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Ding X, Chang RT, Zhang X, Liu L, Yang Y, Lu L, Lin X. Clinical spectrum and possible pathogenesis of progressive outer retinal necrosis. Br J Ophthalmol 2024:bjo-2023-325113. [PMID: 39237291 DOI: 10.1136/bjo-2023-325113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/02/2024] [Indexed: 09/07/2024]
Abstract
OBJECTIVE Progressive outer retinal necrosis (PORN) is an alphaherpesvirus-caused panuveitis with devastating consequences for the eye. Our study aims to describe new findings in the clinical spectrum and propose a mechanism for the pathogenesis of PORN. METHODS Observational, consecutive case series. Seven eyes from five patients diagnosed with PORN were enrolled. Detailed case histories, ocular examination findings and multimodal images of retina were collected. Optic nerve and brain imaging were obtained by MRI. RESULTS All eyes were confirmed human alphaherpesviruses positive in ocular fluid by qPCR. Optic nerve oedema was observed on MRI in all eyes. A relative afferent pupillary defect was recorded in the affected eye for the unilateral cases. Two patients with unilateral involvement had a history of viral encephalitis and focal encephalomalacia found in the temporal lobe on brain MRI. The affected eyes were characterised by sensory retinal necrosis sparing retinal pigment epithelium, starting at the end of the retinal nerve fibre (horizontal raphe or peripheral area of the retina) and progressing rapidly along the nerve fibre. The wall of the retinal artery and vein was destroyed, resulting in blood flow interruption on fluorescein angiography and retinal haemorrhages along the large vessels. CONCLUSIONS Combination the neurotropic characteristics of alphaherpesviruses and the signs of PORN, we hypothesised that the reactivated PORN virus originated from the lateral geniculate nucleus, then propagated along the optic nerve and was released at the terminals, causing necrosis of the entire sensory retina rather than just affecting the outer segment.
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Affiliation(s)
- Xiaohu Ding
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Robert T Chang
- Department of Ophthalmology, Byers Eye Institute at Stanford University, Palo Alto, California, USA
| | - Xiongze Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - LiLi Liu
- Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yangfan Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Lin Lu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Xiaofeng Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
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2
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Kalogeropoulos D, Afshar F, Kalogeropoulos C, Vartholomatos G, Lotery AJ. Diagnostic and therapeutic challenges in acute retinal necrosis; an update. Eye (Lond) 2024; 38:1816-1826. [PMID: 38519714 PMCID: PMC11226642 DOI: 10.1038/s41433-024-03028-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 03/25/2024] Open
Abstract
Acute retinal necrosis (ARN) is a rare but severe ophthalmic pathology defined by panuveitis, retinal necrosis, and high rates of retinal detachment. ARN may lead to poor visual outcomes even if promptly diagnosed and treated. ARN may present with a wide spectrum of clinical findings compatible with panuveitis including anterior uveitis, scleritis, vitritis, necrotizing retinitis, occlusive vasculitis, and optic disc edema. The American Uveitis Society introduced clinical criteria in 1994 for the diagnosis of ARN, while more recent criteria have been proposed by the Standardization of Uveitis Nomenclature (SUN) Working Group and the Japanese ARN Study Group. Multimodal imaging is a valuable tool in evaluating patients with ARN, particularly in unusual cases, while utilizing retinal imaging and applying AI algorithms in these areas of clinical research could be highly beneficial. Over the last few years, significant progress has been made in achieving timely diagnosis and treatment. The precise identification of the viral cause in suspected ARN cases has been greatly enhanced by the advancements in PCR techniques and flow cytometry used for intraocular fluids. systemic (intravenous or oral) antivirals with adjunctive intravitreal antiviral therapy are recommended as first-line therapy to reduce disease severity, the risk of vision loss, and retinal detachment incidence. Although aciclovir was the first existing antiviral agent, at present many clinicians prefer high-dose valaciclovir orally or intravenous aciclovir combined with intravitreal foscarnet. Despite significant progress in diagnosing and treating ARN, further research is needed to improve visual outcomes in this challenging clinical condition.
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Affiliation(s)
| | - Farid Afshar
- Southampton Eye Unit, University Hospital Southampton, Southampton, UK
| | - Chris Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Georgios Vartholomatos
- Hematology Laboratory, Unit of Molecular Biology, University Hospital of Ioannina, Ioannina, Greece
| | - Andrew John Lotery
- Southampton Eye Unit, University Hospital Southampton, Southampton, UK.
- Faculty of Medicine, University of Southampton, Southampton, UK.
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Baquet-Walscheid K, Heinz C. [Intermediate and Posterior Uveitis - Disease entities]. Klin Monbl Augenheilkd 2024; 241:119-135. [PMID: 37977201 DOI: 10.1055/a-2193-2568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Intermediate and posterior uveitis can have multiple infectious and noninfectious causes, and posterior uveitis in particular is clinically multifaceted. Some entities require prompt initiation of therapy to ensure visual prognosis. This article presents typical characteristics of intermediate and posterior uveitides and explains special features of their treatment.
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4
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Conrady CD. Infectious Eye Diseases and Prevention Control. Microorganisms 2023; 11:1286. [PMID: 37317260 DOI: 10.3390/microorganisms11051286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 06/16/2023] Open
Abstract
Ocular infections are rare but can be unfortunate, vision-threatening conditions that can affect any part of the eye, from the outer tissues including the episcleral, sclera, and cornea to inside the eye such as the anterior chamber, vitreous, optic nerve, and retina [...].
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Affiliation(s)
- Christopher D Conrady
- Department of Ophthalmology and Visual Sciences, Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE 68105, USA
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68105, USA
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5
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Wu CY, Fan J, Davis JL, Berrocal AM, Haddock LJ, Yannuzzi NA, Fortun JA, Scott NL, Chau V, Albini TA. Surgical Outcomes of Acute Retinal Necrosis-Related Retinal Detachment in Polymerase Chain Reaction-Positive Patients: A Single-Center Experience. Ophthalmol Retina 2022; 6:992-1000. [PMID: 35654364 DOI: 10.1016/j.oret.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To evaluate the clinical features, operative techniques, and surgical outcomes of patients who underwent surgery for acute retinal necrosis (ARN)-related retinal detachment (RD). DESIGN Retrospective, longitudinal, consecutive case series. PARTICIPANTS Patients with polymerase chain reaction-positive ARN presenting from 2011 to 2021 who underwent vitreoretinal surgery for ARN-related RD at our institution. METHODS Univariate, multivariate, and survival analyses were used to determine predictors of anatomic and functional outcomes. MAIN OUTCOME MEASURES Single-surgery anatomic success rate, recurrent RD, and visual acuity (VA) at 1 year. RESULTS Thirty-four eyes of 34 patients (32.4% women, mean age, 45.1 ± 20.4 years) were included for analysis with a median follow-up of 2.5 years (interquartile range [IQR], 0.8-5.5 years). Presenting VA was 1.1 ± 0.8 logarithm of the minimum angle of resolution (LogMAR) (Snellen ∼20/250). The median time from presentation to RD surgery was 1.7 months (IQR, 0.8-4.1 months), and the mean preoperative VA was 1.6 ± 0.8 LogMAR (Snellen ∼20/800). Small-gauge pars plana vitrectomy (PPV) with or without a scleral buckle (SB) was performed for all eyes with an overall single-surgery success rate of 63.6%, with no statistically significant differences in visual/anatomic outcomes between PPV and PPV/SB cases. Silicone oil was used for tamponade in 33 (97.1%) cases and was removed in 10 (30.3%) with good anatomic and final functional outcomes (Snellen ∼20/80). Independent predictors of recurrent RD included the female sex (hazard ratio, 8.38; 95% confidence interval, 2.03-34.68; P < 0.01) and zone 1 retinitis involvement at presentation (hazard ratio, 10.95; 95% confidence interval, 2.12-56.48; P < 0.01). The mean VA at 1 year (VA1year) and at the final follow-up both had a Snellen equivalent of 20/640 (P > 0.05 for both compared with preoperative VA, respectively). Eyes that achieved single-surgery success had VA1year of 20/200 versus hand movements in those with single-surgery failure (P < 0.01). On multivariate linear regression, younger age (P = 0.04) and better presenting VA (P < 0.01) were both associated with better VA1year. CONCLUSIONS Moderate single-surgery anatomic success can be achieved with modern vitreoretinal surgical techniques for ARN-related RD, although visual outcomes remain poor. Further studies investigating interventions for increasing single-surgery success rates, for the inflammatory complications of ARN, and for preventing ARN-related RD are needed.
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Affiliation(s)
- Chris Y Wu
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Jason Fan
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Janet L Davis
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | | | - Luis J Haddock
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | | | - Jorge A Fortun
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Nathan L Scott
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Viet Chau
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Thomas A Albini
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida.
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Hojjatie S, Shantha JG, O’Keefe GD, Kraft CS, Voloschin A, Grossniklaus H, Yeh S. Cytopathology of Vitreous Specimens in Acute Retinal Necrosis. Ocul Immunol Inflamm 2022; 30:1609-1616. [PMID: 34242097 PMCID: PMC8742848 DOI: 10.1080/09273948.2021.1922926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/27/2021] [Accepted: 04/19/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE To report the cytopathology of vitreous biopsy samples in patients with acute retinal necrosis (ARN) who underwent pars plana vitrectomy (PPV). We also describe two patients with unique clinical courses, cytopathologic findings, and immune response. METHODS A retrospective review of patients with ARN who developed retinal detachment (RD) and underwent PPV from 22011 to 2019 at the Emory Eye Center was performed to assess cytopathology findings of vitreous biopsy samples. Patient demographics and laboratory testing including aqueous humor PCR for viral pathogens were recorded. Additional clinical details abstracted included intravitreal injections, surgical procedures, and vitreous cytopathological reports including immunohistochemistry findings. RESULTS Fourteen eyes of 12 patients with RD were reviewed. Ten eyes showed HSV DNA (71%) and 4 demonstrated VZV DNA (29%). All eyes received intravitreal antivirals (i.e. ganciclovir or foscarnet) with a median of 8.5 intravitreal injections per eye. Diagnoses prompting PPV included tractional RD in 14 eyes (100%), rhegmatogenous RD in 8 eyes (57%), vitreous hemorrhage in 4 eyes (29%) and vitreous opacity in 4 (29%). Ophthalmic pathology reports showed lymphocyte populations in 10 eyes (71%) with a CD3 + T-cell predominance in two patients where immunohistochemistry of CD3+ and CD20+ for T- and B-cell populations was performed. Observed immune cell populations included macrophages or histiocytes (11 eyes, 79%) and polymorphonuclear cells in 4 eyes (29%). Initial median VA was 2.5 (IQR 2.0-3.0) and improved to 2.0 (IQR 1.48-3.00, p = .48) at 6-months and 1.8 (IQR 1.2-3.0, p = .45) at 12 months follow-up. CONCLUSIONS Our cohort of ARN patients undergoing PPV show a spectrum of immunologic findings with the majority demonstrating a lymphocytic response. Histiocytes, macrophages, and PMNs were also observed. Cytopathologic and immunologic studies suggest that both innate and adaptive immunity are responsible for the clinical disease findings observed in ARN. The variability of the response to treatment in patients with ARN may reflect patient-to-patient differences in their antigen-specific immune response. Understanding the immunologic response associated with ARN may provide valuable information regarding the dosing and timing of treatment.
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Affiliation(s)
- Sara Hojjatie
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | | | | | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Alfredo Voloschin
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, GA
| | - Hans Grossniklaus
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
- L.F. Montgomery Pathology Laboratory, Atlanta, GA
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
- Emory Global Health Institute, Emory University, Atlanta, GA
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE
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7
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Mojarrad A, Omidtabrizi A, Ansari Astaneh M, Bakhtiari E, Shiezadeh E, Hassani M, Hosseini SM. Acute retinal necrosis. Management and visual outcomes: a case series. Int J Retina Vitreous 2022; 8:66. [PMID: 36109794 PMCID: PMC9476592 DOI: 10.1186/s40942-022-00417-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The present study reports the functional and anatomical outcomes of eyes with acute retinal necrosis(ARN).
Methods
This is a retrospective case series conducted at a tertiary Eye Hospital from March 2015 to March 2020. Medical records of patients with clinical and laboratorial—Polymerase Chain Reaction (PCR)—diagnosis of ARN were reviewed. To identify factors related to the outcomes of visual acuity(VA) and retinal detachment (RD) over time, Cox proportional hazards regression modeling and survival analyses were used.
Results
Twenty-three eyes of 23 patients (16 male, 7 female) were reviewed. Based on the PCR results, 16 cases (69.6%) had Varicella zoster virus, 3 cases (13%) had Cytomegalovirus, 1 patient (4.3%) had Herpes simplex virus associated ARN, and 1 case (4.3%) had negative PCR. The incident rate for ≥ 2-line VA gain was 0.28/eye-year (EY) (95% CI 0.21 ± 0.26) while the rate of severe vision loss was 0.09/eye-year (95% CI 0.05 ± 0.08). The RD development was observed at a rate of 0.43/eye-year (0.42 ± 0.02), which occurred in 9 eyes with a mean time of 100 days after the initial presentation of ARN. Patients’ age was the only factor associated with 2-line or more gain in VA over time with a hazard ratio of 0.921 (95% CI 0.854–0.993, P = 0.032).
Conclusions
Generally, although being crucial, treatment is not highly effective in improvement of VA and decrease of RD development, as well as vision loss, in patients with ARN. However, treatment prevents fellow eye involvement efficiently. Younger age is associated with better response to treatment and more chance to achieve better VA.
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8
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Lains I, Eliott D. Challenges and Updates on the Management of Acute Retinal Necrosis. Int Ophthalmol Clin 2022; 62:173-196. [PMID: 35325918 DOI: 10.1097/iio.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Bavinger JC, Anthony CL, Lindeke-Myers AT, Lynch S, Xu LT, Barnett J, Levine D, Patel P, Shah R, Jain N, Rao P, Hendrick A, Cribbs BE, Yan J, Hubbard GB, Shantha JG, O'Keefe GD, Yeh S. Risk Factors for Retinal Detachment in Acute Retinal Necrosis. Ophthalmol Retina 2022; 6:478-483. [PMID: 35114414 DOI: 10.1016/j.oret.2022.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Retinal detachment (RD) is associated with poor visual outcome in patients with acute retinal necrosis (ARN). This research was undertaken to assess risk factors for RD in ARN. DESIGN Retrospective cohort study SUBJECTS: Patients diagnosed with ARN at a tertiary referral center from 2010-2020. METHODS Chart review was performed for all clinical and surgical encounters. Univariate and multivariate logistic analysis of demographic and clinical variables associated with RD was performed. Survival analysis with Kaplan-Meier estimates were performed to compare time to RD in HSV- and VZV-associated ARN. MAIN OUTCOME MEASURES Demographic information, clinical information including visual acuity, intraocular pressure (IOP), intraocular inflammation level, extent of retinitis, incidence and timing of retinal detachment, date of diagnosis, and treatments performed including intravitreal injections of antiviral medications. RESULTS Fifty-four eyes of 47 patients who were diagnosed with ARN were included with equal proportions of eyes (27, 50%) with VZV-ARN and HSV-ARN. Subjects with VZV-ARN were on average older, more likely to be male, and more likely to be immunosuppressed compared with subjects with HSV-ARN. Clinical characteristics were similar between eyes with VZV- and HSV-ARN, including initial visual acuity (VA), initial IOP, anterior segment inflammation, clock hours and posterior extent of retinitis. In univariate analysis of clinical and demographic variables associated with development of RD, initial VA (p = 0.0083) and greater clock hours of retinitis (p = 0.009) were significantly associated with RD. These two variables remained significant in multivariate logistic regression; worse VA at presentation had an odds ratio of 2.34 (95% CI: 1.01 - 5.44) (p = 0.042) and greater clock hours of retinitis had an odds ratio of 1.23 (95% CI: 1.02 - 1.47) (p = 0.025). Kaplan Meier survival analysis demonstrated no statistical difference in RD-free survival between HSV- and VZV-ARN. CONCLUSION Patients with VZV-ARN were more likely to be older, male, and immunosuppressed compared to HSV-ARN although no clear difference was observed in RD by viral etiology. Poor initial VA and clock-hours of retinitis were significantly associated with RD development and may be relevant for patient counseling and prognosis.
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Affiliation(s)
- J Clay Bavinger
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Casey L Anthony
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Stephanie Lynch
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Lucy T Xu
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Barnett
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - David Levine
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Purnima Patel
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel Shah
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Nieraj Jain
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Prethy Rao
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew Hendrick
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Blaine E Cribbs
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jiong Yan
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - G Baker Hubbard
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Ghazala D O'Keefe
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.
| | - Steven Yeh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, Nebraska.
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Update on the Management of Uveitic Macular Edema. J Clin Med 2021; 10:jcm10184133. [PMID: 34575244 PMCID: PMC8470573 DOI: 10.3390/jcm10184133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/07/2021] [Accepted: 09/11/2021] [Indexed: 12/15/2022] Open
Abstract
Uveitic macular edema (ME) is a frequent complication in 8.3% of uveitis patients and is a leading cause of serious visual impairment in about 40% of cases. Despite the numerous available drugs for its treatment, at least a third of patients fail to achieve satisfactory improvement in visual acuity. First-line drugs are steroids administered by various routes, but drug intolerance or ineffectiveness occur frequently, requiring the addition of other groups of therapeutic drugs. Immunomodulatory and biological drugs can have positive effects on inflammation and often on the accompanying ME, but most uveitic randomized clinical trials to date have not aimed to reduce ME; hence, there is no clear scientific evidence of their effectiveness in this regard. Before starting therapy to reduce general or local immunity, infectious causes of inflammation should be ruled out. This paper discusses local and systemic drugs, including steroids, biological drugs, immunomodulators, VEGF inhibitors, and anti-infection medication.
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