You suddenly find that you can’t see so well, your eye is red and has a stinging sensation, so you go see an ophthalmologist with the expectation that you will receive expert treatment in keeping with the best available evidence. If you have uveitis, that’s not always what you get. A recent study of ophthalmologists and rheumatologists in the US that was presented at the 2010 Meeting of the American Academy of Ophthalmology in Chicago found that 75% of the surveyed physicians who treat patients with uveitis (inflammation of the uvea, the layer between the sclera, or white of the eye, and the retina) do not follow recommended guidelines for managing the condition either because they are unaware of the guidelines or choose not to follow them. It’s no small divergence either — the majority of these doctors are prescribing systemic steroids at far higher doses and for far longer than recommended. That can spell trouble, because ongoing use of steroids at high doses can lead to an extensive array of dangerous complications, including heart disease, diabetes, hypertension, bone loss, weight gain and depression.
What Doctors Are Doing Wrong
Uveitis affects about 0.2% of people worldwide and causes 10% to 20% of new cases of legal blindness each year. It is associated with a variety of conditions, including autoimmune disorders, inflammatory conditions (such as Crohn’s disease and ulcerative colitis) and infections. Symptoms include eye redness, pain, light sensitivity and blurred vision. Though it usually can be cleared up or controlled with proper treatment, uveitis needs to be taken seriously because it is one of the leading causes of irreversible vision loss and blindness, which sometimes can happen very quickly.
The goal of treatment is to eliminate the inflammation in the eye, which usually is achieved with the use of the corticosteroid prednisone. The guidelines from the American Uveitis Society, several panels of uveitis experts and other scientific societies stipulate that corticosteroids should be prescribed at no more than 7.5 mg to 10 mg/day, and the duration of steroid therapy should be no more than two to three months. If the inflammation is not fully resolved, uveitis patients should then be on a combination of prednisone (at a dose of less than 10 mg/day) and a “steroid-sparing” agent, notably an immunomodulator (a drug that soothes symptoms by systemically suppressing the body’s immune response), such as methotrexate, mycophenolate mofetil or cyclosporine, among others… or an immunomodulator alone.
But that’s not what’s happening: Some doctors responding to the survey reported that they prescribe steroid doses as high as 46 mg/day, sometimes for as long as 22 months! Only a small percentage of patients were being treated according to the guidelines.
See a Uveitis Specialist
I spoke with the study’s lead author, Quan Dong Nguyen, MD, MSc, associate professor of ophthalmology at the Wilmer Eye Institute of the Johns Hopkins University School of Medicine. He indicated that it may be acceptable to begin uveitis treatment with systemic corticosteroids — but not to continue for prolonged periods and, most especially, not in such high doses. “Uveitis is usually a chronic disease that requires ongoing treatment,” he said — but “steroids should not be used chronically.” According to Dr. Nguyen, a number of scientific studies have shown twice as many cardiovascular events in patients using steroids daily at doses of as little as 5 mg to 7.5 mg for extended periods. Therefore, Dr. Nguyen said, some experts currently suggest that even 10 mg of prednisone or the equivalent daily may be too high and advocate limiting the dosage to no more than 5 mg/day of prednisone (or its equivalent).
According to Dr. Nguyen, immunomodulatory drugs may be safer than corticosteroids when used properly. Side effects of immunomodulatory therapy can include lowered white blood cell count, risk for infections, mouth sores, loss of appetite and bleeding, among others, but these side effects can be lessened or eliminated by careful monitoring of the dose and early detection of adverse events.
If a doctor diagnoses you with uveitis, Dr. Nguyen recommends seeking evaluation and treatment as early as possible from an ophthalmologist who specializes in the condition so that your vision may be preserved. Uveitis specialists are ophthalmologists who have completed additional training (one to two years after a residency in ophthalmology) in uveitis and ocular immunology. Whoever you see, it is important to discuss how the doctor manages patients with uveitis. You can go to the Web site www.Uveitis.org to see a listing of uveitis specialists in your community.