THERAPY FOR UVEITIS

OBSERVATION For development of complications For change in the appearance / severity/progression

MEDICAL THERAPY 1 - CYCLOPLEGICS To relieve pain To break posterior synechiae/pupillary block 2 – Topical or systemic nonsteroidal anti- inflammatory drugs (NSAIDS)

3 – CORTICOSTEROIDS Topical drops / ointment Sub – tenon’s or retroseptal injection Oral or intra venous injection Intra vitreal injection of triamcinolone Intravitreal fluocinolone implant (surgically placed)

T-Lymphocyte modulators Biologic response modifiers 4 – I MMUNOMODULATORS Alkylating agents Antimetabolites T-Lymphocyte modulators Biologic response modifiers

Mydriatic and cycloplegic Agents Breaking or preventing the formation of PS and for relieving photophobia secondary to ciliary spasm cyclogyl-tropicamide

NSAIDS Inhibiting cyclooxygenase and reduce the synthesis of prostaglandins that mediate inflammation Complications of prolonged systemic NSAID: gastric ulceration , GI bleeding , nephrotoxicity , Hepatotoxicity.

CORTICOSTEROIDS Treatment of active inflammation in the eye The mainstay of uveitis therapy Treatment of active inflammation in the eye Prevention or treatment of complications such as CME Reduction of inflammatory infiltration of the retina , choroid , optic nerve

TOPICAL For anterior uveitis For vitritis or macular edema in pseudophakic or aphakic Rimexolone , Loteprednol and fluorometholone have been shown to have less of an ocular hypertensive effect than other medication

Periocular When a more posterior effect is needed or when a patient is non compliant or poorly responsive to topical or systemic administration Triamcinolone acetonide (40mg) Methylprednisolone acetate (40-80mg)

Sub – tenon̕̕s (NOZIK technique) Complications : Superotemporal: upper lid ptosis periorbital hemorrhage globe perforation

Transseptal Complications: Periorbital and retrobulbar hemorrhage Lower lid retractor ptosis Orbital fat prolapse Orbital fat atrophy Skin discoloration

Contraindication of periocular injections Infectious uveitis (eg, toxoplasmosis) Necrotizing scleritis High IOP

Systemic Oral or intravenous For vision – threatening chronic uveitis when topical are insufficient The systemic disease also requires therapy Prednisone is the most commonly used Duration of treatment may last for 3 months Longer than 3 months , immunomodulatory therapy is indicated 1-2 mg/kg/day oral prednisone taperd every 1 to 2 weeks

in explosive onset of sever noninfectious posterior uveitis or panuveitis, Iv, high-dose pulse methylprednisolone (1 gm/day infused over 1 hour) therapy for 3 days , followed by a gradual taper of oral prednisolone starting at 1.0-1.5 mg/kg/day Side effects : Psychological disturbances hypertension and elevated glucose levels . This form of therapy should be performed in a hospital

INTRAVITREAL Triamcinolone acetonide (kenalog) 4mg (0.1cc)of triamcinolone improve VA for 6 months or more cystoid ME may relapse after 3 to 6 months multiple inj. increase the risk of cat formation & IOP Endophthalmitis & rhegmatogenous RD Implantation of a sustained – release device

IMMUNOMODULATORY Severe sight-threatening uveitis Resistant to or intolerant of corticosteroids killing the rapidly dividing clones of lymphocytes that are responsible for the inflammation

INDICATIONS Vision – threatening intraocular inflammation Reversibility of the disease process Inadequate response to corticosteroid treatment Failure of therapy Contra indication of corticosteroid treatment because of systemic problems or intolerable side effects Unacceptable corticosteroid side effect Chronic corticosteroid dependence

Adamantiades – Behcet syndrome sympathetic ophthalmia , VKH disease, necrotizing sclerouveitis

Treatment Absence of infection Absence of hepatic and hematologic contraindications Meticulous follow – up by a physician Objective longitudinal evaluation of the disease process Informed consent