Treatment of Uveitis

Medication Recommendations

For juvenile idiopathic arthritis-associated uveitis, the American College of Rheumatology conditionally recommends subcutaneous methotrexate administration over oral administration, and combination therapy with methotrexate and a monoclonal antibody TNFi immediately over methotrexate monotherapy 1
Etanercept should not be used for uveitis due to lack of efficacy, as stated by the American College of Rheumatology 1
Methotrexate (subcutaneous preferred over oral) is a first-line immunosuppressive agent for panuveitis, with a dosing of 0.5-1 mg/kg/week (maximum 30 mg per week) 2
Anti-TNF biologics, specifically adalimumab, infliximab, and golimumab, are recommended as second-line therapy if methotrexate is ineffective or not tolerated, with a moderate level of evidence 3
The following treatment protocol is recommended:

Prednisolone acetate 1% is preferred over difluprednate as the first-line treatment for most conditions, particularly anterior uveitis, due to its better corneal penetration, as recommended by the American College of Rheumatology 1
Initial dosing of prednisolone acetate 1% topical drops should be frequent (every 1-2 hours) and tapered as inflammation comes under control, with the goal of rapid control to prevent permanent tissue damage and regular ophthalmologist monitoring 1
Short-term use of steroid eye drops is preferred, and prolonged use beyond 3 months increases the risk of complications, with follow-up recommended every 2-6 weeks for active inflammation and every 3 months for controlled inflammation 1
Prolonged topical steroid monotherapy should be limited to ≤3 months if possible, as recommended by the European League Against Rheumatism, and overreliance on systemic corticosteroids should be avoided 3, 1

Urgent ophthalmology referral (preferably to a uveitis specialist) is required prior to initiating any treatment for panuveitis, followed by systemic corticosteroids in addition to topical, intravitreal, and/or periocular corticosteroids as initial treatment, as recommended by the American College of Ophthalmology 5
Systemic corticosteroids should be considered in addition to topical treatment, with a typical starting dose of 1-2 mg/kg/day methylprednisolone equivalents IV for severe cases of panuveitis 5
Systemic immunosuppression should be initiated if topical steroids are insufficient after 3 months, or if inflammation reactivates during steroid taper, according to the American College of Rheumatology, with a moderate level of evidence 3

Ongoing monitoring for panuveitis should be done no less frequently than every 3 months while on stable therapy, with ophthalmologic evaluation within 1 month after each change in topical therapy, as recommended by the American Academy of Ophthalmology and the American College of Rheumatology 6, 1
Patients with panuveitis should be monitored for complications such as cataracts, glaucoma, increased intraocular pressure, posterior synechiae, band keratopathy, and cystoid macular edema 2
Regular monitoring of IOP is recommended, especially with prolonged use of steroid eye drops, and the risk of IOP elevation increases with dosing of ≥4 drops daily and prolonged use beyond 3 months 1
Children have a higher risk of steroid-induced IOP elevation and require more aggressive monitoring of IOP, as recommended by the American College of Rheumatology 1

Regular communication between the ophthalmologist and rheumatologist is essential for collaborative care, with a moderate level of evidence, according to the American College of Rheumatology 3
Uveitis management requires close collaboration between ophthalmologists and rheumatologists, with regular ophthalmologic monitoring essential within 1 month after each change in topical therapy and no less frequently than every 3 months while on stable therapy, as recommended by the American Academy of Ophthalmology and the American College of Rheumatology 6, 1
A comprehensive autoimmune workup is strongly recommended for patients with episcleritis or scleritis who only respond to prednisolone acetate 1% ophthalmic drops, as up to 50% of these cases are associated with underlying systemic autoimmune disease 1
Poor prognostic factors that may warrant earlier systemic therapy include male gender, posterior synechiae, band keratopathy, glaucoma, or cataract, poor initial vision, and macular edema, as stated by the European League Against Rheumatism 3