Chapter 15: Ocular Disorders Associated With Systemic Diseases
IMMUNOSUPPRESSIVE AGENTS USED IN MANAGEMENT OF EYE DISEASE
Immunosuppressive agents are used to suppress inflammatory reactions within the eye, particularly those affecting the uveal tract but also the sclera, retina, and optic nerve. Frequently, the cause of inflammation is not known, and the use of these drugs is therefore empirical. All patients must have a full medical examination before treatment is started. Special consideration must be given to patients with infections and blood diseases, and regular blood counts must be performed during the course of treatment.
Corticosteroids (eg, prednisolone) are the mainstay of immunosuppressive treatment in ophthalmology. High doses (eg, 60 mg of prednisolone daily) may be required to control inflammation, and there is a high incidence of side effects. Weight gain, acne, and hirsutism are common; peptic ulceration, myopathy, osteoporosis, and avascular necrosis are less frequently encountered. Alternate-day regimens produce fewer side effects in some patients. Azathioprine may be added as a corticosteroid-sparing drug; 2.5 mg/kg daily is an effective dose, and the total course should not last longer than 18 months. Intravenous methylprednisolone (1 g/d given over 3 hours in dextrose saline for 3 days) is an effective method of controlling exacerbations in patients already taking high doses of corticosteroids.
Cyclosporine is an immunosuppressive agent isolated from the fermentation products of a fungus that was recovered from Norwegian soil. It has an effective immunomodulating action and causes suppression of T helper cells. It is a useful alternative drug for refractory sight-threatening noninfectious inflammatory eye disease in patients who have not responded to corticosteroids or in whom the optimal therapeutic dose of corticosteroids is associated with intolerable side effects. The recommended dose is 5 mg/kg orally daily. The most important side effect is renal toxicity, but liver toxicity may also occur. Close surveillance and monitoring of kidney and liver function are mandatory on every patient receiving cyclosporine therapy. The drug should not be given to hypertensive patients. Reduction of the daily dose may be associated with troublesome rebound of the ocular inflammation.
Fortunately, cytotoxic agents are rarely indicated in the management of inflammatory eye disease except in severe cases of Beh·et's syndrome and Wegener's granulomatosis. These drugs and their important side effects are listed in Table 15-3. Cytotoxic agents are sometimes used in the treatment of myasthenia gravis (see Figure 15-36).
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10.1036/1535-8860.ch15