TARGETED APPROACH

Early diagnosis, referral to a uveitis specialist and therapeutic aggressiveness employing a ‘stepladder’ approach that is both steroid-sparing and individually tailored offers the best approach to successfully treating uveitis, a dedicated symposium on uveitis at the 2014 Irish College of Ophthalmologists Annual Conference heard.

Stephen Foster MD, Harvard Medical School, US, noted that uveitis is the third leading cause of worldwide blindness and currently accounts for 10 per cent of vision loss in the US and 15 per cent worldwide. There is an increased incidence of uveitis worldwide, attributable to the increase in the ageing population. Generally, infectious entities of uveitis carry a poorer overall prognosis than non-infectious posterior uveitides, Prof Foster noted.

To prevent irreversible structural damage and crippling blindness, the guiding principle of management of patients with uveitis is the philosophy of diagnostic and therapeutic vigour: early diagnosis, referral to a uveitis specialist and therapeutic aggressiveness employing a stepladder algorithmic approach which is both steroid-sparing and titrated to the severity of intraocular inflammation, Prof Foster stated.

Acute aggressive medical therapy should include topical, regional and/or systemic corticosteroids, as well as topical cycloplegics and mydriatics when appropriate, he said. While corticosteroids remain a mainstay of treatment and are valuable in the control of inflammation, when used long-term they have a wide array of potential toxicity, Prof Foster acknowledged.

Therapeutic options

It is pivotal to recognise intolerability or early failure of a regimen to control inflammation in order to “move up the ladder” on to other therapeutic options by escalating treatment, Prof Foster stressed. Other options such as NSAIDs and immunomodulatory therapy (IMT), such as conventional, biologics, cytotoxics, should then be initiated depending on the indication. The addition of IMT may benefit patients with sight-threatening uveitis or patients who are resistant to or intolerant of corticosteroids.

However, he stressed a therapeutic response may not occur for several weeks after initiation of IMT and therefore most patients need to be maintained on corticosteroid therapy until the immunomodulatory agent begins to take effect, at which time the corticosteroid dose may be gradually tapered. Because of the potential side effects with IMT, patients on such medications require close monitoring, he added.

Meanwhile, Conor Murphy MD, PhD, ophthalmic surgeon, RVEEH, Dublin, noted that infectious uveitis diagnosis requires a thorough history and targeted investigations based on the clinical findings and history. The approach of delivering carefully timed, targeted therapy in order to achieve steroid-free durable remission, and providing individualised care that enhances patient quality of life should be the key goal of uveitis treatment, Prof Foster added.

Stephen Foster: sfoster@mersi.com

Conor Murphy: conorcmurphy@rcsi.ie