Treatment of Infectious Uveitis
Treatment of infectious uveitis is dependent on the specific microbe.
Treatment of Non-infectious Uveitis
Anti-inflammatories
Periocular, intravitreal, or systemic steroids are the mainstay of the acute treatment of non-infectious posterior uveitis. Topical steroids do not penetrate sufficiently to the posterior segment to control inflammation in posterior uveitis.
In addition to direct injection of corticosteroid formulations like triamcinolone into the periocular or intravitreal space, there are three intravitreal corticosteroid delivery devices currently approved for treatment of non-infectious posterior uveitis: the injectable dexamethasone 0.7 mg implant (Ozurdex), the injectable fluocinolone 0.18 mg implant (Yutiq) and the surgically implanted fluocinolone 0.59 mg implant (Retisert).
Side effects
Potential side effects of corticosteroids include increased intraocular pressure and cataracts (local delivery) and weight gain, diabetes and osteopenia (systemic delivery), which make them less desirable for long-term treatment of chronic forms of uveitis.
Treatment of Chronic, Non-infectious Uveitis
Systemic Therapy
For chronic disease, steroid-sparing systemic therapies are necessary. While the two fluocinolone implants can provide control for up to three years, there is evidence from the Multicenter Uveitis Steroid Treatment (MUST) Trial that outcomes with the surgically implanted fluocinolone implant may be slightly worse than with systemic immunomodulatory therapy at seven years (Kempen et al. JAMA 2017).
Conventional immunomodulatory medications, such as methotrexate and mycophenolate, are the most commonly used agents, but biologic agents are being increasingly used. Adalimumab, a self-injectable biologic that blocks tumor necrosis factor alpha (TNF-alpha), is approved for the treatment of non-infectious posterior uveitis. Because these agents are associated with potential side effects, including susceptibility to infections and hepatic toxicity, these agents require co-management with a uveitis specialist or rheumatologist trained in
the use of these medications.
At Mass Eye and Ear, our uveitis specialists manage these medications and direct an infusion center dedicated to ocular inflammation to deliver intravenous biologics for the most severe uveitis patients.
Safety of Immunomodulatory Agents
Immunomodulatory agents are safe and associated with excellent outcomes. The Systemic Immunosuppressive Therapy for Eye Diseases (SITE) study, led by Dr. John Kempen, Director of Epidemiology at Mass Eye and Ear, found that patients treated with conventional immunomodulatory therapies have no increased risk of overall mortality or cancer-related mortality (Kempen et al. BMJ 2009). The
MUST trial has shown that patients treated \with systemic immunomodulatory therapies are able to maintain visual acuity improvement over seven years (Kempen et al. JAMA 2017).
Future Therapies
Still, not all patients respond to or tolerate available agents, and there is a need for additional therapies. Multiple medications are currently in clinical trials for the treatment of non-infectious uveitis. Researchers are exploring new mechanisms, including intravenous
interleukin 6 (IL-6) inhibitor therapy (sarilumab), oral Janus kinase (JAK) inhibitors (filgotinib), and intravitreal sirolimus (an mTOR inhibitor).