The treatment of uveitis is dependent upon the cause, location and severity of the disease. The immediate treatment goal is elimination of active inflammation, while the longer-term treatment aim is to prevent the inflammation from returning, and treating any underlying systemic diseases that caused the uveitis to appear.
Uveitis caused by an infection (‘infectious uveitis’) usually improves with treatment of the underlying infection. Antiviral drugs, antibiotics, or antifungal drugs may be used depending on the cause of the infection.
For patients with non-infectious uveitis, corticosteroids are usually the first choice of treatment. Corticosteroids work by inhibiting the part of the immune system that causes inflammation within the body. They are available in several forms including: eye drops, injections (into or around the eye), and oral preparations (tablets/capsules), or as surgical implants. However, corticosteroids have a number of side effects that make them unsuitable for long-term use, particularly in the already vulnerable eye affected by diabetes. For example, use of eye drops and injections can result in raised pressure within the eye and cataract formation if used long-term, these are complications eyes affected by diabetes are already susceptible to. Therefore, alternative treatments are required for the longer-term treatment of uveitis.
In patients who have chronic or sight-threatening uveitis that requires longer-term treatment, immunomodulatory drugs (also known as ‘immunosuppressant’ drugs) provide an alternative to corticosteroids, which are unsuitable for prolonged use due to the side effects. Immunomodulatory drugs work by suppressing the inflammatory response provided by the immune system. They are also used as the first treatment for some types of uveitis in order to help treat the underlying systemic disease. Some of the immunomodulatory drugs that are currently used in the treatment uveitis include:
- Anti-metabolites (methotrexate, azathioprine, mycophenolate)
- Calcineurin inhibitors (ciclosporin, tacrolimus)
- Alkylating agents (cyclophosphamide, chlorambucil)
- Biological response modifiers (adalimumab, infliximab, rituximab)
Of these immunomodulatory agents, only adalimumab is officially licensed for the treatment of uveitis. It is approved in the US and Europe for the treatment of non-infectious intermediate and posterior uveitis and panuveitis. The other immunomodulatory drugs are currently used off-label.
Regarding the use of off-label therapies you should check with you doctor regarding access and insurance company regarding reimbursement. The FDA does not have the legal authority to regulate the practice of the medicine, and the physician may prescribe a drug off-label. Contrary to popular notion, it is legal in the United States and in many other countries to use drugs off-label. However, many insurance companies will not pay for an expensive drug that’s used in a way that’s not listed in the approved drug label.
Cycloplegics agents are drugs that can block the nerve impulses to eye muscles, helping to relieve pain by immobilizing the inflamed iris tissue, and reducing light sensitivity by dilating the pupil. They also help to reduce the amount of inflammation in the eye. Cycloplegics used in the treatment of uveitis include: atropine, cyclopentolate, homatropine, and tropicamide. These agents are applied as eye drops.
A surgical procedure known as a vitrectomy may also be used for the treatment of severe uveitis that does not respond to corticosteroids and/or immunosuppressants. This procedure is performed under a general or local anesthetic and involves the removal of the vitreous humor (jelly-like substance that fills the eye), which is substituted with gas and/or air, or oil. Over time, the eye will then eventually replace the vitreous humor naturally.