Immune-Mediated Uveitis

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CLINICAL DESCRIPTION

Inflammation of the uvea. Usually associated with systemic disease; arthritis.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Redness, photophobia/tearing, blurred vision/floaters, circumlimbal injection, flare, cells in anterior chamber, posterior synechiae

INVESTIGATIONS

  • FBC, ESR/CRP, VDRL/RPR, HIV, serum ACE
  • Imaging: Chest xray/CT chest

Treatment

  • Treatment of immune-mediated uveitis involves predominantly the use of anti- inflammatory and immunosuppressive agents.
  • Mydriatics
    • Tropicamide (0.5% and 1%),
    • Cyclopentolate (0.5% and 1%),
    • Phenylephrine (2.5% and 10%),
    • Atropine 0.5% to 1%
  • Steroids
    • Topical steroids useful only for anterior uveitis because therapeutic levels are not reached behind the lens.
    • Periocular steroids
    • Therapeutic concentrations maybe achieved behind the lens e.g. Triamcinolone Acetonide (Kenalog) and depot steroids such as Methylprednisolone Acetate (Depomedrone).
    • Intraocular steroids
      • Intravitreal injection of Triamcinolone Acetonide (4mg in 0.1ml) or Slow-release steroid implant (Flucinolone Acetonide) via pars plana. Useful in patients with posterior uveitis.
  • Systemic steroids
    • Give oral Prednisolone 1mg/kg
    • Intravenous injection of Methylprednisolone 1g/day for 3 days.
  • Antimetabolites
    • Azathioprine 1mg/kg/day once a day or in 2 divided doses. Double dose after 1-2 weeks. For Sight- threatening uveitis and as a steroid-sparing therapy in patients with intolerable side effects from systemic steroids
    • Methotrexate 10-15mg/week (children can be given 30mg/week) as a steroidsparing agent in patients with uveitis associated with Sarcoidosis. Folic Acid 5- 5.0mg/day is co-administered to reduce bone marrow toxicity.
      • Patients must refrain from alcohol.
    • Mycophenolate Mofetil 1g every 12hrs which may be increased to 4g daily. A good alternative to azathioprine in unresponsive or intolerant patients.
      • Contraindicated in children. Monitoring involves a weekly full blood count for 4 weeks and then monthly.