Ocular Sarcoidosis Group Issues Steroid Protocol for Uveitis

The International Workshop on Ocular Sarcoidosis (IWOS) established several recommendations for the management of the inflammatory disease, and any associated uveitis, following a discussion of survey results that polled 98 uveitis experts from 29 countries. The recommendations, published in the British Journal of Ophthalmology, review treatments with local and systemic corticosteroids.

Participants at the IWOS reviewed the survey responses from all members of the International Uveitis Study Group (IUSG) and the International Ocular Inflammation Society (IOIS). The survey asked the participants about the management of anterior uveitis (AU), intermediate uveitis (IU) and posterior uveitis (PU) and the use of drugs in respective treatments. When at least 70% of the international uveitis experts agreed in their responses, the workshop generated recommendations for the management of OS without further discussion.

A consensus expressed that ophthalmologists must consider visual acuity when they decide whether to treat any of the 3 types of uveitis.

The panel advocated for corticosteroid eye drops (prednisolone acetate 1% or equivalent) therapy at least 10 times daily as first-line therapy for severe AU cases, and 6 times daily for moderate AU. All panelists agreed that second-line therapy for severe AU included subconjunctival dexamethasone injection, periocular triamcinolone acetonide (TA) injection and systemic corticosteroid, and that second-line therapy for moderate AU included more frequent corticosteroid eye drops, subconjunctival dexamethasone injection, periocular TA injection and systemic corticosteroid. Questionnaire-driven statements indicated inactive AU did not require treatment and mydriatic eye drops were used when AU was active.

For active bilateral or unilateral IU, 7 of the 10 panelists agreed that including local corticosteroid and system corticosteroid as first-line therapy. Second-line therapy for either form of IU included local corticosteroid, systemic corticosteroid and non-biologic corticosteroid-sparing systemic immunosuppressive drugs, all panelists agreed.

Macular edema, optic disc nodules/granulomas, nodular and/or segmental periphlebitis, active chorioretinal peripheral lesions and choroidal nodules were determined to be indications for treatment of PU. First-line therapy for active bilateral or unilateral PU included systemic corticosteroid or local corticosteroid alone, or with non-biologic corticosteroid-sparing systemic immunosuppressive drugs, and second-line therapy for both was determined to be the same as first-line, with 1addition: biologic drugs were another option for corticosteroid-sparing systemic immunosuppressive drugs.

Regarding the use of systemic corticosteroids, 7 panelists agreed to recommend a mean initial dose of prednisone/prednisolone as 0.5 to 1.0 mg/kg/day, to a maximum dose of 80 mg/day; 8 agreed that the mean duration of this initial prednisone/prednisolone was 2 weeks to 4 weeks; and 9 agreed that the average of total duration of therapy with prednisone/prednisolone was 3 months to 6 months.

All panelists agreed that the initial corticosteroid-sparing immunosuppressive drugs included methotrexate, azathioprine, mycophenolate mofetil and cyclosporine. Questions regarding the biologics had already achieved more than 70% of agreement on the questionnaire; 74% of respondents answered that they used biologic drugs for ocular sarcoidosis, specifically adalimumab.

Limitations of the study included the diversity in availability of devices and drugs based medical care systems and health insurance policies across the globe and the varying numbers of respondents from each country.

The researchers said the recommendations should be validated by an international multicenter prospective study on the treatment of ocular sarcoidosis because the signs and symptoms of the disease vary among patients. A future international collaborative study is planned to establish recommendations on the management of complications of ocular sarcoidosis, such as cataract, glaucoma and other vitreoretinal disorders that may require surgical intervention and adequate peri-operative control of inflammation, they also noted.

Reference

Takase H, Acharya NR, Babu K, et al. Recommendations for the management of ocular sarcoidosis from the International Workshop on Ocular Sarcoidosis. Bri J Ophthalmol. Published onlineSeptember 15, 2020. doi: 10.1136/ bjophthalmol-2020-317354