Uveitis, treatment

Nodular episcleritis is similar to diffuse but may have a more insidious onset and longer duration. In severe cases of episcleritis, one may observe rare anterior chamber cells that resolve with the episcleritis and do not represent a true uveitis. In the case of concurrent uveitis and episcleritis, the uveitis treatment may also control the episcleritis, and a systemic evaluation may be indicated to explore the possibility of an underlying etiology. 

Uveitis treatments can be delivered topically, periocularly, intraocularly or systemically, and there are problems common to all delivery techniques and specific to each delivery method. Compliance with any form of regular medication can be a problem particularly if its administration is associated with discomfort or if its side effects are unpleasant. Some medications, particularly hydrophobic compounds, may cross the blood-retinal barrier poorly, which is an important consideration for all delivery systems except intraocular injections. Topical medications, which have the least side effects, do not penetrate into the posterior segment and are unsuitable for posterior uveitis, which is often sight-threatening. 

Viral retinitis may be caused by herpes simplex virus, cytomegalovirus (CMV), adenovirus, and varicella zoster virus. With the highly active antiretroviral therapy (see Chapter 50), CMV retinitis does not appear to progress when specific anti-CMV therapy is discontinued, but some patients develop an immune recovery uveitis. Treatment usually involves long-term parenteral administration of antiviral drugs. Intravitreal administration of ganciclovir has been found to be an effective... 

Toxoplasmosis may present as a posterior e.g., focal retinochoroiditis, papillitis, vitritis, or retinitis) or occasionally as an anterior uveitis. Treatment is indicated when inflammatory lesions encroach upon the macula and threaten central visual acuity. Several regimens have been recommended with concurrent use of systemic steroids (1) pyrimethamine, sulfadiazine, and folinic acid (leucovorin) (2) pyrimethamine, sulfadiazine, clindamycin, and folinic acid (3) sulfadiazine and... 

Inflammatory conditions Treatment of steroid-responsive inflammatory conditions of the palpebral and bulbar conjunctiva, lid, sclera, cornea, and anterior segment of the globe, such as Allergic conjunctivitis acne rosacea superficial punctate keratitis herpes zoster keratitis iritis cyclitis and selected infective conjunctivitis (when the inherent hazard of steroid use is accepted to obtain an advisable diminution in edema and inflammation [prednisolone]) vernal conjunctivitis episcleritis epinephrine sensitivity and anterior uveitis. 

Efficacy In other conditions The clinical efficacy in the treatment of stromal keratitis and uveitis caused by herpes simplex or ophthalmic infections caused by vaccinia virus and adenovirus, or in the prophylaxis of herpes simplex virus keratoconjunctivitis and epithelial keratitis has not been established by well-controlled clinical trials. Not effective against bacterial, fungal, or chlamydial infections of the cornea or trophic lesions. 

Tacrolimus is used in situations where cyclosporine has been shown to be ineffective or cannot be used because of toxicity or otherwise. It is also used in a topical preparation in the treatment of severe atopic dermatitis, severe refractory uveitis after bone marrow transplants and in vitiligo. 

There is comparative effectiveness of anti TNF-a modalities in the treatment of patients with RA and AS (see Canete et al., 2004). This would apply to all the disease entities of SpA such as, PsA, ReA, Crohn s disease. Ulcerative Colitis, Acute Anterior Uveitis (AAU), and Undifferentiated Spondylarthritis (UspA). 

Cyclosporine appears to have promise in the treatment of autoimmune diseases. It has a beneficial effect on the course of rheumatoid arthritis, uveitis, insulin-dependent diabetes, systemic lupus erythematosus, and psoriatic arthropathies in some patients. Toxicity is more of a problem in these conditions than during use in transplantation, since higher doses of cyclosporine are often required to suppress autoimmune disorders. 

Vin eova G, lonin A, lonin G (1999) The treatment of post Traumatic uveitis with low-intensity laser radiation. Vestn Oftalmol (Moscow) 115(5) 209-211... 

Subtenon local injection of a glucocorticoid is effective in the treatment of certain forms of uveitis. Central serous chorioretinopathy, confirmed by optical coherence tomography, developed after a single local subtenon glucocorticoid injection to treat HLA-B27-associated iritis (70). 

Glucocorticoids that have been used for local ophthalmic treatment include medrysone, fluorometholone, tetrahy-droxytriamcinolone, and clobetasone. Loteprednol etabo-nate 0.5% increases intraocular pressure less than dexamethasone. Studies on animal models of uveitis and two randomized double-masked trials showed that loteprednol etabonate 0.5% was less potent than dexamethasone, prednisolone acetate 1%, or fluorometholone, which may partly explain the improved toxicity profile of loteprednol etabonate (429). 

The ocular adverse effects of latanoprost include conjunctival hyperemia, iris pigmentation, periocular skin color changes, anterior uveitis, and cystoid macular edema in pseudophakic patients (77,78). H. simplex dendritic keratitis has been reported after treatment with latanoprost (79). In patients with uveitic glaucoma, latanoprost can cause increased intraocular pressure and recurrence of inflammation (80). 

Behar-Cohen, F.F., et al. 1997. Iontophoresis of dexamethasone in the treatment of endotoxin-induced-uveitis in rats. Exp Eye Res 65 533. 

Voclosporin (ISA-247, R1524) 88 (Isotechnika) is being evaluated in a Phase III trial for the treatment of psoriasis,250 as well as a Phase III trial by Lux Biosciences as for the treatment of uveitis (coded as LX211, Luveniq ).251,252 In addition, voclosporin 88 has completed a Phase lib trial for the prevention of kidney graft rejection. Voclosporin 88253,254 is a slightly more potent but less toxic semi-synthetic derivative of the fungal-derived immunosuppressant cyclosporin A 89, which has the same mechanism of calcineurin inhibition. Cyclosporin A 89 was first isolated from Tolypocladium inflatum by workers at Sandoz and its structure was published in 1976.255,256... 

In recent years intraocular delivery of medication, including anti-vascular endothelial growth fector, corticosteroids and related compounds, and antiviral agents, has either been approved or is under study for treatment of macular degeneration, uveitis, cytomegalovirus, or diabetic macular edema (Table 2-5).This area of research and development is growing rapidly. 

Posterior snb-Tenon s injection of corticosteroids is most often nsed in the treatment of chronic eqnatorial and mid-zone posterior uveitis, including inflammation of the macnlar region. Cystoid macular edema after cataract extraction and diabetic macular edema are treated occasionally with snb-Tenon s repository steroids. 

Intravitreal triamcinolone has been used to treat diffuse diabetic macular edema. Also, an intravitreal implant delivering fluocinolone acetonide (Retisert) is effective in the treatment of patients with noninfectious posterior uveitis who have failed to respond to conventional treatment. 

Treatment of Uveitis. Atropine is extremely useful in the treatment of anterior uveal inflammation. Atropine relieves the pain associated with the inflammatory process by relaxing the ciliary muscle spasm and helps prevent posterior synechiae by dilating the pupil. 

Because of its prolonged mydriatic and cycloplegic effect and relatively weak cycloplegic action, particularly in darkly pigmented irides, homatropine is not a drug of choice for fundus examination or cycloplegic refraction. Homatropine is primarily used in the treatment of anterior uveitis, in which its effects are similar to those of atropine. 

Cyclopentolate is also useful in the treatment of anterior uveitis, particularly in patients sensitive to atropine. If the inflammation is severe, more frequent instillations may be necessary, because its duration of action is less than that of atropine. 

Several randomized double-blind trials provided evidence that oral acyclovir 800 mg, five times daily, is the most effective dosage for treating HZO. Studies also stressed the importance of initiating treatment within the first 72 hours to prevent severe complications of HZO (i.e., keratitis, uveitis, secondary glaucoma, scleritis, optic neuritis, and acute retinal necrosis [ARN]).When there is ophthalmic involvement, it is recommended to treat even if the rash has been present for more than 72 hours. In addition, there is evidence that 7 days of treatment may be adequate. Studies have been shown that oral acyclovir may lessen the incidence and duration of postherpetic neuralgia associated with HZO, as shown in Table 11-10. 

Alternate-day therapy can prove useful for such conditions as chronic uveitis that require long-term systemic administration. This approach has also been advocated for treatment of chronic conditions in children because it minimizes growth suppression.The alternate-day regimen has not been widely accepted, and modifications have been suggested. Clinical experience also indicates that this treatment method is not as effective as divided daily doses, particularly in severe ocular inflammatory conditions. Adrenal gland suppression and other side effects associated with systemic therapy can still occur with the alternate-day regimen. 

Like fluorometholone, rimexolone lacks a hydroxyl group in the 21 position. Available as a 1% ophthalmic suspension (Vexol) (see Table 12-4), it has FDA approral for treatment of uveitis and postoperative inflammation. 

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