Inflammatory Eye Disease and Immunosuppressive Therapy: A Rheumatologist’s Perspective

Inflammatory eye disease, including uveitis, scleritis, episcleritis, peripheral ulcerative keratitis (PUK), and orbital inflammation, is among the most consequential extra-articular manifestations encountered by rheumatologists, both because ocular inflammation can cause irreversible vision loss within weeks and because it frequently signals an underlying systemic rheumatic disease.Ophthalmologists establish the anatomic diagnosis and assess the severity of intraocular inflammation; rheumatologists contribute systemic disease evaluation, selection of immunomodulatory therapy, and long-term toxicity monitoring.Neither specialty can optimally manage these patients alone.Systemic corticosteroids remain the fastest means of controlling acute ocular inflammation but are not a viable long-term strategy given their cumulative ocular and systemic toxicity.Methotrexate and mycophenolate mofetil are the best-supported conventional steroid-sparing agents, with comparable overall efficacy in randomized comparison, although subgroup data suggest that methotrexate may be preferred for posterior/panuveitis and mycophenolate for intermediate uveitis.Among biologics, adalimumab has the strongest randomized evidence for noninfectious intermediate, posterior, and panuveitis; infliximab and rituximab occupy important but more circumscribed, largely observational roles, particularly when ocular disease is associated with Behçet disease or antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis.Janus kinase (JAK) inhibitors are an emerging option for refractory disease, but the supporting evidence remains predominantly observational.This review synthesizes current evidence from recent guidelines, consensus recommendations, clinical trials, systematic reviews, and observational studies into a practical, phenotype-driven framework for the rheumatologist.It addresses which ocular presentations warrant urgent rheumatologic evaluation, which systemic diseases to consider, when to escalate beyond corticosteroids, how to select among conventional and targeted therapies, and how to structure ongoing multidisciplinary collaboration with ophthalmology.