From the Guidelines
Management of sarcoid uveitis requires a systematic approach beginning with corticosteroids as first-line therapy, with the goal of controlling inflammation, preventing vision loss, and minimizing medication side effects while addressing both ocular and systemic manifestations of sarcoidosis. For anterior uveitis, topical prednisolone acetate 1% is initiated frequently (every 1-2 hours) and tapered based on response, often over 4-6 weeks 1. Periocular corticosteroid injections (triamcinolone acetonide 40mg/mL) may be used for intermediate uveitis. For posterior uveitis or panuveitis, oral prednisone at 1mg/kg/day (maximum 60-80mg daily) is typically started and gradually tapered over 3-6 months. In cases resistant to corticosteroids or requiring steroid-sparing therapy, methotrexate (15-25mg weekly) is commonly used, along with folic acid supplementation, as indicated by the guidance on noncorticosteroid systemic immunomodulatory therapy in noninfectious uveitis 1. Other immunomodulatory options include mycophenolate mofetil (1-3g daily), azathioprine (1-3mg/kg/day), or TNF-α inhibitors like adalimumab (40mg subcutaneously every 2 weeks) for refractory cases, although the use of adalimumab for ocular sarcoidosis is based on limited studies 2.
Some key points to consider in the management of sarcoid uveitis include:
- Indications for introducing noncorticosteroid systemic immunomodulatory therapy (NCSIT) include persistent or severe inflammation, contraindications or intolerance to other therapies, or a need for corticosteroid-sparing effect to maintain disease remission 1.
- Severe inflammation may be indicated by impairment of visual function, bilateral disease, vitreous haze, macular or optic nerve disease, retinal vascular inflammation, macular edema, exudative detachment, or ocular structural complications that threaten visual function 1.
- Regular monitoring for medication side effects is essential, including liver function tests, complete blood counts, and blood pressure checks, as well as regular ophthalmologic examinations to assess disease activity and complications such as cataract, glaucoma, and macular edema.
- The decision to treat sarcoidosis patients depends on two major factors: risk for death or organ failure and impairment of quality of life (QoL), with about 5% of patients with sarcoidosis dying from the disease 2.
Given the limited information available on the treatment of ocular sarcoidosis, the most recent and highest quality study available should be prioritized, which in this case is the guidance on noncorticosteroid systemic immunomodulatory therapy in noninfectious uveitis 1. However, it is also important to consider the general principles of treating sarcoidosis, as outlined in the ERS clinical practice guidelines on treatment of sarcoidosis 2.
From the FDA Drug Label
7 Respiratory Diseases Symptomatic sarcoidosis 6 Ophthalmic Diseases Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: ... Diffuse posterior uveitis and choroiditis ... Iritis and iridocyclitis
Management of Sarcoid Uveitis:
- Prednisolone and Prednisone can be used for the management of sarcoid uveitis, as they are indicated for symptomatic sarcoidosis and severe acute and chronic allergic and inflammatory processes involving the eye, including uveitis and iritis [3] [4].
- These medications can help reduce inflammation and prevent tissue damage in the eye.
- However, the specific dosage and treatment duration should be determined by a healthcare professional, as they may vary depending on the individual case and severity of the condition.
From the Research
Management of Sarcoid Uveitis
- The management of sarcoid uveitis typically involves the use of corticosteroids, with systemic corticosteroids indicated when uveitis does not respond to topical corticosteroids or when there is bilateral posterior involvement, especially macular edema 5, 6, 7.
- In cases where patients are resistant to corticosteroids or require an unacceptable dose to maintain remission, additional immunosuppression may be used, including methotrexate, leflunomide, and mycophenolate mofetil 5, 6, 7.
- Monoclonal antibodies against tumor necrosis factor-α, such as infliximab, have also been used in the treatment of refractory or sight-threatening disease 5, 6, 7.
- Low-dose methotrexate has been shown to be an effective and safe adjunct to treat chronic sarcoid-associated panuveitis, with improvements in visual acuity, reduction in oral and topical corticosteroid requirements, and decreased inflammation 8.
Treatment Outcomes
- Studies have shown that with proper treatment, the visual prognosis of sarcoid uveitis can be improved, with one study finding that 90% of eyes had preserved or improved visual acuity after treatment with low-dose methotrexate 8.
- However, some cases of sarcoid uveitis may demonstrate an unfavorable visual outcome, with one study reporting that 15% of cases had an unfavorable visual outcome despite treatment 9.
Diagnostic Criteria
- The diagnosis of sarcoid uveitis is typically made based on a combination of suggestive ophthalmological findings and laboratory tests, with histologic proof from a biopsy being the gold standard for diagnosis 6, 7.
- An international workshop has established diagnostic criteria for sarcoidosis uveitis when biopsy is unavailable or negative, based on a combination of ophthalmological findings and laboratory tests 6, 7.