Therapeutics Q&A

Getting Uveitis Under Control

Q. In acute noninfectious anterior uveitis, what is your preferred method of cycloplegia? When is angle closure or pupillary block likely, and how do you avoid it? Would the presence of synechiae cause you to alter your approach?

A. Our panelists agree that prompt cycloplegia is needed to alleviate pain and to either avoid or break adhesion between the iris and the anterior lens capsule. In any acute anterior uveitis, or panuveitis involving the anterior segment, Dr. Suhler prefers to use cycloplegics in any situation where there is a brisk anterior segment inflammatory response (i.e., 1+ or greater) to prevent formation of posterior synechiae.

Each of our three panelists prefers a different cycloplegic agent — homatropine for Dr. Foster, scopolamine for Dr. Suhler, and cyclopentolate for Dr. Davanzo — but acknowledge that any of the three short-acting agents are considered acceptable. "Atropine is useful in some situations but is less preferred, at least by me," says Dr. Suhler, "due to its long duration" of about 2 weeks. Although phenylephrine is to be avoided as it lacks anti-inflammatory effect and can cause shedding of iris pigment, it can sometimes help to break unresolved posterior synechia.

Angle closure is likely with very severe uveitis and is secondary to either extensive posterior or anterior synechiae or a combination of both, says Dr. Davanzo. Fortunately, it's rare. "I've never seen it in 35 years," says Dr. Foster. "Pupillary block, on the other hand, can occur if the pupil zippers with posterior synechiae."

Q. What steroid regimen will be effective in quickly reducing pain and inflammation? Are there any notable differences among medications? At what point can you begin to taper steroids to prevent adverse effects? Is there a role for NSAIDs?

A. Topical prednisolone has been the mainstay for years. Generics are available, but Dr. Suhler prefers brand name Pred Forte (Allergan, Irvine, CA). "Many in the uveitis community believe it is more efficacious than generic prednisolone acetate or other topical prednisolone formulations," says. Dr. Suhler. The recent introduction of difluprednate (Durezol, Sirion Therapeutics, Tampa, FL) provides a new and, some say, better option. Drs. Davanzo and Foster consider it more potent than prednisolone. "Durezol is by far the most effective," says Dr. Davanzo. "Prednisolone acetate would be second, Lotemax might be third, and Non-steroidals would be a distant fourth."

Although steroid regimens of 8x or more per day are typical in the acute phase, shorter regimens may be possible. A recent study by Sirion found that Durezol was effective when dosed q.i.d. At day 7, patients averaged a 71% pain reduction from baseline. At day 14, mean cell grade reduction averaged 2.1.

Regardless of the steroid used, withdrawal of the agent depends on the response to therapy. When the patient has a deep and quiet chamber, says Dr. Foster, begin tapering the drug. "I usually titrate the dosage to the cell and flare as well as to the symptoms," Dr. Davanzo says.

Q. If the patient has other ocular pathology such as glaucoma, or a systemic condition such as connective tissue disease, how would you alter your treatment approach?

A. "One must always be vigilant for steroid-responsive ocular hypertension in the treatment of anterior segment inflammatory disease with topical steroids," says Dr. Suhler. "This may be found in patients with or without preexisting glaucoma." Previous history of uveitis or collagen vascular diseases may require a more frequent dosage or maybe even oral Prednisone or sub-Tenon's injections, says Dr. Davanzo.

If a coexisting systemic disease requires systemic immunosuppression, says Dr. Suhler, ophthalmologists should assist internists in selecting a regimen that will also quiet the associated ocular inflammatory disease. Such diseases might include, but not be limited to, ankylosing spondylitis, reactive arthritis, inflammatory bowel disease, psoriatic arthritis, sarcoidosis, juvenile idiopathic arthritis, tubulointerstitial nephritis and uveitis, Behcet's disease, or multiple sclerosis. "A thorough history and physical may offer the ophthalmologist the opportunity to be the first in finding signs of such associated diseases," Dr. Suhler notes. OM