Every inflammatory condition has the potential of causing irreversible damage to the affected area, with each uncontrolled event building in a cumulative fashion. Because of the large number of nerve cells present in the eye, uncontrolled episodes of ocular inflammation may cause permanent cumulative damage leading to rapid loss of visual acuity (VA) and eventually blindness.

While it is widely accepted that cumulative damage can occur with any uncontrolled inflammation, there are some ocular disorders that are easier to treat and that cause less severe damage; conversely, there are others that are very difficult to treat with worse visual outcomes. Anterior-segment inflammation can be the easiest to quell and has less impact on loss of VA; however, in many disorders—including uveitis—the effects of cumulative damage are much more pronounced. Posterior uveitis (inflammation of the retina, choroid, optic nerve, or vitreous) can be extremely tough to treat, and even the more successful cases will develop cumulative damage over time due to periodic exacerbations.

As far back as 1996, publications have backed the theory of cumulative damage in ocular inflammatory disease. Despite this, the development of new treatment options has been few and far between, forcing ECPs to treat inflammation with what is available. In many disorders, local therapy (eg, intravitreal corticosteroid injections) affords only transient inflammatory suppression, and the use of systemic agents may be very limited by serious adverse events. Therefore, the disease course of uveitis—and other similar conditions—can be noted by recurrent inflammatory episodes, each causing progressive, permanent decrease in VA, and can be formidable when using traditional treatments.

Several therapeutic options are available, each with pros and cons:

  • Systemic–oral corticosteroids can be effective in anterior and mild posterior inflammation; however, they carry many side effects due to the need for higher doses because of poor penetration into the eye. Other oral options include cytokine inhibitors and immunomodulatory drugs such as antimetabolites, T-cell inhibitors, and alkylating agents. which also carry a long list of adverse events including hepatic and hematologic toxicities and gastrointestinal issues that can lead to titration or discontinuation of treatment, allowing inflammation to return
  • Topical–drops to dilate the pupil can prevent muscle spasms in the iris and ciliary body, while steroidal drops can reduce inflammation. Both are generally well tolerated and have minor AEs such as cataract formation and increased IOP. Unfortunately, these agents are not effective in advanced disease
  • Local corticosteroid injections–because of the way they are administered, injections cycle through periods of hyper-therapeutic and sub-therapeutic levels, leading to uncontrolled inflammation between treatments. They include a high rate of cataract and increased IOP/glaucoma
  • Ocular implants–while sustained-release corticosteroid “devices” can completely control posterior inflammation, they include accelerated cataract formation and complications due to increased IOP. Biodegradable implants can control inflammation for up to 6 months, while non-degradable implants can last up to 3 years, making them an ideal option for the hard-to-treat patient
  • New options in the clinic–a range of new treatment options are currently in clinical trials, including new and improved ocular implants; immunomodulating agents targeting the mTOR pathway; a number of new biologics; improved systemic therapeutics; electric current application (Iontophoresis) to increase the levels of systemic medication allowed to enter the eye, and gene therapies for certain genetic disorders. Safety and efficacy of these new treatments will be seen over time as they advance through the clinic

Regardless of the cause or location of ocular inflammation, the treatment goal should not only be to suppress recurrent inflammation, but to achieve complete remission of inflammation. It is important to educate eyecare professionals and their patients on the effects of cumulative damage from uncontrolled inflammatory events.

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