New options achieve equivalent efficacy, reduce adverse effects

Inflammatory eye diseases are relatively rare, affecting about 345,000 Americans. Uveitis, a major cause of visual morbidity, accounts for 10% of legal blindness in the United States. Oral corticosteroids are the mainstay of therapy, but long-term use can produce a host of adverse effects from glaucoma to diabetes, says UAB ophthalmologist Russell W. Read, MD.

Patients with chronic uveitis who cannot tolerate or are resistant to steroids or whose disease is not adequately controlled on doses of ≤10 mg per day of prednisone have new treatment options. Mycophenolate mofetil (MMF) and antitumor necrosis factor (TNF) drugs — all steroid-sparing agents — and Retisert, an intraocular steroid-releasing implant, often can relieve inflammation with fewer side effects than traditional therapy. “To control disease flares, newer options may need supplementation with steroids or older steroid-sparing agents such as methotrexate,” he says. “Combination therapy may let patients reap benefits with lower doses of each drug.”

Alternative Agents
Retisert slowly releases fluocinolone acetonide directly into the posterior of the eye for about 1000 days. Direct intraocular delivery of steroids results in fewer systemic effects than oral steroids. Each implant, which costs more than $18,000, treats only one eye, and many patients have bilateral disease, says Read, who notes the device produces a 100% incidence of cataracts within 3 years and increased intraocular pressure in about 60% of patients. “Patients receiving the implant potentially face three procedures per eye — an outpatient procedure to insert the implant, a cataract operation, and surgery to control intraocular pressure.”

He most often recommends the device for patients with chronic unilateral disease and contraindications to traditional steroid-sparing agents.

MMF, an immunosuppressive drug originally developed to prevent rejection of transplanted organs, has shown efficacy for controlling a range of autoimmune diseases, including immune-mediated uveitis. “MMF appears to work as well as traditional steroid-sparing agents, and patients often tolerate it better than older drugs,” he says.

Anti-TNF therapies such as infliximab, etanercept, and adalimumab also show promise for ocular inflammatory conditions, particularly Behçet’s disease, a chronic relapsing disorder that affects multiple organ systems including the eyes.

“Most uveitis therapies, including older agents, have equivalent efficacy, controlling the condition in about 80% of patients,” Read says. “For disease that is chronic, recurrent, or poorly responsive to corticosteroids, newer options, used alone or in combination with other drugs, may relieve inflammation with fewer side effects.”

No head-to-head trials of newer agents and corticosteroids have been completed, and Read says treatment choice depends on disease severity, the patient’s ability to tolerate various drugs, and comorbidities.

“Because inflammatory eye diseases can produce severe complications including macular edema, scarring, and blindness, physicians should refer patients with unusual or refractory signs or symptoms to a specialist,” he says. “Early, aggressive treatment can reduce chronic damage and preserve vision.”

For more information:
Dr. Russell Read
1.800.UAB.MIST
mist@uabmc.edu