Treatment of uveitis

In cases of uveitis for the prevention of chronic course, bilateral eye injury and relapse of uveitis, early etiologic diagnosis is important, timely etiotropic and pathogenetic treatment with immunocorrective agents and substitution immunotherapy.

The main thing in the treatment of uveitis is the prevention of the development of complications that threaten the loss of vision, and the treatment of the disease underlying the pathological changes (if possible). There are 3 groups of medications: mydriatica, steroids, systemic immunosuppressive drugs. Antimicrobial and antiviral drugs are also used to treat uveitis of infectious etiology.

Midriatiki

Short-acting drugs

• Tropicamide (0.5% and 1%), duration of action up to 6 hours.
• Cyclopentol (0.5% and]%), duration of action up to 24 hours.
• Phenylephrine (2.5% and 10%), duration of action up to 3 hours, but without cycloplegic effect.

Prolonged action: Atropine 1% has a strong cycloplegic and mydriatic effect, the duration of action is about 2 weeks.

Indications for use

1. Atropin is used to relieve unpleasant sensations, eliminate spasm of ciliary muscle and sphincter, but it is not recommended to use it more than 1-2 honey. If signs of easing the inflammatory process appear, it is necessary to replace this medication with a short-acting midratik, for example tropicamide or cyclopentolate.
2. To prevent the formation of posterior synechia, short-acting mydriatica are used. With chronic anterior uveitis and moderate inflammation, they are instilled once a night to avoid disruption of accommodation. However, the posterior synechia can also form with a long-lasting pupil. In children, prolonged atropinization can cause the development of amblyopia.
3. For the rupture of the formed synechia, intensive instillation of mydriatic (atropine, phenylephrine) or their subconjunctival injections (adrenaline, atropine and procaine) is used.

Steroid drugs in the treatment of uveitis

Steroids are the main component of the treatment of uveitis. Variants of destination: topically, in the form of drops or ointments, parabulbar injections, intravitreal injections, systemically. Initially, regardless of the mode of administration, steroids are prescribed in high doses, followed by a gradual decrease in it, depending on the activity of the inflammatory process.

Local use of steroid drugs in the treatment of uveitis

Steroids are prescribed topically in the anterior uveitis, since their therapeutic concentration is formed in front of the lens. It is preferable to use strong steroid preparations, such as dexamethasone, betamethasone and prednisolone, in contrast to fluorometholone. Drug solutions penetrate the cornea better than suspensions or ointments. Nevertheless, the ointment can be stored at night. The frequency of instillations of eye drops depends on the severity of the inflammatory process and can vary from 1 drop every 5 minutes to 1 drop 1 time per day.

Treatment of acute anterior uveitis depends on the severity of the inflammatory process. Initially, the treatment is performed every 15 minutes for several hours, and then the dose is gradually reduced to 4 times a day for several days. If the activity of the inflammatory process subsides, the frequency of instillation is reduced to 1 drop per week and stop digging in 5-6 weeks. In order to dissolve the fibrinous exudate and prevent subsequent development of glaucoma in the pupillary block, a tissue plasminogen activator (12.5 μg in 0.1 ml) is injected into the anterior chamber using a needle.

Treatment of chronic anterior uveitis is quite complicated due to the existence of an inflammatory process for several months, and sometimes years. When the process is exacerbated (cells in the moisture of anterior chamber +4), the treatment is performed as in acute anterior uveitis. When the process calms down (cells in moisture up to +1), the amount of instillation is reduced to 1 drop per month, followed by cancellation.

After discontinuation of treatment, the patient should be examined for several days to confirm the absence of signs of recurrent uveitis.

Complications of steroids

• glaucoma;
• Cataracts caused by the use of steroid drugs both locally and systemically. The risk of developing cataracts depends on the dose and regimen of the drug;
• complications from the cornea are infrequent, include secondary bacterial or fungal infections, keratitis caused by the herpes simplex virus, melting of the cornea, which is due to inhibition of collagen synthesis;
• Systemic complications caused by long-term use of drugs are often found in children.

Parabulbar injection of steroids

Advantages over local application:

• Promotes the achievement of therapeutic concentration behind the lens.
• Aqueous solutions of drugs are not able to penetrate the cornea with topical application, but penetrate transsclerally with parabulbar injections.
• A long-term effect is achieved with the administration of such drugs as triamcinolone acetonide (Kenalog) or methylprednisolone acetate (denomedron).

Indications for use

• Acute anterior uveitis of a severe degree, especially in patients with ankylosing spondylitis, with fibrinous exudate in the anterior chamber or hypopion.
• As an additional tool in the treatment of chronic anterior uveitis, in the absence of positive dynamics from local and systemic therapy.
• Peripheral uveitis.
• Lack of patient consent to the use of local or systemic therapy.
• Surgical intervention with uveitis.

Conjunctival anesthesia

• the instillation of a local anesthetic, for example ametocaine, every minute with an interval of 5 minutes;
• A small cotton ball soaked in a solution of ametocaine or another substance is placed in a conjunctival bag on the side of the injection with an exposure of 5 minutes.

[1], [2], [3], [4], [5], [6], [7], [8]

Anterior subtenoin injection

• in a syringe with a volume of 2 ml, 1 ml of a steroid preparation is taken up, a needle 10 mm long is inserted;
• the patient is asked to look to the side opposite the injection site (more often - up);
• anatomical tweezers capture and lift the conjunctiva with a tenon capsule;
• At some distance from the eyeball, the needle is injected through the conjunctiva and the tenon capsule at the point of their capture;
• slowly injected with 0.5 ml of the drug.

[9], [10], [11], [12]

Subtenone injection

• in a syringe with a volume of 2 ml, 1.5 ml of a steroid preparation is collected, a 16 mm needle is inserted;
• the patient is asked to look to the side opposite the injection site: most often to the nose if the injection is made to the upper quadrant;
• puncture bulbar conjunctiva produce in the immediate vicinity of the eyeball, the needle is directed toward the arch of the orbit;
• slowly push the needle backward, keeping it as close as possible to the eyeball. To prevent damage to the eyeball, light intermittent movements with a needle are made and the limb area is observed: the displacement of the limb region indicates the scleral perforation.
• if it is not possible to further advance the needle, pull the plunger slightly and, if there is no blood in the syringe, inject 1 ml of the drug. If the needle is far from the eyeball, there may not be enough absorption of the steroid substance through the sclera.

As an alternative method, cut the conjunctiva and the tenon capsule and inject the drug with a blind subtenon or tear cannula.

Intravitreal injection of steroid drugs

Intravitreal injection of the steroid drug triamcinolone acetonide (2 mg in 0.05 ml) continues to be studied. The drug was successfully used for the treatment of cystic macular edema in chronic uveitis.

Systemic therapy with steroids

Systemic therapy of uveitis:

• Inside prednisolone 5 mg. Patients with high acidity of gastric juice are prescribed coated tablets;
• injections of adrenocorticotropic hormone are prescribed to patients if there is no effect of taking the drug inside.

Indications for the use of systemic therapy of uveitis

• Persistent anterior uveitis, resistant to local therapy, including injection.
• Peripheral uveitis, resistant to subtenon injection.
• Certain saws of posterior uveitis or panoveitis, especially with severe bilateral lesions.

General rules for prescribing:

• Begin with large doses of the drug, gradually reducing them.
• The recommended initial dose of prediisolone is 1 mg per kg of body weight, taking the dose 1 time in the morning.
• With a decrease in the activity of the inflammatory process, the dose of the drug is gradually reduced after a few weeks.
• When appointing the drug for less than 2 weeks, there is no need for a gradual dose reduction.

The side effects of systemic therapy depend on the duration of the drug:

• short-term therapy can lead to dyspeptic and mental disorders, electrolyte imbalance, aseptic necrosis of the scalp and thighs. Sometimes hyperosmolar hyperglycemic coma develops;
• long-term therapy leads to the development of cushingoid status, osteoporosis, growth in children, exacerbation of diseases such as tuberculosis, diabetes, myopathy, and the appearance of cataracts.

Immunosuppressive drugs

Immunosuppressive drugs are divided into: antimetabolic (cytotoxic), inhibitors of T cells.

Indications for use:

1. Uveitis with the threat of vision loss, bilateral, non-infectious etiology, with frequent exacerbations, with no effect of steroid therapy.
2. Pronounced side effects due to the use of steroid drugs. With the initial appointment of a properly selected dose of an immunosuppressive drug, the duration of admission is 6-24 months. Then gradually reduce the dose and cancel for the next 6-12 months. However, some patients need a longer duration of the drug when monitoring the activity of the inflammatory process.

Antimetabolics

Azathioprine

• indications: Behcet's disease:
• dose: 1-3 mg per 1 kg of body weight (tablets of 50 mg) in the morning or dose is selected individually;
• side effects: suppression of bone growth, gastrointestinal and hepatotoxic complications;
• control: a general blood test every 4-6 months and the definition of liver function every 12 ked.

Methotrexate

• indications: a group of chronic uveitis of non-infectious etiology, resistant to steroid therapy;
• dose: 7.5-25 mg once a week;
• side effects: suppression of bone growth, hepatotoxic manifestations, pneumonia. When taking the drug in small doses are rare, often there are gastrointestinal disorders;
• control: a complete blood test and a study of liver function every 1-2 months.

Mycophenolate mofetil

• readings: not fully studied. It is intended to be used as an alternative means;
• dose: 1 g 2 times a day;
• side effects: gastrointestinal disorders and suppression of bone growth;
• control: a general blood test first weekly for 4 weeks, then - less often.

[13], [14], [15]

T cell inhibitors

Cyclosporin

• indications: Behcet's disease, peripheral uveitis, Vogt-Koyanagi-Harada syndrome, Birdshoi chorioretinitis, sympathetic ophthalmia, retinal vasculitis;
• dose: 2-5 mg per 1 kg of body weight 1 time in 2 divided doses;
• side effects: hyietension, hirsutism, gingival mucosa hyperplasia, nephro- and hepatotoxic disorders;
• control: measurement of blood pressure, a general blood test and determination of liver and kidney function.

Tacrolimus (FK 506)

• readings: not fully studied. Used as an alternative to cyclosporins in the absence of a positive effect on their use or the development of pronounced side effects;
• Dose: 0.05-0.15 mg per 1 kg of body weight 1 time per day;
• side effects: nephrotoxic and gastrointestinal disorders, hyperglycemia, neurological disorders;
• control: monitoring blood pressure, kidney function, determining blood glucose weekly, then - less often.

Prevention of uveitis

Prevention of uveitis is a complex problem related to eliminating the effects of unfavorable environmental factors, as well as strengthening protection mechanisms. Since intrauterine and early infection of children is possible, as well as chronic human contaminants by various viral and bacterial pathogens due to their wide spread in nature, the main measures for preventing uveitis should include:

1. prevention of fresh diseases and exacerbations of chronic infections (toxoplasmosis, tuberculosis, herpes, cytomegalovirus, rubella, influenza, etc.) in pregnant women, especially in family and other foci of infections;
2. elimination of the effects of unfavorable environmental factors (hypothermia, overheating, occupational hazards, stress conditions, alcohol, eye trauma), especially in persons suffering from frequent colds, chronic infections, various manifestations of allergy, syndromes, meningoencephalitis;
3. prevention of transmission of infection to susceptible persons, taking into account sources and ways of infection with regard to the type of infectious agent, especially in the period of epidemic spread of viral and bacterial infections in children's groups, medical institutions.