Immunosuppressive therapy for eye diseases: Effectiveness, safety, side effects and their prevention

Ocular inflammation is a significant cause of ocular morbidity and visual impairment. Topical, periocular, intraocular, and systemic corticosteroids are highly effective for treating appropriate forms of ocular inflammation. However, their use may be constrained by local and/or systemic side effects, especially if long-term therapy is required. As a result, immunosuppressive agents increasingly have been used to manage ocular inflammation alongside or in place of corticosteroids. The four categories of agents used today are antimetabolites [primarily methotrexate, mycophenolate mofetil (MMF), and azathioprine]; T-cell inhibitors (usually cyclosporine, less often tacrolimus or sirolimus); alkylating agents (cyclophosphamide and chlorambucil); and biologic agents [tumor necrosis factor (TNF) inhibitors, lymphocyte inhibitors, and interleukin inhibitors]. The primary goals of immunosuppressive therapy are (1) to control inflammation when corticosteroids fail to do so; (2) to prevent corticosteroid-induced toxicity when the necessary corticosteroid dosage exceeds the desired or safe level (corticosteroid sparing); and (3) to treat specific high-risk uveitis syndromes known to respond poorly to corticosteroids alone. Growing evidence shows the effectiveness of immunosuppressive drugs in achieving these goals, as well as improved visual function, prevention of ocular complications, and in some cases even disease remission. However, these agents also have side effects, which must be considered in each patient's management. In this report, we summarize the effectiveness and safety of immunosuppressive drug therapy utilized in the treatment of ocular inflammatory diseases.