What is the role of corticosteroids in the treatment of human leukocyte antigen (HLA) B27–associated acute anterior uveitis (AAU)?

Updated: Apr 09, 2021
  • Author: Huy D Nguyen, MD, MBA; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Answer

Answer

Corticosteroids may be administered by 4 routes, including topical, periocular, intraocular (intravitreal), and systemic. Topical corticosteroids are the mainstay of uveitis therapy. The goal is to use the minimum amount necessary to control inflammation and to prevent complications. Aggressive initial therapy may hasten recovery and limit the duration of therapy. Prednisolone acetate 1% given every hour is strongly recommended for acute presentations. Ointment form is available to those who cannot tolerate the preservative in the drops and may be particularly useful for a longer-acting bedtime dosage. Usually, 2-3 weeks at maximal frequency is all that is necessary to completely eliminate all cells, and a taper regiment is recommended when discontinuing therapy.

Occasionally, severe inflammation may not respond and may require periocular, intraocular, or systemic corticosteroids, especially if the posterior segment is involved. Periocular corticosteroids are usually given as depot injections in the sub-Tenon space. Intravitreal corticosteroids by injection or by implantation of a sustained released device have been shown to be useful in the treatment of both chronic uveitis and uveitic cystoid macular edema. These sustained devices are particularly promising in treating long-standing inflammation, as they can release medications for as long as several years after implantation. This would allow reduction or elimination of systemic corticosteroids or immunosuppressive agents, thereby minimizing systemic effects related to treatment with these agents. Notable ocular side effects include accelerated cataract development and steroid-induced glaucoma, therefore intraocular pressures should be monitored on a regular basis.

Systemic corticosteroids can be administered orally or intravenously. These are especially beneficial when the systemic disease requires therapy as well. It is important to discuss the adverse effects of corticosteroids with the patient and to have these monitored by the patient's primary care physician. Prednisone at 1 mg/kg/d is a common starting dose and is titrated based on comorbidities and response.


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