Inflammatory Eye Diseases Call for Careful, Individualized Treatment to Maintain Vision

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.