Medical Management of Uveitis

Treatment of uveitis is primarily based on the use of pharmacological agents. The inflammatory process is destructive to ocular structures and can lead to irreversible vision loss. The main objective of treatment is to suppress the intraocular inflammation, preserve visual function and prevent relapses, and anti-inflammatory agents are used in most cases of infectious and non-infectious uveitis. Some diseases are self-limiting and may resolve on their own, with a favorable visual prognosis (e.g., acute posterior multifocal placoid pigment epitheliopathy and multiple evanescent white dot syndrome); the majority of these diseases do not need treatment. 1 Acute monophasic and recurring acute uveitis (such as spondylitis/HLA-B27-associated uveitis) usually only require treatment during active episodes. On the other hand, many chronic, non-infectious uveitides require long-standing therapy to control the inflammation.1,2 In cases of infectious uveitis, treatment must address the pathogen and antimicrobial drugs used accordingly. Drugs can be delivered locally or systemically, and consideration must be taken to pharmacokinetics and penetration of the drugs across the ocular barriers and into the eye.1 In-vitro efficacy is not a clear enough indication of a drug’s pharmacological effect on the human eye.3 Topical corticosteroids have variable penetration across the cornea, methylated corticosteroids cross the cornea easily, while fluorinated molecules have very poor penetration. Topical fluocinolone is considered a weak corticosteroid, used mainly for surface disease with little intraocular effect.4 However, intravitreal fluocinolone implants are highly effective in controlling intraocular inflammation but the high rate of complications must be considered, including raised intraocular pressure (IOP) and cataract. 5,6 Similarly, oral acyclovir is used for controlling corneal or anterior segment infection, but blood concentrations are not high enough for adequate blood-retinal barrier penetration and treating posterior disease. In cases of acute retinal necrosis, use of high-dose intravenous acyclovir or oral valacyclovir is indicated.