Comanagement may be needed for best uveitis care
The accompanying cover story on uveitis is quite comprehensive, and I have only a few thoughts to add.
The uveitis being discussed in this issue is uveitis that includes inflammation in the posterior segment, with flare and cells in the vitreous and in some patients chorioretinitis. While I am comfortable managing acute anterior nongranulomatous and even some cases of granulomatous iridocyclitis, intermediate and posterior uveitis for me is a case best referred to a colleague with specialty training in treating these challenging cases. Infection must always be ruled out, and some cancers can present as a so-called “masquerade syndrome” with cells in the vitreous.
The etiologic causes of posterior uveitis are diverse and often require a vitreous tap with sophisticated pathology laboratory evaluation. In our city, most of these cases are managed by our vitreoretinal colleagues, but every city is different. For me, a referral for proper diagnosis and therapy is appropriate for these patients.
Management usually requires significant use of steroids, often delivered topically, subconjunctivally, suprachoroidally, intravitreally and/or via sub-Tenon’s. Today there are several depot versions of steroid, some lasting as long as 3 years. Systemic steroids and/or steroid-sparing agents such as Humira (adalimumab, AbbVie) or methotrexate are also often required.
The key vision-threatening issues to monitor if we are comanaging these patients are macular edema, cataract, secondary glaucoma and band keratopathy. We are all capable of monitoring patients for these diagnoses and, in collaboration with our colleague subspecialists, treating them. Cataract surgery and glaucoma surgery are often required. It is best to have inflammation under good control and, if possible, a dry macula when cataract surgery is contemplated. Steroids and NSAIDs make sense in these patients and may be delivered by several routes in the perioperative period starting before surgery and continuing long term after surgery. In an adult, I prefer an aspheric or toric aspheric hydrophobic acrylic monofocal IOL. In children, it is usually best to initially leave the child aphakic and manage the patient until maturity with glasses and/or contact lenses. At a later date, a secondary intraocular implant is an option. Many patients develop glaucoma, and surgery may be required to treat it. Again, I usually consult with a glaucoma specialist experienced in treating these patients when their glaucoma is not well managed on medical therapy. These are tough patients who require lifelong therapy, and significant vision loss is not uncommon.
Fortunately, most large urban areas have well-trained ophthalmologists highly experienced with uveitis treatment. For the rural patient, annual travel to an urban center is often necessary with comanagement with their local ophthalmologist.
Disclosure: Lindstrom reports he consults for Bausch Health.