Immunomodulatory Therapy Associated With Best Outcomes for Sympathetic Ophthalmia

Immunomodulatory therapy (IMT) leads to better visual outcomes in patients with steroid-resistant or recurrent sympathetic ophthalmia (SO), according to a study published in the American Journal of Ophthalmology.

Researchers conducted a retrospective, comparative clinical study to compare visual acuity outcomes of long-term steroid therapy to those of immunomodulatory therapy in the treatment of SO. The study included 35 patients with SO with follow-up between 1 and 17 years.

The study found that longer periods of active uveitis and steroid treatment correlated with higher rates of vision loss, and longer periods of uveitis remission on immunomodulatory therapy alone and drug-free remission correlated with lower rates of vision loss. SO remission was more likely to occur following treatment with alkylating agents of combination therapy with an antimetabolite, a biologic-response modifier, and cyclosporine.

The study notes that treatment of SO is delicate given that many patients are monocular and at risk of adverse effects from both corticosteroids and immunomodulatory therapies. Additionally, because long-term drug-free remission is not yet a common outcome in SO, patients must also adhere to long-term treatments. Therefore, the researchers aimed to examine the long-term treatment course and ophthalmic outcomes of patients with SO who were treated with corticosteroids, immunomodulatory therapies, or both.

“When considering the choice of IMT using the stepladder approach to uveitis treatment, SO is often insufficiently controlled by antimetabolite monotherapy and may require adjunct therapy with cyclosporine or a biologic response modifier such as infliximab or adalimumab,” the study authors explain.

Immunomodulatory therapy should represent the mainstay of SO treatment, unless contraindicated, while corticosteroids should be limited to acute treatment, bridging therapy, or for recalcitrant cases, according to the study.

While systemic corticosteroid potencies can be directly compared, ophthalmic routes of administration do not yet have standard dose equivalencies. This, in addition to the fact that patients may receive variable doses of topical corticosteroid, is a limitation of the study.