What is the recommended management for chronic non‑infectious iriditis in an adult patient, including topical corticosteroids, cycloplegics, intra‑ocular pressure monitoring, and indications for systemic steroids or immunomodulatory therapy?

Management of Chronic Non-Infectious Iriditis

Initiate treatment with topical corticosteroids (prednisolone acetate 1% or dexamethasone) combined with cycloplegic agents, monitor intraocular pressure regularly, and escalate to systemic immunomodulatory therapy when topical steroids fail to control inflammation or when doses exceed 3 drops daily to avoid cataract and glaucoma complications. 1, 2

First-Line Topical Management

Topical corticosteroids are the cornerstone of initial therapy for chronic iriditis:

• Prednisolone acetate 1% or dexamethasone are the treatments of choice for both acute and chronic anterior uveitis 1, 2
• Add cycloplegic agents to all patients to prevent posterior synechiae formation and relieve ciliary spasm 3, 4
• Keep topical corticosteroid doses ≤3 drops daily when possible to minimize cataract risk during extended treatment 1, 2
• Doses ≤2 drops daily show zero incidence of cataract formation per eye-year of follow-up, while doses >3 drops daily significantly increase both cataract and glaucoma risk independent of inflammation severity 1, 5

Mandatory Intraocular Pressure Monitoring

Regular IOP monitoring is critical during chronic topical steroid therapy:

• Using ≥2 drops/day topical prednisolone is a strong risk factor for IOP elevation 5
• High-dose topical steroids (>3 drops daily) significantly increase glaucoma risk 1
• Monitor for steroid-induced glaucoma at every follow-up visit, as this is a common vision-threatening complication 3, 6

Indications for Systemic Immunomodulatory Therapy

Escalate to noncorticosteroid systemic immunomodulatory therapy (NCSIT) based on these specific criteria:

Therapeutic Failure Indicators:

• Active uveitis while taking doses of ≥30 mg or ≥0.5 mg/kg prednisone per day 7, 5
• Relapse of uveitis after reduction of oral corticosteroid dose to <7-10 mg/day prednisone 7, 5
• Failure to control inflammation with topical steroids alone 7
• Steroid dependency (inability to taper without recurrence) 6

Severity Indicators:

• Visual acuity worse than 20/100 7, 5
• Increase in vitreous haze of grade 2+ 7, 5
• Relapse of cystoid macular edema 7, 5
• Bilateral sight-threatening disease 7
• Chronic persistent inflammation requiring prolonged control beyond 3 months 5
• Disease that severely impairs quality of life 7, 5

Poor Prognostic Factors at Presentation:

• Posterior synechiae, band keratopathy, glaucoma, cataract, poor initial vision, hypotony, macular edema, or dense vitreous opacification warrant immediate systemic therapy 1

Steroid Intolerance:

• Contraindications to corticosteroids include history of tuberculosis, hepatitis, noncompliance, or reproductive status concerns 7, 5
• Need for steroid-sparing effect to avoid cumulative toxicity 7

Pre-Treatment Evaluation Before Systemic Therapy

Before initiating NCSIT, mandatory screening includes:

• Baseline vital organ function tests (hepatic, renal, hematologic) 7, 5
• Screening for latent or active tuberculosis 7, 5
• HIV testing 7
• Hepatitis B and C screening 7, 5
• Assessment for history of malignancy, age, and family history of malignancy 7, 5
• Testing for active or latent infectious diseases that may be reactivated by immunosuppression 7

Systemic Treatment Algorithm

Follow this stepwise escalation approach:

Step 1: First-Line NCSIT (Non-Biologic Immunomodulators)

• Methotrexate is the preferred initial disease-modifying agent for moderate to severe disease, achieving remission in approximately 52% of patients 1, 2, 5
• Dose: 0.5-1 mg/kg/week, maximum 30 mg 5
• Alternative first-line options include mycophenolate mofetil and azathioprine 5

Step 2: Second-Line NCSIT (Biologic Therapy)

• For inadequate response to methotrexate, add monoclonal antibody TNF inhibitors (adalimumab or infliximab) 1, 5
• Adalimumab is FDA-approved for non-infectious intermediate, posterior, and panuveitis: 40 mg subcutaneous every other week for adults and children ≥30 kg 5
• Never use etanercept in patients with uveitis history—it is explicitly contraindicated and may worsen disease 1, 2

Step 3: Treatment Adjustment When NCSIT is Inadequate

• First rule out treatment nonadherence, infections, and masquerade syndromes 5
• Consider dose escalation to maximum tolerated therapeutic dose 5
• Finally, transition to alternative or additional agent 5

Special Management for Recurrent Iriditis

Patients with recurrent episodes should receive:

• Prescriptions for topical corticosteroids for prompt at-home initiation when typical symptoms develop 1, 2
• This approach decreases episode severity and duration while reducing likelihood of ocular complications 1, 2
• This strategy should be restricted to patients with recurrent episodes who are knowledgeable about iritis symptoms and must include prompt ophthalmologic examination 1

Critical Pitfalls to Avoid

These errors can lead to permanent vision loss:

• Never use etanercept in patients with uveitis—it is contraindicated and may worsen disease 1, 2
• Never exceed 3 drops daily of topical corticosteroids chronically without compelling indication due to exponential cataract risk 1, 2
• Never use NSAIDs as monotherapy—they are only adjunctive to corticosteroids and should never replace them 1, 2
• Never use systemic corticosteroids as monotherapy for posterior involvement—they must be combined with immunosuppressive agents 5
• Never limit topical prednisolone to >3 months without transitioning to steroid-sparing agents due to significant risk of elevated IOP and cataract formation 5

Long-Term Monitoring Requirements

Regular ophthalmologic monitoring is essential:

• Monitor during treatment and for at least 3 years after remission 5
• Monitor for elevated intraocular pressure and cataract formation with corticosteroid use 5
• Steroid-free remission is the goal of therapy and can be achieved with chemotherapeutic agents 8
• Chronic systemic corticosteroid therapy is not an acceptable long-term treatment plan unless all other medications have failed 8