Drug-Induced Uveitis
Drug-Induced Uveitis
Topical metipranolol, corticosteroids, brimonidine, and prostaglandin analogs have all been definitively associated with uveitis. The topical cutaneous medications, podophyllum and capsaicin have recently been described to have a probable association with uveitis.
Metipranolol, a nonselective β-blocker used for the treatment of ocular hypertension and glaucoma, was the first topical agent to be definitely associated with granulomatous anterior uveitis. Strong, reproducible dechallenge and rechallenge data exist for metipranolol. The cause of metipranolol-induced uveitis is unknown.
There are several reports in the early studies of steroid-induced ocular hypertension of African-American patients developing uveitis after being tapered off of topical Dexamethasone phosphate 0.1% drops or triamcinolone acetonide ointment. Ironically, the uveitis responded to intensive topical corticosteroid therapy and topical cycloplegics. There have been no new reports of corticosteroid-induced uveitis since 1979.
Brimonidine is a selective α2-adrenergic receptor agonist used to treat primary open angle glaucoma and ocular hypertension. Granulomatous anterior uveitis and intraocular pressure elevations have recently been reported with the use of topical brimonidine for more than 1 year. Reproducible dechallenge and rechallenge data make the association definite. The most effective treatment is discontinuation of the medication. The mechanism of brimonidine-induced inflammation is unknown.
Topical prostaglandin analogs such as latanoprost, travoprost, and bimatoprost are effective agents for the treatment of ocular hypertension and glaucoma by improving uveoscleral outflow. These medications have been associated with numerous side-effects including development of cutaneous pigmentation in the periorbital skin, change in iris color, conjunctival hyperemia, growth of eyelashes, cystoid macular edema, anterior uveitis, and reactivation of herpes simplex virus keratitis. Up to 5% of patients treated with latanoprost can develop anterior uveitis after several months. Dechallenge and rechallenge data are strong and reproducible, making the association definite. Patients who already had glaucoma and anterior uveitis did not appear to be at increased risk of topical prostaglandin-induced cystoid macular edema or uveitis, perhaps because many of these patients may already be taking corticosteroids and/or other immunomodulatory agents that reduce the potential side-effects of prostaglandins. The mechanism by which prostaglandins cause anterior uveitis probably involves the breakdown of the blood–aqueous barrier, downstream stimulation of proinflammatory eicosanoids, and increased production of IL-1 and IL-6 in tears and the anterior chamber.
Topical podophyllum, an extract of Podophyllum peltatum (May apple) used to treat cutaneous warts has been associated with one recent (2012) case of unilateral, anterior nongranulomatous uveitis occurring after topical cutaneous application to a facial wart 10 mm below the ipsilateral lateral canthus. The anterior uveitis resolved with topical corticosteroids and drug cessation but recurred even with reapplication of a lower dose of the drug.
Capsaicin is the chemical that gives chilli peppers their 'heat' and sometimes used as a topical analgesic. One recent (2013) case of bilateral, acute, nongranulomatous, anterior uveitis has recently been reported 24 h after application of a cutaneous capsaicin patch on the patient's neck. The anterior uveitis resolved with drug cessation and topical corticosteroids. No rechallenge was performed. These observations suggest a probable association of podophyllum and topical capsaicin with anterior uveitis.
Topical Medications
Topical metipranolol, corticosteroids, brimonidine, and prostaglandin analogs have all been definitively associated with uveitis. The topical cutaneous medications, podophyllum and capsaicin have recently been described to have a probable association with uveitis.
Metipranolol
Metipranolol, a nonselective β-blocker used for the treatment of ocular hypertension and glaucoma, was the first topical agent to be definitely associated with granulomatous anterior uveitis. Strong, reproducible dechallenge and rechallenge data exist for metipranolol. The cause of metipranolol-induced uveitis is unknown.
Corticosteroids
There are several reports in the early studies of steroid-induced ocular hypertension of African-American patients developing uveitis after being tapered off of topical Dexamethasone phosphate 0.1% drops or triamcinolone acetonide ointment. Ironically, the uveitis responded to intensive topical corticosteroid therapy and topical cycloplegics. There have been no new reports of corticosteroid-induced uveitis since 1979.
Brimonidine
Brimonidine is a selective α2-adrenergic receptor agonist used to treat primary open angle glaucoma and ocular hypertension. Granulomatous anterior uveitis and intraocular pressure elevations have recently been reported with the use of topical brimonidine for more than 1 year. Reproducible dechallenge and rechallenge data make the association definite. The most effective treatment is discontinuation of the medication. The mechanism of brimonidine-induced inflammation is unknown.
Prostaglandin Analogs
Topical prostaglandin analogs such as latanoprost, travoprost, and bimatoprost are effective agents for the treatment of ocular hypertension and glaucoma by improving uveoscleral outflow. These medications have been associated with numerous side-effects including development of cutaneous pigmentation in the periorbital skin, change in iris color, conjunctival hyperemia, growth of eyelashes, cystoid macular edema, anterior uveitis, and reactivation of herpes simplex virus keratitis. Up to 5% of patients treated with latanoprost can develop anterior uveitis after several months. Dechallenge and rechallenge data are strong and reproducible, making the association definite. Patients who already had glaucoma and anterior uveitis did not appear to be at increased risk of topical prostaglandin-induced cystoid macular edema or uveitis, perhaps because many of these patients may already be taking corticosteroids and/or other immunomodulatory agents that reduce the potential side-effects of prostaglandins. The mechanism by which prostaglandins cause anterior uveitis probably involves the breakdown of the blood–aqueous barrier, downstream stimulation of proinflammatory eicosanoids, and increased production of IL-1 and IL-6 in tears and the anterior chamber.
Podophyllum and Capsaicin
Topical podophyllum, an extract of Podophyllum peltatum (May apple) used to treat cutaneous warts has been associated with one recent (2012) case of unilateral, anterior nongranulomatous uveitis occurring after topical cutaneous application to a facial wart 10 mm below the ipsilateral lateral canthus. The anterior uveitis resolved with topical corticosteroids and drug cessation but recurred even with reapplication of a lower dose of the drug.
Capsaicin is the chemical that gives chilli peppers their 'heat' and sometimes used as a topical analgesic. One recent (2013) case of bilateral, acute, nongranulomatous, anterior uveitis has recently been reported 24 h after application of a cutaneous capsaicin patch on the patient's neck. The anterior uveitis resolved with drug cessation and topical corticosteroids. No rechallenge was performed. These observations suggest a probable association of podophyllum and topical capsaicin with anterior uveitis.
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