Case #1: Impressions and Clinical Insights
A uveitis specialist discusses impressions and key take away points from patient case.
Thomas Albini, MD: I think the biggest problem with this patient is the chronicity recurrence and the need for steroids to preserve his vision. I saw him for the first time on 60 mg of prednisone, and he'd been on prednisone for a year prior to my seeing him. He was on doses of prednisone that are likely to cause side effects at such high doses. The American College of Rheumatology has recommended now that patients be no more than seven and a half mg past the first 8 weeks of a prednisone taper. We really want to get him down to seven and a half mg, and that was impossible with the strategies that were being used before I saw him. But the addition of methotrexate as a long-term immunosuppressive and the addition of the intravitreal fluocinolone implants with 3-year duration allowed us to get him off of systemic prednisone. That's the biggest challenge with this patient.
How is the quality of life affected in patients with uveitis? That answer is obvious to anybody who's treated these patients: they are miserable. If they have moderate to severe uveitis, they are impaired visually: they can't drive, they can't read. The inflammation starts to escalate when you get to a point where there's complications with glaucoma, cataracts, macular edema; they start to lose vision rapidly and sometimes irreversibly. It's a disease that really has profound effects on patients' lives, especially when it becomes moderate too severe. Now, even for the mild cases, they are affected, oftentimes suffering from light sensitivity, from just painful eyes, uncomfortable eyes, red eyes. All those things also make life difficult. At all levels of disease, uveitis really causes significant morbidity for patients.
How does one differentiate uveitis from other retinal disorders? The real benefit of uveitis is that unlike inflammation seen in other parts of the body, with uveitis, we can see inflammatory cells and inflammatory lesions directly in the eye. The inflammation is usually picked up on exam where you can see cells in the anterior chamber, in the vitreous cavity, and that allows you to make the diagnosis, and also, to a great extent, hone in on the differential from the different types of uveitis that there are based on the appearance and the phenotype of the information that you’re seeing within the eye.
What are the current treatment options available for this patient? This patient had a number of them: steroids are still the best treatment in the acute setting, often oral. Sometimes local steroids, intravitreal, periocular steroids can also be used. But steroids for long-term treatment are not often the healthiest thing for the patient. There are a number of off-label immunosuppressive drugs that have been used to treat uveitis for decades. Among these are methotrexate and CellCept, the T-cell inhibitors such as cyclosporine or Prograf, and, very rarely used, the alkylating agents such as chlorambucil. These alkylating agents have very high degree of side effects and are used very sparingly. But the anti-metabolites are very well-tolerated and make up the mainstay of systemic treatment for these patients if they cannot be controlled completely with prednisone. The biologic Humira has been FDA approved now for uveitis over the last couple of years. We still don't have comparative data, although there is currently an NIH-sponsored trial called the advised trial that is comparing adalimumab with the standard off-label immunosuppressives for efficacy and side effects. Humira is really the main biologic that's used and other biologics such as Remicade and others are used off-label.
Serial injections with steroids such as Ozurdex or Triesence are sometimes used to control inflammation in these eyes. But I find that serial use of steroids like this can be problematic, because, between the injections, patients tend to have relapses and recurrences of disease, and each one of those agents has the potential to cause some harm. I prefer a sustained-release steroids; there are two main forms that are available: Yutiq implant or the injectable fluocinolone 3-year implant, and then the Retisert, or the surgically implanted fluocinolone implant. The surgically implanted fluocinolone device has three times the daily dose of the injected one. While the injected one has a better safety profile, the surgically implanted one has a better efficacy profile.
My main takeaway really is that you can successfully treat these patients, even though they may have had a very difficult time before you see them, if you use the full armamentarium of drugs that are available. In this case, it was the tried-and-true anti metabolite methotrexate in conjunction with the more novel injectable fluocinolone implant. If you use the full armamentarium, you can almost always treat these patients successfully and really limit their morbidity.
Transcript Edited for Clarity
