Uveitis: which treatment path will you take?

A Medline search for the term "uveitis" produced nearly 2,000 citations within the past year alone; a very active period indeed for uveitis specialists. Of these citations, I have selected one article each from four of the most widely read and cited journals in the field: American Journal of Ophthalmology, Archives of Ophthalmology, British Journal of Ophthalmology, and Ophthalmology. We then asked one of the authors of each of these articles to comment on the importance and relevance of their findings. The articles were selected for their overall quality and relevance to practicing ophthalmologists.

The intravitreal implant

Last year, Glenn Jaffe, MD and associates reported, in Ophthalmology, on 34-week data from a three-year trial of the intravitreal fluocinolone acetonide (Retisert; Bausch & Lomb) implant.¹ The extended results from this trial demonstrated clearly that in appropriately selected patients with non-infectious posterior uveitis, use of the intravitreal fluocinolone device can result in a marked and sustained improvement in intraocular inflammation. Of course, patient selection is key because a sizable proportion of patients will require cataract extraction, treatment with intraocular pressure (IOP)-lowering drops and/or glaucoma surgery.

The literature includes evidence that visual morbidity from chronic, non-infectious posterior uveitis is most closely associated with the cumulative damage that results from the number of recurrences. Therefore, therapy that keeps the eyes "quiet" for an extended period has the potential to improve long-term visual outcomes substantially and liberate patients from continual treatment with systemic corticosteroids and immunosuppressive agents.

Interim 34-week results from the multicentre, randomized trial of the investigational fluocinolone acetonide implant showed that both doses used in the study (0.59 mg versus 2.1 mg) very effectively controlled the inflammation during and beyond that endpoint. Subjects in this study had disease characteristics suggesting that, in the absence of systemic treatment, they would have at least two recurrences over the course of six months. Individuals who received the implant, however, experienced a significant decrease in the rate of recurrence of inflammation as well as a decrease in the need for additional anti-inflammatory therapy.

Visual acuity (VA) improved in a significant number of subjects, primarily owing to the decrease in macular oedema. It was noted that the placement of corticosteroids in the back of the eye produced expected adverse events such as cataract formation and increased IOP. Long-term safety and efficacy results are currently being analysed.

Idiopathic uveitis in children: will it burn out?

In the American Journal of Ophthalmology last year, Joke de Boer and colleagues described long-term follow-up in a cohort of 32 consecutive children with idiopathic intermediate uveitis (pars planitis).² Fifteen of these young subjects had five years of follow-up or more and, within this subgroup, seven subjects, or nearly 50%, went into "remission" following appropriate therapy. This observation is important and helps us all answer what must be one of the most common questions from patients and parents alike: "Will the inflammation burn out?"

The answer is "yes" and within five years in a sizable proportion of patients, but not by itself. Long-term therapy with corticosteroids and one or more non-corticosteroid immunosuppressive agent are almost always needed to achieve sustained control of the uveitis.