Comprehensive Guide to Eye Drops and Topical Treatment for Uveitis

Key Points at a Glance

• The basic topical treatment for uveitis is a combination of steroid eye drops and mydriatics.
• Tapering is not required for short-term topical steroids lasting less than 3–4 weeks.
• Mydriatics are essential for preventing and breaking posterior synechiae.
• Prostaglandin analogs and pilocarpine are generally not used in uveitis.
• For moderate to severe cases requiring systemic therapy, consider immunomodulators and biologics.

1. What is the Eye Drop Guide?

The eye is a highly unique organ. It is easily examined externally, and drugs can be administered directly in the form of topical eye drops. Uveitis is an inflammatory disease of the iris, ciliary body, and choroid, and eye drops are the first-line treatment for anterior segment involvement.

This guide categorizes and explains the eye drops frequently used in the management of uveitis into the following categories.

Topical Medications

Steroid eye drops: Basic treatment for anterior uveitis

Mydriatics and cycloplegics: Prevention and treatment of posterior synechiae

Antibiotics and antimicrobials: Causal treatment for infectious uveitis

Medications for Complications

Intraocular pressure-lowering drugs: Management of secondary glaucoma and steroid-induced glaucoma

However: Prostaglandin analogs and pilocarpine are generally avoided in uveitis

Nonsteroidal anti-inflammatory drugs: Alternative when inflammation is mild and stable

2. Main Symptoms and Clinical Findings

Fluorescein angiography findings of retinal vasculitis.

Meng PP, et al. Use of Ultra-Widefield Fluorescein Angiography to Guide the Treatment to Idiopathic Retinal Vasculitis, Aneurysms, and Neuroretinitis-Case Report and Literature Review. Medicina (Kaunas). 2022. Figure 2. PMCID: PMC9611749. License: CC BY.

Fluorescein angiography shows aneurysmal dilation around the optic disc (A), peripheral non-perfusion areas (B), and focal inflammation of the optic nerve and macula (C). This corresponds to retinal vasculitis discussed in section “2. Main Symptoms and Clinical Findings”.

Subjective Symptoms

Uveitis presents with the following subjective symptoms:

• Eye pain and photophobia (anterior uveitis)
• Blurred vision and decreased visual acuity
• Redness (ciliary injection)
• Floaters and blurred vision (vitreous opacities)

Clinical findings

Finding	Details
Keratic precipitates (KP)	Fine to mutton-fat (sarcoidosis, tuberculosis)
Anterior chamber flare and cells	Graded 1+ to 4+ for inflammation severity
Posterior synechiae	Prevent or break with mydriatics
Vitreous opacities	Indicators of intermediate or posterior uveitis
Secondary glaucoma	Elevated intraocular pressure → hypotensive eye drops (caution in drug selection)

Uveitis is classified into anterior, intermediate, posterior, and panuveitis based on the location. The choice of topical treatment depends on this classification and the degree of inflammation.

Q Why are mydriatic agents used when inflammation is severe?

A

When severe inflammation occurs in the anterior chamber, posterior synechiae (adhesion of the iris to the anterior lens surface) can develop. Mydriatic agents relax the ciliary muscle and pupillary sphincter, preventing and breaking these adhesions. A combination of tropicamide and phenylephrine (Mydrin P) is widely used.

3. Causes and Risk Factors

Uveitis is broadly divided into infectious and non-infectious types.

Causes of infectious uveitis:

• Herpes virus, cytomegalovirus
• Tuberculosis, syphilis, toxoplasmosis, toxocariasis
• Fungi (e.g., Candida)

Causes of non-infectious uveitis:

• Autoimmune diseases (HLA-B27-associated, sarcoidosis, Vogt-Koyanagi-Harada disease, etc.)
• Juvenile idiopathic arthritis-associated
• Idiopathic

Daily Care and Prevention

For prevention of infectious uveitis, proper management of underlying diseases (tuberculosis, syphilis, etc.) is important. In immunocompromised states (e.g., HIV), attention to reactivation of fungi and viruses is necessary. During long-term steroid use, regular check-ups for cataracts and glaucoma should not be neglected.

4. Diagnosis and Examination Methods

Diagnosis is based on detailed evaluation of the anterior and posterior segments using slit-lamp microscopy. Serological tests (including PCR) are performed to rule out infectious uveitis.

The following screening is recommended before starting immunomodulatory therapy. ¹⁾

• Blood chemistry tests (performed by 98.2% of specialists)
• Complete blood count (performed by 93.7%)
• QuantiFERON (TB test, performed by 88.7%)

Inflammation severity is assessed based on the SUN (Standardization of Uveitis Nomenclature) Working Group classification. ¹⁾

Q Can steroids be used for infectious uveitis?

A

In infectious uveitis, steroids may be used alongside treatment of the cause (antibiotics, antivirals, etc.) to control postoperative inflammation. However, steroid monotherapy without adequate infection control may worsen the infection. Always prioritize treatment of the underlying cause.

5. Standard Treatment

Steroid Eye Drops

The mainstay of local treatment for uveitis is steroid eye drops. In order of increasing potency: fluorometholone → loteprednol → rimexolone → prednisolone → difluprednate.

Drug Name	Concentration	Characteristics/Uses	Main Side Effects
Fluorometholone (FML)	—	For mild inflammation	Increased intraocular pressure (low)
Loteprednol (Lotemax)	0.2, 0.5, 1%	Low risk of increased intraocular pressure	Increased intraocular pressure (low)
Prednisolone (Pred Forte)	0.12, 1%	Standard treatment for intraocular inflammation	Cataract, increased intraocular pressure
Difluprednate (Durezol)	0.05%	Potent. For severe cases	Cataract, increased intraocular pressure

About tapering

Tapering of topical steroids (eye drops) is not mandatory. If the treatment duration is less than 3–4 weeks, tapering is unnecessary regardless of the dose. Tapering is recommended only when steroids are used for more than 3–4 weeks, to promote recovery of the hypothalamic-pituitary-adrenal axis. This concept applies to systemic steroids; topical eye drops pose almost no risk of adrenal suppression.

Mydriatics and cycloplegics

While anterior chamber inflammation is present, continue instilling mydriatic eye drops to prevent posterior synechiae.

Drug name	Duration of effect	Concentration	Main use
Atropine	7–12 days	0.5–3%	Severe uveitis, hyphema
Scopolamine	3–7 days	0.25%	Atropine allergy
Homatropine	1–3 days	2–5%	Useful for uveitis
Cyclopentolate	About 1 day	—	Uveitis and refraction testing
Tropicamide	6–24 hours	0.5, 1%	Fundus examination under mydriasis

Tropicamide/phenylephrine combination (Mydrin P) is widely used in Japan as a standard mydriatic for anterior chamber inflammation. A typical prescription is one drop at bedtime.

Intraocular pressure-lowering drugs

Uveitis is often complicated by secondary glaucoma and steroid-induced glaucoma. For elevated intraocular pressure, beta-blockers and carbonic anhydrase inhibitors are preferred.

Drug class	Representative drugs	Characteristics
Beta-blockers	Timolol, betaxolol	Suppress aqueous humor production. Twice daily
Carbonic anhydrase inhibitors	Dorzolamide, brinzolamide	Suppress aqueous humor production. Three times daily
Alpha agonists	Brimonidine	Suppress aqueous humor production and promote outflow. Contraindicated in infants

Intraocular pressure-lowering drugs to avoid in uveitis:

• Prostaglandin analogs (e.g., latanoprost): May paradoxically increase intraocular pressure. Also reported risk of exacerbating inflammation
• Pilocarpine: A miotic agent that may promote posterior synechiae

Systemic immunomodulatory drugs

For intermediate, posterior, or panuveitis that is inadequately controlled with topical steroid eye drops, systemic therapy should be considered.

The standard first-line treatment is oral prednisolone (initial dose 1 mg/kg/day, tapered within 4 weeks). ¹⁾ For steroid-dependent cases or those with difficulty tapering steroids, conventional immunomodulatory drugs or biologics are added.

First-line conventional immunomodulatory drugs (by disease):¹⁾

• Juvenile idiopathic arthritis-associated uveitis: methotrexate (93.2%)
• HLA-B27-positive uveitis: methotrexate (80.1%)
• Sarcoidosis: methotrexate (62.4%)

Biologics:¹⁾

Adalimumab is used as first-line therapy by 97.7% of specialists. The VISUAL I/II trials established the efficacy of TNF-α inhibition, and it is approved by the FDA and EMA. Combination therapy with methotrexate and adalimumab is used by 84.0% of specialists. ¹⁾

Precautions

Contraindications for adalimumab and TNF-α inhibitors: TNF-α inhibition is associated with demyelinating lesions, so adalimumab is contraindicated in patients with uveitis and multiple sclerosis. ¹⁾

Complications of long-term steroid use: Steroid-induced cataract and steroid-induced glaucoma occur frequently. Once inflammation is controlled, consider switching to a lower-potency drug such as fluorometholone or nonsteroidal anti-inflammatory eye drops.

Preoperative drug-free period: Before uveitic cataract surgery, it is recommended that non-infectious uveitis be inactive for at least 3 months. ¹⁾

Q Is it okay to use topical steroids for a long time without tapering?

A

For short-term use of less than 3–4 weeks, tapering is not necessary. The European Society of Endocrinology guidelines also state that “for use of less than 3–4 weeks, tapering is not required regardless of dose.” However, if used for more than 3–4 weeks, tapering is necessary to allow recovery of the hypothalamic-pituitary-adrenal axis. With topical eye drops, the risk of systemic adrenal suppression is almost nonexistent, but gradual reduction is safer than abrupt discontinuation.

6. Pathophysiology and Mechanisms

The mechanisms of intraocular pressure elevation in uveitis include:

1. Clogging of the trabecular meshwork (inflammatory cells, proteins)
2. Trabeculitis (direct inflammation)
3. Angle nodules
4. Peripheral anterior synechiae
5. Steroid-induced intraocular pressure elevation
6. Neovascular glaucoma
7. Pupillary block due to posterior synechiae

Since treatment strategies differ for each mechanism, it is important to accurately evaluate the mechanism of intraocular pressure elevation by gonioscopy.

Mechanism of action of mydriatics and cycloplegics:

Anticholinergic drugs (e.g., atropine, tropicamide) relax the ciliary muscle and pupillary sphincter, causing mydriasis and cycloplegia. Relaxation of the ciliary muscle reduces pain and photophobia, and also decreases contact between the posterior iris and anterior lens surface, preventing posterior synechiae. Adrenergic receptor agonists (e.g., phenylephrine) contract the dilator pupillae muscle and assist mydriasis.

Mechanism of action of topical steroids:

Topical steroids suppress anterior segment inflammation by inhibiting inflammatory cytokine production and immune cell migration. Difluprednate, with high potency, has high receptor affinity and shows excellent efficacy against severe anterior segment inflammation. However, it also carries a high risk of cataract induction and intraocular pressure elevation, so the principle is to select the minimum necessary potency.

Local treatment flow for anterior uveitis

Step 1: Steroid eye drops (select potency according to inflammation severity)

Step 2: Mydriatic agents (e.g., Mydrin P) to prevent posterior synechiae

Step 3: If intraocular pressure rises, use beta-blockers and carbonic anhydrase inhibitors (prostaglandin analogs and pilocarpine are contraindicated)

Step 4: If control is insufficient → systemic steroids or sub-Tenon injection

Local additional treatment for intermediate and posterior uveitis

Sub-Tenon injection: Triamcinolone (40 mg/mL) 0.5 mL

Indications: Macular edema, vitreous opacity, posterior pole inflammation

Systemic therapy: Systemic steroids are the mainstay for intermediate and posterior uveitis

Immunomodulatory drugs: Added for cases with poor control for 6 months or more

7. Latest Research and Future Perspectives

Advances in biologic agents have greatly changed the treatment of uveitis. The widespread use of adalimumab has been established, and evidence for many disease types has accumulated from the VISUAL I/II and SYCAMORE trials. ¹⁾

Future challenges include the following:

• Widespread use of local drug delivery systems (e.g., dexamethasone intravitreal implant)
• Improved treatment access with the advent of biosimilar biologic agents
• Establishment of optimal combinations and treatment durations of immunomodulatory drugs
• Elucidation of the optimal timing for drug discontinuation (generally after maintaining remission for more than 2 years) ¹⁾

Disclaimer

This article is intended to provide medical information and does not recommend any specific diagnosis or treatment. For actual treatment, be sure to consult your ophthalmologist. The choice, dosage, and duration of eye drops vary depending on individual cases.

8. References

1. Branford JA, et al. Practice patterns of a large international group of uveitis specialists in the treatment of non-infectious uveitis. Br J Ophthalmol. 2025;109:482–489. doi:10.1136/bjo-2024-326239