How is Uveitis treated?

The key to treating uveitis is to identify the underlying cause. However, the specific cause may not always be found. Therefore, it is helpful to place a given case of uveitis into various classifications in order to treat most effectively. In some cases there is an infection that requires treatment with antibiotics. In other cases there is an underlying inflammation in the body outside the eye that is not associated with infection. In such cases the treatment of the systemic condition is required to settle the eye. Finally, there are inflammatory conditions not associated with infection that only affect the eyes. In these cases treatment may be directed to the eye alone. Such treatment often starts with eye drops.

What infections cause uveitis?

A large variety of organisms may infect the eye: bacteria, viruses, fungi, worms, insect larvae, protozoa, and other parasites. Some infect the eye alone. Others infectious agents affect other parts of the body as well. Infectious agents may enter the eye from a cut or opening into the eye from an eye injury. This is called endophthalmitis. Urgent antibiotic treatment is required as the risk of permanent loss of vision is high.

In other types of infection, the organism enters the eye through the blood stream. An infectious agent may enter the body through a cut in the skin, through the gastro-intestinal tract, the uro-genital tract or through the lungs. Once it is in the body the organism may enter the blood vessels and travel to the eye. For example, toxoplasmosis is a parasite found in contaminated food that enters the gastro-intestinal tract. It then spreads to the eye through the blood stream and infects the retina.

Because a large variety of infectious agents may enter the eye, the patient must inform the doctor of possible exposure to infection and carefully complete a uveitis questionnaire. Sometimes, a medical specialist in infectious disease is consulted.

What systemic inflammatory conditions can affect the eye?

Many autoimmune conditions cause inflammation without infection. The immune system abnormally identifies the body as being “foreign.” The resultant inflammation may affect various organs of the body. For example, rheumatoid arthritis in an autoimmune condition that affect the joints and sometimes causes inflammation of the sclera (the white outer coat of the eye).

In order to identify an autoimmune disease, the doctor will ask many questions about inflammation outside the eye (uveitis questionnaire) and order appropriate tests.

What are inflammatory conditions that affect the eye alone?

Sometimes, the immune system attacks the eye without affecting other organs in the body. The underlying trigger or cause of inflammation cannot usually be found. These conditions are placed into categories that help plan treatment strategies. For example, anterior uveitis (inflammation of the front of the eye) is initially treated with anti-inflammatory eye drops. On the other hand, Birdshot Chorioretinitis (BSCR) is an inflammation of the back part of the eye that usually requires long-term systemic treatment (pills or injections in the skin). There are many different ocular inflammatory conditions, which are identified by tests ordered by the doctor.

What medications are used for uveitis?

The type of treatment depends on the cause and category of inflammation. Antibiotics are used if an infection is suspected. The doctor prescribes antibiotics by pill or IV (intravenous) if the infection affects organs outside the eye. The doctor prescribes eye drops, pills, and/or injections if the infection affects only the eye.

The eye doctor may consult a rheumatologist to help monitor treatment with a systemic anti-inflammatory medication (pills and/or injections) if an inflammation affects organs outside the eye. Sometimes, an inflammation only affecting the eye requires the use of systemic medication, too. The ophthalmologist may also use eye drops and painless eye injections to control the inflammation.

Anti-inflammatory eye drops include steroid eye drops and non-steroid eye drops. They may be used separately or together depending on the type of inflammation. Steroid eye drops may cause the intra-ocular pressure to rise and must be monitored. Non-steroid eye drops may irritate the cornea (the front window of the eye). Dilating drops are often used to minimize pain from inflammation and help prevent harmful scar tissue from damaging the iris (the brown or blue part on the front of the eye).

Steroid injections may be given next to the eye (subtenon’s injection) or into the eye (intravitreal injection). Anesthetics help prevent pain with injection. Steroid implant injections (Ozurdex and Iluvien) offer longer duration of effect. Steroid injections may be especially useful in the treatment of macular edema (swelling of the retina) in patients with uveitis.

Steroid pills are often used at the beginning of treatment to control severe inflammation. Prednisone is the most common medication used to treat uveitis. It is usually used at high starting doses and then is slowly tapered down to an acceptable dose for long-term use or is completely discontinued. Prednisone has unacceptable side effects if used in high doses for many months to years.

Non-steroidal anti-inflammatory drugs (NSAIDS) given as pills may provide steroid-free treatment for some cases of uveitis. Some are available over-the-counter. Others are available by prescription. They may adversely affect the stomach and kidney.

Immune system suppressants help to quell uveits. Methotrexate, azathioprine, mycophenolate mofetil, cyclosporin are often used safely and effectively. Routine blood tests help detect side effect before permanent damage occurs. Although there was concern of an increased risk of skin cancer and lymphoma due to immune suppression, the SITE extension study showed that cancer risk is not increased. Very strong medications are used in very severe inflammation that threatens life or blindness (cyclophosphamide and chlorambucil). Pregnancy is avoided while on immune suppressants.

Biologic medications are new and very effective in the treatment of uveitis. Humira is given at home as an injection under the skin every two weeks. Long-term effects are being studied.

By Scott E. Pautler, MD

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