Simple brief about medications in Uveitis

1. Drugs used in Uveitis
Capt Md Ferdous Islam
Trainee in Ophthalmology
CMH ,Dhaka

2. Introduction
• The purpose is to describe the different drugs
used in the treatment of uveitis. The term
drug would incl eye drops, tablets and
injections.
• It may be useful to remember the aims of
treatment in uveitis:

3. What Should Treatment Achieve?
• Relieve pain and discomfort.
• Prevent sight loss due to the disease or its
complications.
• Treat the cause of the disease where possible,
that is, treat the inflammation.
• In a few types , the inflammation is caused by
an infection and treated with antibiotics or
antiviral drugs.
• The drugs fall into 3 main groups: Steroids,
Immunosuppressants and Mydriatics

4. Cycloplegics
Mydriatics
• These ophthalmic preparations block the
responses of the iris sphincter and the
accommodative muscle of the ciliary body
to cholinergic stimulation, producing
pupillary dilation (mydriasis) and paralysis
of accommodation (cycloplegia)
• Tropicamide 1%, cyclopentolate and
atropine have both properties
• Phenylephrine has only mydriasis.

5. Cycloplegics
Purpose:
•To break or prevent posterior
synechiae and to relieve ciliary spasm
induced photophobia.
•Dosing depends on the extent of
inflammation

6. Posterior synechiae

7. Corticosteroids
Mainstay of initial therapy

9. Topical Steroids
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with uveitis. Can
J Opthalmol 2010; 45:352-8

10. Topical Steroids

11. Injections

12. Adverse Effects of Corticosteroids

13. Cont.

14. Cont.

15. NSAIDS

16. Systemic NSAIDS
Complications of prolonged use:
• Myocardial infarction
• Hypertension
• Stroke (selective cox-2 inhibitors)
• PUD
• GI bleeding
• Nephrotoxicity
• Hepatotoxicity

17. Immunomodulatory Medications
(IMT)
• Antimetabolites
• T Cell Signaling Inhibitors
• Alkylating Agents
• Biologic Response Modifiers

20. Indications For IMT
 Inadequate response of uveitis to corticosteroid therapy
for greater than 3 months with doses exceeding 5-
10mg/day.
 Vision threatening Intraocular inflammation.
 Reversibility of disease process.
 Contraindications to corticosteroid use:
1. diabetes, hypertension, peptic ulcer, GERD,
immunocompromised state, psychiatric conditions
2. exacerbated side effects
3. chronic corticosteroid dependence

21. Precautions
No infection present
No hepatic or hematologic contraindications
Close physician follow up
Teratogenic
Informed Consent

22. Antimetabolites
• Azathioprine, methotrexate, mycophenolate mofetil
• Azathioprine (purine nucleoside analogue)
-interferes with DNA replication and RNA transcription
-found beneficial in VKHsyndrome, int. uveitis, Behcet uveitis,
sympathetic opthalmia and necrotizing scleritis
-GI side effects (nausea, upset stomach) are cause for D/C.
-CBC, LFT every 4-6 weeks.

23. Methotrexate
• Folic Acid analogue
• Inhibitor of dihydrofolate reductase and it’s DNA replication
• Causes extracellular accumulation of adenosine to create an
anti-inflammatory effect.
• Useful for iridocyclitis (first line choice IMT treatment for
children), sarcoidosis, panuveitis, various other types of
uveitis
• Prospective study for IV inj. for refractory uveitis and uveitic
CME.

24. Mycophenolate Mofetil
• Inhibits inosine monophosphate dehydrogenase and
DNA replication
• Side effects: reversible GI distress, diarrhea
• CBC monthly
• 85% effectivity in chronic uveitis patients and a good
second choice IMT for children.

25. CYCLOSPORINE and TACROLIMUS
• Calcineurin inhibitors- disrupt T-cell
receptor signal transduction and down
regulate IL-2 transcription and CD4 T
lymphocyte receptor expression.
SIROLIMUS
• Non-calcineurin inhibitor- disrupts T cell
signaling that inhibits Ab production
and B-lymphocytes.
T Cell Signaling Inhibitors

26. Cyclosporine
• SE: Nephrotoxicity and systemic hypertension;
paresthesia, hypertrichosis.
• BP, CBC, s creatinine monthly.
• Used for int. uveitis and posterior uveitis cases from
Behcets and VKH.
• Used in combination with corticosteroids

27. Tacrolimus
• Low dose and increased potency to cyclosporine
• Less risk of hypertension and hyperlipidemia
• Useful for chronic int. and posterior uveitis.
• Nephrotoxicity

28. Sirolimus
• One open-label, prospective study it was found
useful in treatment for refractory noninfectious
uveitis
• GI side effects
• Under active investigation for use in treating uveitis

29. Alkylating Agents
CYCLOPHOSPHAMIDE
• Active metabolites alkylate purines in DNA and RNA, creating
impaired DNA replication and cell death
• Cytotoxic to dividing and resting lymphocytes
• myelosuppression, hemorrhagic cystitis, sterility
CHLORAMBUCIL
• Interferes with DNA replication
• myelosuppression, sterility
Treatment for int. uveitis, VKH, SO, Behcet
Increased risk for malignancy (leukemia, various cancers)

30. Biologic Response Modifiers
{inhibitors of cytokines}INFLIXIMAB
• Chimeric, monoclonal IgG1k antibody against TNF alpha
• Treatment for Behcet, sarcoidosis and VKH. Some HLA B27
ant. Uveitis
• Drug induced toxicity (lupus, systemic vascular thrombosis,
CHF, malignancy, demyelinating disease and vitreous
hemorrhage)
ADALIMUMAB
• less AE, same effectiveness

31. Alternative Therapy Under FDA
Investigation
• RITUXIMAB chimeric monoclonal antibody
against CD20 positive cells (B lymphocytes)
• DACLIZUMAB monoclonal Ab to IL-2
• IFN alpha 2a: antiviral, immunomodulatory and
antiangiogenic effects (leukopenia and
thrombocytopenia,depression)