The use of medicine is like the use of an army, and the use of an army (i.e., commanding a war) requires a guiding ideology. The author has gradually formed the idea of treating diseases (uveitis) during his long-term clinical work, which is reflected in the author’s systematic thinking, discriminatory thinking, holistic thinking and aesthetic thinking. The author proposes three basic principles for the treatment of uveitis, namely, simplicity, individualization, and “long-term treatment”, which are derived from the principles of “quick and easy”, “long-lasting”, and “quick and easy”. The three principles are derived from the five strategies of “quick fix”, “protracted war”, “urgent treatment”, “combined medication” and “support the righteous and dispel the evil”. The four types of thinking, three principles and five strategies constitute the author’s ideological system of understanding and treating diseases.
I. Four types of thinking in the treatment of uveitis
(A) Systemic thinking
Uveitis, like other diseases, is an abnormality in a subsystem of a larger system, which is either caused by abnormalities in other subsystems (e.g., immune system dysfunction leading to uveitis) or by external factors acting directly on the subsystem (e.g., infection, trauma leading directly to uveitis), in either case, the abnormality in the subsystem will likely lead to abnormalities in other subsystems, such as uveitis. In either case, abnormalities in this subsystem will likely lead to abnormalities in other subsystems, such as uveitis causing exposure to hidden antigens in the eye, which may induce an autoimmune response and an immune response against the uvea or other pigmented tissues, causing changes such as vitiligo and hair whitening; furthermore, uveitis can cause complications such as secondary glaucoma, concurrent cataracts, and retinal neovascularization. It can be seen that although the disease (uveitis) manifests itself locally and in a particular system, it is closely linked to other subsystems, and therefore treatment of the disease must be based on systems thinking, looking at and thinking about various ways to deal with and intervene in the disease from a systems perspective.
Systems thinking has two major characteristics.
① Emphasize that problems should be dealt with in order of priority, i.e., what problems should be solved first and then what problems should be solved, e.g., for complications of cataract caused by uveitis, inflammation should be controlled first and then cataract surgery should be performed, rather than cataract surgery first and then inflammation treatment;
Since the occurrence of the disease (uveitis) is the result of the interaction between several subsystems in terms of cause and effect, the treatment of the disease should be directed at the cause of the disease, so as to solve the problem at the source of the disease and eliminate the disease fundamentally, instead of only solving the superficial problems or branch conflicts, such as the retinal neovascular membrane and subretinal neovascular membrane caused by uveitis. For example, for retinal neovascularization and subretinal neovascularization caused by uveitis, we should first control uveitis with drugs so that the factors of neovascularization can be controlled from the source, and then combine with fundus laser treatment to eliminate the formed neovascularization. neovascularization. For uveitis complicated by corneal banding degeneration and vesicular changes, the inflammation should be controlled first, and corneal transplantation should be performed only after the inflammation is completely controlled to replace the degenerated cloudy cornea, otherwise it is very easy to cause corneal transplantation immune rejection after surgery, resulting in surgical failure.
In my clinical work, I often encounter some problems or serious consequences brought about by failure to deal with the disease according to systematic thinking, and now I choose one or two to draw your attention.
In one case, a 14-year-old male patient suffered from juvenile chronic arthritis with uveitis and concurrent cataract in both eyes. In this case, the local surgeon performed the same surgery on the other eye, which also resulted in increased inflammation and eventually complete blindness in both eyes. The second case was a 53-year-old patient with ankylosing spondylitis associated with uveitis, who had bilateral uveitis, concurrent cataract, glaucoma and large vesicular changes in the cornea. Later, the patient underwent corneal transplants one after another, and both eyes were transplanted 10 times, each time failing due to rejection. If cataract surgery and corneal transplantation were performed after the inflammation was completely controlled with medication, the patient would have recovered his vision, or even better vision. Failure to apply systemic thinking to deal with the disease has brought irreparable or even never-returnable consequences to the patient, which shows that the lesson is not too deep. A common sense in life also tells us the importance of systematic thinking: if you want to build a house next to a volcanic crater, the house can only be built when the volcano no longer spews lava, if the volcano keeps spewing lava, the house is absolutely impossible to build, to say the truth is so simple!
(B) Discriminatory thinking
As everything in nature is developing and changing, to understand things and grasp its essence, we must also look at things with development, change and linkage thinking, which is discriminative thinking. There are multiple drugs and surgical procedures to treat the disease, and each treatment has its own indications and contraindications. Therefore, when dealing with the disease (uveitis), discriminatory thinking is mainly about identifying the disease (uveitis), the person who has the disease (the individual with uveitis) and the treatment (various drugs and surgical procedures used for treatment). The following are some examples
1. Identifying uveitis
In terms of identifying uveitis, based on years of experience, the author has summarized the following three characteristics, namely, the complexity of uveitis, the variability of uveitis, and the camouflage of uveitis.
(The clinical manifestations, severity of inflammation, disease progression, response to treatment and prognosis of various types of uveitis are very different, such as some types of uveitis can cause severe eye redness, severe eye pain, photophobia and tearing, while some types do not cause obvious eye symptoms; some types Some types can cause severe vision loss, even light perception or even no light perception within a few days, while some types do not cause long-term vision loss or only cause transient vision loss; some types do not cause complications, while some types are prone to complications, even irreversible complications; some types do not require treatment or only require local spot treatment, while some types require systemic treatment with a variety of immunosuppressive agents, or even require continuous treatment for several years; some types do not require treatment or only require local spot treatment, while some types require systemic treatment with a variety of immunosuppressive agents, or even require Some types have a good prognosis, while others have a rather poor prognosis even with aggressive treatment; some types are often associated with systemic disease, while some types show only intraocular inflammation. Thus, it is not enough to diagnose “uveitis” for a disease such as uveitis; it is important to diagnose the cause and type of uveitis in order to guide treatment.
Understanding the complexity of uveitis has led to the realization that.
(i) In the case of uveitis as a whole, one or more approaches cannot be used to treat all types of uveitis, but rather the treatment should be selected based on the type of uveitis the patient has;
(2) In the management of an individual patient with uveitis, it is important to first identify the type of uveitis that the patient has and then treat it according to the severity of the inflammation and the complications it causes.
(2) Identifying the variability of uveitis As a group of autoimmune diseases, uveitis is not only highly variable in its clinical manifestations (e.g., the nature of inflammation can change from non-granulomatous to granulomatous, granulomatous inflammation can become non-granulomatous at certain stages; the site of inflammation can progress from anterior to posterior or spread from posterior to anterior), but its association with systemic autoimmune diseases is also highly variable. The association with systemic autoimmune diseases is also highly variable, such as juvenile chronic arthritis with uveitis, where arthritis can occur before or after uveitis, or simultaneously with uveitis. In addition, previous substandard treatment has resulted in a very variable presentation of uveitis rather than the classical changes that occur.
The analysis of the variability of uveitis has led us to realize that.
(1) The essence of the disease must be captured in the diagnosis of the disease and not be confused by the “change in appearance” of the manifestations;
For example, Vogt-Koyanagi Harada syndrome presents as non-granulomatous chorioretinitis, chorioretinitis, and neuroretinitis in the posterior uveitis phase and granulomatous inflammation in the recurrent anterior uveitis phase. The two are very different in terms of the nature of inflammation, the site of inflammation, and the impact on visual function, but they are different manifestations of a disease at different times, and although there are differences in treatment, the treatment strategies and timing are the same.
(3) Identify the pseudophakic nature of uveitis Some non-inflammatory diseases can appear similar to uveitis in their clinical manifestations, especially some malignant tumors, such as retinoblastoma, intraocular-central nervous system lymphoma, and intraocular metastases of malignant tumors, which can manifest as uveitis for a considerable period of time (pseudophakic syndrome) , some degenerative diseases can also manifest as uveitis. It is well known that the principles and treatment of uveitis are very different from those of tumors and degenerative diseases, and that misdiagnosis of malignant tumors may also lead to delayed treatment and serious consequences. Understanding the artifactual nature of uveitis allows us to recognize that
① When diagnosing uveitis, great care should be taken, especially not to diagnose non-inflammatory diseases as uveitis, let alone the pseudomonal syndrome due to malignancy as a general inflammatory disease;
② In order to avoid diagnosing pseudomonal syndrome due to malignancy as general uveitis, it is fundamental to think discriminately, to grasp the essence of the disease, and not to be confused by appearances.
The author had a case of a 10-year-old female patient who visited a famous hospital with red eyes and decreased vision. The patient was treated with antibiotics, corticosteroids, and ciliary muscle paralytics for two weeks, but the disease did not decrease but worsened. The patient was referred to the author’s clinic, where the author examined the patient and found that he had visual acuity of 1.5 in the right eye and 0.1 in the left eye, ciliary congestion, flocculent anterior chamber pus accumulation, and multiple large creamy nodules on the iris surface, which led to the diagnosis of pseudophakic syndrome due to retinoblastoma. In order to confirm the clinical diagnosis, the patient underwent B-mode ultrasound and MRI, which did not reveal any abnormality, and histological examination of the anterior chamber punctures resulted in the diagnosis of “tumor cannot be excluded”. CDE: No significant blood flow signal was seen in the cluster. The author cautiously recommended ophthalmopexy with this result, and the postoperative pathological findings were “retinoblastoma”. If this patient had been treated as “uveitis” or “endophthalmitis” for a period of time, it might have caused tumor metastasis and endangered the patient’s life.
One doctor asked me, “How did you diagnose retinoblastoma?” I told him that the diagnosis was based on the characteristics of the disease, and that the details of anterior chamber pus and iris nodules reveal the essence of the disease, which requires your discerning eye to recognize these qualities, and your keen insight and penetrating mind to grasp these qualities. It is also clear from this case that no matter how advanced the instruments and equipment are, they have blind spots and cannot replace human thinking; only when the right way of thinking is combined with these instruments and equipment can they function as they should.
2.Identify the patient
Uveitis can occur in individuals of different ages, genders, physiques, economic status, underlying diseases, and psychological qualities. The differences in these background factors largely influence the clinical manifestations of uveitis, and are also shaping the development of our treatment strategies and the choice of medications:.
(i) The patient’s family has much higher expectations for the treatment of pediatric patients than for older patients;
② The use of glucocorticoids in pediatric patients, especially when used in high doses over a long period of time, should pay special attention to its effects on growth and development, while in elderly patients more consideration is given to drug-induced osteoporosis and femoral head necrosis;
③ Immunosuppressants affecting growth and development (e.g., benzodiazepine, cyclophosphamide) are in principle prohibited in pediatric patients, while the effects on fertility need not be considered in elderly patients;
④ The drug dose is generally given according to kilogram of body weight when treating the disease, but patients who are too thin and too obese should not be given the drug in the usual way, and the therapeutic dose should be decided according to the specific situation;
⑤ The consideration of treatment cost for patients with different family economic status is also self-evident;
⑥ For patients with different underlying diseases and different tolerance levels, the determination of drug type, drug dose, and drug treatment duration also varies greatly.
In the early 1990s, the author treated a male patient, 26 years old, who came from abroad with scleral uveitis. After treatment in several hospitals, the eye was finally removed because the inflammation could not be controlled. The same disease occurred in the other eye a few months after he returned to his hometown, and the local doctor treated him with glucocorticoids, which were not effective. Under such circumstances, a professor referred the patient to Guangzhou and asked the author to treat him. After examining the patient, the author found that the scleral uveitis was indeed quite serious, and also found that the patient was particularly weak due to the long-term use of high doses of glucocorticoids.
On the one hand, the dosage of glucocorticoids was gradually reduced, and on the other hand, Chinese herbal medicine was administered to strengthen the spleen and benefit the qi according to the Chinese medical diagnosis, in order to restore the positive qi. After 3 months of treatment, the patient’s weight decreased by 15 kg, his physical condition improved significantly, his scleral uveitis improved significantly, and his visual acuity improved from 0.05 before treatment to 0.5. According to the patient’s condition, the author adjusted the dose and treated him for about one year, and his scleral uveitis was completely controlled, and his visual acuity remained stable at 0.5 (the patient had a posterior subcapsular clouding of the lens that affected further improvement of visual acuity). The treatment of this patient shows that the treatment of the disease must pay attention to the patient’s own condition. If the patient is given a strong immunosuppressive therapy considering the severity of the inflammation, the treatment may be discontinued because the patient’s physique cannot tolerate it, and more seriously, the drug may lead to further weakening of the patient’s physique or even to his death. When a treatment endangers the patient’s life, what is the point of such treatment?
From the above analysis we can see that.
① There is no uniform pattern in the treatment of uveitis, even if it is the same type, and the principle of individualization must be followed;
② The treatment of uveitis (all diseases) must start with the person who has the disease and end with the person who has the disease (this is the so-called “patient-centered”), not treating the person as an animal, not treating the disease for the sake of treating the disease.
3, identify drugs and treatment methods
Uveitis is a class of inflammatory diseases that can be caused by various factors or mechanisms such as autoimmune response, infection, trauma, etc. Therefore, anti-inflammatory drugs, immunosuppressants and anti-infective agents are mainly used in the treatment, but the mode of action, linkage of action, strength of action, type and size of side effects, and cost of different anti-inflammatory drugs, immunosuppressants and anti-infective agents are very different and are used to treat uveitis The surgical procedures, indications and contraindications for the treatment of complications caused by uveitis (e.g. cataract, glaucoma, retinal detachment) are also very different, so the following two points should be noted in the treatment of uveitis and its complications.
① One must be familiar with the indications and contraindications of various drugs and surgical methods and various information about them;
(2) The type, dosage, route of administration, duration of treatment, surgical approach, timing of surgery, and preoperative and postoperative treatment should be decided according to the patient’s own characteristics in order to achieve the goal of “targeted” treatment.
(C) Holistic thinking
In the treatment of disease (uveitis), the disease should be considered and dealt with as a whole, rather than focusing only on the local lesions, in order to achieve the purpose of curing the disease at its root, such thinking is holistic thinking. In general, the disease is mostly localized, such as uveitis, arthritis, ulcerative colitis, etc. Although their inflammation is confined to the local area, the reactions that cause these diseases are often systemic, and local medication can act directly on the inflammation site to play a significant role in suppressing inflammation locally, so that the inflammation is reduced or temporarily subsided, therefore, is an important treatment method. However, if the focus is only localized and the cause of the disease is not eliminated, either the inflammation is not completely cured, or it tends to become chronic, or the inflammation subsides and then recurs. Therefore, when treating the disease (uveitis), it is important to pay attention to both local treatment and the overall removal of the “breeding ground” where the disease occurs or persists, in order to completely cure the disease and eliminate future problems.
The author treated a patient with Behcet’s disease from Turkey, who presented with uveitis and two ulcers on the legs, the diameter of which was more than 5 cm. The first thing that the author saw during the consultation was not the uveitis in the eye or the ulcers in the legs, but the nature of the pathogenesis of Behcet’s disease and the patient’s autoimmune response. It was based on this judgment that we gave the patient systemic immunosuppressants combined with oral treatment with herbs to clear heat and dampness, cool the blood and detoxify the blood and dissolve decay and create muscle, without any local treatment of the ulcer, which completely healed after two months of treatment, and the whole treatment lasted for 1 year, with complete healing of the uveitis and leg ulcer, which has been followed for 5 years without recurrence. This example shows that it is impossible to solve the problem completely without addressing the problem as a whole and at the root, but only from the local or branch end. Ancestral medicine has the saying “it is better to stop the boiling water than to draw the salary from the bottom of the kettle”, which can be said to be the crux of the matter!
(D) aesthetic thinking
Nature is a harmonious whole, man and nature is a harmonious whole, society is a harmonious whole, the human body is also a harmonious whole, everything in nature follows the laws of harmony, harmony is beauty, the destruction of harmony is a disaster, chaos and disease. Harmony in nature is beauty, and disruption of harmony is disaster, chaos and disease. Dissonance in nature leads to floods and droughts, dissonance in society leads to turmoil and war, and dissonance in the human body leads to disease and suffering. In terms of healing, it is actually the process of correcting the disorder, adjusting the balance and restoring the beauty of harmony. Since the treatment of disease is to restore the beauty of harmony, it should only remove the disorder and should not cause new disorder and imbalance, which is the aesthetic thinking (thought) in the treatment of disease.
Aesthetic thinking in the treatment of disease is to examine the various drugs and methods used in the treatment from the perspective of harmony, to evaluate the advantages and disadvantages, costs and benefits of the treatment in a comprehensive manner, with the aim of achieving the ultimate aesthetic treatment. Thus, aesthetic thinking emphasizes the use of the least amount of drugs, the smallest dose (just the right amount to control the disease), the easiest way, the least pain to the patient, the most optimal plan, and the most appropriate treatment time, with the ultimate goal of curing the disease and restoring harmony without realizing it.
The author has seen a report that about 1/3-1/2 of SARS patients in a certain region had femoral head necrosis after their lung diseases were cured. There is no evidence that SARS can cause femoral head necrosis, but it is an indisputable fact that the high-dose glucocorticoids used by patients can cause femoral head necrosis. One could argue that femoral head necrosis is so insignificant to the life of the patient that the side effects of the drug can be ignored in order to save the patient’s life, but the question is, do these patients necessarily need to use glucocorticoids in doses large enough to cause femoral head necrosis? Common sense pharmacology tells us that within a certain range, the efficacy of a drug is positively correlated with its dose, and that increasing the dose beyond a certain point does not necessarily increase the effect.
The author knows very little about SARS and is not qualified to comment on the use of glucocorticoids in these patients, but the fact that glucocorticoids cause femoral head necrosis does require serious consideration and research. The author often encounters patients with uveitis who have developed Cushing’s syndrome, femoral head necrosis, growth disorders, short stature (in children), or even schizophrenia and suicide after long-term high-dose glucocorticoid use, which have brought heavy financial burdens to patients and their families, as well as serious, even lifelong, psychological shadows and injuries to patients and their families. The authors are deeply concerned about this. In fact, most of these patients do not need long-term high-dose hormone therapy, much less the so-called high-dose shock glucocorticoid therapy. What worries the author is that not only is there abuse and misuse of glucocorticosteroids, but in fact, it is not uncommon to see a wide range of medications (e.g., antibiotics, so-called nutritional drugs, vitamins, vasodilators, blood-stasis-boosting drugs, etc.) and overtreatment in the treatment of uveitis, which, on the one hand, reflects a lack of understanding of this disease and, more importantly, reveals The lack of systemic, discriminatory and aesthetic thinking in the treatment of diseases.
The basic principles of uveitis treatment
Under the guidance of the above four types of thinking, the author has repeatedly thought about, refined, and refined three basic principles for the treatment of uveitis in clinical work, namely, the principles of individualization, simplicity, and “long-term treatment”.
(I) The principle of individualization
The principle of individualization is a concrete manifestation of discriminative and aesthetic thinking in treatment. It emphasizes the need to develop a treatment plan suitable for each patient based on the type of uveitis, severity of inflammation, patient’s age, gender, physical condition, underlying disease, tolerance to medications, patient’s expectations for treatment, and patient’s economic status.
To achieve individualized treatment, physicians need to have the following three conditions.
① A high level of expertise and a comprehensive understanding of uveitis;
The doctor should have the wisdom to select drugs and administer reasonable treatment plans scientifically because there are so many different types of uveitis and the factors affecting them are so complex. and “magic”;
③ To have love, love is reflected in the responsibility for patients, that is, to relieve the suffering of patients as their own responsibility, only in this way can we think of patients from all aspects, treating diseases as artistic creation to review, to carve to perfection.
(2) Simplicity principle
The principle of simplicity is the specific embodiment of the four types of thinking in treatment: systematic thinking, discriminative thinking, holistic thinking and aesthetic thinking. The so-called simplicity principle is to identify the root cause, essence and main contradiction of uveitis through discriminatory, systematic and holistic thinking, and to treat uveitis with one or a few targeted drugs in order to cure uveitis from the source and at the root. This principle of treatment embodies the aesthetic concept of curing the disease with the least amount of drugs, the easiest way, the most economical cost, and with the least amount of pain to the patient.
In fact, there are serious problems of complication and overtreatment in the treatment of uveitis, which are usually caused by the failure to apply the above-mentioned four types of thinking: one-sided emphasis on the hypercoagulability of Behcet’s disease, i.e., anticoagulant therapy and so-called herbal treatment to promote blood circulation and remove blood stasis; emphasis on the tissue cell damage caused by uveitis, i.e., so-called energy synergists, vitamins, etc. The false equivalence between inflammation and bacterial infection leads to the misuse and abuse of antibiotics. It is the incorrect consideration of these branching, non-essential, local issues that has led to a large encirclement of medications in the treatment of uveitis, and in fact these large encirclement medications have resulted in over-treatment of patients, bringing about serious drug waste and greatly increasing the cost of treatment. According to the authors’ conservative estimate, the drug waste caused by drug abuse and misuse in uveitis in China is at least hundreds of millions of RMB per year, and more seriously, drug abuse and misuse lead to some undesirable drug side effects, even serious side effects that affect the patients’ lifetime.
(C) “Long-term cure” principle
The “long-term treatment” is a specific application of systemic and aesthetic thinking in the clinical treatment of uveitis. By “long-term treatment”, we mean that through systemic thinking, we can grasp the type and course of uveitis and its progression, as well as the individual characteristics of the patient, and provide systematic and standardized treatment in order to fundamentally eliminate the causes and mechanisms of chronicity and recurrence of uveitis and achieve a complete cure of uveitis. The distinctive feature of the “long-term treatment” principle is that it focuses on the long term and the future. The goal of treating uveitis is not to restore vision tomorrow, not to give patients a month’s vision or a few months’ vision, but to give patients vision forever and to give them sight forever. If we understand this point, we will not blindly give patients with uveitis the so-called shocking high-dose medication and large-encirclement treatment, we will not perform cataract surgery when the inflammation is not under control, we will not perform vitrectomy once we see uveitis with vitreous opacity, and we will not perform corneal transplantation once we see uveitis causing large vesicular keratopathy. In clinical practice, I often see some patients with concurrent cataract undergoing surgery when the inflammation is not fully controlled, and the inflammation intensifies or recurs after surgery, and even pay the price of bilateral blindness for the surgery. This is a profound lesson (see the examples given earlier).
It is worth mentioning that the term “long-term treatment” should not be interpreted as long-term treatment, but rather as a state of long-term quietness and non-recurrence of uveitis through standardized treatment.
Treatment strategies in uveitis
In addition to the guiding ideology and treatment principles in the treatment of the disease, there should also be treatment strategies, and the authors have summarized the following strategies for the treatment of uveitis in their clinical work.
(A) “Quick and dirty” strategy
The aim of treatment for this type of uveitis is to rapidly “eliminate” the inflammation and avoid or reduce the occurrence of complications, so it is appropriate to adopt a “quick fix” strategy. “In patients with acute anterior uveitis, for example, the author uses frequent doses of 0.1% dexamethasone drops for For example, in patients with acute anterior uveitis, authors use frequent dexamethasone 0.1% eye drops to treat the inflammation, often achieving significant therapeutic effects in the short term, while giving low-frequency, mild glucocorticoid drops to such patients makes it difficult for the inflammation to subside rapidly and predisposes them to complications such as post-iris adhesions.
(ii) “Persistent warfare” strategy
Some types of uveitis show chronic and persistent inflammation, for this type of inflammation can not take a quick strategy, but should adopt a “protracted war” strategy, that is, the use of small doses (just enough to control the inflammation), a small number (i.e., with one or a few drugs) of drugs so that the inflammation is slowly “This strategy appropriately reproduces the “aesthetic thinking” proposed by the author.
In clinical work, the authors have seen many physicians use “quick fix” strategies to deal with this chronic inflammatory disease, such as the so-called “shock” treatment of patients with Vogt-Koyanagi Harada syndrome, Behcet’s disease, sympathetic uveitis, retinal vasculitis, etc., using high doses of glucocorticoids. The use of large doses of glucocorticoids in intravenous or periocular injections is expected to eliminate the inflammation in a short period of time. It is undeniable that such treatment can also reduce or subside inflammation, but it usually does not change the course of the disease, and without understanding the chronicity of these types of uveitis, rapid reduction or discontinuation of the drug when clinical signs of inflammation are not seen often results in recurrence or chronicity of the inflammation. In the end, it often does not control uveitis, but also leads to serious side effects of glucocorticoids and the loss of visual function in many patients.
(C) Urgency as a strategy for treating symptoms
In patients with uveitis, the sudden rise in IOP due to complete post-iris adhesions, inflammation is no longer the main conflict, but the sharp rise in IOP is the most prominent conflict, which will cause serious damage to visual function in the short term if not controlled in a timely and effective manner. This is the so-called emergency treatment strategy. In severe acute retinitis or optic neuritis, which can cause serious damage to the retina or optic nerve in a short period of time, it is also appropriate to use the strategy of treating the symptoms as a matter of urgency, that is, to give high doses of glucocorticoids (the high doses emphasized here are reasonable high doses, not the larger the better high doses), in order to quickly “extinguish” the inflammation and reduce the damage caused by inflammation In order to save the visual function, it is necessary to take the long view and give the standardized individualized medication to cure the uveitis fundamentally.
(iv) Combined medication strategy
Some types of uveitis, when treated with an immunosuppressant, may require a large dose to control inflammation, but the patient is not able to tolerate such a large dose of medication, at this time, two or more drugs need to be combined; some types of uveitis, when treatment with an immunosuppressant is not enough to control inflammation, it is also appropriate to combine two or more immunosuppressant treatments; in addition, patients need to use a drug ( In addition, patients need to be treated with one drug (e.g., glucocorticoids), but due to the presence of an underlying disease (e.g., diabetes mellitus), the combination of drugs may reduce the impact on the original disease. In general, the dose of a combination drug is smaller than that used alone, thus reducing the side effects of the drug and making it easier to be tolerated by the patient. Therefore, the combination of drugs is a sensible strategy for the treatment of chronic, intractable uveitis, especially types like Vogt-Koyanagi Harada syndrome, Behcet’s disease, sympathetic uveitis, intermediate uveitis, and retinal vasculitis.
It is worth mentioning that the combination of drugs is not an envelope of drugs, but a rational treatment based on the analysis of various factors, and therefore it reflects the concept of “aesthetic thinking”. Combination medication can be a combination of two, three or more drugs. The following points should be noted when combining drugs.
① It is appropriate to combine drugs with different mechanisms of action and action links;
② Drugs with the same side effects should not be used in combination to avoid the superposition of side effects leading to serious consequences;
③ Glucocorticosteroids are the basic drugs in the combination;
④ The dosage of each drug in the combination should generally be lower than the dosage used alone.
According to the author’s experience, there are several commonly used drug combinations as follows.
① Glucocorticoids combined with cyclophosphamide;
(2) Glucocorticoids in combination with benzodiazepine;
(iii) Glucocorticoids in combination with cyclosporine;
④ Glucocorticoids in combination with azathioprine;
⑤ Glucocorticoids in combination with cyclophosphamide and cyclosporine;
(6) Glucocorticoids combined with azathioprine and cyclosporine (see relevant chapters for details).
(E) “Support the righteous and dispel the evil” strategy
The long-term use of immunosuppressants in the treatment of uveitis often causes some side effects, such as leukopenia, liver and kidney function damage, etc., which, to borrow the terminology of traditional Chinese medicine, means that the process of “eliminating evil” hurts the “righteousness”, and if the righteousness is not supported, there is no way to fight the disease. “At this time, Chinese herbal medicine should be given to regulate the yin and yang qi and blood to reduce or avoid the side effects caused by immunosuppressive drugs, so that the positive qi can be restored and the treatment can be tolerated and continued, otherwise the patient may be forced to discontinue the treatment due to the side effects of the drug, and stopping the drug means that the patient’s uveitis loses effective treatment. It can be seen that the combination of Chinese herbal medicine in the treatment of patients with immunosuppressive drugs can be a good adjunct to the treatment according to TCM evidence-based treatment. In addition, Chinese herbal medicine has a beneficial effect on the recovery of uveitis and also has a good therapeutic effect on some systemic manifestations of patients such as irritability, irritability, insomnia, fatigue, constipation, and loss of appetite.