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Make a list of indications of immunomodulators in ophthalmology

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ophthalmic immunosuppression

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ophthalmology systemic immunomodulatory therapy indications uveitis ocular inflammatory disease

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https://www.aao.org/eyenet/article/uveitis-guidelines-immuno…

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Indications for systemic immunomodulatory therapy in ophthalmology

Systemic immunomodulators are mainly used for noninfectious, immune-mediated ocular inflammation, particularly when corticosteroids alone are ineffective, unsafe, or unsuitable long term.

1. Noninfectious uveitis

  • Chronic or recurrent anterior uveitis
  • Intermediate uveitis / pars planitis
  • Posterior uveitis
  • Panuveitis
  • Bilateral sight-threatening uveitis
  • Posterior segment, macular, optic nerve, or retinal vascular involvement
  • Exudative retinal detachment due to inflammation
  • Chronic progressive entities such as:
    • Birdshot chorioretinopathy
    • Multifocal choroiditis
    • Retinal vasculitis
    • Serpiginous choroiditis
    • Vogt-Koyanagi-Harada disease
    • Sympathetic ophthalmia
    • Behçet uveitis

2. Steroid-related indications

Use as a steroid-sparing treatment when there is:
  • Persistent inflammation despite adequate local or systemic corticosteroids
  • Relapse during tapering, especially below prednisone 7.5-10 mg/day
  • Requirement for prolonged systemic corticosteroid treatment
  • Steroid intolerance or serious adverse effects, such as diabetes, hypertension, osteoporosis, psychosis, cataract, or glaucoma
  • Inadequate response to periocular steroid injections
  • Inadequate control with topical steroids in JIA-associated uveitis
The AAO uveitis guidance specifically lists chronic persistent inflammation, sight-threatening disease, posterior/macular disease, bilateral disease, treatment failure, and the need to avoid corticosteroid toxicity.

3. Systemic disease-associated ocular inflammation

  • Juvenile idiopathic arthritis-associated uveitis
  • Behçet disease with ocular involvement
  • Sarcoid uveitis
  • HLA-B27-associated recurrent severe uveitis
  • Rheumatoid arthritis-associated scleritis or peripheral ulcerative keratitis
  • Granulomatosis with polyangiitis and other ANCA-associated vasculitides
  • Systemic lupus erythematosus-associated retinal vasculitis
  • Relapsing polychondritis
  • Inflammatory bowel disease-associated uveitis

4. Scleritis and episcleritis

  • Necrotizing scleritis
  • Diffuse or nodular scleritis unresponsive to NSAIDs and corticosteroids
  • Recurrent scleritis requiring repeated steroid courses
  • Scleritis associated with systemic vasculitis or connective-tissue disease
  • Posterior scleritis threatening vision

5. Corneal and ocular-surface autoimmune disease

  • Peripheral ulcerative keratitis / corneal melt
  • Mooren ulcer
  • Ocular cicatricial pemphigoid / mucous membrane pemphigoid
  • Stevens-Johnson syndrome and severe chronic cicatrizing ocular-surface inflammation, in selected cases
  • Severe refractory atopic keratoconjunctivitis or vernal keratoconjunctivitis, usually with topical calcineurin inhibitors first

6. Orbital and adnexal inflammatory disease

  • Idiopathic orbital inflammation / orbital pseudotumor that is recurrent or steroid-dependent
  • Severe active thyroid eye disease, where biologic or other immunomodulatory therapy may be indicated
  • IgG4-related ophthalmic disease with recurrent or steroid-dependent inflammation

7. Corneal graft and transplant-related indications

  • High-risk corneal transplantation, such as vascularized corneas, previous graft rejection, or repeated graft failure
  • Recurrent immune corneal graft rejection, in selected cases

Practical principle

Immunomodulators are generally started after excluding infection and masquerade syndromes. They are not a substitute for antimicrobial therapy in infectious uveitis, keratitis, or scleritis. For chronic progressive posterior uveitis or panuveitis, early steroid-sparing therapy may be appropriate because these agents often take months to achieve full effect, as described in an AAO management review.
Common agents include methotrexate, mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus, cyclophosphamide, and biologics such as adalimumab or infliximab. These require monitoring and are usually co-managed with a uveitis specialist, rheumatologist, or internist.
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