Eyeworld

EW RETINA 48 April 2011 by Jena Passut EyeWorld Staff Writer Steroid reliance too common in treating uveitis More training with uveitis experts is needed; disease is curable with immuno- suppressive therapy D espite major inroads in the treatment of many ocular diseases, uveitis rates have remained nearly the same for the past 35 years. The disease has an estimated prevalence of 38 in 100,000. Of that, 10% of patients will become blind. "The reason that there has been no significant progress in driving down the prevalence in developed countries around the world is be- cause of the exclusive reliance on steroid therapy by the bulk of oph- thalmologists who care for patients with uveitis," said C. Stephen Foster, M.D., clinical professor of ophthalmology, Harvard Medical School, Boston. "They do so because that's all they've ever been taught." Dr. Foster is founder and presi- dent of the Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institu- tion, Cambridge. He offered some valuable advice to general ophthal- mologists faced with treating the non-infectious autoimmune intraoc- ular inflammation. Training is key First, ophthalmic training programs need to include faculty who are trained in ocular immunology, specifically in uveitis and the use of drugs other than steroids for treating patients with uveitis, Dr. Foster said. Of the 130 ophthalmology resi- dencies in the U.S., there are about 20 with a fellowship-trained uveitis specialist on the faculty. "Every June 30, another class of graduating residents finishes their training having only seen steroids used in the care of patients with uveitis," he said. "When they go out to their own practice, what do you think they're going to do? They're going to use steroids and only steroids, whether it's injecting or using them as drops. I am con- vinced, and many of us on the exec- utive committee of the American Uveitis Society are convinced, that no measurable change in practice patterns is going to happen until more training programs are devel- oped or more chairmen of the de- partments actively recruit a properly trained ocular immunologist or uveitis specialist onto their facul- ties." Dr. Foster said uveitis specialists are often seen as a drain on a depart- ment's budget because they will eat up space, salary, and support staff re- sources and not result in sufficient reimbursement to the department to cover the cost. "That's categorically wrong," Dr. Foster said. "If the uveitis specialist is correctly trained, he or she will ac- tually be a money maker for the de- partment." Steroids are valuable, but … Since the first steroid was adminis- tered in a human eye in 1949 by Dan Gordon, M.D., professor at Cornell Medical Center, New York, nothing has come close to its effec- tiveness for snuffing out inflamma- tion quickly. However, Dr. Gordon, and doc- tors at the Mayo Clinic who were the first to use systemic steroids to treat patients, soon realized the dis- turbing side effects of the drug. "Within a year, they realized that the chronic use of steroids comes at a fairly high price in terms of side effects that are not desirable," Dr. Foster said. "Most drugs have po- tential side effects. With corticos- teroids, they are 100% guaranteed." When steroids are used locally in the eye long enough, cataracts would be 100% guaranteed. "Thirty percent of the patients who have chronic steroid use end up with elevated IOP and some damage to the retinal ganglion cells that is evidenced by classic glaucoma," Dr. Foster said. Steroids and then what? Like most practitioners, Dr. Foster begins therapy with a course of steroids and then tapers them off. "For example, if I am dealing with a child who has juvenile idio- pathic or juvenile rheumatoid arthri- tis associated uveitis, I always use steroids first and then taper them," he said. "If the problem recurs, I use steroids again and then taper them, and if the problem occurs again, I have a conversation with the par- ents about steroid-sparing therapy, but I will go ahead and use steroids again." If the patient—pediatric or adult—has been using steroid ther- apy for 6 months, whether it is chronic use, steady use, or intermit- tent use, Dr. Foster said that's when it's time to move on. "That's the point that a tremen- dous number of comprehensive ophthalmologists simply have not incorporated into their bone marrow yet," he said. "The easiest and the knee-jerk reflex thing to do is what the doctor was taught to do in resi- dency, and that is to simply do what worked before. That is to start dous- ing with steroids again and not in- vest the time, intellect, and energy in the more difficult matter of con- versations about referrals and steroid-sparing therapy." The type of uveitis dictates how Dr. Foster will approach treatment. "That governs when I will sug- gest getting invasive by doing an in- traocular injection, intraocular implant, or doing surgery, which in- volves cleaning out the vitreous and all the inflammatory cells in it, or pulling the trigger on so-called steroid-sparing immunosuppressive therapy," he said. Immunosuppressive therapy Uveitis doesn't have to involve a lifelong treatment course. "There are a few diseases that re- quire long-term care, but the bulk of the diseases we deal with are, frankly, curable," Dr. Foster said. "The immune system, if manipu- lated correctly, has the capacity to relearn how to behave itself properly and not begin attacking the patient's tissues yet again when medications are taken away." After a patient is entirely off steroids, it takes a minimum of 2 years on immunomodulatory drugs to see a cure. "Patients have to be off the steroids for you to know that the im- Although steroids are useful in treating uveitis (pictured here), long-term use results in side effects, such as cataracts Source: Manolette Roque, M.D. Foveal thickness increase moderate after pars plana for DME R etinal foveal thickness increased moderately after phacoemulsification surgery in eyes that previously underwent pars plana vitrectomy for di- abetic macular edema, according to a study in the February edition of Retina. The increase seemed insignificant, but "prospective studies with a large number of patients are warranted for a more reliable conclusion," the study said. The retrospective, non-comparative study included 22 eyes of 19 dia- betic patients who had uncomplicated cataract surgery with phaco and IOL lens implantation after pars plana vitrectomy for diabetic macular edema that included internal limiting membrane removal. Researchers wanted to report visual acuity results and anatomical outcomes after the procedure. Researchers used optical coherence tomography to measure foveal thickness and assessed the patients' visual acuity. Statistical analysis was prepared by Wilcoxon signed-rank test. According to the study, mean foveal thickness increased by 20.5+/–67.6 microns (8.4%), with a mean pre-op FT of 237+/–69 microns compared with a mean post-op FT of 257.6+/–89.8 microns (P=0.236). Foveal thickness in- creased at least by 20% in six eyes (27.3%), remained within 20% in 14 eyes (63.6%), and decreased by 20% in two eyes (9.1%). Visual acuity improved by more than two lines in 16 eyes (72.7%) and remained stable in six eyes (27.3%). Visual acuity was 20/40 or better in 11 eyes (50%).

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