, rituximab, or abatacept 2

Treatment Monitoring

• Goal of treatment: No cells in anterior chamber 2
• Monitoring frequency:
  • Within 1 month after each change in topical therapy
  • At least every 3 months while on stable therapy 1
• Collaborative care: Regular communication between ophthalmologist and rheumatologist 2, 1

Duration of Therapy and Tapering

• Maintenance of therapy: Minimum 2 years of inactive disease off topical steroids before reducing systemic immunosuppression 2, 1
• Tapering sequence: Reduce topical steroids first, then systemic therapy 1

Special Considerations

Posterior/Panuveitis

• Requires more aggressive systemic therapy from the outset 3
• Higher risk of sight-threatening complications 3

Pediatric Patients (JIA-associated uveitis)

• Higher risk of steroid-induced IOP elevation 1
• More aggressive monitoring required
• Same treatment algorithm applies, with careful attention to growth and development

Common Pitfalls to Avoid

1. Prolonged topical steroid monotherapy (>3 months) without systemic immunomodulatory therapy increases risk of cataract and glaucoma 1

2. Overreliance on systemic corticosteroids instead of steroid-sparing immunomodulatory agents 1, 4

3. Using etanercept for uveitis management (ineffective and associated with high relapse rates) 2, 1

4. Inadequate monitoring for treatment response and complications

5. Premature discontinuation of systemic therapy (maintain for at least 2 years of inactive disease) 2, 1