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Hwang DK, Hung JH, Chang YC, Chen CL, Chen SN, Cheng CK, Hwang YS, Kuo HK, Li AF, Lin CJ, Yang CH, Sheu SJ, Lin CP. Step-wise diagnostic approach for patients with uveitis - Experts consensus in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:573-580. [PMID: 35361552 DOI: 10.1016/j.jmii.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/10/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023]
Abstract
Uveitis is a sight-threatening disease that can be associated with many different etiologies. Successful treatment of uveitis relies on accurate diagnosis and prompt efficient therapy. History taking, physical and ocular examinations, systemic evaluations, and response to treatment provide crucial information to differentiate possible etiologies involved in the pathophysiology of intraocular inflammation. This article provides recommendations for a step-wise approach to patients with uveitis in Taiwan based on an expert meeting and consensus. Systemic evaluations for uveitis should be performed step-by-step and include investigation of patients' general systemic conditions, ruling out infectious etiologies, and obtaining evidential biomarkers to diagnose a specific disease entity.
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Affiliation(s)
- De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jia-Horung Hung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yo-Chen Chang
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Taiwan; Department of Ophthalmology, School of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Taiwan
| | - Ching-Long Chen
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - San-Ni Chen
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan; Department of Optometry, Da-Yeh University, Changhua, Taiwan
| | - Cheng-Kuo Cheng
- Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Catholic Fu-Jen University, New Taipei, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan; Department of Ophthalmology, Chang Gung Memorial Hospital, Xiamen Branch, Xiamen, China
| | - Hsi-Kung Kuo
- Department of Ophthalmology, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung, Taiwan; Chang-Gung University College of Medicine, Kaohsiung, Taiwan
| | - An-Fei Li
- Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan; Department of Optometry, Asia University, Taichung, Taiwan
| | - Chang-Hao Yang
- Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Taiwan; Department of Ophthalmology, School of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Taiwan.
| | - Chang-Ping Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan.
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Patel S, Belamkar A, Hajrasouliha AR, Jusufbegovic D, Ciulla TA. Progress in the pharmacotherapy of uveitis: the art of personalized care. Expert Opin Pharmacother 2022; 23:1445-1455. [PMID: 35880543 DOI: 10.1080/14656566.2022.2104637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Uveitis is a heterogeneous group of inflammatory intraocular disorders which can lead to blindness, but prompt diagnosis and management can improve visual outcomes and reduce treatment burden. AREAS COVERED In this review, the authors provide an overview of commonly used treatments of the management of non-infectious uveitis. EXPERT OPINION Initially, the treatment of non-infectious uveitis was limited to corticosteroids which have a broad range of adverse ocular and systemic effects. Now new options, such as biological response modulators, are a novel yet exciting addition to this armory and have the potential to change the course of treatment as well as prognostic outcomes for uveitis patients. Additionally, further research is needed to evaluate the efficacy of this novel class of immunomodulators in uveitis therapy.
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Affiliation(s)
- Shivam Patel
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Aditya Belamkar
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Amir R Hajrasouliha
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Denis Jusufbegovic
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Thomas A Ciulla
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202.,Midwest Eye Institute, Springmill Medical Building, 10300 N. Illinois St., Suite 1000, Carmel, IN 46290, USA.,Clearside Biomedical, 900 North Point Pkwy # 200, Alpharetta, GA 30005
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Fonollosa A, Gallego-Pinazo R, Sararols L, Adán A, López-Gálvez M, Figueroa MS. Guidance on brolucizumab management recommendations. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:S2173-5794(22)00084-6. [PMID: 35882576 DOI: 10.1016/j.oftale.2022.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/21/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Brolucizumab, a new generation anti-VEGF, has demonstrated efficacy and safety in AMD in the pivotal HAWK and HARRIER trials. Post-marketing, previously undetected adverse events related to intraocular inflammation have been reported. An independent post hoc review of the pivotal trials puts the rate of IOI at 4.6%. The aim of this paper is to propose a set of recommendations for implementing the management of brolucizumab in clinical practice. METHODS The recommendations made by the authors are based on their clinical experience, critical review of (i) the pivotal trials, the post-hoc analysis of the Safety Review Committee, (ii), and (iii) the published literature. RESULTS In the pivotal trials, brolucizumab showed sustained functional gains, superior anatomical outcomes with potentially longer intervals between injections and a well-tolerated overall safety profile. Adverse events reported post-marketing include retinal vasculitis and retinal vascular occlusion. Based on the available information, experts recommend (i) ruling out non-recommended patient profiles (prior history of ORI), (ii) screening the patient prior to each injection to rule out active ORI, (iii) monitoring the patient for early warning signs, and (iv) treating immediately should any adverse events develop. CONCLUSIONS The adverse events reported are rare, but may be associated with severe and irreversible loss of visual acuity. The recommendations made are intended to facilitate the management of brolucizumab in the routine practice of retinologists, to ensure patient safety and, should any adverse events occur, to minimise their impact on vision.
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Affiliation(s)
- A Fonollosa
- Servicio de Oftalmología, Hospital Universitario de Cruces, Barakaldo, Vizcaya, Spain; Instituto Oftalmológico Bilbao, Bilbao, Spain
| | - R Gallego-Pinazo
- Unidad de Mácula y Ensayos Clínicos, Clínica Oftalvist, Valencia, Spain
| | - L Sararols
- Servicio de Oftalmología, Hospital General de Granollers, Granollers, Barcelona, Spain; Servicio de Oftalmología, Hospital Universitario General de Cataluña, Sant Cugat del Vallès, Barcelona, Spain
| | - A Adán
- Institut Clínic d'Oftalmologia (ICOF), Hospital Clínic, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M López-Gálvez
- Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, Spain; Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - M S Figueroa
- Unidad de Retina, Clínica Baviera, Madrid, Spain; Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Wang J, Wang L, Yu S, Jin Y, Wang Y, Chai R, Zhao Z, Bian Y, Zhao S. Condensed Fuzheng extract increases immune function in mice with cyclophosphamide‐induced immunosuppression. Food Sci Nutr 2022; 10:3865-3875. [PMID: 36348791 PMCID: PMC9632192 DOI: 10.1002/fsn3.2982] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/15/2022] [Accepted: 06/18/2022] [Indexed: 11/23/2022] Open
Abstract
Our general purpose was to examine the effect of condensed Fuzheng extract (CFE) on the alleviation of immunosuppression. A mouse model of immunosuppression was established by intraperitoneal injection of CTX. A healthy control group received no CTX and no CFE; different intragastric doses of CFE were administered to three groups of mice for 28 days (4500, 2250, or 1125 mg/kg/day); a negative control received CTX alone, and a positive control received CTX and levamisole hydrochloride. We evaluated the effects of CFE on the immune system organs, cells, and molecules by comparing the different groups. CFE significantly improved immune system organs (spleen and thymus indices and histology), stimulated immune cell activities (number of white blood cells and lymphocytes, phagocytosis of mononuclear phagocytes, proliferation of splenic lymphocytes, antibody formation, and NK cell activity), and increased the levels of immunoglobulins (IgA, IgG, and IgM) and cytokines (IL‐2 and IFN‐γ). Thus CFE effectively alleviated CTX‐mediated immunosuppression and oxidative stress and enhanced the immunological functions of mice.
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Affiliation(s)
- Ji‐Da Wang
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Li Wang
- Pharmaceutical Department Tianjin Second People's Hospital Tianjin China
- School of Intergrative Medicine Tianjin University Tianjin China
| | - Shuang Yu
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Yu‐Tong Jin
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Yi‐Yang Wang
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Run‐Dong Chai
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Ze‐Yu Zhao
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Yu‐Hong Bian
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Shu‐Wu Zhao
- School of Intergrative Medicine Tianjin University of Traditional Chinese Medicine Tianjin China
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Crowell EL, France R, Majmudar P, Jabs DA, Thorne JE. Treatment Outcomes in Birdshot Chorioretinitis: Corticosteroid Sparing, Corticosteroid Discontinuation, Remission, and Relapse. Ophthalmol Retina 2022; 6:620-627. [PMID: 35283323 DOI: 10.1016/j.oret.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To describe treatment-related outcomes among patients with birdshot chorioretinitis (BSCR). DESIGN Retrospective cohort study. PARTICIPANTS Patients diagnosed with BSCR at 2 tertiary care academic medical centers. METHODS Clinical and treatment-related data were collected for all patients with BSCR diagnosed between 2003 and 2017 at the 2 centers and for each eye at each clinical visit. MAIN OUTCOME MEASURES Four outcomes were considered: (1) corticosteroid-sparing success, defined as inactive disease and prednisone dose of ≤7.5 mg/day; (2) corticosteroid-discontinuation success, defined as inactive disease and discontinuation of prednisone; (3) sustained drug-free remission, defined as inactive disease off all medications for ≥3 months; and (4) relapse of BSCR after remission. RESULTS A total of 107 patients with BSCR were identified, of whom 94 had follow-up data. Corticosteroid-sparing success was achieved in 95.4% of the oral corticosteroid-treated patients at a rate of 0.60 successes per person-year (PY) (95% CI: 0.50/PY, 0.70/PY). The median time to corticosteroid-sparing success was 12 months. Corticosteroids were discontinued successfully in 76.5% of oral corticosteroid-treated patients (rate = 0.28/PY; 95% CI: 0.21/PY, 0.35/PY). The median time to successful corticosteroid discontinuation was 2.0 years. A sustained drug-free remission was achieved in 24 patients (rate = 0.06/PY; 95% CI: 0.04/PY, 0.09/PY), with approximately 25% of patients achieving remission by 4 years of follow-up. Relapse of inflammation in patients after achieving a sustained, drug-free remission occurred at a rate of 0.24/PY (95% CI: 0.14/PY, 0.37/PY). CONCLUSIONS Successful corticosteroid sparing and discontinuation was achieved in the majority of patients with BSCR. Remission occurred less often, but data were limited by the time needed to induce a remission (4 years) and the amount of follow-up (median, 4.6 years). The relapse rate after a remission was 0.24/PY.
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Affiliation(s)
- Eric L Crowell
- The Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Current affiliation: Department of Ophthalmology, Mitchel and Shannon Wong Eye Institute, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Richard France
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York; Current affiliation: Eyecare Medical Group, Portland, Maine
| | - Palak Majmudar
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York; Current affiliation: Ridgewood Eye Associates, Paramus, New Jersey
| | - Douglas A Jabs
- The Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer E Thorne
- The Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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Tsui E, Crowell EL, Gangaputra S, Moussa K, Shantha JG, Shusko AJ, Thompson IA, Pham DC, Jackson NJ, Venkat AG. Current Landscape of Uveitis Specialists in the United States. JOURNAL OF ACADEMIC OPHTHALMOLOGY 2022. [DOI: 10.1055/s-0042-1755581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Purpose This study characterizes the current landscape of uveitis specialists and their practice settings in the United States.
Methods An anonymous Internet-based survey with questions pertaining to training history and practice characteristics was distributed via REDCap to the American Uveitis Society and Young Uveitis Specialists listservs.
Results Forty-eight uveitis specialists in the United States responded to the survey out of 174 uveitis specialists that identify as practicing in the United States. Twenty-five of 48 respondents (52%) completed an additional fellowship. These additional fellowships ranged from surgical retina (12/25, 48%), cornea (8/25, 32%), and medical retina (4/25, 16%). Two-thirds of uveitis specialists managed their own immunosuppression, while one-third comanaged immunosuppression with rheumatologists. Thirty-three of 48 (69%) maintained a surgical practice.
Conclusion This is the first survey of uveitis specialists across the United States to provide understanding into training and practice characteristics. These data will provide insight into career planning, practice building, and assist in resource allocation.
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Affiliation(s)
- Edmund Tsui
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric L. Crowell
- Mitchel and Shannon Wong Eye Institute, UT Health Austin, Austin, Texas
| | - Sapna Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Alexander J. Shusko
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Derek C. Pham
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nicholas J. Jackson
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Arthi G. Venkat
- Retina Group of Washington, Washington, District of Columbia
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Tsui E, Chen JL, Jackson NJ, Leyva O, Rasheed H, Baghdasaryan E, Fung SS, McCurdy DK, Sadda SR, Holland GN. Quantification of Anterior Chamber Cells in Children with Uveitis Using Anterior Segment Optical Coherence Tomography. Am J Ophthalmol 2022; 241:254-261. [PMID: 35609675 DOI: 10.1016/j.ajo.2022.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate the feasibility of anterior segment optical coherence tomography (AS-OCT) for measuring anterior chamber (AC) cells in children with uveitis and to compare different AS-OCT acquisition modes. DESIGN Validity and reliability analysis. METHODS We enrolled children younger than 18 years of age who had uveitis involving the anterior segment and children without eye disease as controls. All underwent clinical grading of AC cells. AC images of each eye were obtained using the Optovue Avanti RTVue XR AS-OCT. Two acquisition modes were used: a single cross-sectional line scan and an 8-line radial scan in an asterisk pattern. Two independent, masked graders counted cells manually on AS-OCT images. Rater agreement was assessed using intraclass correlation (ICC). RESULTS Included were 30 children (59 eyes) with uveitis (median age 13.0 years, range 3-17 years) and 20 control children (40 eyes, median age 10.5 years, range 4-17 years). The number of eyes assigned each clinical grade of cells were as follows: none, 32 (54%); 0.5+, 12 (20.3%); 1+, 5 (8.5%); 2+, 8 (13.6%); 3+, 2 (3.4%). ICC of graders for line and radial scan protocols were 0.87 and 0.90. There was no significant difference between acquisition modes for pooled grader results (95% confidence interval [CI] for difference: -0.04 to 0.14). ICC of cell counts between line and radial scan protocols was 0.85 (95% CI: 0.69-0.90). No control eyes had cells on AS-OCT images. CONCLUSIONS Quantification of AC cell in children with uveitis is feasible with AS-OCT and has excellent reliability between different graders and acquisition modes.
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S Mehta N, Emami-Naeini P. A Review of Systemic Biologics and Local Immunosuppressive Medications in Uveitis. J Ophthalmic Vis Res 2022; 17:276-289. [PMID: 35765634 PMCID: PMC9185190 DOI: 10.18502/jovr.v17i2.10804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 01/15/2023] Open
Abstract
Uveitis is one of the most common causes of vision loss and blindness worldwide. Local and/or systemic immunosuppression is often required to treat ocular inflammation in noninfectious uveitis. An understanding of safety and efficacy of these medications is required to individualize treatment to each patient to ensure compliance and achieve the best outcome. In this article, we reviewed the effectiveness of systemic biologic response modifiers and local treatments commonly used in the management of patients with noninfectious uveitis.
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Affiliation(s)
- Neesurg S Mehta
- Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA, USA
| | - Parisa Emami-Naeini
- Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA, USA
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Kim J, Chun J, Ahn M, Jung K, Moon C, Shin T. Blood-retina barrier dysfunction in experimental autoimmune uveitis: the pathogenesis and therapeutic targets. Anat Cell Biol 2022; 55:20-27. [PMID: 35354673 PMCID: PMC8968224 DOI: 10.5115/acb.21.227] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/27/2022] Open
Abstract
Experimental autoimmune uveitis (EAU), an animal model of human uveitis, is characterized by infiltration of autoimmune T cells in the uvea as well as in the retina of susceptible animals. EAU is induced by the immunization of uveitogenic antigens, including either retinal soluble-antigen or interphotoreceptor retinoid-binding proteins, in Lewis rats. The pathogenesis of EAU in rats involves the proliferation of autoimmune T cells in peripheral lymphoid tissues and breakdown of the blood-retinal barrier, primarily in the uvea and retina, finally inducing visual dysfunction. In this review, we describe recent EAU studies to facilitate the design of a therapeutic strategy through the interruption of uveitogenic factors during the course of EAU, which will be helpful for controlling human uveitis.
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Affiliation(s)
- Jeongtae Kim
- Department of Anatomy, Kosin University College of Medicine, Busan, Korea
| | - Jiyoon Chun
- Department of Veterinary Anatomy, College of Veterinary Medicine and Veterinary Medical Research Institute, Jeju National University, Jeju, Korea
| | - Meejung Ahn
- Department of Animal Science, College of Life Science, Sangji University, Wonju, Korea
| | - Kyungsook Jung
- Functional Biomaterials Research Center, Korea Research Institute of Bioscience and Biotechnology, Jeongeup, Korea
| | - Changjong Moon
- Department of Veterinary Anatomy, College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju, Korea
| | - Taekyun Shin
- Department of Veterinary Anatomy, College of Veterinary Medicine and Veterinary Medical Research Institute, Jeju National University, Jeju, Korea
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Rivas AB, Lopez-Picado A, Calamia V, Carreño E, Cocho L, Cordero-Coma M, Fonollosa A, Francisco Hernandez FM, Garcia-Aparicio A, Garcia-Gonzalez J, Mondejar JJ, Lojo-Oliveira L, Martínez-Costa L, Munoz S, Peiteado D, Pinto JA, Rodriguez-Lozano B, Pato E, Diaz-Valle D, Molina E, Tebar LA, Rodriguez-Rodriguez L. Efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis: a protocol for a multicentre, randomised, parallel three arms, active-controlled, phase III open label with blinded outcome assessment study. BMJ Open 2022; 12:e051378. [PMID: 35318229 PMCID: PMC8943738 DOI: 10.1136/bmjopen-2021-051378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Non-infectious uveitis include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than and as safe as their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet. METHODS AND ANALYSIS The Combination THerapy with mEthotrexate and adalImumAb for uveitis (CoTHEIA) study is a phase III, multicentre, prospective, randomised, single-blinded with masked outcome assessment, parallel three arms with 1:1:1 allocation, active-controlled, superiority study design, comparing the efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis. We aim to recruit 192 subjects. The duration of the treatment and follow-up will last up to 52 weeks, plus 70 days follow-up with no treatment. The complete and maintained resolution of the ocular inflammation will be assessed by masked evaluators (primary outcome). In addition to other secondary measurements of efficacy (quality of life, visual acuity and costs) and safety, we will identify subjects' subgroups with different treatment responses by developing prediction models based on machine learning techniques using genetic and proteomic biomarkers. ETHICS AND DISSEMINATION The protocol, annexes and informed consent forms were approved by the Reference Clinical Research Ethic Committee at the Hospital Clínico San Carlos (Madrid, Spain) and the Spanish Agency for Medicines and Health Products. We will elaborate a dissemination plan including production of materials adapted to several formats to communicate the clinical trial progress and findings to a broad group of stakeholders. The promoter will be the only access to the participant-level data, although it can be shared within the legal situation. TRIAL REGISTRATION NUMBER 2020-000130-18; NCT04798755.
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Affiliation(s)
- Ana Belen Rivas
- Unidad de Investigación Clinica y Ensayos Clínicos, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Departamento de Enfermería. Facultad Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
| | - Amanda Lopez-Picado
- Unidad de Investigación Clinica y Ensayos Clínicos, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Valentina Calamia
- Unidad de Proteómica. Grupo de Investigación de Reumatología (GIR), Instituto de Investigación Biomédica de A Coruña, Complexo Hospitalario Universitario de A Coruña, and Universidade da Coruña, A Coruna, Galicia, Spain
| | - Ester Carreño
- Department of Ophthalmology, University Hospital Fundacion Jimenez Diaz, and University Hospital Rey Juan Carlos, Madrid, Madrid, Spain
| | - Lidia Cocho
- Department of Ophthalmology, IOBA (Institute of Applied OphthalmoBiology), University of Valladolid, and Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - Miguel Cordero-Coma
- Uveitis Unit, University Hospital of León, IBIOMED, and University of León, Leon, Spain
| | - Alex Fonollosa
- Department of Ophthalmology, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, País Vasco, Spain
| | - Felix M Francisco Hernandez
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | | | - Javier Garcia-Gonzalez
- Department of Rheumatology, Hospital Universitario 12 de Octubre, Madrid, Comunidad de Madrid, Spain
| | - Jose Juan Mondejar
- Department of Ophthalmology, Hospital General Universitario de Alicante, Alicante, Comunidad Valenciana, Spain
| | | | - Llucí Martínez-Costa
- Department of Ophthalmology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Santiago Munoz
- Department of Rheumatology, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Madrid, Spain
| | - Diana Peiteado
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Jose Antonio Pinto
- Department of Rheumatology, Complexo Hospitalario Universitario de A Coruña, A Coruna, Galicia, Spain
| | - Beatriz Rodriguez-Lozano
- Department of Rheumatology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Canarias, Spain
| | - Esperanza Pato
- Department of Rheumatology, Hospital Clínico San Carlos, IdISSC, Madrid, Madrid, Spain
| | - David Diaz-Valle
- Department of Ophthalmology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Elena Molina
- Department of Pathology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Alberto Tebar
- Unidad de Investigación Clinica y Ensayos Clínicos, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Rodriguez-Rodriguez
- Musculoskeletal Pathology Group, Fundacion para la Investigacion Biomedica del Hospital Clinico San Carlos, IdISSC, Madrid, Spain
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Liberman P, Burkholder BM, Thorne JE, Berkenstock MK. Effectiveness of Difluprednate for the Treatment of Anterior Scleritis. Am J Ophthalmol 2022; 235:172-177. [PMID: 34547279 DOI: 10.1016/j.ajo.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/09/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To describe the effectiveness and side effect profile of difluprednate therapy in a series of patients with anterior scleritis. DESIGN Retrospective, interventional case series. METHODS Data collected from all patients with anterior scleritis who used difluprednate as a single treatment agent from January 1, 2018, to January 1, 2020, including demographics, scleritis type, presence of nodules or necrosis, changes in scleritis activity, intraocular pressure (IOP), number of difluprednate drops used, best-corrected visual acuity (BCVA), and lens status. The primary outcome was clinical resolution of scleritis. Secondary outcomes included BCVA loss ≥2 lines, change in lens status or cataract surgery, and IOP ≥24 mm Hg. RESULTS Twenty-five patients (35 eyes) were analyzed. The median age was 60 years (range 13-78); 60% were female; 64% were White. Forty percent had bilateral disease, and 44% of patients had an associated systemic disease. The majority of eyes (66%) had diffuse anterior scleritis. Eighty-three percent of eyes achieved resolution of scleritis, with a median time of resolution of 6 weeks. Eyes treated with an initial dose of ≥4 times daily were more likely to achieve disease resolution (hazard ratio [HR] = 3.43, 95% confidence interval [CI] 1.19, 9.88, P = .02). Nine eyes had IOP elevation. Four eyes lost ≥2 lines of BCVA, and 1 due to cataract progression. One eye underwent cataract surgery. CONCLUSIONS Difluprednate alone may effectively treat non-infectious anterior scleritis with a tolerable side effect profile.
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Multimodal evaluation of an interphotoreceptor retinoid-binding protein-induced mouse model of experimental autoimmune uveitis. Exp Mol Med 2022; 54:252-262. [PMID: 35264718 PMCID: PMC8979956 DOI: 10.1038/s12276-022-00733-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
We aimed to characterize the vascular phenotypes of an experimental autoimmune retinal uveitis (EAU) model induced by interphotoreceptor retinoid-binding protein (IRBP) using multimodal imaging techniques. We systemically administered IRBP or vehicle to adult C57BL/6 mice. Fundus photography, optical coherence tomography (OCT), in vivo live confocal imaging using different tracers, OCT angiography (OCTA), and electroretinography (ERG) were performed after IRBP immunization. Hematoxylin and eosin and immunofluorescence staining were performed to characterize the immune response and vascular permeability. Mice with EAU exhibited perivascular inflammation, vitritis, and superficial retinal inflammation on fundus photography and OCT. H&E revealed immune cell infiltration in the perivascular area of the retina and choroid accompanied by a significant degree of perivasculitis that subsequently damaged photoreceptors 3 weeks postimmunization. Immunofluorescence staining showed subsequent transcytosis induction after local microglial activation followed by neutrophil recruitment in the perivascular area. Transcytosis in the superficial and deep vascular areas was improved by immune cell suppression. Intravital in vivo confocal imaging showed signs of neutrophil infiltration and obstructive vasculitis with perivascular leakage 3 weeks postimmunization. OCTA revealed a significant decrease in vascular flow in the deep capillary layer of the retina. Functional analysis showed that scotopic responses were intact at 2 weeks; however, normal photopic and scotopic responses were hardly detected in mice with EAU mice at 3 weeks postimmunization. Our data suggest that inflammatory cell activation and subsequent transcytosis induction in endothelial cells might be a major pathogenic factor for vascular leakage in uveitis, providing new insights into the pathophysiology of retinal vasculitis in noninfectious uveitis. Studying a mouse model of autoimmune uveitis, a damaging form of eye inflammation affecting the retina and choroid of the eye, reveals new cellular and molecular details of how blood vessel inflammation can damage the retina. Researchers in South Korea and Japan led by Joo Yong Lee at the University of Ulsan, Seoul, initiated autoimmune uveitis in mice by administering retinoid-binding protein, which is known to stimulate autoimmune changes which model aspects of the human disease. Their work revealed that the inflammation caused by the autoimmune response makes the blood vessels supplying the retina more permeable to a variety of large molecules. This increased permeability, due to a membrane transport process called transcytosis, was preceded by specific cellular changes. This deeper understanding of the pathology of uveitis could help research towards new treatments.
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Anti-TB monotherapy for choroidal tuberculoma: an observational study. Eye (Lond) 2022; 36:612-618. [PMID: 33795836 PMCID: PMC8873194 DOI: 10.1038/s41433-021-01505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/14/2021] [Accepted: 03/10/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Choroidal tuberculoma is possibly the most unequivocal manifestation of ocular infection with Mycobacterium tuberculosis. Here, we investigate the need for adjunctive corticosteroids in the management of this infection. We have compared the efficacy of anti-tubercular therapy (ATT) with or without oral corticosteroids, in management of choroidal tuberculoma. METHODS We report a retrospective, observational study of patients treated with ATT for choroidal tuberculoma. Group A patients were treated with standard 6-month ATT alone, and Group B with ATT and oral corticosteroids, with/without intravitreal triamcinolone/ bevacizumab injections. Primary outcome measure was time to complete resolution of lesions. Secondary measures were time to first sign of resolution and change in best corrected visual acuity (BCVA) at final visit. RESULTS Fourteen patients were included in the study-seven in Group A and seven in Group B. Both groups had similar duration of symptoms and size of lesions but not baseline BCVA (p = 0.02). Perilesional fluid was noted in all eyes in each group. Mean time to complete resolution in group A was 1.89 ± 0.28 (range 1.25-2) months, significantly lesser than group B (5.17 ± 2.64 [range 2-9] months, p = 0.005, Mann-Whitney test). Mean time to first sign of resolution (range from 5 days to 10 weeks, p = 0.35) and mean change in BCVA between presentation and final follow up (p = 0.2) were comparable between both groups. CONCLUSION Anti-TB monotherapy alone, may be sufficient for resolution of at least, select cases of choroidal tuberculoma, without the need for adjunctive corticosteroids.
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Gupta S, Shyamsundar K, Agrawal M, Vichare N, Biswas J. Current Knowledge of Biologics in Treatment of Noninfectious Uveitis. J Ocul Pharmacol Ther 2022; 38:203-222. [DOI: 10.1089/jop.2021.0098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Simple Gupta
- Department of Ophthalmology, Command Hospital, Pune, India
| | - K. Shyamsundar
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Mohini Agrawal
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Nitin Vichare
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Jyotirmay Biswas
- Department of Uveitis and Ocular Pathology, Sankara Netralaya, Chennai, India
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McHarg M, Young L, Kesav N, Yakin M, Sen HN, Kodati S. Practice patterns regarding regional corticosteroid treatment in noninfectious Uveitis: a survey study. J Ophthalmic Inflamm Infect 2022; 12:3. [PMID: 34982279 PMCID: PMC8727651 DOI: 10.1186/s12348-021-00281-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Regional corticosteroid therapy for noninfectious uveitis is well-established but usage patterns have not been studied extensively. This study aims to assess practice patterns of retina and uveitis specialists regarding their preferences on the use of local corticosteroid therapy. Methods A 13-question survey was developed regarding the practice patterns of regional corticosteroid use in specific situations and populations. The survey was distributed to both the American Uveitis Society and Macula Society. Results Responses from 87 ophthalmologists were analyzed. The two most commonly used drugs were the dexamethasone intravitreal implant (Ozurdex®) and posterior sub-tenon’s triamcinolone (also known as posterior sub-Tenon’s Kenalog, or PSTK). Regional corticosteroids were used more frequently as first-line treatment in more than half of posterior uveitis cases when compared to anterior uveitis (39.1–46.0% vs 10.3%, respectively). Respondents were more willing to use regional corticosteroids in more than half of unilateral uveitis cases than in bilateral cases (54.7% vs 18.6%, respectively). A majority of respondents (67.1%) stated that they would avoid using regional corticosteroids in patients under 8 years old. Conclusions Our results demonstrate more frequent regional corticosteroid use in posterior segment uveitis, unilateral cases, and avoidance in younger pediatric patients. Overall, the variability in these responses highlights the need for guidelines regarding regional corticosteroid use. Supplementary Information The online version contains supplementary material available at 10.1186/s12348-021-00281-z.
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Affiliation(s)
- Matthew McHarg
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,George Washington University School of Medicine, Washington, DC, 20052, USA
| | - LeAnne Young
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA
| | - Natasha Kesav
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.,University Hospitals Eye Institute, Cleveland, OH, 44106, USA
| | - Mehmet Yakin
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA
| | - H Nida Sen
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA
| | - Shilpa Kodati
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10N109, Bethesda, MD, 20892, USA.
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Hamzaoui K, Borhani-Haghighi A, Dhifallah IB, Hamzaoui A. Elevated levels of IL-32 in cerebrospinal fluid of neuro-Behcet disease: Correlation with NLRP3 inflammasome. J Neuroimmunol 2022; 365:577820. [DOI: 10.1016/j.jneuroim.2022.577820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/10/2022] [Accepted: 01/16/2022] [Indexed: 12/14/2022]
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Brichová M, Svozílková P, Klímová A, Dušek O, Kverka M, Heissigerová J. MICROBIOME AND UVEITIDES. A REVIEW. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2022; 78:47-52. [PMID: 35105146 DOI: 10.31348/2021/30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Microorganisms inhabiting all surfaces of mucous membranes and skin and forming a complex ecosystem with the host is called microbiota. The term microbiome is used for the aggregate genome of microbiota. The microbiota plays important role in the mechanisms of number of physiological and pathological processes, especially of the hosts immune system. The origin and course of autoimmune diseases not only of the digestive tract, but also of the distant organs, including the eye, are significantly influenced by intestinal microbiota. The role of microbiota and its changes (dysbiosis) in the etiopathogenesis of uveitis has so far been studied mainly in experimental models. Reduction of severity of non-infectious intraocular inflammation in germ-free mice or in conventional mice treated with broad-spectrum antibiotics was observed in both the induced experimental autoimmune uveitis model (EAU) and the spontaneous R161H model. Studies have confirmed that autoreactive T cell activation occurs in the intestinal wall in the absence of retinal antigen. Recent experiments focused on the effect of probiotic administration on the composition of intestinal microbiota and on the course of autoimmune uveitis. Our study group demonstrated significant prophylactic effect of the administration of the probiotic Escherichia coli Nissle 1917 on the intensity of inflammation in EAU. To date, only a few studies have been published investigating intestinal dysbiosis in patients with uveitis (e.g., in Behcets disease or Vogt-Koyanagi-Harada syndrome). The results of preclinical studies will be presumably used in clinical practice, mainly in the sense of prophylaxis and therapy, such as change in the lifestyle, diet and especially the therapeutic use of probiotics or the transfer of faecal microbiota.
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Yıldırım H, Balbaba M, Erdağ M, Dal A, Canleblebici M, İlhan N, Eröksüz Y. Investigation of effect of nintedanib in experimental uveitis model. Cutan Ocul Toxicol 2021; 41:55-59. [PMID: 34905992 DOI: 10.1080/15569527.2021.2016804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aims to investigate the protective efficacy of nintedanib in experimental uveitis induced by endotoxins. MATERIALS AND METHODS In this study, 24 Wistar albino rats were randomly divided into three groups: Group I was the healthy control with no uveitis that did not receive any treatment, Group II (sham) group did not receive treatment, and Group III (nintedanib) received oral nintedanib for 10 days. On the 10th day, endotoxin-induced uveitis (EIU) was induced by lipopolysaccharide (LPS) injection in Groups II and III. The clinical activity score was evaluated in all groups at the 24th hour, when uveitis formation was thought to be the most intense after LPS injection. All rats were then killed via anaesthesia. Tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels were measured in their right eyes using the enzyme-linked immunosorbent assay (ELISA) method. Further, histopathological examinations were performed on their left eyes. RESULTS For Groups I, II, and III, the IL-6 levels were 30.88 ± 1.79, 36.77 ± 1.21, and 30.93 ± 3.96 mg/pr, respectively, and TNF-α levels were 50.20 ± 3.24, 59.87 ± 2.98, and 50.23 ± 4.83 mg/pr, respectively. IL-6, TNF-α levels and clinical activity score were higher in the sham group compared to the other groups, and it decreased significantly in the treatment group (p < 0.05). Intense inflammatory cell infiltration of the ciliary body, edema and hyperaemia were evident in the sham group compared to the healthy control group (p < 0.05). These pathological findings were significantly decreased in the treatment group compared to the sham group (p < 0.05). CONCLUSION Nintedanib may be preferable as a new agent for treating non-infectious uveitis. However, further studies are needed to evaluate its long-term effects, effects on other antiinflammatory pathways, side-effects, and ideal dose optimization.
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Affiliation(s)
- Hakan Yıldırım
- Department of Ophthalmology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Mehmet Balbaba
- Department of Ophthalmology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Murat Erdağ
- Department of Ophthalmology, Faculty of Medicine, Fırat University, Elazığ, Turkey.,Department of Ophthalmology, Van Training and Research Hospital, Van, Turkey
| | - Ali Dal
- Department of Ophthalmology, Dr.Kemal Beyazıt State Hospital, Türkoğlu, Turkey
| | - Mehmet Canleblebici
- Department of Ophthalmology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Nevin İlhan
- Department of Biochemistry, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Yesari Eröksüz
- Department of Pathology, Faculty of Veterinary Medicine, Fırat University, Elazig, Turkey
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A 15-YEAR-OLD BOY WITH PROTRACTED VISION LOSS FROM ACUTE POSTERIOR MULTIFOCAL PLACOID PIGMENT EPITHELIOPATHY. Retin Cases Brief Rep 2021; 15:756-759. [PMID: 31764882 DOI: 10.1097/icb.0000000000000881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To present an atypical case of acute posterior multifocal placoid pigment epitheliopathy in a 15 year old treated with immunosuppressive therapy. METHODS Interventional case report. RESULTS On initial presentation, the vision was 20/200 in the right eye and 20/300 in the left eye. The posterior poles of both eyes showed numerous creamy-white placoid lesions. Fundus autofluorescence demonstrated hypoautofluorescence lesions with hyperautofluorescence rims, while fluorescein angiography showed early blockage followed by late staining. These findings were consistent with a diagnosis of acute posterior multifocal placoid pigment epitheliopathy. Optical coherence tomography demonstrated outer retinal disruptions and thinning. Due to the severity of his disease, the patient was treated first with oral prednisone and later transitioned to mycophenolate mofetil by 2 months. His poor vision persisted beyond a 5-month follow-up visit despite fading of the lesions and reconstitution of the outer retinal layers and thickness on optical coherence tomography. By 8 months of follow-up, the visual acuity returned to 20/20 bilaterally without any further recurrences. CONCLUSION Although most patients with acute posterior multifocal placoid pigment epitheliopathy have a relatively short course and recover vision quickly, the use of steroids and immunosuppression may be of benefit for those patients with severe and prolonged visual loss.
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Tang Lee Say TL, Yang V, Fingret JM, Zagora S, Symes R, Younan C, Cornish EE, Verma N, Sammel A, Wakefield D, Speden D, McCluskey PJ. Adalimumab in patients with vision-threatening uveitis: real-world clinical experience. BMJ Open Ophthalmol 2021; 6:e000819. [PMID: 34632076 PMCID: PMC8477319 DOI: 10.1136/bmjophth-2021-000819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives Biologics are rapidly emerging as an effective vision saving addition to systemic uveitis therapy. The aim of this multicentre retrospective study is to review the outcomes of a large group of patients treated with adalimumab. Methods A retrospective chart review of patients with refractory non-infectious, active uveitis treated with adalimumab was conducted. The main outcome measures were ability to reduce prednisolone dose, ability to control uveitis, final visual acuity and time to treatment failure. Results Forty-six patients with uveitis, treated with adalimumab were included in the study. The most common anatomical uveitis phenotype was panuveitis (n=17, 37.0%). The most common diagnosis was idiopathic uveitis (n=19, 41.3%). At their latest review (mean: 4.46 years; median 4.40 years), 35 (76.1%) patients were able to discontinue corticosteroids, 11 (23.9%) patients were able to taper to <7.5 mg/day and only 1 (2.2%) patient required 10 mg of prednisone. The mean visual acuity at the latest follow-up of the worse eye was logarithm of the minimum angle of resolution (logMAR) 0.42 (SD 0.72), while the mean visual acuity of the better eye was logMAR 0.19 (SD 0.34). Of the 89 eyes, 21 (23.6%) eyes improved by at least 2 lines, 5 eyes (5.6%) deteriorated by ≥2 lines while vision was unchanged in the remaining 63 (70.8%) eyes. The time to recurrence was 1 in 12.47 person-years for adalimumab, with a 17.4% (8 patient) relapse rate. There were no serious adverse events. Conclusions This study highlights the efficacy of adalimumab in patients with vision-threatening non-infectious uveitis, preserving vision and allowing reduction of corticosteroid dose.
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Affiliation(s)
- Timothy Lee Tang Lee Say
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Cardinal Santos Medical Center, San Juan, Manila, Philippines
| | - Verlyn Yang
- Royal Hobart Hospital, Hobart, Tasmania, Australia.,Gold Coast Hospital and Health Service, Southport, Queensland, Australia.,University of Tasmania, Hobart, Tasmania, Australia
| | - Jacob M Fingret
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Sophia Zagora
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Richard Symes
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Christine Younan
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Elisa Eleanor Cornish
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Nitin Verma
- Royal Hobart Hospital, Hobart, Tasmania, Australia.,University of Tasmania, Hobart, Tasmania, Australia.,East Timor Eye Program, Hobart, Tasmania, Australia
| | - Anthony Sammel
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Denis Wakefield
- Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | | | - Peter J McCluskey
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Royal Hobart Hospital, Hobart, Tasmania, Australia.,Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
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Xiong A, Liu D, Chen H, Yang G, Xiong C, Shuai Y, He L, Guo Z, Zhang L, Yang Y, Cui B, Shuai S. The Efficacy and Safety of Infliximab in Refractory Noninfectious Uveitis: A Meta-Analysis of Observational Studies. Front Pharmacol 2021; 12:620340. [PMID: 34603013 PMCID: PMC8481770 DOI: 10.3389/fphar.2021.620340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/02/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Although infliximab has been recommended for the second-line treatment of seronegative spondyloarthropathy- or juvenile idiopathic arthritis-related uveitis, the issue of its systemic efficacy and safety in a broader diversity of refractory noninfectious uveitis is debatable. To assess the short-term and relatively long-term efficacy of infliximab in refractory noninfectious uveitis, we performed a systematic review and meta-analysis of observational studies. Methods: PubMed, Cochrane Library, EMBASE, and Wanfang Med Online were systematically searched from January 2005 to March 2020. Two investigators independently assessed eligibility. Data were independently collected by two investigators. The pooled proportions were estimated with patients for intraocular inflammation control and improvement of visual acuity. Pooled proportions with 95% credible intervals were computed. Study homogeneity was investigated using I2 statistics to quantify the percentage of variation across studies. To pool the results, the Mantel–Haenszel fixed-effects or random-effects models were used. Results: Of 2316 studies identified, 16 unique studies with 509 unique participants were included in the meta-analysis. The pooled proportions of intraocular inflammation control reached 92% (95% CI: 87%–98%; I2: 1%; p=0.42) and 95% (95% CI: 93%–97%; I2: 0%; p=0.91) in groups of ≤6- and ≥12-month follow-up durations. During the relatively long follow-up period, the pooled proportions of maintaining visual acuity stable or increasing at least one line reached 99% (95% CI: 96%–100%; I2: 0%; p=0.54) in the involved eyes. The corticosteroid-sparing effect of infliximab was also well demonstrated, with the proportion of corticosteroid-sparing success reaching 85.5% (112/131). Besides, about serious adverse events, 2.6% (13/500) of patients experienced hypersensitivity reactions, 2.4% (12/500) of patients experienced serious infections, 1.8% (9/500) of patients experienced autoimmune diseases, and 0.6% (3/500) of patients experienced neoplasia. Conclusions: This meta-analysis provided evidence that infliximab might be a promising choice in controlling inflammatory activity, gaining visual acuity, and sparing corticosteroid use with relatively few side effects when applied in treating refractory noninfectious uveitis. Systematic Review Registration: [website], identifier [registration number]
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China
| | - Deng Liu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Huini Chen
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Guancui Yang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Chen Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yu Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Linqian He
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Zepeng Guo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Liangwen Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yuan Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Beibei Cui
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China
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Gunardi TH, Susantono DP, Victor AA, Sitompul R. Atopobiosis and Dysbiosis in Ocular Diseases: Is Fecal Microbiota Transplant and Probiotics a Promising Solution? J Ophthalmic Vis Res 2021; 16:631-643. [PMID: 34840686 PMCID: PMC8593547 DOI: 10.18502/jovr.v16i4.9754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 06/30/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To highlight the role of atopobiosis and dysbiosis in the pathomechanism of autoimmune uveitis, therefore supporting fecal microbiota transplant (FMT) and probiotics as potential targeted-treatment for uveitis. METHODS This review synthesized literatures upon the relation between gut microbiota, autoimmune uveitis, FMT, and probiotics, published from January 2001 to March 2021 and indexed in PubMed, Google Scholar, CrossRef. RESULTS The basis of the gut-eye axis revolves around occurrences of molecular mimicry, increase in pro-inflammatory cytokines, gut epithelial barrier disruption, and translocation of microbes to distant sites. In patients with autoimmune uveitis, an increase of gut Fusobacterium and Enterobacterium were found. With current knowledge of aforementioned mechanisms, studies modifying the gut microbiome and restoring the physiologic gut barrier has been the main focus for pathomechanism-based therapy. In mice models, FMT and probiotics targeting repopulation of gut microbiota has shown significant improvement in clinical manifestations of uveitis. Consequently, a better understanding in the homeostasis of gut microbiome along with their role in the gut-eye axis is needed to develop practical targeted treatment. CONCLUSION Current preliminary studies are promising in establishing a causative gut-eye axis relationship and the possibility of conducting FMT and probiotics as targeted treatment to mitigate autoimmune uveitis, to shorten disease duration, and to prevent further complications.
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Affiliation(s)
| | | | - Andi Arus Victor
- Department of Ophthalmology, Dr. Cipto Mangunkusumo National General
Hospital – Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ratna Sitompul
- Department of Ophthalmology, Dr. Cipto Mangunkusumo National General
Hospital – Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Kaushik M, Nawaz S, Mufti H, Qureshi TS. Etiological spectrum of irreversible blindness in Kashmir in North India. Indian J Ophthalmol 2021; 69:2630-2636. [PMID: 34571602 PMCID: PMC8597535 DOI: 10.4103/ijo.ijo_3818_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: To determine the etiological spectrum of irreversible blindness in Kashmir Valley in India. Methods: Patients presenting to a tertiary care hospital in Kashmir, India, with unilateral or bilateral blindness from April 2019 to March 2020 were included in this cross-sectional study. Blindness was defined using the World Health Organization (WHO) criteria. All subjects had a complete ophthalmologic examination and information was gathered regarding their demographic profile, nature of ocular disorder whether primary or secondary and laterality, if the ocular involvement was unilateral. Results: 248 patients were enrolled in the study. The mean age of the patients was 57.17 years. The male: female ratio was 2.17:1. The commonest cause of unilateral or bilateral blindness was glaucoma (22.58%) followed by diabetic retinopathy (DR) (17.74%). Unilateral blindness was seen in 78.62% of the patients. Unilateral blindness occurred mainly due to glaucoma (16.41%), DR (14.87%), age-related macular degeneration (13.33%), and trauma (pellet injury: 10.76%, non-pellet injury: 10.25%). The major causes of bilateral blindness were glaucoma (45.28%), DR (28.30%), and hereditary/congenital retinal diseases (16.98%). Socioeconomic status and educational status were significantly associated (P < 0.05 each) while age, gender, place of residence, and occupation were not significantly associated (P > 0.05 each) with the number of eyes affected by blindness. Conclusion: Glaucoma and DR are the foremost causes of irreversible blindness in Kashmir. Public health plans aimed at encouraging good health education of patients should be developed in this region. Moreover, patients should be screened effectively for glaucoma and diabetes at the level of primary health care facilities.
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Affiliation(s)
- Madhurima Kaushik
- Department of Ophthalmology, Govt. Medical College, Srinagar, Jammu and Kashmir, India
| | - Shah Nawaz
- Department of Ophthalmology, Govt. Medical College, Srinagar, Jammu and Kashmir, India
| | - Haniyaa Mufti
- Department of Ophthalmology, Govt. Medical College, Srinagar, Jammu and Kashmir, India
| | - Tariq Syed Qureshi
- Department of Ophthalmology, Govt. Medical College, Srinagar, Jammu and Kashmir, India
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Classification Criteria for Birdshot Chorioretinitis. Am J Ophthalmol 2021; 228:65-71. [PMID: 33845003 PMCID: PMC8517033 DOI: 10.1016/j.ajo.2021.03.059] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine classification criteria for birdshot chorioretinitis. DESIGN Machine learning of cases with birdshot chorioretinitis and 8 other posterior uveitides. METHODS Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior uveitides / panuveitides. The resulting criteria were evaluated on the validation set. RESULTS One thousand sixty-eight cases of posterior uveitides, including 207 cases of birdshot chorioretinitis, were evaluated by machine learning. Key criteria for birdshot chorioretinitis included a multifocal choroiditis with (1) the characteristic appearance of a bilateral multifocal choroiditis with cream-colored or yellow-orange, oval or round choroidal spots ("birdshot" spots); (2) absent to mild anterior chamber inflammation; and (3) absent to moderate vitreous inflammation; or multifocal choroiditis with positive HLA-A29 testing and either classic "birdshot spots" or characteristic imaging on indocyanine green angiography. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval 94.3, 99.3) in the validation set. The misclassification rates for birdshot chorioretinitis were 10% in the training set and 0% in the validation set. CONCLUSIONS The criteria for birdshot chorioretinitis had a low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.
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Classification Criteria for Multifocal Choroiditis With Panuveitis. Am J Ophthalmol 2021; 228:152-158. [PMID: 33845016 PMCID: PMC8559518 DOI: 10.1016/j.ajo.2021.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE To determine classification criteria for multifocal choroiditis with panuveitis (MFCPU). DESIGN Machine learning of cases with MFCPU and 8 other posterior uveitides. METHODS Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the posterior uveitides. The resulting criteria were evaluated on the validation set. RESULTS One thousand sixty-eight cases of posterior uveitides, including 138 cases of MFCPU, were evaluated by machine learning. Key criteria for MFCPU included (1) multifocal choroiditis with the predominant lesions size >125 µm in diameter; (2) lesions outside the posterior pole (with or without posterior involvement); and either (3) punched-out atrophic chorioretinal scars or (4) more than minimal mild anterior chamber and/or vitreous inflammation. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval 94.3, 99.3) in the validation set. The misclassification rates for MFCPU were 15% in the training set and 0% in the validation set. CONCLUSIONS The criteria for MFCPU had a reasonably low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.
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Kramer M, Brichova M, Tugal-Tutkun I, Panchenko M, Gormezano N, Koenigsbauer F, Franco P, Muccioli C, Hasanreisoglu M. Noninfectious Intermediate, Posterior, or Panuveitis: Results from the Retrospective, Observational, International EyeCOPE Study. Ophthalmol Ther 2021; 10:565-580. [PMID: 34117983 PMCID: PMC8319263 DOI: 10.1007/s40123-021-00351-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/06/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction The EyeCOPE study characterized noninfectious intermediate posterior, or panuveitis (NIIPPU) before biologic agents were widely available. Methods This retrospective, observational study included adults with NIIPPU attending a routine ophthalmological visit. Data were collected from the study visit and medical records. Results Of 565 patients, 58.8% were female, and the mean age was 41.3 years; 33.8% had idiopathic uveitis and 45.8% had panuveitis. The median time from symptom onset to diagnosis and treatment was 27.0 and 30.5 days, respectively. Patients received immunosuppressants and systemic/local corticosteroids. Most patients experienced substantial decline in ocular function (mean best corrected visual acuity, 0.4 logMAR). Mean total work productivity impairment among employed patients was 31.0%. Most patients reported ocular complications (70.8%) such as vision loss and cataracts. Conclusions Despite treatment, most patients with NIIPPU experienced a decline in ocular function and ocular complications. There is an unmet need for additional NIIPPU treatment, such as targeted monoclonal antibodies. Supplementary Information The online version contains supplementary material available at 10.1007/s40123-021-00351-4.
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Affiliation(s)
- Michal Kramer
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michaela Brichova
- Department of Ophthalmology, Charles University and General University Hospital, Prague, Czech Republic
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mykola Panchenko
- Department of Ophthalmology, Kharkiv National Medical University, Kharkiv, Ukraine
| | | | | | - Pablo Franco
- Organización Médica de Investigación, Buenos Aires, Argentina
| | - Cristina Muccioli
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Murat Hasanreisoglu
- Department of Ophthalmology, Faculty of Medicine, Gazi University, 13th Floor, Besevler, Cankaya, 06500, Ankara, Turkey.
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Lu J, Tang S, Yu N, Yi X, Li Y. Successful secukinumab treatment of erythrodermic psoriasis and psoriatic arthritis concomitant with severe noninfectious uveitis: a case report. J Int Med Res 2021; 48:300060520969494. [PMID: 33161790 PMCID: PMC7658516 DOI: 10.1177/0300060520969494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Uveitis is considered a relatively rare but serious ocular complication of psoriasis. We report the first successful treatment of severe noninfectious uveitis with secukinumab in a 70-year-old woman with erythrodermic psoriasis and psoriatic arthritis. Anti-tumor necrosis factor (TNF) agents were administered for 5 years for the treatment of erythrodermic psoriasis and psoriatic arthritis. Although the symptoms improved, she later developed noninfectious uveitis, resulting in a sharp decline in vision. After switching to secukinumab, her vision slightly improved, her skin lesions subsided, and her joint symptoms were relieved. Given the rarity of psoriasis combined with uveitis, it is unclear whether uveitis is related to anti-TNF therapy. In addition, the selection of effective biological agents for the treatment of uveitis remains a challenge and requires extensive clinical experience.
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Affiliation(s)
- Jiajing Lu
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Suwei Tang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ning Yu
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuemei Yi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Li
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
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Recurrence Rates of Inflammation after Switching from the Originator Infliximab to Biosimilar Infliximab-abda for Noninfectious Uveitis. Am J Ophthalmol 2021; 225:172-177. [PMID: 32795432 DOI: 10.1016/j.ajo.2020.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/26/2020] [Accepted: 08/03/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe the frequency of ocular flares in patients with noninfectious uveitis who were switched from the originator infliximab to a biosimilar infliximab. DESIGN Retrospective case series. METHODS All patients with noninfectious uveitis who were switched from the originator infliximab to biosimilar infliximab-abda for nonmedical reasons were reviewed. Patients were excluded if they had less than 3 months of follow-up on either drug. Data included patient demographics, infliximab dosage information, additional immunosuppression medications, and numbers of and times to flares. The main study outcome was frequency of flares, defined as new or worsening inflammatory activity on examination or imaging. RESULTS A total of 17 patients met the inclusion criteria. There were no statistical differences between the duration of follow-up while on the originator and the duration while on the biosimilar infliximab (12.0 vs. 10.1 months, respectively; P = .307). Patients experienced more flares per person-years after switching to infliximab-abda (.92), than on the originator infliximab (0.19; P = .028). Four of the 6 patients (66.7%) who experienced flare after switching to infliximab-abda did so within 90 days. Only 1 patient had flares while on originator infliximab went on to develop a single flare on infliximab-abda. The final normalized dosage for patients who flared and remained on infliximab-abda (1.301 mg/kg/week) was higher than that for those who did not flare (1.186 mg/kg/week) but was not statistically significant (P = .417). CONCLUSIONS Patients who were switched to biosimilar infliximab-abda experience more flares than when previously treated with the originator infliximab. Providers should closely observe patients who switch to biosimilar infliximab, especially within the first 90 days. Patients who do have flares after switching may achieve quiescence with increased biosimilar dosage.
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Agrawal R, Testi I, Lee CS, Tsui E, Blazes M, Thorne JE, Okada AA, Smith JR, McCluskey PJ, Kempen JH, Tappeiner C, Agarwal M, Bodaghi B, Nguyen QD, Gupta V, De Smet MD, Zierhut M, Pavesio C. Evolving consensus for immunomodulatory therapy in non-infectious uveitis during the COVID-19 pandemic. Br J Ophthalmol 2021; 105:639-647. [PMID: 32586933 PMCID: PMC7313529 DOI: 10.1136/bjophthalmol-2020-316776] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Immunomodulatory therapy (IMT) is often considered for systemic treatment of non-infectious uveitis (NIU). During the evolving coronavirus disease-2019 (COVID-19) pandemic, given the concerns related to IMT and the increased risk of infections, an urgent need for guidance on the management of IMT in patients with uveitis has emerged. METHODS A cross-sectional survey of international uveitis experts was conducted. An expert steering committee identified clinical questions on the use of IMT in patients with NIU during the COVID-19 pandemic. Using an interactive online questionnaire, guided by background experience and knowledge, 139 global uveitis experts generated consensus statements for IMT. In total, 216 statements were developed around when to initiate, continue, decrease and stop systemic and local corticosteroids, conventional immunosuppressive agents and biologics in patients with NIU. Thirty-one additional questions were added, related to general recommendations, including the use of non-steroidal anti-inflammatory drugs (NSAIDs) and hydroxychloroquine. RESULTS Highest consensus was achieved for not initiating IMT in patients who have suspected or confirmed COVID-19, and for using local over systemic corticosteroid therapy in patients who are at high-risk and very high-risk for severe or fatal COVID-19. While there was a consensus in starting or initiating NSAIDs for the treatment of scleritis in healthy patients, there was no consensus in starting hydroxychloroquine in any risk groups. CONCLUSION Consensus guidelines were proposed based on global expert opinion and practical experience to bridge the gap between clinical needs and the absence of medical evidence, to guide the treatment of patients with NIU during the COVID-19 pandemic.
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Affiliation(s)
- Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore
- Department of Medical Retina and Uveitis, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - Ilaria Testi
- Department of Medical Retina and Uveitis, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - Cecilia S Lee
- Department of Ophthalmology, University of Washington, Seattle, USA
| | - Edmund Tsui
- UCLA Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, USA
| | - Marian Blazes
- Department of Ophthalmology, University of Washington, Seattle, USA
| | - Jennifer E Thorne
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA, Baltimore
| | - Annabelle A Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, New South Wales, Japan
| | - Justine R Smith
- Flinders University College of Medicine and Public Health, Adelaide, Australia
| | - Peter J McCluskey
- Department of Ophthalmology, Director Save Sight Institute, The University of Sydney, Sydney, Pennsylvania, Australia
| | - John H Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, USA
- Eye Unit, MyungSung Christian Medical Center, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Christoph Tappeiner
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Bahram Bodaghi
- Department of Ophthalmology,, Sorbonne University, Paris, France
| | | | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education (PGIMER), Chandigarh, India
| | - Marc D De Smet
- Department of Ophthalmology ZNA Middelheim, Antwerp, Belgium
| | - Manfred Zierhut
- Centre of Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Carlos Pavesio
- Department of Medical Retina and Uveitis, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
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Hassman LM, Paley MA, Esaulova E, Paley GL, Ruzycki PA, Linskey N, Laurent J, Feigl-Lenzen L, Springer L, Montana CL, Hong K, Enright J, James H, Artyomov MN, Yokoyama WM. Clinicomolecular Identification of Conserved and Individualized Features of Granulomatous Uveitis. OPHTHALMOLOGY SCIENCE 2021; 1:100010. [PMID: 35937550 PMCID: PMC9352144 DOI: 10.1016/j.xops.2021.100010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/17/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
Objective To identify molecular features that distinguish individuals with shared clinical features of granulomatous uveitis. Design Cross-sectional, observational study. Participants Four eyes from patients with active granulomatous uveitis. Methods We performed single-cell RNA-sequencing with antigen-receptor sequence analysis to obtain an unbiased gene expression survey of ocular immune cells and identify clonally expanded lymphocytes. Main Outcomes Measures For each inflamed eye, we measured the proportion of distinct immune cell types, the amount of B or T cell clonal expansion, and the transcriptional profile of T and B cells. Results Each individual had robust clonal expansion arising from a single T or B cell lineage, suggesting distinct, antigen-driven pathogenic processes in each patient. This variability in clonal expansion was mirrored by individual variability in CD4 T cell populations, whereas ocular CD8 T cells and B cells were more transcriptionally similar between patients. Finally, ocular B cells displayed evidence of class-switching and plasmablast differentiation within the ocular microenvironment, providing additional support for antigen-driven immune responses in granulomatous uveitis. Conclusions Collectively, our study identified both conserved and individualized features of granulomatous uveitis, illuminating parallel pathophysiologic mechanisms, and suggesting that future personalized therapeutic approaches may be warranted.
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Affiliation(s)
- Lynn M. Hassman
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Michael A. Paley
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ekaterina Esaulova
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Grace L. Paley
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Philip A. Ruzycki
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Nicole Linskey
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer Laurent
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lacey Feigl-Lenzen
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Luke Springer
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Cynthia L. Montana
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Karen Hong
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer Enright
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Hayley James
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Maxim N. Artyomov
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Wayne M. Yokoyama
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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Abstract
The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.
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Affiliation(s)
- Bryn M Burkholder
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Clinical Trials and Evidence Synthesis, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Ferreira LB, Smith AJ, Smith JR. Biologic Drugs for the Treatment of Noninfectious Uveitis. Asia Pac J Ophthalmol (Phila) 2021; 10:63-73. [PMID: 33481396 DOI: 10.1097/apo.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The management of noninfectious uveitis is constantly evolving. A new "biologic era" in treatment began after the effectiveness of tumor necrosis factor-alpha blocking drugs was demonstrated in rheumatologic inflammatory diseases. The goal of specific immunomodulation with a biologic drug is to target inflammation at the molecular level with a low rate of serious adverse events. The purpose of this review is to summarize current knowledge of biologic drugs in the treatment of noninfectious uveitis by describing clinical studies and recent pharmacological developments.
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Affiliation(s)
| | - Anthony J Smith
- College of Medicine & Public Health, Flinders University, Adelaide, Australia
- Clinical Immunology and Allergy Unit, Flinders Medical Centre, Adelaide, Australia
| | - Justine R Smith
- College of Medicine & Public Health, Flinders University, Adelaide, Australia
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83
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Alba-Linero C, Alba E. Ocular side effects of checkpoint inhibitors. Surv Ophthalmol 2021; 66:951-959. [PMID: 33440195 DOI: 10.1016/j.survophthal.2021.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 01/06/2023]
Abstract
The incidence and impact of ocular side effects in patients treated with checkpoint inhibitors are not clearly defined. We reviewed prospective phase III clinical trials of checkpoint inhibitors applied in lung cancer, renal cell cancer, and melanoma. Case reports of the occurrence of ocular toxicities in patients receiving immune checkpoint inhibitors were also included. Of the 35 articles corresponding to phase III clinical trials with checkpoint inhibitors, ocular toxicity was described in four. Forty-six clinical cases of ocular toxicity after therapy with checkpoint inhibitors have been reported. The most frequently described ocular toxicities are uveitis, inflammatory orbital disease, and alterations of the ocular surface. Ocular toxicity is underestimated in checkpoint inhibitors clinical trials. Early ophthalmic examination and treatment with corticosteroids may improve the visual prognosis in these patients.
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Affiliation(s)
- Carmen Alba-Linero
- Hospital Regional Universitario Málaga, Málaga, Spain; Departamento Oftalmología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain.
| | - Emilio Alba
- Unidad de gestión clínica (UGI) Oncología Médica Hospital Regional y Universitario de Málaga, Instituto de Investigación de Biotecnología de Málaga (IBIMA), Málaga, Spain
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84
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Li JJ, Yi S, Wei L. Ocular Microbiota and Intraocular Inflammation. Front Immunol 2020; 11:609765. [PMID: 33424865 PMCID: PMC7786018 DOI: 10.3389/fimmu.2020.609765] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 12/20/2022] Open
Abstract
The term ocular microbiota refers to all types of commensal and pathogenic microorganisms present on or in the eye. The ocular surface is continuously exposed to the environment and harbors various commensals. Commensal microbes have been demonstrated to regulate host metabolism, development of immune system, and host defense against pathogen invasion. An unbalanced microbiota could lead to pathogenic microbial overgrowth and cause local or systemic inflammation. The specific antigens that irritate the deleterious immune responses in various inflammatory eye diseases remain obscure, while recent evidence implies a microbial etiology of these illnesses. The purpose of this review is to provide an overview of the literature on ocular microbiota and the role of commensal microbes in several eye diseases. In addition, this review will also discuss the interaction between microbial pathogens and host factors involved in intraocular inflammation, and evaluate therapeutic potential of targeting ocular microbiota to treat intraocular inflammation.
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Affiliation(s)
- Jing Jing Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Sanjun Yi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lai Wei
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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de Groot EL, ten Dam‐van Loon NH, de Boer JH, Ossewaarde‐van Norel J. The efficacy of corticosteroid-sparing immunomodulatory therapy in treating patients with central multifocal choroiditis. Acta Ophthalmol 2020; 98:816-821. [PMID: 32410393 PMCID: PMC7754275 DOI: 10.1111/aos.14473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/24/2020] [Accepted: 04/21/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE To evaluate the efficacy of corticosteroid-sparing immunomodulatory therapy (IMT) in patients with recurrent and/or sight-threatening central multifocal choroiditis (MFC). METHODS This was a retrospective cohort study in a tertiary uveitis centre including all patients with MFC who have been treated with IMT for at least 12 months. Clinical data and imaging results were collected regarding the period prior to the start of IMT and at 3, 6, 12 and - where available - 24 months after the start of IMT. Main outcome measure was the number of annual recurrences of choroiditis with or without active choroidal neovascularization before and after the start of IMT. Secondary outcomes were the percentage of patients with (steroid-free) remission and the median time between the start of IMT and (steroid-free) remission. RESULTS Thirty-two patients (39 eyes) were included. At the start of IMT, none of the patients were in (steroid-free) remission. At 24 months, the probability of achieving remission and steroid-free remission was 88,5% and 50%, respectively. The median time to achieve remission and steroid-free remission was 21 and 83 weeks, respectively. In 17 patients (20 eyes) with available clinical data and imaging results for ≥ 12 months prior to the start of IMT, the mean number of recurrences/year decreased significantly from 1.40 ± 0.81 at baseline to 0.49 ± 0.47 (p = 0.001) after the start of IMT. CONCLUSIONS Preventive therapy with IMT should be considered in patients with recurrent and/or sight-threatening MFC to decrease the number of recurrences/year and to increase the prospects of achieving either remission or steroid-free remission.
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Affiliation(s)
- Evianne L. de Groot
- Department of OphthalmologyUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
| | | | - Joke H. de Boer
- Department of OphthalmologyUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
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86
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de Groot EL, Ossewaarde - van Norel J, Ho L, ten Dam - van Loon NH, de Boer JH. The efficacy of adalimumab in treating patients with central multifocal choroiditis. Am J Ophthalmol Case Rep 2020; 20:100921. [PMID: 33024886 PMCID: PMC7528052 DOI: 10.1016/j.ajoc.2020.100921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/13/2020] [Accepted: 08/22/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the efficacy of adalimumab in patients with central multifocal choroiditis (cMFC) refractory to conventional corticosteroid-sparing immunomodulatory agents (IMT). METHODS Medical records were reviewed from all patients with cMFC and treated with adalimumab with follow-up of at least 12 months. The study focused on the 12 months prior to and after the start of adalimumab. The imaging results were independently evaluated by two ophthalmologists. The main outcomes were the number of patients without a relapse of disease activity in 12 months after the start of adalimumab and the ability to stop the systemic corticosteroids to evaluate the corticosteroid-sparing effect. RESULTS Twelve patients (18 eyes) were included. In 8/12 (67%) patients no relapse of disease activity was observed in the 12 months after the start of adalimumab. In 9/12 patients the systemic corticosteroid treatment could be stopped and in an additional 2 patients tapered to ≤7,5mg daily. In the 12 months before the start of adalimumab, the patients experienced a median of 3 (range 2-4) relapses of disease activity. Nine patients experienced relapses while treated with a combination of systemic corticosteroids (mean dose 13,6 mg; range 5-25 mg) and IMT. Moreover, 3 patients treated with IMT, experienced relapses after tapering and stopping the systemic corticosteroids. In all eyes (n = 5) with CNV before the start of adalimumab, the intravitreal anti-VEGF injections could be stopped after the start of adalimumab. CONCLUSIONS AND IMPORTANCE: Adalimumab may be effective in patients with cMFC refractory to IMT and may be considered as a treatment option in patients with cMFC.
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Affiliation(s)
- Evianne L. de Groot
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | | | - Lintje Ho
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Ninette H. ten Dam - van Loon
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Joke H. de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
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87
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Abstract
AbstractChildhood uveitis is an ophthalmological challenge, since on the one hand it often remains asymptomatic and difficult to detect, and on the other hand it often has a chronic course and is associated with a high risk of complications threatening the vision. The most important risk factors for childhood uveitis are underlying rheumatic diseases; recommendations for ophthalmological monitoring have been developed together with paediatric rheumatologists. Intermediate and posterior uveitis are rare in children. The therapy must effectively control inflammation and at the same time cause only minimal side effects. Since steroids in particular cause side effects frequently, an immunosuppressive therapy must be initiated early in an interdisciplinary cooperation with paediatric rheumatologists and parents with the goal of minimising steroids.
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Affiliation(s)
- Stephan Thurau
- Augenklinik, Klinikum der LMU München, München, Deutschland
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88
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Tomkins-Netzer O, Lightman SL, Burke AE, Sugar EA, Lim LL, Jaffe GJ, Altaweel MM, Kempen JH, Holbrook JT, Jabs DA. Seven-Year Outcomes of Uveitic Macular Edema: The Multicenter Uveitis Steroid Treatment Trial and Follow-up Study Results. Ophthalmology 2020; 128:719-728. [PMID: 32918964 DOI: 10.1016/j.ophtha.2020.08.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To evaluate the long-term outcomes of uveitic macular edema (ME). DESIGN Longitudinal follow-up of a cohort of participants in a randomized clinical trial. PARTICIPANTS A total of 248 eyes of 177 participants with uveitic ME enrolled in the Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study. METHODS OCT measurements, taken at baseline and annually, were graded by reading center graders masked to clinical data. Macular edema was defined as a center macular thickness (CMT) ≥240 μm on time-domain OCT or time-domain OCT equivalent. Resolution of ME was defined as normalization of macular thickness on OCT. Relapse of ME was defined as increase in macular thickness to ≥240 μm in an eye that previously had resolution. Visual acuity was measured at each visit with logarithmic visual acuity charts. MAIN OUTCOME MEASURES Resolution and relapse of ME. Visual acuity. RESULTS Among 227 eyes with ME followed ≥1 year, the cumulative percent of eyes with ME resolving at any point during 7 years was 94% (95% confidence interval [CI], 89-97). Epiretinal membranes on OCT were associated with a lower likelihood of ME resolution (hazard ratio [HR], 0.74; 95% CI, 0.55-1.01; P = 0.05). Among 177 eyes with resolved ME, the cumulative percent with relapse within 7 years was 43% (95% CI, 32-51). Eyes in which ME resolved gained a mean of 6.24 letters (95% CI, 4.40-8.09; P < 0.001) compared with eyes that remained free from ME during the 1-year follow-up intervals, whereas eyes in which ME did not resolve experienced no gain in vision (mean change -1.30 letters; 95% CI, -2.70 to 0.09; P = 0.065), and eyes that developed ME during the year (incident or relapsed) experienced a mean loss of -8.65 letters (95% CI, -11.5 to -5.84, P < 0.001). CONCLUSIONS Given sufficient time and treatment, nearly all uveitic ME resolves, but episodes of relapse were common. Visual acuity results were better among eyes with resolved ME, suggesting that control of inflammation and resolution of ME might be visually relevant treatment targets.
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Affiliation(s)
- Oren Tomkins-Netzer
- Institute of Ophthalmology, University College London, and Moorfields Eye Hospital, London, United Kingdom; Department of Ophthalmology, Lady Davis Carmel Medical Center, Ruth and Bruch Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Susan L Lightman
- Institute of Ophthalmology, University College London, and Moorfields Eye Hospital, London, United Kingdom
| | - Alyce E Burke
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Sugar
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Lyndell L Lim
- Department of Ophthalmology, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Glenn J Jaffe
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Michael M Altaweel
- Department of Ophthalmology and Reading Center, University of Wisconsin, Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - John H Kempen
- Department of Ophthalmology Harvard Medical School and Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; MCM Eye Unit, Myung Sung Christian Medical Center General Hospital and Medical School, Addis Ababa, Ethiopia
| | - Janet T Holbrook
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Douglas A Jabs
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, the Wilmer Eye Institute, the Johns Hopkins University School of Medicine, Baltimore, Maryland.
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89
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Zhao L, Peng M, Lin W, Tan Q, Khan MA, Lin D. Efficacy of Sub-Tenon Micro-Perfusion of Cyclophosphamide in Rabbits with Severe Ocular Inflammation. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:3407-3416. [PMID: 32903954 PMCID: PMC7445515 DOI: 10.2147/dddt.s250541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022]
Abstract
Purpose To explore the feasibility of cyclophosphamide (CP) via a sub-Tenon micro-perfusion system (SMS) in rabbits, and assess its therapeutic efficacy in severe ocular inflammation. Materials and Methods Distribution and pharmacokinetics of CP were evaluated in vivo, and the concentrations of CP in plasma, vitreous humor, and retina/choroid were quantitated by ultra-high-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) at different time points. After induction of severe experimental uveitis, rabbits were divided into three groups (n=8 in each): the SMS group, subconjunctival injection (SI) group, and control group. Clinical inflammatory score was assessed in rabbits. Electroretinography and histopathology were performed on post-treatment day 8. Statistical analyses were performed using Mann–Whitney and Kruskal–Wallis tests. P-value less than 0.05 was considered significant. Results The concentrations of CP in vitreous humor and retina/choroid in the SMS group were significantly higher than that of the SI group at 3, 6, 10, and 24 hours (P<0.01), while plasmatic CP concentrations were comparable at all time points in the SMS group and SI group (P>0.05). The SMS group showed significantly less inflammation compared to the control group and SI group. Furthermore, the restoration of retinal structure and function were more obvious in the SMS group compared with conventional SI application. Conclusion Sub-Tenon micro-perfusion of CP exhibited satisfied therapeutic efficacy in rabbits with severe ocular inflammation and may provide a promising alternative for controlling ocular inflammatory disease and immune-mediated ocular diseases.
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Affiliation(s)
- Libei Zhao
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
| | - Manqiang Peng
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
| | - Wenxiang Lin
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
| | - Qian Tan
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
| | - Muhammad Ahmad Khan
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
| | - Ding Lin
- Department of Ophthalmology, Changsha Aier Eye Hospital, Aier School of Ophthalmology, Central South University, Changsha, People's Republic of China
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90
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Zhu M, Yang H, Chen Z, Xia X, Deng Q, Shen Y. A cell-permeable peptide inhibitor of p55PIK signaling alleviates ocular inflammation in mouse models of uveitis. Exp Eye Res 2020; 199:108180. [PMID: 32777209 DOI: 10.1016/j.exer.2020.108180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 06/15/2020] [Accepted: 07/31/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Previously we developed TAT-N24 as a synthetic cell-permeable peptide inhibitor of p55PIK signaling and demonstrated its anti-inflammatory effects. This study aimed to evaluate the potential of TAT-N24 as a new agent for the treatment of ocular inflammatory diseases. METHODS The endotoxin-induced uveitis (EIU) model was established by intravitreal injection of lipopolysaccharide (LPS) in BALB/c mice and experimental autoimmune uveitis (EAU) model was established by subcutaneous injection of a peptide spanning amino acid residues 161-180 of interphotoreceptor retinoid binding protein (IRBP161-180) with complete Freund's adjuvant (CFA) in B10.RIII mice. TAT-N24 was topically administered in EIU model and intraperitoneally administered in EAU model. The severity levels of uveitis were assessed by clinical and histopathological scores. The mRNA levels of inflammatory cytokines in iris-ciliary body (ICB) and retina were analyzed by reverse transcription quantitative polymerase chain reaction (RT-qPCR). The protein levels of inflammatory factors were determined by ELISA or Western blotting. RESULTS The results showed that TAT-N24 alleviated clinical signs, decreased inflammatory cell infiltration and the expression of inflammatory cytokines in both EIU and EAU models. Furthermore, protein levels of tumor necrosis factor-alpha (TNF-α), interleukin-1β (IL-1β) and interleukin-6 (IL-6) in aqueous humor and mRNA and protein levels of NF-κB p65 in the ICB significantly decreased in EIU model. In EAU model, TAT-N24 application induced a significant decrease of IFN-gamma (IFN-γ) and interleukin-17 (IL-17) in the retina, which were secreted by Th1 and Th17 cells, respectively. CONCLUSION In conclusion, TAT-N24 suppressed intraocular inflammation in both EIU and EAU models, and the anti-inflammatory effects were mediated by suppressing the expression of inflammatory cytokines by PI3K/NF-κB signaling pathway. TAT-N24 could be potential candidate for the treatment of ocular inflammatory diseases.
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Affiliation(s)
- Meijuan Zhu
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China; Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, 441000, Hubei, China
| | - Hongxia Yang
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Zhen Chen
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Xianmin Xia
- Wuhan Yicheng Biotechnology Co., Wuhan, 430060, Hubei, China
| | - Qinqin Deng
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China.
| | - Yin Shen
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China; Frontier Science Center for Immunology and Metabolism, Medical Research Institute, Wuhan University, Wuhan, 430071, Hubei, China.
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91
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Lee SH, Yoo YS, Oh HS. The Effect of Adalimumab on Refractory Uveitis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.7.746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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92
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Merrill PT, Vitale A, Zierhut M, Goto H, Kron M, Song AP, Pathai S, Fortin E. Efficacy of Adalimumab in Non-Infectious Uveitis Across Different Etiologies: A Post Hoc Analysis of the VISUAL I and VISUAL II Trials. Ocul Immunol Inflamm 2020; 29:1569-1575. [PMID: 32469621 DOI: 10.1080/09273948.2020.1757123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE To assess efficacy of adalimumab versus placebo in patients with active or inactive noninfectious intermediate, posterior, or panuveitis across different etiologies. METHODS VISUAL I (V-I) and VISUAL II (V-II) clinical trials included adults with active or inactive uveitis, respectively, randomized to receive adalimumab or placebo. In a post hoc subgroup analysis, time to treatment failure (TTF) starting at week 6 (V-I) or week 2 (V-II) was analyzed using the Kaplan-Meier method. Hazard ratios (HR) for TTF with 95% CI were calculated with Cox proportional hazards regression. RESULTS The analysis included 217 V-I patients and 226 V-II patients. Treatment failure occurred later and risk was significantly lower in patients with idiopathic uveitis receiving adalimumab versus those receiving placebo in V-I (HR = 0.50 [CI, 0.30-0.84]; P = .006) and V-II (HR = 0.43 [CI, 0.22-0.83]; P = .010). CONCLUSIONS Treatment failure risk was lower in patients with idiopathic noninfectious uveitis receiving adalimumab versus those receiving placebo.
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Affiliation(s)
- Pauline T Merrill
- Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA
| | - Albert Vitale
- John A. Moan Eye Center, University of Utah, Salt Lake City, UT, USA
| | | | - Hiroshi Goto
- Department of Ophthalmology, Tokyo Medical University, Tokyo, Japan
| | - Martina Kron
- AbbVie Deutschland GmbH & Co KG, Ludwigshafen, Germany
| | | | | | - Eric Fortin
- University of Montreal, Montreal, QC, Canada
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93
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Retinal vasculitis: A framework and proposal for a classification system. Surv Ophthalmol 2020; 66:54-67. [PMID: 32450158 DOI: 10.1016/j.survophthal.2020.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.
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94
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Trivedi A, Katelaris C. The use of biologic agents in the management of uveitis. Intern Med J 2020; 49:1352-1363. [PMID: 30582273 DOI: 10.1111/imj.14215] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 12/08/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022]
Abstract
The uveitides are a heterogenous group of ocular inflammatory disorders that account for the third highest cause of blindness worldwide, responsible for 5-10% of visual impairment globally. Up to 35% of patients with uveitis can suffer significant vision loss. To prevent irreversible structural damage and blindness, it is important that the diagnosis and commencement of appropriate therapy occurs promptly. Management includes topical and systemic corticosteroid therapy and conventional immunomodulatory agents, including methotrexate, azathioprine, mycophenolate mofetil and cyclosporin. Significant progress has been made in the past decade in our understanding of the immunopathological pathways that drive intraocular inflammation, allowing the development of targeted therapy with biologic agents. These include TNF-α inhibitors, such as infliximab, adalimumab and etanercept; interleukin blockers, such as tocilizumab and daclizumab; and other targeted therapies, such as rituximab and abatacept. The efficacy of these agents has been studied in cases of severe uveitis that are refractory to conventional immunomodulatory agents and provide exciting results that have revolutionised uveitis management. Though the biologic era has provided a large armamentarium to treat uveitis, ongoing challenges and cases of recalcitrant uveitis remain, posing a challenge to internal medicine physicians. This comprehensive review aims to construct an updated summary on the existing evidence pertaining to the use of biologic agents in the treatment of uveitis. Methods include a systematic search for studies between 2000 and 2018 using PubMed, EMBASE, Ovid MEDLINE and Cochrane libraries.
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Affiliation(s)
- Amruta Trivedi
- Campbelltown Hospital, Sydney, New South Wales, Australia
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95
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Tagirasa R, Rana K, Kaza H, Parai D, Damera S, Basu S. Role of Multidrug Resistance Proteins in Nonresponders to Immunomodulatory Therapy for Noninfectious Uveitis. Transl Vis Sci Technol 2020; 9:12. [PMID: 32821484 PMCID: PMC7401954 DOI: 10.1167/tvst.9.5.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/03/2020] [Indexed: 01/22/2023] Open
Abstract
Purpose Nearly a third to half of patients with noninfectious uveitis (NIU) fail to achieve control with immunomodulatory therapy (IMT). Multidrug resistance (MDR) proteins are transmembrane proteins that allow efflux of intracellular drugs, leading to drug resistance. The aim of our study was to compare MDR protein function in blood CD4+ cells between responders and nonresponders to IMT. Methods We included NIU patients on IMT for ≥6 months and corticosteroid dose ≤10 mg/d. Nonresponders to treatment were those with worsening (two or more steps) of inflammation in the past 3 months on full-dose immunosuppressive therapy. MDR function was assessed by Rhodamine-123 dye retention in blood CD4+ cells. Three nonresponders were treated with adjunctive oral cyclosporine A (CSA, MDR inhibitor) therapy for 2 months and reevaluated. Results Fourteen NIU patients were recruited. Most (n = 8) had Vogt-Koyanagi-Harada disease. These included nine nonresponders and five responders to IMT. Nonresponders produced significantly higher MDR function and proinflammatory cytokines (interferon γ, tumor necrosis factor α, interleukin 17, and Granulocyte Macrophage Colony Stimulating Factor (GM-CSF)) than responders. In vitro CSA treatment of CD4+ cells inhibited MDR expression and proinflammatory cytokine production while increasing Foxp3. Finally, adjunctive oral CSA therapy led to improvement in clinical inflammatory scores with a concurrent decrease in MDR function and proinflammatory cytokine secretion. Conclusions MDR function is significantly higher in CD4+ T cells of nonresponders to IMT. Adjunctive CSA therapy may decrease MDR function and allow improvement in treatment response to IMT. Translational Relevance Our study highlights the need for MDR inhibition strategies in NIU patients not responding to IMT for improving the efficacy of anti-inflammatory therapy.
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Affiliation(s)
- Ravichandra Tagirasa
- Ocular Immunology, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India.,National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Khokan Rana
- Ocular Immunology, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India
| | - Hrishikesh Kaza
- Retina and Uveitis Services, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India
| | - Debaprasad Parai
- Ocular Immunology, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India
| | - Santhoshkumar Damera
- Ocular Immunology, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India
| | - Soumyava Basu
- Ocular Immunology, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India.,Retina and Uveitis Services, Brien Holden Eye Research Centre, Mithu Tulsi Chanrai Campus, L V Prasad Eye Institute, Bhubaneswar, India
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96
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Zagora SL, Cornish EE, Symes RJ, Younan C, Sammel A, Wakefield D, McCluskey P. Inflammatory eye and rheumatic disease. Int J Rheum Dis 2019; 22:2091-2095. [PMID: 31797538 DOI: 10.1111/1756-185x.13714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Sophia L Zagora
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Elisa E Cornish
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Richard J Symes
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Christine Younan
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Anthony Sammel
- Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia.,Rheumatology Department, Prince of Wales Hospital and Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Denis Wakefield
- Immunology Department, University of New South Wales, Sydney, NSW, Australia
| | - Peter McCluskey
- Uveitis Unit, Sydney Eye Hospital, Sydney, NSW, Australia.,Save Sight Institute & Discipline of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
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97
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Affiliation(s)
- Douglas A. Jabs
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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98
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Zagora S, McCluskey P. Biologic therapy for uveitis: a new beginning. Intern Med J 2019; 49:1349-1351. [PMID: 31713337 DOI: 10.1111/imj.14635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Sophia Zagora
- Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter McCluskey
- Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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99
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Gómez-Gómez A, García-González J, Peiteado D, Borrego-Sanz L, Arriola-Villalobos P, Esteban-Ortega M, Martín-López M, Ventura-Hidalgo M, Perez-Blazquez E, Pato E, Díaz-Valle D, Muñoz-Fernández S, Rodriguez-Rodriguez L. Inflammatory Relapses after Immunosuppressive Drug Discontinuation in Uveitis Patients: A Survival Analysis. Ocul Immunol Inflamm 2019; 29:376-387. [PMID: 31710514 DOI: 10.1080/09273948.2019.1681469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To estimate the incidence rate (IR) and identify risk factors associated to inflammatory relapse after immunosuppressive drug (ISD) discontinuation in noninfectious uveitis patients.Methods: Multicenter longitudinal retrospective study, including patients from four uveitis clinics followed-up until December 2018. Hazard ratios for different variables were estimated using multivariable Cox models.Results: 32 patients (34 episodes of ISD discontinuation) were analyzed (median and maximum follow-up time: 2.4 and 19.2 years, respectively). Fourteen patients presented at least one relapse: anterior (8 patients), intermediate (5) and posterior (8). IR (95% confidence interval) of the first relapse was 14.3 (8.6-23.8) episodes per 100 patient-years (median survival time: 4.8 years). Early use of ISDs, panuveitis, and higher oral corticosteroid dosage at discontinuation were associated with higher hazards of relapse in multivariable analysis.Conclusions: Relapse is a frequent and early event after ISD discontinuation. Identifying relapse risk factors could support the physician's decision regarding ISD discontinuation.
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Affiliation(s)
- Alejandro Gómez-Gómez
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Rheumatology Department, Hospital Universitario Infanta Sofía, Madrid, Spain
| | | | - Diana Peiteado
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Lara Borrego-Sanz
- Ophthalmology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Mar Esteban-Ortega
- Ophthalmology Department, Hospital Universitario Infanta Sofía, Madrid, Spain.,Medicine Department, Universidad Europea, Madrid, Spain
| | - María Martín-López
- Rheumatology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Esperanza Pato
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - David Díaz-Valle
- Ophthalmology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Luis Rodriguez-Rodriguez
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
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Rathinam SR, Gonzales JA, Thundikandy R, Kanakath A, Murugan SB, Vedhanayaki R, Lim LL, Suhler EB, Al-Dhibi HA, Doan T, Keenan JD, Rao MM, Ebert CD, Nguyen HH, Kim E, Porco TC, Acharya NR. Effect of Corticosteroid-Sparing Treatment With Mycophenolate Mofetil vs Methotrexate on Inflammation in Patients With Uveitis: A Randomized Clinical Trial. JAMA 2019; 322:936-945. [PMID: 31503307 PMCID: PMC6737523 DOI: 10.1001/jama.2019.12618] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Methotrexate and mycophenolate mofetil are commonly used immunomodulatory therapies for achieving corticosteroid-sparing control of noninfectious uveitis, but there is uncertainty about which drug is more effective. OBJECTIVE To compare the effect of methotrexate and mycophenolate for achieving corticosteroid-sparing control of noninfectious intermediate uveitis, posterior uveitis, and panuveitis. DESIGN, SETTING, AND PARTICIPANTS The First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial screened 265 adults with noninfectious uveitis requiring corticosteroid-sparing immunosuppressive therapy from 9 referral eye centers in India, the United States, Australia, Saudi Arabia, and Mexico between August 22, 2013, and August 16, 2017. Follow-up ended on August 20, 2018. INTERVENTIONS Patients were randomized to receive oral methotrexate, 25 mg weekly (n = 107), or oral mycophenolate mofetil, 3 g daily (n = 109). MAIN OUTCOMES AND MEASURES The primary outcome was treatment success at 6 months, which was defined as having control of inflammation in both eyes, no more than 7.5 mg prednisone daily and less than or equal to 2 drops of prednisolone acetate 1%, and no treatment failure due to safety or intolerability. Patients underwent follow-up to 12 months while receiving the same treatment or switched to the other antimetabolite, depending on their 6-month outcome. RESULTS Among 216 patients who were randomized (median age, 38 years; 135 (62.5%) women), 194 (89.8%) completed follow-up through 6 months. Treatment success occurred in 64 (66.7%) patients in the methotrexate group vs 56 (57.1%) in the mycophenolate group (difference, 9.5% [95% CI, -5.3% to 21.8%]; odds ratio [OR], 1.50 [95% CI, 0.81 to 2.81]; P = .20). Among patients with posterior uveitis or panuveitis, treatment success was achieved in 58 (74.4%) in the methotrexate group vs 42 (55.3%) in the mycophenolate group (difference, 19.1% [95% CI, 3.6% to 30.6%]; OR, 2.35 [95% CI, 1.16 to 4.90]; P = .02); whereas among patients with intermediate uveitis treatment success occurred in 6 (33.3%) in the methotrexate group vs 14 (63.6%) in the mycophenolate group (difference, -30.3% [95% CI, -51.6% to 1.1%]; OR, 0.29 [95% CI, 0.08 to 1.05]; P = .07; P for interaction = .004). Elevated liver enzymes were the most common nonserious laboratory adverse event, occurring in 14 patients (13.0%) in the methotrexate group and 8 patients (7.4%) in the mycophenolate group. CONCLUSIONS AND RELEVANCE Among adults with noninfectious uveitis, the use of mycophenolate mofetil compared with methotrexate as first-line corticosteroid-sparing treatment did not result in superior control of inflammation. Further research is needed to determine if either drug is more effective based on the anatomical subtype of uveitis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01829295.
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Affiliation(s)
- S. R. Rathinam
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - John A. Gonzales
- F. I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Radhika Thundikandy
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - Anuradha Kanakath
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Coimbatore, India
| | - S. Bala Murugan
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Pondicherry, India
| | - R. Vedhanayaki
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - Lyndell L. Lim
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Eric B. Suhler
- Casey Eye Institute, Portland, Oregon
- Oregon Health and Science University, Portland
- OHSU-PSU School of Public Health, and VA Portland Health Care System, Portland, Oregon
| | - Hassan A. Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Thuy Doan
- F. I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jeremy D. Keenan
- F. I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Maya M. Rao
- F. I. Proctor Foundation, University of California, San Francisco
| | - Caleb D. Ebert
- F. I. Proctor Foundation, University of California, San Francisco
| | - Hieu H. Nguyen
- F. I. Proctor Foundation, University of California, San Francisco
| | - Eric Kim
- F. I. Proctor Foundation, University of California, San Francisco
| | - Travis C. Porco
- F. I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R. Acharya
- F. I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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