Drug-induced uveitis

Journal of Ophthalmic Inflammation and Infection, Aug 2013

A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.

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Drug-induced uveitis

Journal of Ophthalmic Inflammation and Infection Drug-induced uveitis Nikolas JS London 2 Sunir J Garg 0 Ramana S Moorthy 1 5 Emmett T Cunningham Jr 3 4 0 MidAtlantic Retina, The Retina Service of Wills Eye Institute, Thomas Jefferson University , 840 Walnut Street, Suite 1020, Philadelphia, PA 19107 , USA 1 Associated Vitreoretinal and Uveitis Consultants, St. Vincent Hospital and Health Services , Indianapolis, IN 46260 , USA 2 Retina Consultants San Diego , 9850 Genesee Avenue, Suite 700, La Jolla, CA 92037 , USA 3 Department of Ophthalmology, Stanford University School of Medicine , Stanford, CA 94305-5101 , USA 4 Department of Ophthalmology, California Pacific Medical Center , San Francisco, CA 94115 , USA 5 Associate Clinical Professor of Ophthalmology, Indiana University School of Medicine , Indianapolis, IN 46202 , USA A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates. Review Introduction Although most cases of uveitis are due to autoimmune disorders or infections, medications are recognized as an increasingly important cause of uveitis. A number of medications encompassing various forms of administration, including topical formulations, periocular and intraocular injections, and systemic medications, have been associated with uveitis. The recent availability of treatments for neovascular diseases of the retina and choroid with anti-vascular endothelial growth factor (anti-VEGF) agents has increased the prevalence and recognition of drug-induced uveitis. The mechanism(s) underlying drug-induced uveitis are generally unclear, although both inflammatory and toxic reactions have been suggested to play a role [ 1-3 ]. As such, for each agent summarized below, we only discuss the mechanism of drug-induced uveitis when specific studies have provided additional insight. This review highlights both wellestablished and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis. Although many drugs have been reported as causing uveitis, only those drugs with multiple independent publications to help confirm causation were further ranked. Using an algorithm originally proposed by Naranjo and associates, we quantitatively describe the association of various drugs to uveitis as ‘definite,’ ‘probable,’ ‘possible,’ and ‘doubtful’ (Table 1) [ 4 ]. Naranjo scores of 9 or higher imply a definite association, scores of 5 to 8 a probable association, scores of 1 to 4 a possible association, and scores of 0 make an association doubtful. Table 2 lists the drugs most strongly associated with uveitis. Table 3 provides a list of those reviewed in the current paper and their likelihood of causing uveitis based on the Naranjo scoring system. In addition, the likelihood of causation per the Naranjo criteria is listed in parentheses next to the name of the medication in each subsection. Current updates regarding specific agents may be found at www.eyedrugregistry.com. Systemic medications Cidofovir (Naranjo score 11, definite) Cidofovir is an infrequently administered antiviral medication initially utilized for the treatment of cytomegalovirus (CMV) retinitis in patients with profound immune suppression due to human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS). It selectively inhibits viral DNA polymerase, preventing virus replication. Cidofovir can be administered intravenously or directly into the vitreous cavity through an intravitreal injection. The efficacy of intravenous cidofovir for the treatment of previously untreated CMV retinitis in patients with HIV/AIDS has been demonstrated in a multicenter randomized trial and in a dose-ranging study of cidofovir in patients with HIV/AIDS and previously treated relapsing CMV retinitis [ 5,6 ]. Compared to other treatments for CMV retinitis, cidofovir has several advantages, including a long intracellular half-life [ 7 ]. However, it is rarely used today due to several important side effects, the most serious of which is potentially irreversible nephrotoxicity. In addition, cidofovir has been shown to induce a non-granulomatous anterior uveitis in 17% to 89% of cases and hypotony in approximately 10% of cases [ 8-14 ]. These side effects occurred more frequently if patients received concomitant protease inhibitors, were previously treated for CMV retinitis, had chronic or recurrent retinitis, or had immune recovery [ 13 ]. Cidofovir2. Did the adverse event appear after the suspected drug was administered? 3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? 4. Did the adverse reaction reappear when the drug was readministered? 5. Are there alternative ca (...truncated)


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Nikolas JS London, Sunir J Garg, Ramana S Moorthy, Emmett T Cunningham Jr. Drug-induced uveitis, Journal of Ophthalmic Inflammation and Infection, 2013, pp. 43, Volume 3, Issue 1, DOI: 10.1186/1869-5760-3-43