What is the initial management of unilateral uveitis in a 60-year-old male without known comorbidities?

Initial Management of Unilateral Uveitis in a 60-Year-Old Male

Start prednisolone acetate 1% eye drops immediately, 1-2 drops into the affected eye 2-4 times daily, while simultaneously pursuing urgent diagnostic workup to rule out infectious causes and systemic disease. 1, 2

Immediate First Steps

Topical Corticosteroid Therapy

• Initiate prednisolone acetate 1% (preferred over other formulations for superior corneal penetration) at 1-2 drops 2-4 times daily. 3, 1
• During the initial 24-48 hours, dosing frequency may be increased if necessary based on severity of inflammation. 1
• Re-evaluate the patient within 48 hours; if signs and symptoms fail to improve after 2 days, reconsider the diagnosis and escalate workup. 1

Critical Diagnostic Considerations at Presentation

In a 60-year-old male with unilateral uveitis, you must immediately rule out masquerade syndromes (particularly intraocular lymphoma) and infectious causes before assuming noninfectious etiology. 3, 2

Essential Initial Workup

• Syphilis serology is mandatory in all cases of uveitis regardless of presentation. 4
• HLA-B27 testing if the presentation is acute, unilateral, non-granulomatous anterior uveitis. 4, 5
• For intermediate or posterior involvement in patients over 40 years: obtain brain MRI and consider anterior chamber tap with IL-10 analysis to exclude intraocular lymphoma. 4
• Chest CT and interferon-gamma release assay (IGRA) for tuberculosis screening, particularly if chronic presentation. 4
• Serum angiotensin-converting enzyme (ACE) level for sarcoidosis consideration in chronic cases. 4

Age-Specific Red Flags in This Population

• Giant cell arteritis (GCA) must be considered in any patient over 60 with unilateral posterior uveitis, even without classic temporal artery symptoms. 6
• If GCA is suspected based on systemic symptoms (headache, jaw claudication, scalp tenderness, elevated inflammatory markers), start high-dose systemic corticosteroids immediately and obtain temporal artery biopsy and/or 18FDG-PET scan. 6

Anatomic Classification Guides Further Management

Anterior Uveitis Only

• Topical prednisolone acetate 1% is sufficient as initial therapy for isolated anterior uveitis. 3, 2
• Systemic immunosuppression is generally not required unless poor prognostic factors present (though these typically apply to younger patients with JIA). 3
• Monitor closely; if requiring >1-2 drops daily of prednisolone acetate 1% beyond 3 months to maintain control, consider systemic therapy. 3

Intermediate, Posterior, or Panuveitis

These presentations are at high risk for sight-threatening complications and require more aggressive management beyond topical therapy alone. 2

• Moderate to severe intermediate uveitis, any posterior uveitis, or panuveitis requires systemic corticosteroids and/or immunosuppressive agents, not topical therapy alone. 2
• First-line systemic immunosuppression options include: 3, 7
  • Methotrexate (achieves remission in 52.1% of posterior uveitis cases) 2
  • Mycophenolate mofetil (controls inflammation in 70.9% of cases) 2
  • Azathioprine (level IB evidence) 3, 7
  • Cyclosporine-A (level IB evidence) 3, 7

When to Escalate Beyond Initial Therapy

Indications for Systemic Immunosuppression

Consider immediate systemic therapy (not just topical) if any of the following are present at diagnosis: 7

• Bilateral disease
• Vitreous haze
• Macular edema or optic nerve involvement
• Retinal vascular inflammation
• Exudative retinal detachment
• Impairment of visual function

Treatment Failure Criteria

If inflammation persists or worsens after 3 months of appropriate first-line therapy, escalate to biologic agents. 8, 7

• Monoclonal anti-TNF antibodies (adalimumab or infliximab) are second-line agents for refractory noninfectious uveitis. 8, 7, 2
• Adalimumab extended time to treatment failure from 13 to 24 weeks and reduced treatment failure rates from 78.5% to 54.5% compared to placebo. 2
• Avoid etanercept—it lacks efficacy for uveitis and may paradoxically worsen inflammation. 3, 8

Critical Pitfalls to Avoid

Do Not Miss Infectious Causes

• Never start systemic immunosuppression without first ruling out infectious etiologies (syphilis, tuberculosis, herpes, toxoplasmosis, HIV). 2, 4
• Investigations ordered without clinical orientation are almost always unhelpful and waste resources. 4

Do Not Use Systemic Corticosteroids as Monotherapy

• For posterior segment involvement, systemic glucocorticoids should only be used in combination with immunosuppressive agents (azathioprine or other systemic immunosuppressives), never alone. 3, 7
• This minimizes corticosteroid-related adverse effects while maintaining disease control. 3

Recognize Masquerade Syndromes

• In patients over 40 with intermediate or posterior uveitis not responding to corticosteroids within 2 days, strongly consider diagnostic vitrectomy or anterior chamber tap to exclude lymphoma. 3, 4
• Malignancy masquerade incidence may be as high as 2.5% in tertiary referral clinics. 3

Monitoring Requirements

• Ophthalmologic examination every 3 months minimum while on stable systemic therapy. 8
• Within 1 month follow-up after any medication change or dose adjustment. 8
• Re-evaluate within 48 hours of initiating topical therapy; lack of improvement warrants diagnostic reconsideration. 1