A 28-year-old woman with a history of recurrent posterior uveitis and vitritis presents with floaters, photopsia, and visual blurring. Fundoscopy shows vitritis with retinal vasculitis. Serological testing is negative for syphilis, TB, and HIV. What is the drug of choice for initial management of this idiopathic posterior uveitis?

## First-Line Management of Posterior Uveitis **Key Point:** Posterior uveitis (vitritis, retinitis, retinal vasculitis) requires **systemic corticosteroids** as first-line therapy because topical drops do not achieve adequate intraocular penetration to the posterior segment. ### Why Systemic Corticosteroids Are Preferred **High-Yield:** Oral prednisolone is the gold standard for posterior uveitis because: 1. **Systemic absorption** — achieves therapeutic concentrations in vitreous and retina 2. **Rapid anti-inflammatory effect** — controls vitritis, vasculitis, and prevents vision-threatening complications (cystoid macular edema, optic atrophy) 3. **Established safety profile** — well-tolerated in acute inflammatory disease 4. **Dosing:** 0.5–1 mg/kg/day (typically 40–60 mg/day), tapered over 6–12 weeks based on response ### Typical Treatment Algorithm for Posterior Uveitis ```mermaid flowchart TD A[Posterior uveitis confirmed]:::outcome --> B{Infectious cause excluded?}:::decision B -->|No| C[Treat infection first]:::action B -->|Yes| D[Start oral prednisolone 0.5-1 mg/kg/day]:::action D --> E{Response at 2-4 weeks?}:::decision E -->|Good| F[Taper prednisolone over 6-12 weeks]:::action E -->|Poor/Incomplete| G[Add immunosuppressant or biologic]:::action G --> H[Mycophenolate, azathioprine, or TNF-α inhibitor]:::action ``` ### Adjunctive Therapy | Agent | Role | Timing | |-------|------|--------| | **Cycloplegics** (cyclopentolate, homatropine) | Pain relief, prevent anterior synechiae | Concurrent with systemic steroids | | **NSAIDs** (indomethacin) | Reduce inflammation, spare steroids | Adjunctive in chronic disease | | **Immunosuppressants** (mycophenolate, azathioprine) | Steroid-sparing agents | Add if inadequate response or steroid dependence | | **Biologics** (TNF-α inhibitors) | Refractory cases (Behçet, sympathetic ophthalmia) | Reserve for severe, uncontrolled disease | **Clinical Pearl:** Cystoid macular edema (CME) is a common complication of posterior uveitis and may require additional topical NSAIDs (ketorolac, indomethacin) or intravitreal corticosteroid injections if inadequately controlled by systemic therapy. ### Why Other Options Are Not First-Line **Warning:** Topical dexamethasone alone is insufficient for posterior uveitis because the cornea and sclera act as barriers to drug penetration — only ~5% of topically applied corticosteroid reaches the posterior segment. [cite:Kanski & Bowling Ophthalmology Ch 8; American Academy of Ophthalmology Uveitis Preferred Practice Pattern]