Are patients being treated with immunosuppression for ocular inflammatory disease adequately?

Abstract

Ocular inflammatory disease is often vision threatening to an individual, has significant socioeconomic impact to society and constitutes one of the more complex problems in ophthalmology. Adequate care of patients with ocular inflammatory disease requires enormous diagnostic and therapeutic efforts. Ocular immunologists need comprehensive training in several aspects of ophthalmology, and frequently, additional support from other specialties. Many reports have demonstrated the benefits of steroid-sparing agents in controlling inflammation and reducing the rate of adverse events, but it has to be stressed that poor adherence to current guidelines continues. The reasons for this are multifactorial, including unfamiliarity with the medications and concern for causing adverse events. We stress the importance of developing collaborations with rheumatologists, onocologists, allergists, dermatologists and infectious disease immunologists and adding trained ocular immunologists to faculty positions. In such ways, comprehensive ophthalmologists and those in training may gain comfort with steroid-sparing approaches to ocular inflammatory disease, reducing overreliance on chronic corticosteroids.

Keywords:

• blindness
• corticosteroids
• immunomodulatory therapy
• inflammatory eye disease
• uveitis

Acknowledgements

Dr. Jose Maria Herreras for sharing his experience and valuable help in the construction of this manuscript.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Uveitis accounts for 10% of legal blindness in the USA and an even greater number of patients with significant visual impairment.

• In the acute setting, there is nothing better than corticosteroids to rapidly extinguish inflammation. With short-term use, the potential side effects are limited.

• Long-term corticosteroid monotherapy for chronic uveitis is inappropriate due to the unfavorable risk–benefit profile and known ocular and systemic side effects that include, but are by no means limited to, cataract, glaucoma, hypertension, weight gain and osteoporosis.

• Guidelines for the initiation of steroid-sparing agents in chronic ocular inflammatory disease exist but are not being routinely followed. Ophthalmologists surveyed on immunomodulatory therapy have reported concerns about effectiveness, safety and tolerability, cost and lack of data on long-term outcomes.

• Immunomodulatory therapy with steroid-sparing agents has repeatedly been shown to be safe and efficacious in both ocular and systemic inflammatory conditions. With careful monitoring of blood work and attention to identifying occult side effects, these agents are well tolerated.

• Many adverse effects to steroid-sparing therapy are reversible and potentially avoided by close monitoring.

• Long-term studies of thousands of patients treated with conventional immunosuppressive therapy have not found an increase in overall or cancer-specific mortality. Alkylating agents have shown a non-significant trend toward increased cancer mortality

• Co-management with a rheumatologist or ocular immunologist remains the best way to maximize both the safety and efficacy of these medications for patients with chronic ocular inflammation.

• In these collaborations, it is important for the ophthalmologist to take the leading voice in reporting the status of the ocular inflammation and, if necessary, the need for alteration of therapy.