What is the initial treatment for panuveitis?

Initial Treatment for Panuveitis

For panuveitis, the initial treatment should include urgent ophthalmology referral (preferably to a uveitis specialist) followed by systemic corticosteroids in addition to topical, intravitreal, and/or periocular corticosteroids as recommended by the ophthalmologist. 1

Understanding Panuveitis

Panuveitis is a generalized inflammation affecting all layers of the uveal tract (iris, ciliary body, and choroid) as well as the retina and vitreous humor. It represents one of the most severe forms of uveitis and requires prompt, aggressive treatment to prevent vision loss.

Common causes include:

• Tuberculosis
• Vogt-Koyanagi-Harada syndrome
• Sympathetic ophthalmia
• Behçet's disease
• Sarcoidosis
• Idiopathic (many cases) 2

Treatment Algorithm

Step 1: Initial Assessment and Referral

• URGENT ophthalmology referral (preferably to a uveitis specialist) prior to initiating any treatment 1
• Coordinate treatment plan with ophthalmology specialists

Step 2: Initial Therapy

1. Topical corticosteroids

   • Prednisolone acetate 1% is preferred over difluprednate due to better corneal penetration 3
   • Initial dosing should be frequent (every 1-2 hours) and tapered as inflammation comes under control 3

2. Systemic corticosteroids

   • Consider systemic corticosteroids in addition to topical treatment as recommended by ophthalmologist 1
   • Typical starting dose: 1-2 mg/kg/day methylprednisolone equivalents IV for severe cases 1

3. Additional local therapy options (as directed by ophthalmologist)

   • Intravitreal corticosteroid injections
   • Periocular corticosteroid injections 1

Step 3: Immunosuppressive Therapy (if needed)

If inflammation persists or recurs despite corticosteroid therapy, or to allow steroid-sparing:

1. First-line immunosuppressive agent:

   • Methotrexate (subcutaneous preferred over oral) 1, 3
   • Dosing: 0.5-1 mg/kg/week (maximum 30 mg per week) 1

2. Second-line therapy (if inadequate response to methotrexate):

   • Monoclonal antibody TNF inhibitors (adalimumab preferred) 3, 4
   • Avoid etanercept as it has been shown ineffective for uveitis 3

3. Third-line options (for refractory cases):

   • Alternative TNF inhibitor (infliximab)
   • Abatacept or tocilizumab
   • Mycophenolate, leflunomide, or cyclosporine 1, 3

Monitoring and Follow-up

• Initial monitoring: Within 1-2 days of starting treatment
• Ongoing monitoring: No less frequently than every 3 months while on stable therapy 1
• After therapy changes: Ophthalmologic evaluation within 1 month after each change in topical therapy 1
• Monitor for complications: Cataracts, glaucoma, increased intraocular pressure, posterior synechiae, band keratopathy, and cystoid macular edema 1, 3

Important Considerations

• Panuveitis has poorer visual outcomes compared to other forms of uveitis due to more widespread inflammation 2
• Prolonged topical steroid monotherapy should be limited to ≤3 months if possible 3
• Long-term topical steroid use (>3 months) increases the risk of cataracts and glaucoma 3
• Regular communication between ophthalmologist and rheumatologist/internist is essential for optimal management 3
• Treatment should be maintained for a minimum of 2 years of inactive disease off topical steroids before reducing systemic immunosuppression 3

Prognosis

Without appropriate treatment, panuveitis can lead to serious complications including cataracts, glaucoma, macular edema, retinal detachment, optic nerve damage, and permanent vision loss 5. Early, aggressive treatment coordinated between ophthalmology and other specialists offers the best chance for preserving vision and preventing complications.