Periocular corticosteroid injections treat uveitis in most patients

Some patients, however, developed cataract and elevated IOP.

Issue: October 10, 2014

Most patients with uveitis who received at least one periocular depot corticosteroid injection during follow-up benefited from the therapy, including an improvement in reduced visual acuity attributed to macular edema, a study found.

“Local treatment strategies are frequently used in the management of uveitis, often as an adjunct to systemic treatment in severe cases,” lead author H. Nida Sen, MD, MHSc, director of the Uveitis and Ocular Immunology Fellowship Program at the National Eye Institute, said. Such local strategies have the advantage “of sparing patients from systemic side effects, but there is concern for local side effects such as cataract and intraocular pressure elevation,” she said.

The 1,192 eyes of 914 patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study, a large multicenter, retrospective cohort study.

“This is the largest cohort to date for periocular steroid injections,” Sen told Ocular Surgery News.

The study was published in Ophthalmology.

Effective in most patients

Patients were categorized based on the site of uveitis into three roughly equal groups: anterior uveitis, intermediate uveitis, and posterior uveitis or panuveitis. The mean duration of inflammation before the first periocular corticosteroid injection was 4.8 years (range: 0 years to 36.3 years).

Within 6 months after the first injection, 72.9% of eyes achieved complete resolution of inflammation and 49.7% reached a visual acuity greater than 20/40.

“These results are consistent with clinical impressions that physicians treating uveitis have held for many years: that periocular injections appear effective in most patients, with resultant quiescence of active inflammation and/or resolution of macular edema that can lead to visual acuity improvement,” Sen said.

However, as expected, cataract and elevated IOP occurred in a minority of eyes, which may be related to the treatment or the uveitis itself, or possibly both, Sen said.

Some other potential side effects of injections, such as ptosis and pigment changes, were not evaluated by the study. “Globe perforation also can occur, but it is extremely rare,” Sen said.

Sen said periocular corticosteroid injections are particularly useful in patients with episodic disease who are likely to remain in remission for an extended period of time after the inflammation from a flare-up has been controlled or as an adjunct to systemic immunosuppressive therapy when rapid control of inflammation is needed.

“These injections quell active inflammation when ongoing suppression is not likely to be necessary or as an adjunct to a suppressive treatment when rapid control of active inflammation is needed,” she said.

Injections also are a beneficial rescue therapy for anterior uveitis that has not responded to topical corticosteroid therapy.

“Periocular corticosteroid injection also is helpful in clearing macular edema that has persisted after uveitis has been quieted,” Sen said. “In some cases, treatment can address both indications at the same time.”

Observations

For the most part, the location of the uveitis did not notably affect outcomes, except that anterior uveitis was associated with better visual acuity and inflammatory response outcomes.

“As expected, shorter duration of uveitis was associated with better outcomes in general,” Sen said.

Additionally, study results suggested that injections administered multiple times may have less value than previously thought.

“Repeated injections were associated with increased risk of cataract and cataract surgery, but not necessarily with increased likelihood of favorable outcomes,” Sen said. “Overall, ocular side effects such as ocular hypertension and need for cataract surgery were much less common than has been reported with intravitreal injections of corticosteroids.”

The SITE-2 study is ongoing and may allow for further assessment. – by Bob Kronemyer

Reference:

Sen HN, et al. Ophthalmology. 2014;doi:10.1016/j.ophtha.2014.05.021.

For more information:

H. Nida Sen, MD, MHSc, can be reached at National Eye Institute, NIH, 10 Center Drive, Building 10N112, Bethesda, MD 20892; 301-435-5139; email: senh@nei.nih.gov.

Disclosure: Sen has no relevant financial disclosures.