Treatment

Uveitis due to infection should be treated with the appropriate antimicrobial agent combined with judicious use of corticosteroids to modulate the inflammation. Antimicrobials are specific to the infecting agent, and are discussed in the relevant chapters in this book. Uveitis secondary to lymphoma should be referred to a hematologist-oncologist for treatment. (See Chapter 17 for further discussion of lymphoma.) Uveitis and other ocular inflammatory manifestations of systemic vasculitis should be treated according to the underlying illness.

The therapeutic aims for the patient with uveitis are to control symptoms, decrease inflammation, prevent visual loss, minimize long-term complications of the disease, and keep therapeutic side effects and complications to a minimum. Corticosteroids are the mainstay of treatment for uveitis. Anterior uveitis usually responds to topical corticosteroid therapy such as prednisolone acetate, and mydriatics to ensure the pupil is dilated and moving to limit synechiae formation. With acute attacks, hourly instillation of topical corticosteroids while awake, followed by a taper, may be necessary to achieve prompt control of symptoms. While topical therapy may have limited efficacy in intermediate uveitis, it does not penetrate to the posterior pole of the eye. Posterior uveitis and the common complication of cystoid macular edema (CME) may be treated with triamcinolone (or its equivalent) by injection via the posterior subtenons or the orbital floor. These injections are contraindicated in patients with glaucoma or a history of corticosteroid-induced intraocular pressure elevation. If corticosteroid injections are unsuccessful or

TABLE 1 Differential Diagnostic Considerations Based on Site of Ocular Inflammation

Location

Type

Differential diagnostic considerations

Anterior

Spondyloarthropathy (often recurrent) HLA-B27-associated (often recurrent)

Chronic

Juvenile rheumatoid arthritis Sarcoidosis

Fuch's heterochromic cyclitis Herpetic keratouveitis Chronic idiopathic Masquerade syndromes3

Intermediate

Chronic

Multiple sclerosis Sarcoidosis Syphilis Lyme disease Lymphoma

Pars planitis (idiopathic)

Posterior

Acute

Acute retinal necrosis (herpes-related) Toxoplasmosis (often recurrent) Cytomegalovirus (associated with HIV) Serpiginous choroiditis (often recurrent) Fungal endophthalmitis

Behget's disease

Vogt-Koyanagi-Harada syndrome

Syphilis

Lyme disease

Tuberculosis

Toxocara canis

Birdshot choroidopathy

Multifocal choroiditis with panuveitis

Sympathetic ophthalmia

Lymphoma

aMasquerade syndromes include lymphoma and low-grade infections, which are difficult to diagnose.

aMasquerade syndromes include lymphoma and low-grade infections, which are difficult to diagnose.

require a frequency greater than two to four per year, systemic corticosteroid therapy should be considered, particularly if the patient's visual acuity is decreased and CME is present. Treatment usually begins at 1 mg/kg/day of prednisone or equivalent for two weeks, with subsequent taper of the daily dose by 10 mg a week to the lowest dose possible, to minimize corticosteroid side effects (1).

If systemic corticosteroids are ineffective or unable to be tapered to 10 mg/day or less, then consideration should be given to initiation of other systemic immunosuppressive therapy (Table 2) (1,14,16). Surgery may be indicated for certain complications of uveitis such as glaucoma or cataracts. Vitrectomy may be needed to improve vision. Surgery should be performed when the eye is quiet and with a boost in the dose of corticosteroids, as surgery tends to increase uveitic inflammation (1,16).

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