Management of Multifocal Choroiditis with Panuveitis

Clinical Presentation and Diagnosis

Multifocal choroiditis with panuveitis (MCP) is a bilateral inflammatory disorder predominantly affecting young to middle-aged women, characterized by multiple yellow-white or gray focal lesions at the level of the retinal pigment epithelium and choroid, accompanied by inflammation in all uveal compartments, according to the American Academy of Ophthalmology 1
Patients present with floaters, blurred vision, photophobia, and visual field changes, as reported by the American Academy of Ophthalmology 2

Multimodal imaging is essential to establish diagnosis and guide treatment decisions, including optical coherence tomography (OCT), fluorescein angiography (FA), indocyanine green angiography (ICGA), and OCT-angiography, as recommended by the American Academy of Ophthalmology 1

Systemic corticosteroids must always be combined with immunosuppressive agents and never used as monotherapy for posterior uveitis, according to the American College of Rheumatology 1, 3
High-dose systemic corticosteroids provide rapid suppression during acute attacks but require concurrent immunosuppression, as reported by the European League Against Rheumatism 4
Patients with MCP affecting the posterior segment should be on systemic immunomodulatory therapy with azathioprine, cyclosporine-A, interferon-alpha, or monoclonal anti-TNF antibodies, as recommended by the American College of Rheumatology 3
Azathioprine has level IB evidence for posterior segment inflammation, according to the American College of Rheumatology 3, 4
Cyclosporine-A has level IB evidence for preserving visual acuity and preventing relapses, as reported by the European League Against Rheumatism 3, 4
Interferon-alpha has level IIA evidence for effectiveness in posterior uveitis, according to the American College of Rheumatology 3, 4
Monoclonal anti-TNF antibodies (infliximab or adalimumab) have level IIA evidence and should be considered for refractory cases, as recommended by the American College of Rheumatology 3, 4

Regular ophthalmologic surveillance is mandatory, with monitoring for at least 3 years after achieving remission to detect recurrence early, as recommended by the American Academy of Ophthalmology 1, 3
After stopping immunosuppression, patients should be screened by an ophthalmologist at least every 3 months for a minimum of 1 year, according to the European League Against Rheumatism 5
The period of uveitis inactivity should be greater than 2 years before withdrawing immunosuppressive therapy, as recommended by the European League Against Rheumatism 5
Patients should have 2 years of inactive disease while not using topical steroids before reducing systemic immunosuppression, according to the European League Against Rheumatism 5