Across the Table: Cush & Schwartzman on Uveitis Save

Uveitis is a relatively common manifestation of autoimmune disease and may be a frequent complication of all of the spondyloarthritis group of diseases, JIA, Behcet's, and sarcoidosis. Autoimmune ophthalmic disease may also be an early clinical clue to the presence of a systemic or infectious disorder. As many as 50% of patients with uveitis will have an underlying systemic disorder. Uveitis is classified on the basis of several variables:

1. Anatomical involvement, anterior, intermediate, posterior or panuveitis
2. Time course- acute or chronic
3. Underlying etiology

Anterior uveitis is most common encountered by the rheumatologist, as this is the most common form of uveitis seen in SpA. Sarcoidosis and Behcet's syndrome are unique conditions that may involve either the anterior or posterior chamber.

The abrupt onset of eye pain, photophobia, and decreased visual acuity, usually with ophthalmic injection, heralds the onset of anterior uveitis. Posterior uveitis often has insidious onset with less discomfort (rather than pain), decreased visual acuity, and floaters. Patients with a history of uveitis or symptoms of new onset uveitis are not infrequent in the rheumatology clinic.

In this edition of “Across the Table” Drs. Cush and Schwartman discuss uveitis. Our expert, Dr. Sergio Schwartzman offers up his approach to diagnosis and management. Dr. Schwartzman holds the Franchellie M. Cadwell Chair at Weill Medical College of Cornell University and the Hospital for Special Surgery in New York City.

Cush: As a rheumatologist with a long time interest in inflammatory eye disorders, what is one pearl that you would share with your fellow rheumatologists about the diagnosis of uveitis?

Schwartzman: While we see many SpA patients with what appears to be SpA-related uveitis, it’s important to always exclude an infectious process before treating patients with uveitis. Classic infections to rule out include TB and syphilis, but other infections, such as herpetic infections, may be more difficult for the rheumatologist to exclude. For this you will need the assistance of an ophthalmologist.

Cush: Is all inflammatory uveitis treated the same? With topical or intraocular corticosteroids? And for how long will patients require local corticosteroids?

Schwartzman: There are different types of uveitis (e.g., posterior, anterior, infectious, inflammatory) and treatment may vary depending on the type of uveitis and the underlying disease or cause. Ideally, one should succeed in treating uveitis by treating the identified underlying systemic disease. Although in the past it was traditional to treat resistant uveitis with prolonged systemic steroids, the current approach relies on instituting remittive and biologic agents early.

Cush: As rheumatology is the “home clinic” for many patients with uveitis, should rheumatologists take the initiative and manage patients with acute anterior uveitis without sending the patient to the eye clinic?

Schwartzman: Unequivocally the rheumatologist and ophthalmologist should work together. There are significant potential complications from topical steroids (eg,glaucoma, cataracts) and the ophthalmologist will detect these early.

Cush: Isn’t there good evidence that TNF inhibitors should be second line therapy (after steroids) in problematic or chronic uveitis?

Schwartzman: Anti-TNF agents are NOT created equally for the treatment of uveitis. Monoclonal antibodies, particularly adalimumab or infliximab, should be used in patients not responding to remittive type medications. There are few drugs approved for uveitis. Adalimumab and gevokizumab (anti-IL-1 beta monoclonal antibody) currently have “orphan drug status” in the United States and adrenocorticotropic hormone (Acthar) is actually approved for uveitis based on historical data.

Cush: There are patients with refractory or difficult uveitis – how should these be approached and managed?

Schwartzman: Identifying the underlying disease is critical. It is also important to recognize that as a “blood-ocular” barrier exists, the dose of traditional therapies used by rheumatologists frequently need to be maximized. Finally, in difficult to treat uveitis, one must always consider an underlying infection and ocular lymphoma as possible underlying etiologies

Cush: Sergio, any thanks for this insight and instruction. These pearls are invaluable to me and other rheumatologists.