Treatment Guidelines for Non-Infectious Uveitis

Initial Treatment Approach

The American Academy of Ophthalmology recommends corticosteroids as the first-line treatment for non-infectious uveitis, but noncorticosteroid systemic immunomodulatory therapy (NCSIT) should be initiated when corticosteroid therapy fails, causes intolerable side effects, or when disease requires prolonged control beyond 3 months 1, 2
Systemic corticosteroids should not be used as monotherapy for posterior uveitis—they must be combined with immunosuppressive agents to minimize adverse effects 3
Topical prednisolone should be limited to ≤3 months due to significant risk of elevated intraocular pressure and cataract formation 4

NCSIT should be initiated based on specific ocular and therapeutic criteria, including sight-threatening acute disease, chronic persistent inflammation, visual acuity worse than 20/100, vitreous haze increase of grade 2+, relapse of cystoid macular edema, and disease impacting quality of life 1, 2
Failure of regional corticosteroids, active uveitis while taking ≥30 mg or ≥0.5 mg/kg prednisone daily, and relapse when oral corticosteroid dose reduced to <7-10 mg/day prednisone are also indications for NCSIT 1, 2
Steroid intolerance or contraindications, such as history of tuberculosis, hepatitis, noncompliance, or reproductive status, are additional indications for NCSIT 1, 2, 5

Before initiating NCSIT, mandatory screening includes baseline vital organ function tests, screening for latent or active tuberculosis, HIV testing, assessment for history of malignancy, age, and family history of malignancy, and screening for hepatitis 1, 2, 6
The American Academy of Ophthalmology recommends screening for latent or active tuberculosis before initiating biologic therapy 1, 2

The American Academy of Ophthalmology recommends methotrexate, mycophenolate mofetil, and azathioprine as first-line NCSIT options, with Grade B evidence for effectiveness in non-infectious uveitis 8
Methotrexate is recommended as first-line for JIA-associated uveitis, with a dose of 0.5-1 mg/kg/week, maximum 30 mg 3
Mycophenolate mofetil has a Grade B recommendation with evidence of inflammation control, steroid-sparing effect, and visual acuity improvement 8

The American Academy of Ophthalmology recommends TNF-α inhibitors, such as adalimumab, as second-line NCSIT options, with Level IIA evidence for posterior uveitis 3
Adalimumab is FDA-approved for non-infectious intermediate, posterior, and panuveitis in adults and pediatric patients ≥2 years of age, with dosing of 40 mg subcutaneous every other week for adults and children ≥30 kg 3

When NCSIT is inadequate, the treatment algorithm recommends first ruling out treatment nonadherence, infections, and masquerade syndromes, then considering dose escalation to maximum tolerated therapeutic dose, and finally transitioning to alternative or additional agent 8, 9

Regular ophthalmologic monitoring during treatment and for at least 3 years after remission is recommended, with monitoring for elevated intraocular pressure and cataract formation with corticosteroid use 3, 4, 7
Using ≥2 drops/day topical prednisolone is a strong risk factor for IOP elevation 4

The American Academy of Ophthalmology recommends screening for tuberculosis and hepatitis before initiating biologic therapy, with a risk of hepatosplenic T-cell lymphoma, particularly when combined with azathioprine or 6-mercaptopurine in adolescent/young adult males with Crohn's disease or ulcerative colitis 1, 2