- James T Rosenbaum, MD
James T Rosenbaum, MD
- Professor of Ophthalmology, Medicine, and Cell Biology
- Oregon Health & Science University
- Chief of Ophthalmology
- Devers Eye Institute, Portland, Oregon
Intraocular inflammation (ie, uveitis) results from many causes. The approach to therapy depends upon the etiology, location, and severity of the inflammation . The management of a patient with uveitis will require consultation with an ophthalmologist or other specialist in uveal eye disease. Ideally, therapy should be initiated within 24 hours of the onset of acute, anterior uveitis, and infectious causes of uveitis should be treated promptly.
This topic will focus primarily on the treatment of uveitis that is not related to an active infection. A general approach to evaluation and treatment of the patient presenting with a painful red eye is discussed separately. Treatment of uveitis that is due to infection is discussed in more detail in topic reviews that address management of the specific infection. The etiology, clinical manifestations, and diagnostic approach to a patient with uveitis are presented separately. (See "Evaluation of the red eye" and "Uveitis: Etiology, clinical manifestations, and diagnosis".)
The uvea is the middle portion of the eye. The anterior portion of the uvea includes the iris and ciliary body. The pars plana is the tissue just posterior to the ciliary body and just anterior to the retina. The posterior portion of the uvea is known as the choroid (figure 1).
●Inflammation of the anterior uveal tract is called anterior uveitis and is synonymous with iritis. When the adjacent ciliary body is also inflamed, the process is known as iridocyclitis.
●Terms used to describe uveitis posterior to the lens include vitritis, intermediate uveitis, pars planitis, choroiditis, retinitis, chorioretinitis, or retinochoroiditis. Panuveitis refers to inflammation in the anterior chamber, vitreous humor, and choroid or retina simultaneously. The presence of inflammatory cells in the vitreous humor posterior to the lens is termed intermediate uveitis, even though the vitreous humor is not technically part of the uveal tract.
- Smith JR, Rosenbaum JT. Management of uveitis: a rheumatologic perspective. Arthritis Rheum 2002; 46:309.
- Chee SP, Jap A. Cytomegalovirus anterior uveitis: outcome of treatment. Br J Ophthalmol 2010; 94:1648.
- Quentin CD, Reiber H. Fuchs heterochromic cyclitis: rubella virus antibodies and genome in aqueous humor. Am J Ophthalmol 2004; 138:46.
- Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol 2000; 130:492.
- Levy-Clarke G, Jabs DA, Read RW, et al. Expert panel recommendations for the use of anti-tumor necrosis factor biologic agents in patients with ocular inflammatory disorders. Ophthalmology 2014; 121:785.
- Sheppard JD, Toyos MM, Kempen JH, et al. Difluprednate 0.05% versus prednisolone acetate 1% for endogenous anterior uveitis: a phase III, multicenter, randomized study. Invest Ophthalmol Vis Sci 2014; 55:2993.
- Sfikakis PP, Theodossiadis PG, Katsiari CG, et al. Effect of infliximab on sight-threatening panuveitis in Behçet's disease. Lancet 2001; 358:295.
- Ohno S, Nakamura S, Hori S, et al. Efficacy, safety, and pharmacokinetics of multiple administration of infliximab in Behçet's disease with refractory uveoretinitis. J Rheumatol 2004; 31:1362.
- Tugal-Tutkun I, Mudun A, Urgancioglu M, et al. Efficacy of infliximab in the treatment of uveitis that is resistant to treatment with the combination of azathioprine, cyclosporine, and corticosteroids in Behçet's disease: an open-label trial. Arthritis Rheum 2005; 52:2478.
- Tabbara KF, Al-Hemidan AI. Infliximab effects compared to conventional therapy in the management of retinal vasculitis in Behçet disease. Am J Ophthalmol 2008; 146:845.
- Mackensen F, Jakob E, Springer C, et al. Interferon versus methotrexate in intermediate uveitis with macular edema: results of a randomized controlled clinical trial. Am J Ophthalmol 2013; 156:478.
- Joshi L, Talat L, Yaganti S, et al. Outcomes of changing immunosuppressive therapy after treatment failure in patients with noninfectious uveitis. Ophthalmology 2014; 121:1119.
- Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005; 140:509.
- Pasadhika S, Kempen JH, Newcomb CW, et al. Azathioprine for ocular inflammatory diseases. Am J Ophthalmol 2009; 148:500.
- Daniel E, Thorne JE, Newcomb CW, et al. Mycophenolate mofetil for ocular inflammation. Am J Ophthalmol 2010; 149:423.
- Ali A, Rosenbaum JT. Use of methotrexate in patients with uveitis. Clin Exp Rheumatol 2010; 28:S145.
- Jaffe GJ, Dick AD, Brézin AP, et al. Adalimumab in Patients with Active Noninfectious Uveitis. N Engl J Med 2016; 375:932.
- Nguyen QD, Merrill PT, Jaffe GJ, et al. Adalimumab for prevention of uveitic flare in patients with inactive non-infectious uveitis controlled by corticosteroids (VISUAL II): a multicentre, double-masked, randomised, placebo-controlled phase 3 trial. Lancet 2016; 388:1183.
- HIGHLIGHTS OF PRESCRIBING INFORMATION. HUMIRA (adalimumab) injection, for subcutaneous use. http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125057s397lbl.pdf (Accessed on July 25, 2016).
- European Medicines Agency. Humira. http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/000481/smops/Positive/human_smop_000983.jsp&mid=WC0b01ac058001d127 (Accessed on July 25, 2016).
- Ramanan AV, Dick AD, Jones AP, et al. Adalimumab plus Methotrexate for Uveitis in Juvenile Idiopathic Arthritis. N Engl J Med 2017; 376:1637.
- Joseph A, Raj D, Dua HS, et al. Infliximab in the treatment of refractory posterior uveitis. Ophthalmology 2003; 110:1449.
- Lindstedt EW, Baarsma GS, Kuijpers RW, van Hagen PM. Anti-TNF-alpha therapy for sight threatening uveitis. Br J Ophthalmol 2005; 89:533.
- Bodaghi B, Bui Quoc E, Wechsler B, et al. Therapeutic use of infliximab in sight threatening uveitis: retrospective analysis of efficacy, safety, and limiting factors. Ann Rheum Dis 2005; 64:962.
- Foeldvari I, Nielsen S, Kümmerle-Deschner J, et al. Tumor necrosis factor-alpha blocker in treatment of juvenile idiopathic arthritis-associated uveitis refractory to second-line agents: results of a multinational survey. J Rheumatol 2007; 34:1146.
- Galor A, Perez VL, Hammel JP, Lowder CY. Differential effectiveness of etanercept and infliximab in the treatment of ocular inflammation. Ophthalmology 2006; 113:2317.
- Suhler EB, Smith JR, Wertheim MS, et al. A prospective trial of infliximab therapy for refractory uveitis: preliminary safety and efficacy outcomes. Arch Ophthalmol 2005; 123:903.
- Braun J, Baraliakos X, Listing J, Sieper J. Decreased incidence of anterior uveitis in patients with ankylosing spondylitis treated with the anti-tumor necrosis factor agents infliximab and etanercept. Arthritis Rheum 2005; 52:2447.
- van Denderen JC, Visman IM, Nurmohamed MT, et al. Adalimumab significantly reduces the recurrence rate of anterior uveitis in patients with ankylosing spondylitis. J Rheumatol 2014; 41:1843.
- Fluocinolone acetonide ophthalmic--Bausch & Lomb: fluocinolone acetonide Envision TD implant. Drugs R D 2005; 6:116.
- Dick AD, Tugal-Tutkun I, Foster S, et al. Secukinumab in the treatment of noninfectious uveitis: results of three randomized, controlled clinical trials. Ophthalmology 2013; 120:777.
- Bodaghi B, Ali Y, Yang Y, et al. Changes in vitreous haze over time with intravitreal sirolimus in non-infectious posterior uveitis: results of SAKURA Study I. Acta Ophthalmol 2014; 92:s253.
- Deuter CM, Kötter I, Günaydin I, et al. Efficacy and tolerability of interferon alpha treatment in patients with chronic cystoid macular oedema due to non-infectious uveitis. Br J Ophthalmol 2009; 93:906.
- Muñoz-Fernández S, Hidalgo V, Fernández-Melón J, et al. Sulfasalazine reduces the number of flares of acute anterior uveitis over a one-year period. J Rheumatol 2003; 30:1277.
- Benitez-Del-Castillo JM, Garcia-Sanchez J, Iradier T, Bañares A. Sulfasalazine in the prevention of anterior uveitis associated with ankylosing spondylitis. Eye (Lond) 2000; 14 ( Pt 3A):340.
- Artornsombudh P, Pistilli M, Foster CS, et al. Factors predictive of remission of new-onset anterior uveitis. Ophthalmology 2014; 121:778.
- UVEITIS DUE TO INFECTION
- NONINFECTIOUS UVEITIS
- Initial treatment
- Disease resistant to initial treatment
- - Oral glucocorticoids
- - Antimetabolites or cytotoxic agents
- - Anti-tumor necrosis factor-alpha
- - Intraocular glucocorticoid releasing implant
- Investigational approaches
- Prevention of recurrent episodes
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS