It is not always clear when to begin birdshot treatment. However, there is an increasing move towards actively treating birdshot when it is diagnosed. This is something that has to be discussed with the doctors treating you because it is different in every case.
When treatment is decided upon, there is a range of medications used to treat birdshot. Choice of medications depends on the severity of your birdshot and on how you respond to the medications. They are listed in the order of what is most commonly tried first.
High dose corticosteroids (steroids) are nearly always used initially when there is a need to quell eye inflammation rapidly. Other medications (immunosuppressants) used for treating birdshot often take time to become effective while the steroids are continuing to reduce the inflammation. Because of the known side-effects of high dose steroids on the eye (cataract formation and glaucoma) and on the body, the dose of steroid will be reduced as quickly as the inflammation will allow, once the immunosuppressant(s) have become effective. A low dose of steroid may continue to be used in combination with immunosuppressant(s). The link below takes you to a 2007 publication on “Steroids in Uveitis” which, even if it is quite old, is very informative if you are new to taking steroids
Methotrexate, azathioprine (Imuran) and mycophenolate (CellCept, Myfortic) are in the first group of immunosuppressants most often used for treating birdshot. In particular, mycophenolate has been found to be effective in controlling birdshot, but a second immunosuppressant may need to be added from the next group of medications.
Ciclosporin and tacrolimus may be effective on their own for treating birdshot, but some patients will also require an immunosuppressant from the first group and possibly low dose steroid as well. Tacrolimus may work when ciclosporin has not.
By way of an introduction, you may like to listen to this fascinating interview with the chemist who developed the technique to allow biologic treatments like adalimumab to be developed. It’s an interesting listen for anyone prescribed a biologic who wants to find out more about its origin. BBC Radio 4 Life Scientific interview, with the 2018 Chemistry Nobel Prize winner, Sir Gregory Winter.
Infliximab (Remicade) and adalimumab (Humira) are biologics, given by infusion or injection. They are also known as Tumour Necrosis Factor alpha (TNF-α) inhibitors or antagonists. They may be used when medications from the first two groups of immunosuppressants have either failed to be effective, or if side-effects have made their use difficult. Infliximab is given by intravenous (into a vein) infusion (slow injection) and adalimumab treatment is by self-injection under the skin every two weeks. These newer medications are expensive and, depending on your country’s funding arrangements, your doctors may have to present a special case to get funding for them.
Steroid injections into or around the eye
Steroids can be injected into the eye (intraocular) or around the eye (periocular). These can be effective ways of treating inflammation at the back (posterior chamber) of the eye and for treating macular oedema.
A periocular injection can take longer than an intraocular injection to have its full effect, so the choice between giving steroid by intraocular injection or by periocular injection depends very much on the amount of inflammation in the eye.
For an intraocular injection, a steroid such as triamcinolone acetonide (Kenalog) is injected via a very fine needle through the wall of the eye into the posterior chamber (vitreous cavity) of the eye. It then sits there as a deposit in the eye, allowing the steroid’s anti-inflammatory effect to work over approximately four months. It is a quick and effective way of controlling inflammation, but it is associated with risks such as increased eye pressure and cataract formation. The advantage of injecting a steroid directly into the eye is that it avoids many of the side-effects associated with oral steroid use. It may be used if only one eye has inflammation or macular oedema.
For a periocular injection, the technique is similar to that for an intraocular injection but the injection is made into the tissues surrounding the eye. Like intraocular injection of steroid, periocular steroid injection carries the risks of increased eye pressure and cataract formation.
Ozurdex is a 700-microgram sterile pellet of the steroid dexamethasone which is injected into the back (posterior chamber) of the eye using a special applicator. Ozurdex is biodegradable, and it slowly dissolves over three to six months. It is sometimes used instead of an intra-ocular injection of steroid as it is thought to last slightly longer. However, the side-effects and risks of Ozurdex are similar to those of an intra-ocular steroid injection, particularly increased eye pressure and cataract formation.
Ozurdex was originally introduced for the treatment of macular oedema in patients with retinal vein occlusion. NICE (National Institute for Health and Care Excellence) guidance on the NHS use of Ozurdex implants for patients with birdshot and other forms of non-infectious posterior uveitis should be available in July 2017. Until then, Ozurdex implants are not yet routinely available for NHS birdshot patients in England and Wales, though in certain circumstances a special case may be made for funding Ozurdex.
Retisert is a sterile device containing 0.59mg of the steroid fluocinolone acetonide. It is surgically placed in the back (posterior chamber) of the eye, where it releases the steroid for around 24 to 30 months. Side-effects include the formation of cataracts and the risk of raised intraocular pressure.
Retisert is not available for NHS treatment in the UK. It may be available privately.
Iluvien is a tiny tube containing 190 micrograms of the steroid fluocinolone acetonide which is injected into the back (posterior chamber) of the eye using a special applicator. The implant slowly releases the drug into the eye over 24 to 36 months.
Iluvien is currently licensed in UK for use in treating macular oedema in diabetic retinopathy, but it is being trialled in some birdshot patients. It is not yet an officially approved NHS treatment for non-infectious posterior uveitis.
A short video of Carlos Pavesio at the Birdshot Day 2015 discussing the differences between the various types of intravitreal implants can be found on our YouTube channel Birdshot100:
Intravenous immunoglobulin (IVIg) is given by intravenous infusion (slow injection into a vein). Use of IVIg in the UK is controlled by a rationing system according to the condition being treated. The UK’s NHS National Demand Management Programme for Immunoglobulin www.igd.nhs.uk under ‘clinical information’ indicates on a ‘summary poster’ (February 2016) that IVIg use in autoimmune uveitis is classed as ‘medium priority’ and for short-term treatment only. It is rarely used in UK for treating uveitis. IVIg is used in France and other European countries, and also in US.
Below are some links to research papers that discuss various treatment options which may also be of interest:
September 2014: Robert J Barry, Quan Dong Nguyen, Richard W Lee, Philip I Murray, Alastair K Denniston
May 2014: Evangelos Minos, Robert J Barry, Sue Southworth, Annie Folkard, Philip I Murray, Jay S Duker, Pearse A Keane, Alastair K Denniston
June 2013: Rushmia Karim, Evripidis Sykakis, Susan Lightman, Samantha Fraser-Bell
August 2013: Shenzhen Tempest-Roe, Lavnish Joshi, Andrew D Dick, Simon RJ Taylor
Further research papers can be found at: Birdshot research papers