Uveitis in Behçet's disease

[Retinal venous occlusion in Behçet disease]

PURPOSE

The aim of our study is to report three cases of retinal venous occlusion in patients with Behçet disease and to discuss the physiopathology of this vascular accident.

METHODS

In this retrospective study, out of a series of 32 patients suffering from Behçet disease, we report three cases of retinal venous occlusion. General and ophthalmologic features are described. Treatment strategy is detailed for each case.

RESULTS

There were 2 cases of branch retinal venous occlusion and one case of central retinal venous occlusion. Relapses and retinal neovascularization were the most common complications.

CONCLUSION

The retinal venous occlusion in Behçet's disease is a non-common but severe complication. Early and appropriate treatment is required to improve the functional prognosis.

Topographic optic disc analysis by Heidelberg retinal tomography in ocular Behcet's disease

AIM

To compare the topographic characteristics of the optic discs in patients with severe and mild ocular Behçet's disease by using Heidelberg retinal tomographaphy (HRT).

METHODS

This prospective study included 47 eyes of 47 patients with ocular BD who were being followed-up at the Uveitis Clinic of the Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey. The patients were divided into two groups. Group 1 consisted of 21 eyes with mild uveitis, and group 2 consisted of 26 eyes with severe uveitis. All patients underwent topographic optic disc analysis by HRT II, and the quantitative optic disc parameters of both groups were compared by non-parametric Mann-Whitney U test.

RESULTS

The mean cup volume, rim volume, cup area, disc area and cup depth in group 1 were found to be statistically significantly greater than those in group 2 (p<0.0001, p = 0.03, p = 0.021, p = 0.01 and p = 0.017, respectively), while the difference between the mean cup-to-disc ratios in group 1 and group 2 were found to be statistically insignificant (p = 0.148).

CONCLUSION

A relationship was found between the severity of ocular BD and optic disc topography determined by HRT. In eyes with smaller optic discs, uveitis was observed to have a more severe course with more frequent relapses than those with larger discs.

Trabeculectomy With Mitomycin C in Secondary Glaucoma Associated With Behçet Disease

PURPOSE

To determine the outcome of initial trabeculectomy with mitomycin C (MMC) in the management of secondary glaucoma associated with Behçet disease (BD) in a 1-year follow-up period.

METHODS

Twenty-three eyes of 13 cases with secondary glaucoma associated with BD, were evaluated prospectively. They underwent primary trabeculectomy with MMC. The operative success was defined as an intraocular pressure (IOP) < or =20 mm Hg (+/- medical therapy) in the absence of phthisis and without the necessity of further surgery for glaucoma and success rates at the postoperative first day, first month, sixth month, and first year were determined.

RESULTS

Success was achieved in all of the eyes (100%) at the postoperative first day and month, in 21 eyes (91.3%) at the postoperative sixth month and in 19 eyes (82.6%) at the postoperative first year. The mean preoperative IOP was 30.9+/-5.3 mm Hg under the mean 3.3+/-0.7 antiglaucoma medications but it reduced to 16.8+/-3.1 mm Hg under the mean 1.7+/-0.8 medications at the postoperative sixth month and 18.5+/-3.2 mm Hg under the mean 2.6+/-1.1 medications at the postoperative first year.

CONCLUSIONS

Trabeculectomy with MMC provides reduction of IOP and the number of antiglaucoma medications in cases with secondary glaucoma associated with BD in a 1-year follow-up period.

Intravitreal triamcinolone acetonide injection for the treatment of posterior uveitis

PURPOSE

To assess the efficacy and complications of intravitreal triamcinolone acetonide (IVTA) injection in the treatment of posterior uveitis and to compare the outcomes with patients who had received systemic corticosteroids.

METHODS

This prospective, interventional, clinical case series study included 11 eyes of 9 patients who received 8 mg/0.2 ml of IVTA injection for posterior uveitis that involved vitreous inflammation (group 1). Control group (group 2) consisted of 15 eyes of 12 patients who had received systemic corticosteroids for treatment of posterior uveitis with vitreous inflammation. The main outcome measures included best-corrected visual acuity, vitreous inflammation score and intraocular pressure.

RESULTS

In group 1, mean visual acuity improved significantly (P < 0.001) from a mean logarithm of the minimum angle of resolution (LogMAR) value of 2.05 +/- 0.82 at baseline to a maximum of 0.33 +/- 0.22 during the follow-up period of 5.0 +/- 2.8 months. In control group, mean LogMAR visual acuity before systemic corticosteroid therapy was 1.82 +/- 0.78, and it has reached a maximum of 0.40 +/- 0.22 after treatment (P < 0.001). The mean inflammatory scores decreased significantly in both groups when compared with preinjection values (for each, P < 0.05). There were no statistically significant differences between group 1 and group 2 when pre-and posttreatment visual acuities and inflammatory scores at 1-, 3-, and 5-month follow-up examinations were compared (for each, P > 0.05). In group 1, mean intraocular pressure (IOP) increased significantly from 13.4 +/- 2.6 mmHg to a mean maximal value of 19.3 +/- 4.3 mmHg (P < 0.001), but there was no statistically significant difference between mean IOP at 5-month after IVTA injection and pretreatment value (P = 0.06). Cataract progression was observed in one eye.

CONCLUSIONS

IVTA application may be an alternative therapeutic option for the treatment of acute posterior uveitis that involves vitreous inflammation, especially in patients who carry risks for systemic corticosteroid therapy.

Les manifestations oculaires de la maladie de Behçet (étude de 50 patients consultant en dermatologie)

INTRODUCTION

Behçet disease is a multisystemic vascularitis. Ocular affection is one of the major criteria of this disease. The aim of this study is to specify the clinical, therapeutical characteristics and the prognosis factors of the ocular affection in patients having BD and admitted to the dermatology department.

PATIENTS AND METHODS

It is a retrospective investigation carried out in the dermatology department of Ibn Rochd university hospital center of Casablanca, Morroco, from Jannuary 1990 until December 2003. Two patient groups have been distinguished. The first one involved 50 patients (44,2%) having BD with ocular affection, and the second group involved 63 patients having BD without ocular affection.

RESULTS

The mean age was 29 +/- 8 years in the first group VS 30 +/- 7,9 years in the 2(nd) group. The ocular affection was more frequent in males than in females (P < 0.05). The ocular manifestations were marked by uveitis and retinal periphlebitis. The frequency of the cutaneomucosal and joint manifestations was similar in both groups, whereas neurologic and vascular with ocular affections. The choice of the treatment depended on the type of ocular affection. Evolution was marked by blindness in 6 patients (12%).

DISCUSSION

The ocular affection comes second after the cutanous mucuous affection. Males are more clearly affected than females. This allows saying that there is a marked effect of the sexual hormones on the ocular affection. Age is not predictive of this ocular affection. The ocular affection was severe in our series and was dominated by uveitis and vascularitis. We insist on the severity of ocular Behçet and its evolution? Risk toward blindness especially concerning young man. Currently, the treatment is not codified; however, the encouraging outcome obtained with some immunosuppressive therapies would be better if this treatment was set up early.

CONCLUSION

This study enebed us to re-examine the ocular manifestations of the Behçet disease in the Maroccan population by the means of a consultation of Dermatology. Il should be noted that it is worse forecast because on the one hand of its frequent association to vascular and neurological affections and other share of the delay of consultation noted at the majority of our patients.

Blood-tinged Stools and Blood-shot Eyes

A 37-year-old woman developed red painful eyes, diarrhea, and painful oral and genital ulcerations. Optic disk swelling was noted bilaterally. Colonoscopy was significant for granulomatous lesions consistent with Crohn disease. Epidemiologic factors, diagnostic criteria, and differentiating characteristics for Behcet disease and Crohn disease are discussed.

Evaluation of serum leptin concentration in Behçet's disease with ocular involvement

PURPOSE

To assess the correlation between the serum leptin concentration and ocular involvement in patients with Behçet's disease.

METHODS

The study included 28 male consecutive patients with Behçet's disease ( group A, aged 19-59, median 35.5 years) and 15 male healthy control subjects ( group B, aged 25-45, median 35 years). The body mass index (BMI) was calculated for each subject at the study enrollment stage. We measured serum leptin, neutrophil count and erythrocyte sedimentation rate (ESR). Kruskal-Wallis variance analysis and the Mann-Whitney U-test were used for statistical analysis.

RESULTS

The age and BMI between the patients with ocular Behçet's disease and the control group were not different. White cell count and ESR values were found to be significantly higher among patients with Behçet's disease and ocular involvement (p<0.001). The median serum leptin concentrations were as follows: group A: 2.66 (0.57-7.02 ng/ml) and in group B: 2.55 (1.55-7.82 ng/ml). There was no statistically significant difference between the groups.

CONCLUSION

Serum leptin level does not correlate with ocular involvement in patients with Behçet's disease.

Incidence of Secondary Glaucoma in Beh??et Disease

PURPOSE

To determine the incidence of secondary glaucoma in Behcet disease.

METHODS

A total of 230 eyes of 129 patients with Behcet disease, were examined in uveitis and glaucoma clinics of Ankara Social Security Eye Hospital between January 1997 and September 2002. The data from all patients were investigated both retrospectively and prospectively.

RESULTS

The mean age of 129 patients was 34.2 +/- 7.4 years (range, 18 to 55 years). In 22 patients (17%), the disease was diagnosed on the basis of the ocular findings, while in the remaining 107 patients (83%), the period between the diagnosis of Behcet disease and the onset of the ocular symptoms was 23.3 +/- 17 months (range, 1 month to 5.3 years); 122 eyes (53%) had the episodes of acute recurrent iridocyclitis, while 108 eyes (47%) developed chronic posterior uveitis, including vitreitis, retinitis, vasculitis, or optic nerve involvement. Secondary glaucoma was diagnosed in 25 eyes (10.9%); 11 eyes (44%) with steroid or inflammation induced open angle glaucoma, 6 eyes (24%) with partial angle-closure glaucoma and peripheral anterior synechiae, 5 eyes (20%) with angle closure glaucoma, peripheral anterior synechiae, and pupil block and 3 eyes (12%) with neovascular glaucoma. The treatments included YAG-laser iridotomy in 5 eyes, diode-laser cyclodestruction in 3 eyes, primary trabeculectomies with mitomycin-c in 4 eyes, secondary trabeculectomies with mitomycin-c in 2 eyes, Ahmed valve implantations in 2 eyes, and cyclocryotherapy in 3 eyes.

CONCLUSIONS

We suggest that secondary glaucoma is a common and serious complication of Behcet disease. It develops as a result of multiple factors, generally triggered by recurrent intraocular inflammation. Early recognition and treatment of these factors have vital importance to avoid the visual morbidity.

Macular Hole in Behcet's Disease

Behcet's disease is an inflammatory disorder of unknown cause, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Ocular involvement occurs in 60-80% of patients with Behcet's disease and presents as panuveitis in most cases. Posterior segment involvement may lead to irreversible alterations and significant vision loss. The development of a partial or full-thickness macular hole, though rarely reported, may cause serious vision loss. In this report, we present two cases of macular hole in the worse eye of bilateral cases of Behcet's disease, and discuss the possible mechanisms and management in such cases.

Managing the symptoms of Behçet's disease

Behçet's disease (BD) is a chronic, relapsing, systemic inflammatory vasculitis of unknown aetiology with a myriad of immunological and pathological consequences. Patients with BD are clustered along the ancient silk road, extending from Far-East Asia to Turkey. The disease affects both genders of all ages from infants to the elderly. It is a long-term, cyclical disease and such patients may have symptom-free periods of weeks, months or years that are interrupted by exacerbations of varying intensities lasting a few days, weeks or months. Clinical features include oral aphthae, genital ulcers, ocular inflammation, skin lesions, as well as articular, vascular, neurological, pulmonary, gastrointestinal, renal and genitourinary manifestations. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size or thrombophilia according to the site of involvement. BD may start with just one or two small symptoms but other symptoms may gradually appear over the years. Recurrent ocular inflammation, which occurs in approximately 50% of cases, is the major morbidity that may eventually lead to blindness. The treatment of BD is usually symptomatic and palliative. Therefore, the main objectives are to relieve symptoms associated with mucocutaneous lesions and arthritis, to modify the course of the disease, to control inflammatory eye disease, clinically suppress the inflammation and vasculitis, to prevent recurrences and thus, prevent irreversible damage. The choice of treatment is based on the severity of systemic involvement, clinical presentation and the site affected. The preferred treatment modalities are combined drug therapy and include topical therapies as well as systemic corticosteroids, NSAIDs, colchicine, dapsone and immunosuppressive and cytotoxic agents. Such therapies are tailored to the individual patient depending on clinical manifestations. Thalidomide, tacrolimus, IFN-alpha and anti-TNF monoclonal antibody have recently attracted attention as novel therapeutic approaches.

Hyperhomocysteinaemia is associated with uveitis but not with deep venous thrombosis in Behçet's disease

Plasma homocysteine was assessed in Behçet's disease (BD) patients in order to determine the prevalence of hyperhomocysteinaemia in BD and to test its association with clinical manifestations of the disease. The study included 59 patients with BD and 118 age- and sex-matched healthy subjects. Plasma homocysteine, vitamin B

Ocular vasculitis

Systemic vasculitis can affect practically any structure in or around the eye. Although the ocular presentations of vasculitic disease are highly variable and may be quite subtle, it is important for physicians to understand some of the basic concepts, critical findings, and potential significance of ocular signs and symptoms. In addition to preserving sight, awareness of specific ocular syndromes may afford a critical clue to undiagnosed or newly active systemic vasculitis. A brief discussion of the most common ocular syndromes seen in systemic vascular disease is presented, with special attention given to the signs that may be appreciated by non-ophthalmologists. Recent concepts of ocular immunologic therapy are also reviewed, especially as they relate to the use of systemic immunomodulating drugs, because care of these patients often requires close cooperation between ophthalmologists, primary care physicians, and rheumatologists.

Behçet's disease: a new target for anti-tumour necrosis factor treatment

Behçet's disease is a multisystemic, chronic relapsing inflammatory disease classified among the vasculitides. Recurrent mucocutaneous lesions may be the only symptoms in mild cases, but articular, ocular, vascular, and/or gastrointestinal and central nervous system involvement may occur in most of the patients. Ocular disease is the most frequent cause of morbidity leading to blindness in 25% of those affected. The various non-specific immunosuppressive drugs, used either alone or in combinations, frequently fail to control inflammation or maintain remissions. The aetiology of Behçet's disease is unknown, however it is currently thought that a central pathogenetic role of tumour necrosis factor (TNF) in the inflammatory process is possible. Until June 2002, and according to published and anecdotal data, more than 80 patients from 10 different countries have received anti-TNF treatment. The short-term effects of the anti-TNF monoclonal antibody infliximab have been reported in several case reports and small case series, whereas the effects of etanercept have been presented in recent conferences. Preliminary results strongly suggest that infliximab is remarkably effective in inducing short-term remission of almost all manifestations of the disease, including acute, sight threatening panuveitis. A double blind, placebo controlled, one month study on the efficacy of etanercept in suppressing the mucocutaneous manifestations of the disease showed beneficial results. To date, significant side effects have not been reported. It seems that TNF block is an effective new treatment for patients with Behçet's disease. Whether such treatment is superior to the conventional therapeutic approaches in preventing relapses and progression of the disease remains to be determined by carefully controlled studies. At least three open, long term studies, including larger numbers of patients are currently being conducted.

Inhibition of cytokine production by the traditional oriental medicine, 'Gamcho-Sasim-Tang' in mitogen-stimulated peripheral blood mononuclear cells from Adamantiades-Behçet's patients

Gamcho-Sasim-Tang (GS-Tang) is a traditional Chinese medication, which has been successfully used in Korea for the treatment of Adamantiades-Behçet's disease (ABD). We investigated the modulation effects of GS-Tang on cytokine production from phytohaemagglutinin-stimulated peripheral blood mononuclear cells of Behçet's patients. ABD is a systemic inflammatory disorder and might involve immune dysfunction. Cytokines involved in the regulation of inflammatory reactions and immune responses may play a role in the pathogenesis of ABD. GS-Tang (1 mg/ml) significantly inhibited the production of proinflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta), compared to absence of GS-Tang (by 42.0+/-6.6% inhibition for TNF-alpha and 95.9+/-5.7% for IL-1 beta, P<0.05). GS-Tang also inhibited the production of IFN-gamma, immunoregulatory T helper cell type 1 cytokine, by 80.2+/-5.3% (P=0.001). The inhibitory effects of GS-Tang on cytokine production showed dose-dependent manner. Our results suggest that GS-Tang might have anti-inflammatory and immuno-regulatory effects through the cytokine modulation.

Long-term therapy with low dose cyclosporin A in ocular Behçet's disease

Ocular complications of Behçet's disease can be severe and lead to blindness in 90% of untreated patients. We aimed to evaluate the long-term use of low dose cyclosporin-A (CsA) which is a potent immunomodulatory agent in the treatment of ocular Behçet's disease. Fifty-two patients (104 eyes) with ocular Behçet's disease using CsA for at least 1 year were included in this study. All the patients underwent complete ophthalmological and systemic examination. Five mg/kg/per day CsA was started to the patients with severe posterior uveitis and/or frequent anterior inflammatory attacks unresponsive to the conventional therapeutic agents. According to ocular response and adverse effects, the dose was tapered gradually over 2 months to a maintenance dose of 3 mg/kg/per day. Prednisone (0.2-0.8 mg/kg/per day) was added when necessary. Forty-six of the patients (88.5%) were males and six (11.5%) were females. The mean age was 33.65 +/- 7.75 (range, 19-53) years. The mean ocular involvement period was 64.1 (range, 12-180) months. Posterior uveitis was present in 49 (94.21%) and severe, recurrent anterior uveitis in three (5.8%) patients. The mean CsA administration period was 38 +/- 18.1 months. Visual acuity improved in 31(29.8%), deteriorated in 32 (30.8%) and unchanged in 41(39.4%) of the 104 eyes. No ocular attacks occurred in 50% of the eyes during therapy. Nine (17.3%) of the patients had to stop the therapy because of the adverse effects of the CsA and the others tolerated well for a long-term period. CsA is not the ideal therapeutic agent in ocular Behçet's disease because it can not completely eliminate the disease, but it is currently one of the most effective and efficient drug to control the uveitis and its complications until better treatment modalities are developed.

Vgamma9Vdelta2 T cells recovered from eyes of patients with Behçet's disease recognize non-peptide prenyl pyrophosphate antigens

The phenotype and antigen-specificity of T cells expanded by mitogenic stimulation from intra-ocular fluid (IOF) samples of affected eyes of six Behçet's disease (BD) patients, and seven patients with other uveitis entities, were determined. High numbers of gammadelta T cells, predominantly Vgamma9Vdelta2 T cells, were only detected in the IOF-derived TCL of three BD patients. Whereas no TCL responded to heat shock protein (HSP) 65 kDa, reactivity to isopentyl pyrophosphate (IPP) and related non-peptide prenyl pyrophosphates (PPP) was restricted to the gammadelta T cell containing TCL. Upon IPP stimulation, these TCL secreted IFN-gamma but no IL-4. By single-cell analysis of intracellular IFN-gamma production and CD69 expression the IOF-derived IPP-specific T cells were identified as CD4(-)CD8(-) gammadelta T cells. The data presented suggest the infiltration of PPP-specific Vgamma9Vdelta2 Th1-like cells into the eye of BD patients with uveitis.

Hypopyon uveitis

Hypopyon uveitis has inflammatory, infective, and neoplastic causes and a high association with systemic disease. Careful questioning of the patient and detailed examination of the eye for other signs is necessary to guide the differential diagnosis and relevant investigations. Because the underlying causes require very different types of investigation and, if missed, can have serious sequelae for the patient, a rational approach based on the understanding of the causes of hypopyon uveitis is imperative. In this review, hypopyon uveitis is considered in the context of the associated ocular and systemic diseases that cause it.

Behçet disease

Behçet's disease is a multisystem inflammatory disorder of unknown origin, characterized by recurrent oral and genital ulcerations, ocular and cutaneous lesions, arthritis, central nervous system, and vascular disease. There is no pathognomonic laboratory test, but there are clinical criteria to assist in establishing the diagnosis. Behçet's is most common along the Silk Road. It is particularly common among persons who have the HLA-B51 major histocompatibility type. Cutaneous lesions include pustules, erythema nodosum-like lesions, Sweet's-like lesions, pyoderma gangrenosum-ike lesions, and pathergy. The major cutaneous findings may be classified as neutrophilic vascular reactions. There is considerable morbidity resulting from Behçet's disease, most notably a high risk of blindness from ocular involvement. Mortality may occur as a result of neurologic or vascular disease or gastrointestinal perforation.

Ophthalmologic manifestations of rheumatic diseases

OBJECTIVES

Detailed review of the manifestations of eye involvement in the context of rheumatic diseases.

METHODS

An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors.

RESULTS

Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications.

CONCLUSIONS

The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.

Novel approaches to Behçet's disease

Behçet's disease is a systemic inflammatory disorder. The patients have repeated exacerbations and remissions of the symptoms. This disease may produce a wide variety of symptoms. In mild cases, mucocutaneous lesions are only the symptoms during the whole clinical course, whereas ocular lesions, which occur in about 70% of the patients, can cause blindness. Involvement of the gastrointestinal tract, CNS and large vessels is less frequent, but sometimes life-threatening. Colchicine, NSAIDs, corticosteroids and immunosuppressants are employed for the treatment of Behçet's disease with therapies tailored to individual patients depending on clinical manifestations. Cyclosporin A is the most effective drug for ocular lesions at the present, but its neurotoxicity, which occurs in 20-30% of patients receiving cyclosporin A, restricts usage of the agent. Many patients are still suffering from a severe form of uveitis and serious neurological symptoms, which are resistant to any conventional therapies. New drugs have been investigated for Behçet's disease. IFN-alpha therapy has shown significant efficacy for common symptoms including ocular lesions without any serious adverse effects. Thalidomide and its analogues also appear to be applicable to this disease. Monoclonal antibody to TNF-alpha is now in clinical trials. These novel therapeutic approaches may provide much needed treatment options for patients with Behçet's disease.

Gene therapy in the treatment of ocular inflammation

Gene therapy may become a powerful therapeutic modality in the treatment of both ocular inflammatory disease and as a means of preventing rejection following tissue transplantation. By directly introducing into ocular cells genes that encode proteins capable of down-regulating the immune response, gene therapy has potential for both therapy and as a method for studying mechanisms of disease. While marked and rapid advances in the study of gene therapy have been realized, technical questions regarding the appropriate vector or the choice of efficacious immunomodulatory protein still remain.