What is the treatment for uveitis?

Treatment of Uveitis

The treatment of uveitis begins with topical corticosteroids for anterior uveitis, while moderate to severe cases involving posterior segments require systemic immunosuppression with methotrexate as first-line therapy, followed by monoclonal antibody TNF inhibitors like adalimumab if needed. 1

Initial Treatment Approach

Anterior Uveitis

• First-line therapy: Prednisolone acetate 1% topical drops
  • Initial dosing: Frequent administration (every 1-2 hours)
  • Taper as inflammation comes under control 1
  • Goal: Rapid control to prevent permanent tissue damage
  • Regular ophthalmologist monitoring required

Intermediate, Posterior, and Panuveitis

• Urgent ophthalmology referral required before initiating treatment 1
• Systemic corticosteroids in addition to topical treatment
  • Starting dose: 1-2 mg/kg/day methylprednisolone equivalents IV for severe cases 1
• Topical steroid monotherapy should be limited to ≤3 months 1
  • Prolonged use increases risk of cataracts and glaucoma

Systemic Immunosuppressive Therapy

When to Initiate

• If topical steroids are insufficient after 3 months
• If inflammation reactivates during steroid taper
• If patient requires ongoing topical steroids to maintain control 1

First-Line Immunosuppressive Agent

• Methotrexate (subcutaneous preferred over oral)
  • Dosing: 0.5-1 mg/kg/week (maximum 30 mg per week) 1
  • In juvenile idiopathic arthritis-associated uveitis, subcutaneous administration is conditionally recommended over oral 2

Second-Line Therapy (If Methotrexate Fails)

• Anti-TNF biologics:
  • Adalimumab (Humira): Initial dose of 80 mg followed by 40 mg every other week 3
    • FDA-approved for non-infectious intermediate, posterior, and panuveitis in adults and pediatric patients 2 years and older 3
    • Significantly decreases risk of treatment failure by 75% relative to placebo in pediatric uveitis 3
  • Infliximab: 5-10 mg/kg IV initially, then maintenance based on response 1
  • Important: Etanercept should NOT be used for uveitis due to lack of efficacy 1, 2

For Severe Cases with Sight-Threatening Complications

• Combination therapy with methotrexate and a monoclonal antibody TNFi immediately is recommended over methotrexate monotherapy 2

Treatment Algorithm

1. Initial therapy: Topical steroids + methotrexate
2. If inadequate response: Add adalimumab
3. If adalimumab fails: Switch to infliximab 1

Monitoring and Follow-up

• Monitoring should occur no less frequently than every 3 months while on stable therapy 1
• Ophthalmologic evaluation within 1 month after each change in topical therapy 1
• Regular monitoring for complications:
  • Cataracts
  • Glaucoma
  • Increased intraocular pressure
  • Posterior synechiae
  • Band keratopathy
  • Cystoid macular edema 1

Important Considerations and Pitfalls

Steroid-Related Complications

• Risk of IOP elevation increases with dosing of ≥4 drops daily and prolonged use beyond 3 months 1
• Children have a higher risk of steroid-induced IOP elevation 1
• Long-term topical steroid use (>3 months) increases risk of cataracts and glaucoma 1

Duration of Therapy

• Maintenance of therapy should be for a minimum of 2 years of inactive disease off topical steroids before reducing systemic immunosuppression 1
• The induction treatment must be aggressive to overcome inflammation rapidly and avoid permanent tissue damage 4

Collaborative Care

• Regular communication between ophthalmologist and rheumatologist is essential 1
• Comprehensive autoimmune workup is strongly recommended for patients with episcleritis or scleritis who only respond to prednisolone acetate 1% ophthalmic drops 1

Poor Prognostic Factors

Factors that may warrant earlier systemic therapy include:

• Male gender
• Posterior synechiae
• Band keratopathy
• Glaucoma or cataract
• Poor initial vision
• Macular edema 1

The addition of immunosuppressive therapy is effective in allowing reduction of systemic prednisolone to 10 mg/day or less, controlling inflammation, reducing relapses, and maintaining vision 5.