TREATMENTS

Uveitis treatments range from minimally invasive eye drops to surgical implants depending on the type and severity of the diagnosis.

In general, treatment for uveitis consists of suppressing the immune system to attempt to stave off the inflammation that occurs when the body detects something is out of order.

If the patient’s uveitis is associated with another disease or disorder, treatment will likely be systemic (affecting the whole body), where as if the cause of the uveitis is unknown, localized treatments (affected eye(s) only), such as drops or intraocular injections may be an option.

This article is a recent summary of progressive treatment options from Review of Ophthalmology: Treating Uveitis 2021: The State of the Art

The following are links to descriptions of treatments, citing the actual manufacturer when possible. This list is not all inclusive by any means; it’s an attempt to catalog options that a patient can discuss with a doctor or help folks understand better what the patient is taking. Sometimes there are options and sometimes options are limited, but there are always pros and cons and always side effects. Read about complications and associated procedures here.

The patient can work with doctors to adjust diet and lifestyle to help counteract side effects if possible. It’s critical to note interactions with other medications taken and food and drugs consumed.

If breastfeeding is a concern, the U.S. National Library of Medicine has a database called “LactMed”: “The LactMed® database contains information on drugs and other chemicals to which breastfeeding mothers may be exposed. It includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate. All data are derived from the scientific literature and fully referenced. A peer review panel reviews the data to assure scientific validity and currency. LactMed is updated monthly.” There is also a LactMed app for mobile devices.

Eye Drops

Steroid

These may be prescribed to treat inflammation.

Dilating

These may be prescribed for fixed pupils, which can be associated with anterior uveitis.

Immunosuppressants

Immunosuppressants are prescribed to stop or slow the body from reacting and attacking the eye. However, when taken systemically (oral or injection), the medication does not differentiate between cells. The patient’s entire immune system is suppressed. Patients should discuss sleep habits, nutrition and vaccinations when taking immunosuppressants. A slow taper off of immunosuppressants is critical.

Corticosteroids

Corticosteroids are a class of drug that lowers inflammation in the body by reducing immune system activity or response. Keep in mind not all steroids have the same potency or half life (the amount of time it takes a substance to decrease to half its concentration in the body). A Steroid Conversion Calculator, like this one from mdcalc, is helpful.

Prednisone: Prednisone is often one of the first medications prescribed for uveitis, among a myriad of other conditions. It’s so commonly prescribed that side effects may be downplayed or not discussed. Patients should discuss sugar and food intake (particularly if one has diabetic tendencies), calcium and potassium levels when taking prednisone.

Hydrocortisone: Hydrocortisone is a natural substance (corticosteroid hormone) made by the adrenal gland. Hydrocortisone is may be more easily absorbed since it more closely mimics the body’s natural hydrocortisone and can be useful when treating also used to treat patients with low hydrocortisone levels caused by diseases of the adrenal gland (such as Addison’s disease, adrenocortical insufficiency).

Antimetabolites

An antimetabolite is a substance that interferes with the normal metabolic processes within cells and prevents them from surviving and/or multiplying by targeting specific enzymes.

Methotrexate: Methotrexate works by  interfering with the cell’s ability to absorb and use folate (B vitamin that’s necessary for cell survival). Methotrexate partially inhibits dihydrofolate reductase (an enzyme which plays a critical role in DNA processes) within the cells. Methotrexate is taken as tablets or by injection. It can take about three months before the treatment has an effect on uveitic activity. Patients should discuss folic acid supplementation and anti-nausea medication.

Azathioprine (Imuran) and Mycophenolate Mofetil (Cellcept) are antirejection medicines used to slow down the immune system so the body doesn’t reject transplants. In the case of uveitis, the medication is used to slow the immune system to it doesn’t attack itself.

Azathioprine suppresses blood cells that cause inflammation

Mychophenolate targets an enzyme in the body called inosine monophosphate dehydrogenase that is important for the formation of DNA in cells, which allows cells to multiply.

Mycophenolate Patient Guide

T-Cell Inhibitors / Calcineruin Inhibitors

Calcineurin inhibitors are medicines which inhibit the action of calcineurin. Calcineurin is an enzyme that activates T-cells, which are a type of white blood cell that play a key role in immunity.

Cyclosporine is an antirejection medication that is often used in conjunction with Methotraxate. Patients should discuss limiting grapefruit, grapefruit juice and foods with high potassium. Hair growth is a common side effect. Restasis is cyclosporine drops that reduce dry eye caused by inflammation.

Tacrolimus (Prograf) is a antirejection medication that can be tolerated more easily by some patients.

Biologic Agents

In some patients, the body produces too much Tumor Necrosis Factor (TNF) Alpha Protein, which contributes to inflammation. TNF Inhibitors target and block excess TNF Alpha Proteins from causing inflammation.

Adalimumab (Humira) is an injectable TNF inhibitor. In 2016, the FDA approved Humira for non-infectious uveitis. Humira is injected by the patient or a caregiver every two weeks.

Infliximab (Remicade) is an intravenous infusion given every six to eight weeks. The infusion takes about two hours and blood tests are done before the infusion begins. The infusion will not be done if the patient has an infection.

Periocular & Intravitreal Injections

In order to deliver a localized dosage of medication, corticosteroids, such as orbital floor methylprednisolone or triamcinolone acetonide injectable suspension (Trivaris) , can be injected either around the area of the eyeball (periocular) or into the vitreous humor (intravitreal). These injections have to be done fairly frequently and can take time to take effect. As alluded to in the paper from 2008 linked below, this method of treatment was more common practice before longer acting intravitreal implants were developed and approved.

When to Use Periocular and Intraocular Corticosteroid Injections in Uveitis

Intravitreal Implants

An intravitreal implant is a tiny implant that is injected into the vitreous humor of the eye during an in-office procedure. The patient is awake for the procedure. The eye is cleansed and disinfected, then numbed with gel and/or an injection. The eye is held open with a guard. The patient will feel a decent amount of pressure as the implant is injected. Typically there is a conjunctival blood spot and bleeding in the eye where the injection(s) occurred that takes a few weeks to dissipate.

Intravitreal implants are localized and are a method of getting patients with chronic idiopathic non-infectious posterior uveitis off high doses of systemic medications. The implants release a sustained dosage of the medication over time and eventually dissolve. Side effects should not be taken likely and can (and probably will) include: cataracts and increased eye pressure.

Intravitreal implants are expensive. There is a “Patience Assistance” program associated with each of the following implants; make sure to check out the applicable program, even the patient has insurance.

Ozurdex is an implant that is designed to release 0.7 mg ofthe corticosteriod dexamethasone over a period of up to six (6) months.

Yutiq is an implant that is designed to release .18 mg of fluocinolone acetonide over a period of up to 36 months.

Retisert (FDA approved in 2005) is an implant that is designed to release 0.59 mg of fluocinolone acetonide over a period of up to two and half (2.5) – three (3) years. Retisert contains a higher dosage of medication than the other implants and is larger (about the size of a grain of rice). It is surgically implanted into the posterior segment of the affected eye during a procedure which may or may not include a vitrectomy.

Read about new research in treatments here.