Immunomodulatory therapy (IMT) can be an effective steroid-sparing alternative for treating pediatric intermediate uveitis, according to this retrospective study.
Study design
Investigators reviewed the disease course, treatment and outcomes of 39 pediatric intermediate uveitis patients seen at the Uveitis Clinic at the University of Utah from 1999 to 2012. Immunomodulatory agents included conventional therapies of methotrexate, mycophenolate mofetil and cyclosporine, as well as biologic response modulators adalimumab and infliximab. Mean patient age at presentation was 7.7 years.
Outcomes
Overall, a high rate of significant ocular comorbidities were noted, which included ocular hypertension, cataracts and cystoid macular edema.
Of the 50 eyes that received at least one course of systemic corticosteroids, 40 eyes (20 patients) failed to achieve a sustained remission and were subsequently treated with IMT. All but 1 patient were successfully tapered off systemic corticosteroids while taking at least one IMT agent without uveitis recurrence. The single patient who was unsuccessful in discontinuing corticosteroids had persistent cystoid macular edema and was started on methotrexate shortly before the conclusion of the study.
At the final follow up of 37 months, approximately 75% of eyes had inactive disease.
The authors noted that 43 of eyes were treated with corticosteroid therapy exclusively, and never received any IMT. The outcomes for those patients, however, were not discussed.
A small subset of patients (n=2) with the mildest disease symptoms did not require any interventions except for routine monitoring.
The authors also observed that patients under age 7 at onset were more likely to undergo vitrectomy, and less likely to achieve remission. Younger children also seemed to have more vitritis, while cystoid macular edema was more prevalent in older children.
Limitations
Because intermediate uveitis remains a relatively uncommon condition, data regarding the utility of IMT are limited.
Clinical significance
The findings here show that chronic exposure to corticosteroids in pediatric patients can be eliminated if IMT is initiated early in the disease course. The authors acknowledge a role for local therapy such as injections of corticosteroids, but point out that these can be difficult in young children with bilateral disease and can result in cataract formation or glaucoma.