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Evolving consensus for immunomodulatory therapy in non-infectious uveitis during the COVID-19 pandemic
  1. Rupesh Agrawal1,2,3,4,
  2. Ilaria Testi4,
  3. Cecilia S Lee5,
  4. Edmund Tsui6,
  5. Marian Blazes5,
  6. Jennifer E Thorne7,
  7. Annabelle A Okada8,
  8. Justine R Smith9,
  9. Peter J McCluskey10,
  10. John H Kempen11,12,
  11. Christoph Tappeiner13,
  12. Manisha Agarwal14,
  13. Bahram Bodaghi15,
  14. Quan Dong Nguyen16,
  15. Vishali Gupta17,
  16. Marc D De Smet18,
  17. Manfred Zierhut19,
  18. Carlos Pavesio4
  19. COVID-19 IMT Study Group
  1. 1 National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
  2. 2 Singapore Eye Research Institute, Singapore, Singapore
  3. 3 School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore
  4. 4 Department of Medical Retina and Uveitis, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
  5. 5 Department of Ophthalmology, University of Washington, Seattle, USA
  6. 6 UCLA Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, USA
  7. 7 Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA, Baltimore
  8. 8 Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, New South Wales, Japan
  9. 9 Flinders University College of Medicine and Public Health, Adelaide, Australia
  10. 10 Department of Ophthalmology, Director Save Sight Institute, The University of Sydney, Sydney, Pennsylvania, Australia
  11. 11 Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, USA
  12. 12 Eye Unit, MyungSung Christian Medical Center, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
  13. 13 Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  14. 14 Shroff Eye Centre, New Delhi, India
  15. 15 Department of Ophthalmology,, Sorbonne University, Paris, France
  16. 16 Byers Eye Institute, Stanford Medical School, Stanford, USA
  17. 17 Advanced Eye Centre, Postgraduate Institute of Medical Education (PGIMER), Chandigarh, India
  18. 18 Department of Ophthalmology ZNA Middelheim, Antwerp, Belgium
  19. 19 Centre of Ophthalmology, University of Tuebingen, Tuebingen, Germany
  1. Correspondence to Rupesh Agrawal, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, 308433, Singapore; rupesh_agrawal{at} Carlos Pavesio, Medical Retina and Uveitis, Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, UK; c.pavesio{at} and Quan Dong Nguyen, Byers Eye Institute, Stanford University School of Medicine, California, USA; ndquan{at}


Background Immunomodulatory therapy (IMT) is often considered for systemic treatment of non-infectious uveitis (NIU). During the evolving coronavirus disease-2019 (COVID-19) pandemic, given the concerns related to IMT and the increased risk of infections, an urgent need for guidance on the management of IMT in patients with uveitis has emerged.

Methods A cross-sectional survey of international uveitis experts was conducted. An expert steering committee identified clinical questions on the use of IMT in patients with NIU during the COVID-19 pandemic. Using an interactive online questionnaire, guided by background experience and knowledge, 139 global uveitis experts generated consensus statements for IMT. In total, 216 statements were developed around when to initiate, continue, decrease and stop systemic and local corticosteroids, conventional immunosuppressive agents and biologics in patients with NIU. Thirty-one additional questions were added, related to general recommendations, including the use of non-steroidal anti-inflammatory drugs (NSAIDs) and hydroxychloroquine.

Results Highest consensus was achieved for not initiating IMT in patients who have suspected or confirmed COVID-19, and for using local over systemic corticosteroid therapy in patients who are at high-risk and very high-risk for severe or fatal COVID-19. While there was a consensus in starting or initiating NSAIDs for the treatment of scleritis in healthy patients, there was no consensus in starting hydroxychloroquine in any risk groups.

Conclusion Consensus guidelines were proposed based on global expert opinion and practical experience to bridge the gap between clinical needs and the absence of medical evidence, to guide the treatment of patients with NIU during the COVID-19 pandemic.

  • Choroid
  • Imaging
  • Inflammation
  • Telemedicine
  • Conjunctiva
  • Immunology
  • Macula
  • Retina
  • Infection
  • Iris
  • Treatment medical
  • Epidemiology
  • Cornea
  • Vitreous
  • Treatment lasers
  • Ciliary body
  • Drugs

This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the COVID-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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  • RA and IT contributed equally.

  • Correction notice This paper has been corrected since it was published online. Author Christoph Tappeiner’s first name and surname were transposed.

  • Twitter EdmundTsuiMD.

  • Contributors RA conceptualised this study and was supported by all the authors and COVID-19 IMT study group. The writing committee was comprised of IT, CL, ET and MB, and all these authors worked with RA on writing the first draft of the manuscript, analysis of the data and generation of the tables and figures. The group listed in the appendix participated in administering the survey.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors for any of the authors.

  • Competing interests None declared.

  • Data sharing statement Data are available upon reasonable request.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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