Uveitis
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
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Non-infectious uveitis, anterior
Non-infectious posterior uveitis and panuveitis
H20.0
- Uveitis can be associated with systemic diseases or infection, necessitating a careful history and review of presenting symptoms.
- Physical examination of the eye and pertinent organ systems should be performed to characterise the type of inflammation present and any concomitant systemic disease.
- Multimodal ophthalmic imaging has an important role in characterising certain types of intraocular inflammation. Determining the specific type of uveitis guides the selection of treatment.
- The goal of treatment is to control the disease activity and eliminate or reduce the risk of loss of vision.
- Uveitis is often classified anatomically based on the primary site of inflammation: anterior uveitis (iris and ciliary body), intermediate uveitis (vitreous), posterior uveitis (retina or choroid) and panuveitis (whole eye), with posterior segments of the eye generally associated with more severe disease.
INFECTIOUS UVEITIS
H20.0
Infectious uveitis may be caused by:
- Bacteria - (syphilis (refer to syphilis, meningovascular syphilis), tuberculosis (refer to pulmonary TB , pleural TB, bartonellosis)
- Viruses - (herpes (refer to Herpes zoster, Herpes simplex encephalitis, Section 18.4 Herpes Zoster ophthalmicus, Herpes simplex keratitis, recurrent herpes simplex), cytomegalovirus (refer to CMV, retinitis, HIV CMV)
- Fungi - (histoplasmosis) and
- Protozoa - (toxoplasmosis (refer to Cerebral toxoplasmosis), toxocariasis, and cysticercosis (refer to neurocysticercosis).
Patients must be investigated for infectious causes. Further screening should be performed which should be informed by obtaining a full clinical history along with presenting signs and symptoms. Consider the following for further investigation:
- TB - Chest XR or TB ,
- Syphilis – VDRL test
- Toxoplasmosis - toxoplasma PCR
- Herpes simplex and Herpes zoster: HSV or HZV PCR
- Cat-scratch disease (bartonella): bartonella PCR
If an infectious cause is found, treatment of the ocular disease is as for the systemic disease. Once the infection has been addressed, residual inflammation can be treated with adjuvant anti-inflammatory therapy.
NON-INFECTIOUS UVEITIS, ANTERIOR
H20.0
DESCRIPTION
The commonest form of non-infectious uveitis is acute anterior uveitis, which presents with pain and photophobia, variable loss of vision, circumcilliary injection, and a miotic pupil. Chronic anterior uveitis may lead to cystoid macular oedema with decreased central acuity, cataract formation, and secondary glaucoma.
MEDICINE TREATMENT
- Cycloplegic agent, e.g.:
- Atropine 1%, ophthalmic drops, instil 1 drop 12 hourly.
AND
- Corticosteroids, e.g.:
- Dexamethasone 0.1%, ophthalmic drops, instil 1–2 drops 4–6 hourly.
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REFERRAL
All, for management at an ophthalmology unit.
NON-INFECTIOUS POSTERIOR UVEITIS AND PANUVEITIS
H20.0
DESCRIPTION
- Non-infectious posterior and panuveitis may be sight limiting if inflammation is not controlled. Both auto-inflammatory and autoimmune processes may be implicated.
- Posterior uveitis and panuvetis both present similarly with loss of vision, pain and photophobia, floaters and a red eye and are treated similarly as outlined below.
- Indicators of severe inflammation include:
- Impairment of visual function
- Bilateral disease
- Vitreous haze
- Macular or optic nerve disease
- Retinal vascular inflammation
- Exudative detachment
- Ocular structural complications that threaten visual function
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MEDICINE TREATMENT
- Cycloplegic agent, e.g.:
- Atropine 1%, ophthalmic drops, instil 1 drop 12 hourly.
- Corticosteroids, e.g.:
Acute inflammation/flare- Prednisone, oral 1 mg/kg/day (max 80 mg/day) for one week
- Use lowest possible dose for shortest possible duration to control inflammation.
- Apply a dose tapering regimen over 3-6 weeks typically reducing doses every 1-2 days based on treatment response.
- Prednisone, oral 1 mg/kg/day (max 80 mg/day) for one week
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Chronic inflammation
- Prednisone, oral 1 mg/kg/day (max 80 mg/day) for no longer than one month
- Use lowest possible dose for shortest possible duration to control inflammation.
- Apply a dose tapering regimen typically reducing doses every 1-2 weeks based on treatment response.
- Monitor for infection, hypertension, fluid retention, diabetes mellitus, hyperlipidaemia, atherosclerosis, osteoporosis, glaucoma, and cataracts.
Patients requiring corticosteroid-sparing control or for persistent severe inflammation refractory to corticosteroid therapy:
Initiation of immunosuppressant therapy should be considered under the following conditions:
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- Worsening of disease while on high dose corticosteroids
- No response to high dose corticosteroids after 2 to 4 weeks
- Lack of control of inflammation following treatment with high dose corticosteroids for 4 weeks
- Patients requiring maintenance corticosteroid doses ≥7.5 mg/day for three or more consecutive months
- Contraindication or intolerance to corticosteroids
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- DMARDs (Disease-modifying antirheumatic drugs)
- Methotrexate, oral, 7.5 mg once weekly
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- As the onset of action is slow with a delayed time to full effect, commence dose tapering of concomitant corticosteroid therapy 2 weeks after initiating methotrexate therapy, based on treatment response.
- Pre-treatment screening: exclude any infectious diseases that may be exacerbated by immunosuppression. o Monitoring: FBC and LFTs at baseline, 4 weeks after initiating treatment and 8 weekly thereafter.
- Methotrexate is teratogenic - ensure women of childbearing potential are counselled.
AND - Folic acid, oral 5 mg daily
Patients presenting with concomitant anterior uveitis should also be managed with topical treatment (See Infectious uveitis).
REFERRAL
- All, for management at an ophthalmology unit.
- If there is concomitant systemic disease refer to appropriate specialist.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_30 September 2024
Chapter 18 Eye Disorders_18.7 Uveitis