Uveitis in Behçet's disease

SER recommendations on treatment of refractory Behçet's syndrome

OBJECTIVE

To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (BS) (difficult to treat, severe resistant, severe relapse) to conventional treatment.

METHODS

A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format (patient, intervention, comparison and outcome). Systematic reviews of the evidence were conducted, the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations Assessment, Development, and Evaluation (GRADE). After that, the multidisciplinary panel formulated the specific recommendations.

RESULTS

4 PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with BS with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus.

CONCLUSIONS

The treatment of most severe clinical manifestations of BS lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official Recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.

Pulmonary Artery Aneurysm in Behcet Disease: Medical, Endovascular or Surgical Intervention

Behçet's disease is a chronic inflammatory condition that predominantly affects the body's blood vessels, exhibiting various clinical manifestations and complications. The exact cause remains unclear, but genetic predisposition, immune responses, and vascular activation are believed to contribute to its development. This disease is more prevalent in certain geographic regions and primarily affects young adults, particularly males. Pulmonary aneurysm, a complication of Behçet's disease, is the leading cause of mortality in Behcet disease. In this review, we summarize the complications of Behcet disease with a focus on pulmonary artery aneurysms. We discussed the medical, endovascular, and surgical management of pulmonary aneurysms in Behcet disease and the indications and outcomes of the different treatment options. Corticosteroids and cyclophosphamide remain the preferred first-line therapy. However, clinical improvement with infliximab or adalimumab, tumor necrosis factor-alpha (TNFα) blocking agents, have been reported after treatment failure with recommended first-line agents. In patients who fail medical therapy or those with life-threatening hemoptysis, endovascular or surgical intervention is the next option. Endovascular interventions include pulmonary artery embolization with coils or acrylic glue and using plugs, occluders, or stents. Endovascular interventions usually have fewer adverse effects than surgery. Although the risk of surgical procedures is high in pulmonary artery aneurysms, it could be a life-saving procedure in patients with life-threatening hemoptysis. Surgical options, including pulmonary artery ligation, aneurysmorrhaphy, segmentectomy, lobectomy, or pneumonectomy are available. However, the results of surgical therapy for Behçet aneurysms are often disappointing.

Challenges in the Timely Diagnosis of Behcet's Disease

Behcet's disease (BD) is a chronic, multi-systemic inflammatory disorder mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. As no pathognomonic laboratory test exists for BD, the diagnosis relies solely on clinical features. Over the years, great efforts have been invested in creating clinical diagnostic and classification criteria. The international study group criteria introduced in 1990 were the first true multinational set of criteria. Despite improving the ability to diagnose BD, these criteria still have limitations, including the inability to diagnose patients presenting without oral ulcers or presenting with rare manifestations of the disease. This led to the introduction of the international criteria for BD in 2013, which improved the sensitivity with minimal compromise on specificity. Despite the efforts made and as our understanding of the clinical manifestations of BD and genetic pathogenesis continue to evolve, efforts should be made to further enhance the currently accepted international classification criteria, perhaps by incorporating genetic testing (e.g., family history or HLA typing) as well as ethnic group-specific features.

Comparing biologic options for the management of Behcet's disease-related uveitis

INTRODUCTION

Behçet's disease (BD) associated uveitis occurs in approximately 50-70% of the patients. Ocular involvement in BD may induce a severe affection of visual function, leading to a considerable decrease in patients' quality of life. The risk for severe visual loss increases when the ocular posterior segment is involved and in patients with no adequate treatment.

AREAS COVERED

Monoclonal tumor necrosis factor (TNF) biotechnological inhibitors represent a relatively recent milestone for the treatment of non-infectious uveitis (NIU) also in BD patients. In addition to TNF inhibitors, further biologic agents have been increasingly proposed for multi-recalcitrant cases, as for interleukin (IL)-1 and IL-6 inhibitors. However, evidence on these new opportunities requires to be widened in the next future.

EXPERT OPINION

Joining the forces for scientific efforts is essential to quickly obtain solid acquisitions useful for the everyday clinical practice. To this end, the Auto-Inflammatory Disease Alliance (AIDA) Network has recently supported the development of an international registry dedicated to NIU and other inflammatory ocular involvement observed in BD patients. This will be essential to resolve current and future unmet needs burdening the everyday clinical practice.

Autoimmune Disease Classification Based on PubMed Text Mining

Autoimmune diseases (AIDs) are often co-associated, and about 25% of patients with one AID tend to develop other comorbid AIDs. Here, we employ the power of datamining to predict the comorbidity of AIDs based on their normalized co-citation in PubMed. First, we validate our technique in a test dataset using earlier-reported comorbidities of seven knowns AIDs. Notably, the prediction correlates well with comorbidity (R = 0.91) and validates our methodology. Then, we predict the association of 100 AIDs and classify them using principal component analysis. Our results are helpful in classifying AIDs into one of the following systems: (1) gastrointestinal, (2) neuronal, (3) eye, (4) cutaneous, (5) musculoskeletal, (6) kidneys and lungs, (7) cardiovascular, (8) hematopoietic, (9) endocrine, and (10) multiple. Our classification agrees with experimentally based taxonomy and ranks AID according to affected systems and gender. Some AIDs are unclassified and do not associate well with other AIDs. Interestingly, Alzheimer's disease correlates well with other AIDs such as multiple sclerosis. Finally, our results generate a network classification of autoimmune diseases based on PubMed text mining and help map this medical universe. Our results are expected to assist healthcare workers in diagnosing comorbidity in patients with an autoimmune disease, and to help researchers in identifying common genetic, environmental, and autoimmune mechanisms.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Clinical Manifestations and Diagnosis of Axial Spondyloarthritis

BACKGROUND

Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society.

SUMMARY OF WORK

Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA.

MAJOR CONCLUSIONS

A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA.

FUTURE RESEARCH DIRECTIONS

The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.

When obstetrics-gynecology specialists need to call an ophthalmologist urgently: a case report

Background

We report here a case of a healthy 23-year-old female patient who was assessed at the gynecology emergency department for genital ulcers, fever, and blurred vision. After suspicion of herpes simplex virus-2 lesions, the diagnosis of Behçet’s disease was made. We report this case with the aim of including Behçet’s disease in the differential diagnosis of genital ulcers, and emphasize the emergency of the vision loss that can be irreversible.

Case presentation

A healthy 23-year-old European female patient was assessed by gynecology in the emergency department for genital lesions associated with fever and blurred vision. At first, these lesions were suspected to be primary herpes simplex virus-2 infection One day later, she experienced decreased visual acuity in both eyes. After 4 days of worsening genital ulcers and persistent blurred vision, the patient was referred to the ophthalmology department. Fundoscopic examination showed retinal hemorrhages that were consistent with the first presentation of Behçet’s disease.

Conclusions

This case demonstrates that genital ulcers can be the very initial symptom of this ophthalmologic emergency. The differential diagnosis of genital ulcers is challenging. Behçet’s disease should be included, especially when associated with systemic or ocular manifestations, and should be considered an emergency for the gynecologist to prevent long-term vision loss.

An open-label, prospective, single-arm study of switching from infliximab to cyclosporine for refractory uveitis in patients with Behçet's disease in long-term remission

PURPOSE

Although infliximab (IFX) decreases the risk of blindness due to refractory uveitis in patients with Behçet's disease (BD), there are no standard criteria for IFX switching or withdrawal. To evaluate the effect of IFX switching in patients with BD in long-term remission, a prospective, single-arm intervention trial was conducted, switching from IFX to cyclosporine A (CYA).

STUDY DESIGN

A prospective open-label study.

METHODS

Eligible patients met the following criteria: administration of IFX without concomitant immunosuppressants for more than 5 years with no episodes of ocular attacks, no retinal vasculitis on fluorescein fundus angiography, negative C-reactive protein in serum, and no extraocular lesions at the time of IFX withdrawal. CYA 5 mg/kg/day was administered from 6 weeks after IFX withdrawal. The primary outcome was the rate of readministration of tumor necrosis factor inhibitors at 1 year after IFX withdrawal.

RESULTS

Three of 45 BD patients treated with IFX for refractory uveitis were included in the study. At 1 year after withdrawal of IFX, no patient had experienced any ocular attacks or needed readministation of IFX. However, extraocular lesions, such as recurrent oral ulcers, folliculitis, and recurrent fevers, occurred in all patients. Liver or renal dysfunction, which may have been caused by CYA, was also observed in all patients.

CONCLUSIONS

Although no ocular attacks were observed for at least 1 year after IFX withdrawal, this prospective study indicates that IFX withdrawal should be considered carefully, even for patients in long term remission of ocular and extraocular lesions.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

[Behçet's disease : Description and analysis of a French single-center retrospective study of 51 patients]

PURPOSE

To evaluate if the presence of uveitis in Behçet's disease (BD) is associated with a particular clinical phenotype and to analyze the prognostic impact of a missed diagnosis of BD at the time the uveitis is diagnosed.

MATERIEL AND METHODS

Ophthalmologic and systemic clinical features of 51 patients with BD were recorded retrospectively. We compared the clinical phenotype of patients with ocular manifestations with those without ocular manifestations. The patients were divided into two groups depending on the progression of their visual acuity: "decreased visual acuity" versus "stable or improved visual acuity."

RESULTS

In the group of patients with ocular involvement, there was a mean 2.3 systemic manifestations, vs. 3.2 in the group without ocular manifestations (P=0.004). When BD was diagnosed prior to the onset of uveitis, we counted fewer patients in the "decreased visual acuity" group in comparison with the patients who had no prior diagnosis of BD at the onset of the uveitis (91.3% in the "decreased visual acuity" group, P=0.04). The time before initiation of immunosuppressive treatment or a biological agent was shorter for these patients (4.4 vs. 39.3 months, P=0.007).

CONCLUSION

It appears that different phenotypes exist according to whether or not the BD patient has ocular involvement. Moreover, the visual prognosis is better if the uveitis occurs in patients who have already been diagnosed with BD, due to earlier initiation of immunosuppressive therapy.

[Ocular manifestations of Behçet's disease]

INTRODUCTION

Behçet's disease is a systemic inflammatory disease. Ocular involvement is an important diagnostic criterion, and this disease may be associated with severe visual loss.

PURPOSE

The goal of this study was to specify the epidemiological, clinical and therapeutic features of ocular involvement in patients with Behçet's disease and to identify risk factors for poor visual outcomes.

METHODS

A retrospective study was performed in 93 patients diagnosed with ocular Behçet's disease over a period of 9 years. Epidemiological, clinical, and therapeutic data was obtained from medical records and analyzed retrospectively. Poor visual outcome was defined as visual acuity limited to light perception without projection or no light perception.

RESULTS

The male:female ratio was 1.9. The mean age was 34.5 years. Ocular involvement was the presenting sign in 4%, bilateral in 61% and active in 68.8%. Uveitis was the most common presentation (57%), dominated by panuveitis, followed by retinal vasculitis (51.6%) and papilledema (10.7%). Maculopathy (26.8%) and cataract (18.2%) were the most common complications. Twenty patients (21.5%) had no light perception or light perception without projection. Treatment was based on corticosteroids in combination with immunosuppressive therapy (Azathioprine) in 55.9% of cases. Our study indicates a significant association of male gender and panuveitis with a poor visual outcome.

CONCLUSION

Ocular involvement in Behçet's disease is frequent and serious, which may lead to blindness. Male gender and panuveitis were predictors of poor visual prognosis.

A 10-year follow-up of infliximab monotherapy for refractory uveitis in Behçet's syndrome

Infliximab (IFX) was the first biologic introduced for refractory uveitis treatment in Behçet’s syndrome (BS). However, there have been few reports on the safety and efficacy of IFX monotherapy over follow-up periods of more than 10 years. This retrospective study evaluated the 10-year safety and efficacy of IFX monotherapy compared to IFX combination therapies with colchicine or corticosteroid for refractory uveitis in BS patients. Monotherapy was performed in 30 eyes of 16 patients while combination therapies were performed in 20 eyes of 11 patients. Continuation of IFX occurred in 70.3% of enrolled patients for 10 years without any significant difference noted in the retention rate between the monotherapy and combination therapies (p = 0.86). Reduction of ocular inflammatory attacks and improvement of best corrected visual acuity occurred in the monotherapy group after 10 years, which was equivalent to that for the combination therapies. Although adverse events (AEs) or therapy discontinuation occurred during the initial 5 years in both therapies, no AEs were observed for either therapy after 6 years. Our results suggested that IFX monotherapy proved to be effective and not inferior to combination therapies over a 10-year follow-up. Although loss of response and AEs may be noticed during the initial 5-year period, a safe and effective continuation can be expected thereafter.

Behçet's Disease: Different Systemic Manifestations at Different Ages

Behçet's disease, an inflammatory condition, can involve various systems. The disease usually manifests with dermatologic and ocular signs but can also cause serious symptoms due to pulmonary or neurologic involvement. Although the onset may occur at any age, it typically emerges in the second to fourth decades of life. As in the case presented here, Behçet's disease can manifest with the central nervous system involvement early in life and pulmonary involvement in adulthood.

Long-term efficacy of early infliximab-induced remission for refractory uveoretinitis associated with Behçet's disease

BACKGROUND

To evaluate long-term efficacy of infliximab (IFX) in refractory uveoretinitis associated with Behçet's disease (BD) depending on uveoretinitis duration.

METHODS

Records of 16 patients with BD (32 eyes) followed for >5 years after starting IFX, were retrospectively reviewed. Long-term efficacy was compared between patients with short duration (≤18 months, n=7) versus long duration (>18 months, n=9) of their uveoretinitis prior to starting IFX.

RESULTS

The median follow-up after starting IFX was 132 months (76-146 months). Mean frequency of attacks and the 1-year Behçet's Disease Ocular Attack Score 24 decreased significantly over 10 years. Overall, the percentage of eyes with a best-corrected visual acuity (BCVA) ≥1.0 increased from 47% at baseline to 59% at 5 years; the percentage of eyes with a BCVA ≤0.1 was 19% at both baseline and 5 years. The frequency of ocular attacks decreased similarly in both short duration and long duration groups; however, the percentage of eyes with a BCVA ≥1.0 at 5 years was 100% in the short duration group versus 28% in the long duration group. IFX was discontinued in four patients with an excellent response to IFX therapy; all were young male patients in the short duration group with good BCVA bilaterally, and none had inflammatory recurrences over a median follow-up of 56 months off IFX.

CONCLUSION

Initiation of IFX therapy in patients with BD within 18 months of their uveoretinitis onset was more effective in maintaining good BCVA than after 18 months.

Behçet's Disease Under Microbiotic Surveillance? A Combined Analysis of Two Cohorts of Behçet's Disease Patients

Background: In Behçet's disease (BD), an auto-inflammatory vasculitis, an unbalanced gut microbiota can contribute to pro-inflammatory reactions. In separate studies, distinct pro- and anti-inflammatory bacteria associated with BD have been identified.

Methods: To establish disease-associated determinants, we performed gut microbiome profiling in BD patients from the Netherlands (n = 19) and Italy (n = 13), matched healthy controls (HC) from the Netherlands (n = 17) and Italy (n = 15) and oral microbiome profiling in Dutch BD patients (n = 18) and HC (n = 15) by 16S rRNA gene sequencing. In addition, we used fecal IgA-SEQ analysis to identify specific IgA coated bacterial taxa in Dutch BD patients (n = 13) and HC (n = 8).

Results: In BD stool samples alpha-diversity was conserved, whereas beta-diversity analysis showed no clustering based on disease, but a significant segregation by country of origin. Yet, a significant decrease of unclassified Barnesiellaceae and Lachnospira genera was associated with BD patients compared to HC. Subdivided by country, the Italian cohort displays a significant decrease of unclassified Barnesiellaceae and Lachnospira genera, in the Dutch cohort this decrease is only a trend. Increased IgA-coating of Bifidobacterium spp., Dorea spp. and Ruminococcus bromii species was found in stool from BD patients. Moreover, oral Dutch BD microbiome displayed increased abundance of Spirochaetaceae and Dethiosulfovibrionaceae families.

Conclusions: BD patients show decreased fecal abundance of Barnesiellaceae and Lachnospira and increased oral abundance of Spirochaetaceae and Dethiosulfovibrionaceae. In addition, increased fecal IgA coating of Bifidobacterium, Ruminococcus bromii and Dorea may reflect retention of anti-inflammatory species and neutralization of pathosymbionts in BD, respectively. Additional studies are warranted to relate intestinal microbes with the significance of ethnicity, diet, medication and response with distinct pro- and inflammatory pathways in BD patients.

Comparison of Optical Coherence Tomography Angiography Findings in Patients with Behçet's Disease and Healthy Controls

PURPOSE

To investigate optical coherence tomography angiography (OCTA) findings in patients with Behçet's disease (BD).

METHODS

Ninety-four eyes of 49 patients with BD and 53 eyes of 53 healthy subjects were included. Vascular density (VD), foveal avascular zone (FAZ) area, perifoveal capillary hypoperfusion, perifoveal capillary network disorganization, and FAZ irregularity were analyzed.

RESULTS

OCTA revealed retinal VD reduction and higher perifoveal capillary hypoperfusion, perifoveal capillary network disorganization and FAZ irregularity in ocular Behçet's compared to nonocular Behçet's (p = .000). However, compared to normal eyes, there was no difference between any OCTA measurements in nonocular BD patients. The mean area of FAZ was not different in any group (p = .266). In ocular Behçet, visual acuity was inversely correlated with FAZ area and FAZ irregularity.

CONCLUSION

Retinal VD decreases and perifoveal microvascular network changes in ocular Behçet's. FAZ irregularity may be a more valuable marker than FAZ area for indicating ocular involvement.

Folic acid deficiency and vision: a review

Folic acid (FA), also termed folate, is an essential vitamin for health at all ages since it participates in the biosynthesis of nucleotides, amino acids, neurotransmitters, and certain vitamins. It is therefore crucial for rapidly growing tissues such as those of the fetus. It is becoming clear that FA deficiency and impaired folate pathways are implicated in many diseases of both early life and old age. FA can be transported into the cell by the folate receptor, the reduced folate transporter, and proton-coupled folate transporter. Folate transport proteins are present in certain eye tissues, which explains why FA plays an important role in eye development. The purpose of this literature review is to investigate the evidence relating FA deficiency to eye diseases.

Outer Plexiform Layer Elevations as a Marker for Prior Ocular Attacks in Patients With Behcet's Disease

Purpose

Patients with Behcet's disease frequently have abnormal focal outer plexiform layer (OPL) bumps, which compress the inner nuclear layer. This study investigates the clinical relevance of these OPL elevations in Behcet's disease patients.

Methods

Thirty-one consecutive patients (59 eyes) with Behcet's disease in remission and with available optical coherence tomography (OCT) images were included. The number of OPL bumps was counted using spectral-domain OCT images. The relationships between the number of bumps and visual acuity (VA), retinal thickness, choroidal thickness, disease duration, number of prior ocular attacks, and photoreceptor layer status (including external limiting membrane [ELM] and ellipsoid zone [EZ] continuity) were examined.

Results

Eyes with more severe EZ or ELM disruptions had lower VA, more ocular attacks, and thinner retinas. Additionally, EZ line and ELM line status were significantly correlated with the number of OPL elevations. Eyes with OPL elevations had poorer VA, longer disease duration, more ocular attacks, and thinner retinas than those without OPL elevations. Additionally, the number of OPL elevations was strongly correlated with the number of ocular attacks in eyes with a preserved photoreceptor layer (R = 0.720, P < 0.0001).

Conclusions

The number of OPL elevations was associated with the number of prior ocular attacks in eyes with preserved photoreceptor layers. Therefore, OPL elevations may be a marker of prior posterior ocular attacks, which is important when determining how best to manage Behcet's uveitis.

Behçet syndrome: A great imitator

Behçet syndrome is considered to be a multisystemic vasculitis involving the skin, mucosa, eyes, joints, nervous system, cardiovascular system, and gastrointestinal system. The exact pathogenesis of the disease is unknown, but autoimmune factors are thought to play the main role. Vasculitis in Behçet syndrome can involve any kind and size of vessels, and this explains why the disease has the ability of multisystemic involvement. The commonest clinical presentation of Behçet syndrome is recurrent and painful mucocutaneous ulcerations known as aphthosis. The other clinical manifestations vary among patients and populations. The disease tends to be more severe in men. Ocular, vascular, and central nervous system involvements are the major causes of morbidity and mortality. Behçet syndrome is a mimicker of many diseases with its several faces and considered as one of the great imitators in dermatology.

Interferon alpha-2a treatment for refractory Behcet uveitis in Korean patients

BACKGROUND

To evaluate therapeutic outcomes of interferon alpha-2a (IFNα2a) treatment in patients with Behcet's disease who were refractory to immunosuppressive agents.

METHODS

This retrospective case series reviewed the medical records of 5 patients with refractory Behcet uveitis from January 2011 to February 2017. IFNα2a was administered at a dose of 3 million IU 3 times per week. Clinical response, relapse rate, and change of visual acuity were evaluated.

RESULTS

The mean age of patients was 39.60 ± 9.21 years, and the median treatment duration was 6 months. Four of the 5 patients (80%) presented with responses to IFNα2a without any uveitis attack during the treatment period. The mean number of uveitis attacks/year per patient during the treatment was 0.40 ± 0.89. The mean log of the Minimum Angle of Resolution visual acuity improved from 1.44 ± 0.38 at baseline to 1.02 ± 0.58 at the final follow up.

CONCLUSIONS

IFNα2a is an effective therapy for Behcet uveitis refractory to conventional immunosuppressants in Korean patients.

An update on the use of biologic therapies in the management of uveitis in Behçet's disease: a comprehensive review

ᅟ: Behçet's disease (BD) is a systemic vasculitis characterised by a relapsing remitting course, affecting multiple organ systems. In the eye, it is a cause of potentially blinding inflammation in the form of uveitis. Management of uveitis in BD often requires the use of systemic immunosuppression, in order to reduce disease activity and prevent accumulation of irreversible damage. Whilst corticosteroids remain the mainstay of treatment, long-term use is limited by the development of adrenocorticotrophic side effects. There has therefore been significant interest in the use of corticosteroid-sparing immunosuppressive agents, and more recently, biologic therapies. Recent publications have demonstrated biologic therapy to have beneficial effects both on overall disease control, and quality of life for patients with BD. Widespread use of such agents is however limited, partly by the lack of high quality research evidence, and partly by the prohibitive cost of biologic treatments. In this review, we discuss the most recent research investigating the use of biologic therapy in uveitis due to BD, with consideration of health economics and quality of life outcomes.

Serum Profiles of Cytokines in Behcet's Disease

Introduction: Behcet’s disease (BD) is a chronic systemic autoinflammatory vasculitis which is handled by the variety of proteins like cytokines. Therefore, cytokines are considered as one of the prototypic factors during inflammatory responses of BD. Consequently, the present study was designed for evaluation of cytokine profiles in Iranian BD cases, including those with and without uveitis. Materials and Method: All cases were divided into three groups based on ophthalmologic exam results: BD with uveitis, BD without uveitis, and recovered uveitis BD. Cases with a history of BD recovery were placed in the group of recovered uveitis. The patients with infectious uveitis as well as other collagen vascular diseases and patients who have used biologics to treat ocular immune-mediated diseases were excluded. Finally, after venous blood sampling, levels of cytokines were quantified and statistical approaches were performed for measurements. Results: Enrolled cases were divided to 26 patients with active uveitis, 25 patients with recovered uveitis and 24 patients without uveitis and interestingly, just IL-2 was the only cytokine that showed statistical difference in patients with BD uveitis in comparison with other groups (p_value = 0.02). The pair wise comparison showed a significant difference between the patients with and without uveitis groups (p_value = 0.004) as well as patients with uveitis and recovered uveitis groups (p_value = 0.002). Discussion: Significant elevation of IL-2 in patients with uveitis (in comparison with recovered or without uveitis cases) demonstrates that it may be one of the main proteins that enroll in the pathophysiology of BD uveitis and may be considered as a new target for refractory disease therapies. Studies with larger samples can help to obtain more accurate conclusions.

Behçet's disease departs the 'Silk Road': a case report and brief review of literature with geographical comparison

Behçet's disease (BD) is a chronic multisystem inflammatory disease most prevalent in Eastern Asia and along the Mediterranean basin, an area referred to as the ‘Silk Road’. The diagnosis of BD is largely based on the International Study Group (ISG) criteria, which are more specific than sensitive. ISG criteria do not include intestinal manifestations, a feature more commonly seen in the West. Intestinal BD is one of several findings that are not typically seen along the ‘Silk Road’. Herein we report a rare case of intestinal BD and compare Western versus traditional BD. A 25-year-old male with a history of painful oral aphthous ulcers, pericarditis, and diffuse papulopustular rash presented to the emergency department with two terminal ileal perforations. Pathology demonstrated mucosal necrosis with active inflammation and no chronic inflammatory changes. Post-surgical laboratory studies showed an elevated c-reactive protein of 35.57 mg/dL, erythrocyte sedimentation rate of 82 mm/h, and a positive anti-Saccharomyces cerevisiae antibody. Rheumatological workup including ANA, RF, PR3 antibody, MPO antibody, ANCA, SSA and SSB, Smith antibody, SCL-70, and anti-Jo-1 antibodies were all negative. His pericarditis symptoms improved with colchicine and prednisone prior to discharge. Our patient did not meet the current ISG criteria for traditional BD; however, he clearly showed findings typically seen in Western patients with BD, which include intestinal manifestations, cardiac involvement, and lack of pathergy reaction and ocular changes. Our investigation demonstrates that the clinical manifestations common to this disorder vary among geographic and ethnic populations. Commonly used criteria for the diagnosis of BD may not be sensitive for some populations, such as Western BD, potentially leading to underdiagnoses and mismanagement. Recognition and select inclusion of these differences may be one way to assist with diagnosing Western BD in the future. As our knowledge of BD continues to evolve, so must the population-specific criteria used to define BD.

Reconstitution of disrupted photoreceptor layer in uveitis associated with Behçet's disease by infliximab treatment

Background

Behçet’s disease (BD)-associated uveitis causes retinal damage leading to severe visual disturbance. The early morphological changes in the retina are revealed by disappearance or disruption of the external limiting membrane (ELM), inner segment ellipsoid zone (EZ) and cone interdigitation zone (CIZ) in the outer retina shown on spectral domain-optical coherence tomography (SD-OCT). However, it is unknown whether these changes in the retina are reversible in BD-associated uveitis.

Case presentation

A 38-year-old man was referred to our hospital with 5 years history of panuveitis in both eyes. Recurrent oral ulcer, folliculitis, and genital ulcer were noted as systemic complications. Moderate cell infiltration into the anterior chamber, and diffuse vitritis were observed in both eyes, and best corrective visual acuity (BCVA) was 20/60 in the right and 20/200 in the left eye. Fluorescein angiography (FA) showed severe dye leakage from extensive retinal vessels in both eyes. Spectral domain-optical coherence tomography (SD-OCT) revealed retinal cysts and disruption of the external limiting membrane (ELM), inner segment ellipsoid zone (EZ) and cone interdigitation zone (CIZ) in the macular region of both eyes. BD was diagnosed based on the ocular features and systemic lesions, and infliximab therapy was initiated for the severe visual disturbance. After treatment with infliximab, foveal excavation was first recovered with disappearance of retinal cysts, and then ELM and EZ were gradually reconstituted on SD-OCT. Finally, CIZ became distinguishable after 24 months of infliximab therapy. BCVA was recovered to 20/25 in both eyes, and ocular inflammatory attack did not recur after the initiation of infliximab therapy.

Conclusion

Disruption of ELM, EZ, and CIZ shown on SD-OCT in BD-associated uveitis could be reconstituted by continuous infliximab treatment, which leaded to the improvement of visual acuity.

Headache in Behçet's syndrome: review of literature and NYU Behçet's syndrome center experience

Headache, a common and disabling symptom in Behçet's syndrome, may be associated with a variety of neurologic syndromes and ocular inflammation, or may present as an isolated feature. Our objective is to describe the various neurologic and ocular syndromes of Behçet's syndrome of which headache is a symptom, and to review the features of isolated headaches in Behçet's. We also report results of a study of headache in Behçet's syndrome patients who are followed at NYU Hospital for Joint Diseases, the first study of its kind in North American patients, and the first to document prevalence of both episodic and chronic daily headache in Behçet's.

Successful Treatment with Infliximab for Refractory Uveitis in a Hemodialysis Patient with Behçet's Disease and a Review of the Literature for Infliximab Use in Patients on Hemodialysis

A 36-year-old man with a 16-year history of refractory Behçet's disease (BD)-associated uveitis and chronic renal failure requiring hemodialysis suffered from frequent ocular attacks despite treatment with systemic corticosteroids and cyclosporine A. Following infliximab administration, the patient's BD ocular attack score 24 and visual acuity improved. Although he developed mild acute gastroenteritis, he did not experience any other adverse events. In our review of the literature, we identified seven patients on hemodialysis with inflammatory disease successfully treated with infliximab. Infliximab may be effective and safe in cases of BD and other diseases, including in patients under hemodialysis.

Update on the diagnosis and management of Behçet's disease

Behçet’s disease is a multi-organ disorder that is more common in countries around the Silk Road, and manifests as mucosal ulcers and skin lesions, and with ocular involvement. As a systemic disease, it can also involve gastrointestinal organs and the central nervous or cardiovascular systems. Although the etiology of Behçet’s disease is not clearly identified, the pathogenesis of the disease is most commonly hypothesized as a profound inflammatory response triggered by an infectious agent in a genetically susceptible host. As there are no single specific manifestations or specific diagnostic tests, various diagnostic criteria have been proposed around the world, and, among them, the International Study Group criteria have been most commonly used. As the clinical expression of Behçet’s disease is heterogeneous, the treatment should be individualized based on involved organs, severity of the disease, and patient’s background. The choice of therapeutic agents is limited by lack of clinical trials and is based largely on case reports, case series, and several open-label clinical trials. Corticosteroids, colchicine, and traditional immunosuppressive agents, including azathioprine and cyclosporine, have been used for the treatment of Behçet’s disease. Recently, tumor necrosis factor (TNF) inhibitors have become available for several rheumatic diseases, and considerable published data suggest that TNF inhibitors represent an important therapeutic advance for patients with severe and resistant disease, as well as for those with contraindications or intolerance to these treatments.

Long-term efficacy of infliximab on background vascular leakage in patients with Behçet's disease

PURPOSE

To evaluate the effect of infliximab over the initial 4 years of treatment on inflammatory ocular attacks and background retinal/disc vascular leakage in patients with refractory uveoretinitis associated with Behçet's disease.

METHODS

Clinical records of nine patients were retrospectively reviewed. The main outcomes analyzed were frequency of ocular inflammatory attacks, background retinal and disc vascular leakage as assessed by fluorescein angiography during periods of clinical quiescence, best-corrected visual acuity, and adverse effects.

RESULTS

The median follow-up on infliximab was 50 months (range 48-58 months). Mean frequency of attacks decreased significantly in years 1, 2, 3, and 4 compared with the baseline 1-year period before infliximab use. Mean background retinal and disc vascular leakage scores also decreased significantly at the end of each 1-year period compared with baseline. Visual acuity improved or was unchanged at the end of 4 years in 17 of 18 eyes. No serious adverse effects were observed.

CONCLUSION

Infliximab reduced the mean frequency of ocular attacks and mean background retinal/disc vascular leakage in a long-term sustained manner over 4 years of treatment in Behçet's disease patients.

Clinical course of patients with Behçet's uveitis following discontinuation of infliximab therapy

PURPOSE

To investigate the clinical course of Behçet's uveitis patients following discontinuation of infliximab therapy.

METHODS

This retrospective chart review study examined Behçet's disease patients who received infliximab treatment between 2000 and 2012. Medical records of patients whose infliximab treatment was discontinued were reviewed, with special focus on the frequency of uveitis attacks in the period before initiation, during treatment and after cessation of the infliximab therapy. Mean visual acuities were evaluated for each treatment period.

RESULTS

Out of the 43 patients treated with infliximab at our uveitis clinic, ten were discontinued due to adverse events or inefficiency. Data for seven patients followed for more than 12 months before initiation and after cessation of infliximab were analyzed. Frequency of acute uveitis attacks was 7.43 per 12 months before initiation of infliximab, 2.86 during treatment and 0.57 after cessation. A statistically higher frequency of uveitis attacks was observed before initiation of infliximab compared to during (p < 0.05) and after cessation of treatment (p < 0.05). There was no statistical significance observed between the period during treatment and after cessation (p = 0.29). The mean logMAR was 0.79 at baseline, 0.68 during treatment, and 0.88 at 12 months after cessation. These differences were not statistically significant.

CONCLUSIONS

A satisfactory clinical course with well-controlled ocular inflammation was found after discontinuation of infliximab therapy in Behçet's uveitis patients. These results suggest that a safe, pre-planned discontinuation of infliximab therapy can be performed in patients with Behçet's uveitis.

Angiopoietin-like protein 2 mediates endotoxin-induced acute inflammation in the eye

Angiopoietin-like protein (Angptl) 2 is a key mediator linking obesity to chronic adipose-tissue inflammation and systemic insulin resistance, and increasing evidence has shown that Angptl2 is associated with various chronic inflammatory diseases such as cancer and dermatomyositis; however, it remains unclear that Angptl2 functions in acute inflammation. In this study, we investigate whether Angptl2 has a role in acute inflammation in the eye with endotoxin-induced uveitis (EIU). Angptl2 was widely expressed in the normal mouse retina, while Angptl2⁻/⁻ mice did not exhibit any changes in retinal cell marker expression and morphological analyses. Treatment with lipopolysaccharide (LPS) stimulated retinal Angptl2 mRNA expression in vivo and in vitro. We generated EIU in wild-type (C57BL/6) and Angptl2⁻/⁻ mice by injecting LPS intraperitoneally. Compared with wild-type animals, Angptl2⁻/⁻ mice significantly reduced various EIU-associated cellular and molecular parameters including leukocyte adhesion to the retinal vessels and infiltration into the vitreous cavity and retinal mRNA expression levels of monocyte chemotactic protein-1, intercellular adhesion molecule-1, interleukin (IL)-6, and tumor necrosis factor (TNF)-α, together with nuclear translocation of nuclear factor (NF)-κB p65 subunit. In vitro, antibody-based inhibition of α5β1 integrin, a receptor for Angptl2, significantly repressed LPS-induced expression of IL-6 and TNF-α, both of which are the major inflammatory cytokines derived from macrophages. The present findings indicate that Angptl2 mediates endotoxin-induced retinal inflammation through the activation of NF-κB signaling pathway and suggest a potential validity of Angptl2 as a new molecular target for the treatment of acute inflammation.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Behçet disease: visual prognosis and factors influencing the development of visual loss

PURPOSE

To assess the visual prognosis of patients with ocular Behçet disease and to determine factors predictive of visual loss and severe visual loss.

DESIGN

Retrospective case series.

METHODS

One hundred seventy-five eyes of 107 patients diagnosed with ocular Behçet disease were included. The main outcome measures were visual loss (best-corrected visual acuity, worse than 20/40) and severe visual loss (best-corrected visual acuity, 20/200 or worse).

RESULTS

The mean duration of follow-up was 6.5 years. Presenting visual acuity was worse than 20/40 in 50% of eyes and 20/200 or worse in 21% of eyes; approximately one third of this was reversible with treatment. The most common cause of irreversible severe visual loss was ischemic maculopathy. At 10 years, there was a 39% risk of visual loss and a 24% risk of severe visual loss, the latter figure being reduced to 13% if patients with irreversible visual loss at presentation were excluded. After controlling for potentially confounding variables, male sex, unilateral disease, and left eye involvement all were statistically significant risk factors for severe visual loss at 5 and 10 years. Patients who were treated with biologic agents were less likely to have severe visual loss in either eye at both 5 and 10 years.

CONCLUSIONS

Many patients with ocular Behçet disease still have irreversible visual loss at presentation. However, the visual prognosis is otherwise improved, with a 10-year risk of severe visual loss of 13% in this cohort. The use of biologic agents is associated with a lower risk of severe visual loss at 5 and 10 years.

Interferon-γ and nitric oxide production during Behçet uveitis: immunomodulatory effect of interleukin-10

Uveitis is one of the major manifestations of Behçet Disease, a systemic inflammatory vasculitis. Our aim is to investigate in vivo and in vitro production of interferon (IFN)-γ and nitric oxide (NO) during Behçet uveitis (BU). Moreover, we evaluated the implication of IFN-γ and interleukin (IL)-10 in the regulation of NO production in vitro. Cytokines' concentrations were measured by ELISA, and NO levels were assessed by modified Griess's method. Our results showed that patients with active disease had significant elevation of IFN-γ and NO concentrations in both plasma and peripheral blood mononuclear cell culture supernatants compared with controls (P<0.01) or to patients with inactive disease (P<0.05). Further, IFN-γ induced significantly higher production of NO in cell culture supernatants, whereas IL-10 significantly reduced it (P<0.05). In conclusion, the elevated levels of IFN-γ in vivo and in vitro in patients with BU reflect the implication of this cytokine in the disease physiopathology. These results suggest that IFN-γ, through the induction of NO synthase 2 and the production of NO, is implicated in the genesis of the inflammatory process during active BU; whereas IL-10 seems to have protective properties.

Current approach in the diagnosis and management of panuveitis

Panuveitis is a generalized inflammation of not only the whole of the uveal tract but also involves the retina and vitreous humor. It differs from other anatomical sites of inflammation in terms of causes as well as distribution. The common causes of panuveitis in our population are tuberculosis, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, Behcet's disease and sarcoidosis. A large number of cases still remain idiopathic. A stepwise approach is essential while evaluating these patients to be able to identify and treat the disease timely and correctly. Ancillary tests can be appropriately applied once the anatomic site of inflammation is identified. An exhaustive approach comprising a full battery of tests is obsolete. Only specific tailored investigations are ordered as suggested by the preliminary clinical and ocular examination. The mainstay of the treatment of uveitis is corticosteroids. Immunosuppressive agents are administered if the inflammation is not adequately controlled with corticosteroids. One of the recent breakthroughs in the treatment of refractory uveitis includes the introduction of immunomodulating drugs: Tumor necrosis factor-alpha antagonist and Interferon-alpha. Vitrectomy has been used in uveitis for over a few decades for diagnostic and therapeutic purposes. When compared to other anatomical sites of inflammation, panuveitis has poor visual outcome due to more widespread inflammation. The side-effects of the chronic treatment that these patients receive cannot be overlooked and should be specifically monitored under the supervision of an internist with special interest in inflammatory diseases.

Hypopyon in patients with uveitis

PURPOSE

To evaluate the risk of and risk factors for hypopyon among patients with uveitis and to evaluate the risk of visual changes and complications after hypopyon.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with uveitis at 4 academic ocular inflammation subspecialty practices.

METHODS

Data were ascertained by standardized chart review.

MAIN OUTCOME MEASURES

Prevalence and incidence of hypopyon, risk factors for hypopyon, and incidence of visual acuity changes and ocular complications after hypopyon.

RESULTS

Among 4911 patients with uveitis, 41 (8.3/1000) cases of hypopyon were identified at the time of cohort entry. Of these, 2885 initially free of hypopyon were followed over 9451 person-years, during which 81 patients (2.8%) developed hypopyon (8.57/1000 person-years). Risk factors for incident hypopyon included Behçet's disease (adjusted relative risk [RR]=5.30; 95% confidence interval [CI], 2.76-10.2), spondyloarthropathy (adjusted RR=2.86; 95% CI, 1.48-5.52), and human leukocyte antigen (HLA)-B27 positivity (adjusted RR=2.04; 95% CI, 1.17-3.56). Patients with both a spondyloarthropathy and HLA-B27 had a higher risk than either factor alone (crude RR=4.39; 95% CI, 2.26-8.51). Diagnosis of intermediate uveitis (+/- anterior uveitis) was associated with a lower risk of hypopyon (with respect to anterior uveitis only, adjusted RR=0.35; 95% CI, 0.15-0.85). Hypopyon incidence tended to be lower among patients with sarcoidosis (crude RR=0.22; 95% CI, 0.06-0.90; adjusted RR=-0.28; 95% CI, 0.07-1.15). Post-hypopyon eyes and eyes not developing hypopyon had a similar incidence of band keratopathy, posterior synechiae, ocular hypertension, hypotony, macular edema, epiretinal membrane, cataract surgery, or glaucoma surgery. Post-hypopyon eyes were more likely than eyes not developing hypopyon to gain 3 lines of vision (crude RR=1.54; 95% CI, 1.05-2.24) and were less likely to develop 20/200 or worse visual acuity (crude RR=0.41; 95% CI, 0.17-0.99); otherwise, visual outcomes were similar in these groups.

CONCLUSIONS

Hypopyon is an uncommon occurrence in patients with uveitis. Risk factors included Behçet's disease, HLA-B27 positivity, and spondyloarthropathy. Intermediate uveitis cases (+/- anterior uveitis) had a lower risk of hypopyon. On average, post-hypopyon eyes were no more likely than other eyes with uveitis to develop structural ocular complications or lose visual acuity.

One year study of efficacy and safety of infliximab in the treatment of patients with ocular and neurological Behçet's disease refractory to standard immunosuppressive drugs

The aim of the study was to assess the long-term efficacy and safety of Infliximab therapy in the treatment of patients with Behçet's disease refractory to standard immunosuppressive agents. Twenty-one patients that did not respond to corticosteroids and to at least one immunosuppressant (cyclosporin, methotrexate, azathioprine, cyclophosphamide) for the presence of ocular and/or CNS involvement were enrolled. Eighteen patients completed the study up to 54 weeks. Stable doses of prednisone (<10 mg/day) were permitted, immunosuppressants were discontinued at least 4 weeks prior baseline visit. The patients received three infusions of 5 mg/kg Infliximab (at weeks 0, 2 and 6) and then infusions of 5 mg/kg Infliximab every 8 weeks. At each visit data on clinical symptoms, response to therapy and adverse events were collected. The primary outcome of interest was to assess the clinical efficacy (total or partial recovery) of infliximab. Secondary end points were to evaluate quality of life and to monitor the safety of the drug. Eighteen patients achieved a total remission. Two patients achieved a partial remission and relapsed after 3 months from discontinuation of therapy. Infliximab was well tolerated throughout the study. A case of non-Hodgkin lymphoma was observed within 6 months. Minor side effects were headache, dizziness, tachycardia that regressed spontaneously and did not entail interruption. Anti-nuclear antibodies were not detected during the period of observation.

Ocular features of Behcet's disease: an international collaborative study

OBJECTIVE

To investigate the clinical features of ocular lesions in Behçet's disease in different countries.

METHODS

A descriptive questionnaire survey was performed.

RESULTS

25 eye centres in 14 countries returned questionnaires on prevalent cases in 2006. Clinical data were analysed on 1,465 patients with ocular lesions. Recurrent oral aphthous ulcers were reported in 94.5%, skin lesions in 69.5% and genital ulcers in 61.4%. Most of the patients had bilateral and recurrent intraocular inflammation. Poor visual acuity was seen in 18.9% in women, but 24.8% in men (p<0.01). Panuveitis was seen more in men than in women (p<0.01). 23% of the patients had visual acuity equal to or worse than 20/200 at the final visit. The patients with poor vision were more frequently in India, Iran and Japan than in other countries (p<0.01).

CONCLUSIONS

We report the largest contemporary international case series of patients with ocular involvement in Behçet's disease. Panuveitis was significantly more frequent in men than women, and men tended to have a worse visual prognosis. There were some differences in the clinical pattern of Behçet's disease in different countries. Despite modern treatment, the disease still carries a poor visual prognosis with one-quarter of the patients blind.