What is the treatment for uveitis (inflammation of the uvea) following immunotherapy?

Treatment of Uveitis Following Immunotherapy

For uveitis following immunotherapy, treatment should follow a graded approach based on severity, with topical corticosteroids as first-line therapy for anterior uveitis, and systemic corticosteroids plus immunomodulatory therapy for more severe cases. 1

Grading and Initial Management

Treatment depends on the severity and anatomical location of uveitis:

Grade 1 (Asymptomatic)

• Continue immunotherapy
• Ophthalmology referral within 1 week
• Start lubrication drops (artificial tears) 1

Grade 2 (Anterior Uveitis)

• Hold immunotherapy
• Urgent ophthalmology referral within 2 days, before initiating treatment
• Coordinate treatment with ophthalmologist:
  • Topical corticosteroids (preferably prednisolone acetate or dexamethasone) as first-line treatment 1
  • Cycloplegic agents to prevent synechiae formation and reduce pain 1
  • Consider systemic corticosteroids if needed 1

Grade 3 (Posterior or Pan-uveitis)

• Permanently discontinue immunotherapy
• URGENT ophthalmology referral (preferably uveitis specialist)
• Systemic corticosteroids in addition to topical/local treatment 1
• Consider intravitreal or periocular corticosteroid injections as recommended by ophthalmologist 1

Grade 4 (Blindness - 20/200 or worse)

• Permanently discontinue immunotherapy
• URGENT ophthalmology referral (preferably uveitis specialist)
• Aggressive systemic corticosteroids plus local therapy 1

Second-Line Treatment Options

If uveitis is refractory to initial corticosteroid therapy or requires corticosteroid-sparing:

Conventional Immunosuppressants

• Methotrexate is the first choice for systemic immunosuppression 1, 2
• Consider if inflammation cannot be controlled within 3 months or reactivates during steroid dose reduction 1

Biologic Agents

• Anti-TNF treatments are recommended for uveitis refractory to methotrexate 1
• Adalimumab has demonstrated efficacy in clinical trials:
  • Significantly reduces risk of treatment failure by 50% compared to placebo 3
  • Extended time to treatment failure to 24 weeks vs 13 weeks with placebo 2
• Infliximab is an alternative anti-TNF option, particularly effective in Behçet's disease-associated uveitis 1
• Etanercept should NOT be used for uveitis (may worsen or trigger uveitis) 1

Other Biologics for Refractory Cases

• Consider tocilizumab, rituximab, or abatacept for cases refractory to anti-TNF therapy 1
• Interferon alfa-2a has shown efficacy in controlling uveitis flares, particularly in Behçet's disease 1

Treatment Duration and Monitoring

• For immunotherapy-induced uveitis, treatment should continue until complete resolution of inflammation 1
• For other forms of non-infectious uveitis, consider maintaining immunosuppression for 2 years after achieving inactive disease off topical steroids 1
• Regular ophthalmologic monitoring is essential to assess treatment response 1

Important Considerations

• Unlike anterior uveitis, posterior uveitis can be asymptomatic but still progress to visual loss, requiring aggressive treatment 1
• Topical NSAIDs have no demonstrable effect as monotherapy but may be used as additional therapy 1, 4
• Poor prognostic factors at presentation warrant earlier systemic immunosuppression 1
• Switching between different anti-TNF treatments may be valuable if uveitis is refractory to the first anti-TNF 1
• In cases of inadequate response to biologics, consider testing for antidrug antibodies and drug trough levels 1

Special Situations

• For immunotherapy-induced uveitis, carefully selected cases may restart immunotherapy cautiously, depending on severity and response to treatment 1
• For uveitis associated with systemic conditions (e.g., ankylosing spondylitis), adalimumab and infliximab are preferred biologic agents 1
• Multidisciplinary coordination with oncology is essential when managing uveitis in patients receiving immunotherapy 1, 5