Treatment Options for Recurrent Chronic Posterior Uveitis

First-Line Treatment Options

The American College of Rheumatology recommends systemic immunomodulatory therapy with agents such as azathioprine, cyclosporine-A, interferon-alpha, or TNF inhibitors like adalimumab to control inflammation and prevent vision loss in patients with recurrent chronic posterior uveitis 1, 2
Systemic glucocorticoids should be used only in combination with immunosuppressive agents, not as monotherapy, for posterior uveitis to minimize corticosteroid-related adverse effects 1, 3
Azathioprine is a first-line immunosuppressive agent for posterior segment inflammation with level IB evidence 1
Cyclosporine-A is another first-line option with level IB evidence for posterior uveitis 1
Interferon-alpha has level IIA evidence for effectiveness in posterior uveitis 1
Intravitreal glucocorticoid injection can be considered as an adjunct to systemic treatment in patients with unilateral exacerbation 1

Monoclonal anti-TNF antibodies (like adalimumab) have level IIA evidence for posterior uveitis and should be considered for patients who fail first-line therapy 1

Noncorticosteroid systemic immunomodulatory therapy (NCSIT) should be introduced when there is persistent or severe inflammation, risk of ocular structural complications, contraindications or intolerance to corticosteroids, or need for corticosteroid-sparing effect to maintain disease remission 2, 3
Indicators of severe inflammation requiring systemic therapy include impairment of visual function, bilateral disease, vitreous haze, macular or optic nerve disease, retinal vascular inflammation, macular edema, and exudative retinal detachment 2, 4

Any patient with Behçet's syndrome and posterior segment eye involvement should be on a treatment regimen including azathioprine, cyclosporine-A, interferon-alpha, or monoclonal anti-TNF antibodies 1, 5
For acute sight-threatening uveitis in Behçet's, high-dose glucocorticoids, infliximab, or interferon-alpha should be used 1
While primarily causing anterior uveitis, JIA-associated uveitis that extends to posterior segments requires systemic immunosuppression 6, 7
Methotrexate (0.5-1 mg/kg/week, maximum 30 mg) is the first-line systemic agent for JIA-associated uveitis 7, 8
If methotrexate fails or is not tolerated, TNF inhibitors (adalimumab or infliximab) should be used 7, 8

The goal of treatment is to promptly suppress inflammatory exacerbations and recurrences to prevent irreversible organ damage 1, 5
Regular monitoring by an ophthalmologist is essential during treatment and for at least 3 years after remission 6

Before initiating systemic immunomodulatory therapy, patients should be screened for latent or active infections, particularly tuberculosis 2, 3
Baseline organ function tests should be performed before starting immunosuppressive agents 2, 9
Long-term management requires multidisciplinary coordination between ophthalmologists and other specialists (rheumatologists, internists) 1