In 2000, a panel representing ophthalmological, pediatric and rheumatologic specialties published recommendations for the use of immunosuppressive drugs in patients with ocular inflammatory diseases. The panel noted that in many patients, the severity of the disease, corticosteroid-resistant side effects or the need for high doses of systemic corticosteroids ultimately supported the use of steroid-sparing immunosuppressive drugs in the management of those patients.
Corticosteroids remain a cornerstone in the therapeutic approach to uveitis. The only drugs currently approved by the Food and Drug Administration for use in ocular inflammatory diseases, excluding postoperative inflammation, are corticosteroids and topical cyclosporine. "In patients with uveitis who require long-term corticosteroid therapy, however, it often is prudent to add another immunosuppressive agent to the therapeutic regimen, so lower dosages of corticosteroids can be employed," says Wendy M. Smith, M.D., a uveitis specialist with the Department of Ophthalmology at Mayo Clinic in Rochester, Minn.
Some studies indicate that many physicians are not familiar with or do not adhere to recommended guidelines for management of uveitis. "For example, it is important to taper systemic prednisone to a daily dose of 10 mg or less within three months, because of the potential for side effects," says Dr. Smith. "Treatment should be monitored regularly. Many more drug options are available today, but the choice of therapy should still be guided by clinical indication and individual patient characteristics, just as the panel recommended."
Most immunosuppressive agents are extremely potent and have significant adverse effects, so consideration of three patient-related factors is critical:
- Degree of vision loss or vision-threatening complications
- Ability to adhere to therapy
- Compliance with follow-up visits
"The immunosuppressed state can have potentially devastating ocular effects and long-term systemic adverse effects. It is important to weigh the risks and benefits and discuss them with the patient in detail," says Dr. Smith. "The provider should be certain that immunosuppressive therapy has a realistic chance of improving or preserving the patient's vision."
Appropriate diagnostic testing also should be considered before initiation of immunosuppressive therapy. Noninfectious inflammation in the eye is usually considered an autoimmune disease and requires anti-inflammatory agents to modulate the immune system responses. Infections may simulate autoimmune diseases and if so, immunosuppression may lead to disastrous consequences. Immunosuppressives may mask malignancies, confounding diagnostic tests. An intraocular foreign body may present as chronic or acute intraocular inflammation.
A complete clinical history may help providers avoid unnecessary diagnostic and therapeutic interventions. The age and sex of the patient, presence of diabetes, and the history of previous therapy, whether successful or failed, should be included in the decision-making process. The rationale for therapy in uveitis must be carefully considered before a decision is made. Both the therapy and its goals must be tailored to the patient and the condition.
"Therapy should be directed objectively at reducing inflammatory signs such as scleral injection, cells and flare in the anterior chamber; cells and haze in the vitreous; and lesions in the uvea and retina," says Dr. Smith. "If the desired therapeutic effect is not obtained after several months at recommended dosages, the addition of another agent or alternative treatments should be considered." The working diagnosis should also be re-evaluated prior to initiating additional therapy at every stage of treatment.
"It is vital for ophthalmologists and other providers to be aware of the array of immunosuppressive medications available today, and of the intrinsic risks and benefits of each," says Dr. Smith.
For more information
Smith W. Diagnosis of uveitis: Something old, something new and Uveitis treatment: Going beyond the medrol dose pack. Presentation at the Mayo Clinic Ophthalmology Retina Update & Case Conference; September 2012; Rochester, Minn.
Smith W, et al. Noncorticosteroid immune therapy for ocular inflammation. Duane's Foundations of Clinical Ophthalmology. 2012;2:1.
Jabs D, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: Recommendations of an expert panel. American Journal of Ophthalmology. 2000;130:492.