Serum levels of interleukin-2 receptor in ocular Behçet's disease

Interleukin-2 Receptor and Angiotensin-Converting Enzyme as Markers for Ocular Sarcoidosis

PURPOSE

To study the impact of soluble IL2 receptor (sIL2R), chest x-ray (CxR), and angiotensin-converting enzyme (ACE) as markers for sarcoidosis in uveitis patients.

DESIGN

Retrospective study.

METHODS

Serum concentrations of sIL2R and ACE were measured in patients with active uveitis. Those with elevated sIL2R and /or ACE values were examined for suspected systemic sarcoidosis.

MAIN OUTCOME MEASURE

Our main outcome parameters were the specificity and sensitivity of sIL2R, CxR and ACE in screening for ocular sarcoidosis.

RESULTS

We measured 261 patients with uveitis for sarcoidosis using sIL2R and ACE between January 2008 and November 2011; sarcoidosis was been diagnosed using other tests (e.g. computer tomography, brochoalveolar lavage, biopsy) in 41 of 53 patients with elevated sIL2R values (>639 U/ml) and in one patient with normal sIL2R (582 U/ml). Their mean sIL2R value was 1310 U/ml, extending from 582 to 8659 U/ml. Only 9 patients, however, presented elevated ACE (>82 U/l). Their mean ACE value was 116.4 U/l, ranging from 84.1 to 175.5 U/l. IL2R specificity was 94% with 98% sensitivity. In contrast, ACE had a specificity of 99.5%, but a sensitivity of only 22%; the chest x-ray had a specificity of 100% with 50% sensitivity in detecting sarcoidosis. We observed the entire spectrum of uveitis: sixteen patients suffered from anterior, 8 from intermediate, 16 from posterior, and 2 from panuveitis.

CONCLUSIONS

An elevated level of soluble IL2R suggests sarcoidosis with uveitis more convincingly than ACE, making sIL2R a more effective marker parameter for sarcoidosis than ACE or chest x-ray in uveitis patients.

Cytokines and chemokines in uveitis: is there a correlation with clinical phenotype?

Uveitis is a general term for intraocular inflammation and includes a large number of clinical phenotypes. As a group of disorders, it is responsible for 10% of all registered blind patients under the age of 65 years. Immune-mediated uveitis may be associated with a systemic disease or may be localized to the eye. The pro-inflammatory cytokines interleukin (IL)-1beta, IL-2, IL-6, interferon-gamma and tumor necrosis factor-alpha have all been detected within the ocular fluids or tissues in the inflamed eye together with others, such as IL-4, IL-5, IL-10 and transforming growth factor-beta. The chemokines IL-8, monocyte chemoattractant protein-1, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta and fractalkine are also thought to be involved in the associated inflammatory response. There have been a number of studies in recent years investigating cytokine profiles in different forms of uveitis with a view to determining what cytokines are important in the inflamed eye. This review attempts to present the current state of knowledge from in vitro and in vivo research on the inflammatory cytokines in intraocular inflammatory diseases.

Étiopathogénie des modifications de la pression intraoculaire au cours des uvéites

Uveitic glaucoma is a secondary form of glaucoma. Treatment is essentially medical, based on antiglaucomatous medications and immunomodulatory therapy. Therefore, some patients may need filtrating surgery to control intraocular pressure. Understanding the cellular and biochemical modifications of aqueous humor that occur during intraocular inflammation and identification of anatomical modifications of the iridocorneal angle, trabecula, pupil, and ciliary body allow physicians to adapt management depending on the different clinical patterns of uveitic glaucoma. We propose a general review of the role of inflammatory mediators and etiopathogenic mechanisms involved in uveitic glaucoma.

Serum Cytokine Receptor Levels in Noninfectious Uveitis

PURPOSE

Understanding of the role of cytokines in uveitis may provide new clues to its treatment. Therefore, the purpose of our study was to evaluate systemic cytokine receptor expression in patients with noninfectious uveitis.

METHOD

Serum concentrations of soluble interleukin-2 receptor alpha (IL-2 s Ralpha) and soluble tumor necrosis factor receptor-1 (sTNF-R1) were measured in patients with intermediate uveitis (n = 26), posterior uveitis (n = 23) and healthy controls (n = 12) using ELISA. All patients were identified in a consecutive series of 996 uveitis patients who had been diagnosed between 1998 and 2002 and classified according to the recommendations of the International Uveitis Study Group. Inclusion criteria were idiopathic, active intraocular inflammation, uveitis as a primary process and no systemic anti-inflammatory treatment at the time of blood sampling. None of the patients had an underlying systemic disease.

RESULTS

Serum concentrations of IL-2 s Ralpha were significantly increased in patients with posterior (p < 0.005) and intermediate uveitis (p < 0.005) as compared to healthy controls. Similarly, concentrations of sTNF-R1 appeared to be increased in posterior (p < 0.005) and intermediate (p < 0.005) uveitis patients when compared to controls.

CONCLUSIONS

Our results may suggest that patients with noninfectious uveitis express systemic cytokine receptors such as TNF-R1 and IL-2 Ralpha, which may have an important role in the immune response of the eye and may lead to new immunomodulatory approaches.

Neurotological status in Behçet's disease and its ophthalmological correlates

OBJECTIVE

To assess neurotological status and its ophthalmological correlates in Behçet's disease.

STUDY DESIGN

A cross sectional study in which 17 patients with Behçet's disease and 13 healthy controls were included.

PATIENTS AND METHODS

The patients were divided into two groups: those with and without end stage ocular involvement. Neurotological status was evaluated with audiological tests (pure tone and speech audiometry, tympanometry, short increment sensitivity index, tone decay, and evoked response audiometry), and Dix-Halpike positional testing.

RESULTS

The positional test was normal. The audiological test results of the patients with and without end stage ocular involvement were not significantly different (p>0.05). A sloping audiogram with bilateral symmetric and mild sensorineural hearing loss was the main audiogram obtained. There was no relationship between the presence or absence of the end stage ocular involvement and the otological parameters studied excluding I-III interval on evoked response audiometry (p>0.05).

CONCLUSION

Although the main underlying pathogenetic factor in Behçet's disease is the autoimmune vasculitis, the mechanisms involved in the pathogenesis of neurological and ocular damage may be different. Alternatively, the differential involvement of certain organ systems may not reflect the nature of the disease process itself, but rather the manner in which each organ responds to injury.

The pathology and pathogenesis of retinal vasculitis

Retinal vasculitis is a rare, but potentially blinding intraocular inflammatory condition with diverse aetiology. Although commonly idiopathic, it has a strong association with systemic inflammatory diseases known to involve other areas of the central nervous system, most notably Behcet's disease, sarcoidosis, systemic lupus erythematosis and multiple sclerosis. This article describes the clinicopathologic features of retinal vasculitis and its visually damaging sequelae, reviewing available human histopathologic studies and work with experimental models to discuss the pathogenesis and immunopathology. Evidence indicates that noninfective retinal vasculitis is an autoimmune condition that may be induced by antecedent infection with microbes cross-reacting with putative autoantigens, influenced by genetic susceptibility of both HLA associations and cytokine polymorphisms. The growing understanding of the cellular mechanisms involved in the effector immune response is already providing a rationale for more specific therapeutic approaches.

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.

Serum homocysteine level is increased and correlated with endothelin-1 and nitric oxide in Behçet's disease

BACKGROUND/AIMS

Behçet's disease (BD) is a systemic inflammatory vasculitis of young adults with unknown aetiology, characterised by endothelial dysfunction and occlusion in both deep venous and retinal circulation. Ocular involvement occurs in 70% of cases and is characterised by periphlebitis, periarteritis, vascular occlusion, and thrombosis leading to blindness despite vigorous treatment. Endothelin-1 (ET-1) is a vasoconstricting peptide while nitric oxide (NO) is a relaxing molecule and both are released by endothelium for blood flow regulation. Homocysteinaemia is a newly defined term connected to the increased risk of atherothrombotic and atherosclerotic systemic and retinal vascular occlusive diseases, and its role in the course of BD has not been previously described. The authors aimed to detect serum total homocysteine (tHcy), ET-1, and NO in BD and to assess if tHcy, ET-1, and NO are associated with ocular BD or disease activity.

METHODS

43 consecutive patients with ocular (n = 27) or non-ocular (n = 16) BD (36.95 (SD 9.80) years, 22 male, 21 female) satisfying international criteria, and 25 age and sex matched healthy control subjects (37.88 (8.73) years, 13 male, 12 female) without a history of systemic or retinal venous thrombosis were included in this study. Patients were examined by two ophthalmologists with an interest in BD. Serum tHcy, ET-1, and NO concentrations were measured in both groups. Hyperhomocysteinaemia was defined as a tHcy level above the 95th percentile in the control group. Patients were divided into active and inactive period by acute phase reactants including alpha(1) antitrypsin, alpha(2) macroglobulin, erythrocyte sedimentation rate, and neutrophil count.

RESULTS

The overall mean serum tHcy, ET-1, and NO levels were significantly higher in patients with BD than in control subjects (tHcy = 15.83 (4.44) v 7.96 (2.66) ng/ml, p <0.001; ET-1 = 17.47 (4.33) v 5.74 (2.34) micromol/ml, p <0.001; NO = 37.60 (10.31) v 27.08 (7.76) micromol/l, p <0.001). Serum tHcy, ET-1, and NO levels were significantly higher in active patients than in inactive patients and control subjects. In addition, among patients with ocular BD, the mean tHcy levels were significantly increased and correlated with ET-1 and NO levels when compared with non-ocular disease and control subjects. All acute phase reactant levels were significantly higher in active period than in inactive stage and controls.

CONCLUSIONS

Elevated tHcy may be responsible for the endothelial damage in BD and may be an additional risk factor for the development of retinal vascular occlusive disease, contributing to the poor visual outcome in these patients. Assessment of tHcy may be important in the investigation and management of patients with BD, especially with ocular disease.

Immunopathology of the noninfectious posterior and intermediate uveitides

The posterior and intermediate uveitides share an underlying immune etiology; however, they can be clinically and immunopathologically distinguished. Although the initiating stimuli for posterior and intermediate uveities are not known, it is believed that an exogenous agent (such as a bacterium or a virus) or an endogenous molecule may induce disease. In either case, T-helper lymphocytes in conjunction with human leukocyte antigens are likely to be involved. This review examines the epidemiology, histology, immunopathology, and theories of pathogenesis of several posterior and intermediate uveitides, including sympathetic ophthalmia, Vogt-Koyanagi-Harada syndrome, Behçet's disease, sarcoidosis, intermediate uveitis, white dot syndromes, and birdshot retinochoroidopathy.

Interaction between inflammatory cells and heparin-surface-modified intraocular lens

PURPOSE

To investigate the interaction and adherence of inflammatory cells to a heparin-surface-modified intraocular lens (HSM IOL).

SETTING

Department of Ophthalmology, Tokyo Medical University Hospital, Tokyo, Japan.

METHODS

Splenic mononuclear leukocytes from rats with experimental autoimmune uveitis were cultured with the optic of an HSM IOL for 96 hours. The number of adherent cells on the HSM IOL surface was measured with and without the addition of interphotoreceptor retinoid-binding protein and concanavalin A (ConA) to the culture medium. The adherent cells were observed under a light microscope or a scanning electron microscope.

RESULTS

Interphotoreceptor retinoid-binding protein and ConA increased the number of adherent cells on the HSM IOL relative to the control. Adherent cells on the HSM IOL were small and round, considered to be mainly lymphocytes.

CONCLUSION

Activated lymphocytes tended to adhere to the surface of the HSM IOL.

Anti-MHC autoimmunity in Behçet's disease: T cell responses to an HLA-B-derived peptide cross-reactive with retinal-S antigen in patients with uveitis

Immune response to retinal autoantigens plays a central role in the pathogenesis of uveitis. A synthetic peptide (B27PD) from a common sequence of various HLA-B molecules associated with uveitis, such as HLA-B27 and 51, which shares amino acid homologies with a retinal-S antigen (S-Ag)-derived peptide (PDSAg), was shown to be immunogenic in human and experimental uveitis in the rat. In this study we investigated T cell responses to B27PD and PDSAg in patients with Behçet's disease and posterior uveitis (BD-posterior uveitis; n = 33) in comparison with non-Behçet anterior uveitis (AU, n = 14), Behçet's patients without uveitis (BD, n = 15) and healthy controls (HC, n = 32) in a 6-day proliferation assay. Patients with BD and posterior uveitis had significantly higher responses (stimulation index (SI) 2.8 +/- 1.3) than those with AU (SI 1.5 +/- 0.4), BD without uveitis (SI 1.1 +/- 0.4) and HC (SI 1.1 +/- 0.6) for B27PD (P < 0.0001). Responses to PDSAg were also higher in BD with posterior uveitis patients (SI 3.3 +/- 1.6) than AU (SI 1.5 +/- 0.4), BD without uveitis (SI 1.2 +/- 0.3) and HC (SI 1.1 +/- 0.6) (P < 0. 0001). A significant correlation between the responses to PDSAg and B27PD (r = 0.56, P < 0.001) was observed. Elevated levels of IL-2 and tumour necrosis factor-alpha were also observed in culture supernatants obtained from peripheral blood mononuclear cells after stimulation with the peptides, but no correlation was found between the proliferative responses and cytokine levels. These results suggest that cellular immunity to cross-reactive HLA-B and S-Ag-derived peptides might play a role in the pathogenesis of posterior uveitis in BD.

Effects of NG-nitro L-arginine and corticosteroids on aqueous humor levels of nitric oxide and cytokines after cataract surgery

PURPOSE

To assess the efficacy of nitric oxide synthesis (NOS) inhibitor, topical steroids, and nonsteroidal anti-inflammatory drugs on aqueous levels of nitric oxide (NO) and cytokines after cataract surgery.

SETTING

Research Laboratory, Inonu University Turgut Ozal Medical Center, Malatya, Turkey.

METHODS

Fifteen rabbits had intercapsular phacoemulsification and were randomly divided into 3 treatment groups: Group 1 was treated with topical prednisolone acetate 1% drops 5 times a day for 1 week; Group 2, flurbiprofen 0.03% drops 5 times a day for 1 week; Group 3, a 0.1 cc subconjunctival injection of NG-nitro L-arginine (L-NAME) (150 mg/kg) 1 day and 3 days after surgery. Three rabbits serving as controls received a subconjunctival injection of an equal volume of balanced salt solution (BSS) at the same times as the L-NAME injections. Aqueous humor specimens were collected from each eye to determine NO and cytokine levels including interleukin-1-beta (IL-1 beta), interleukin-2R (IL-2R), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha).

RESULTS

The levels of IL-1 beta and IL-6 were higher in Group 2 and the control group than in Groups 1 and 3 at all times. The differences were not statistically significant (P < .05). Nitric oxide and TNF-alpha levels in Groups 1 and 3 were significantly lower than in Groups 2 and the controls 1, 3, and 7 days postoperatively (P < .05).

CONCLUSION

These findings suggest a strong inhibitory effect of NOS inhibitors and corticosteroids on aqueous levels of TNF-alpha and NO and no inhibitory effect on IL-1 beta and IL-6 levels after cataract surgery.

The levels of plasma interleukin-2 and soluble interleukin-2R in Behçet's disease: a marker of disease activity

It is well known that patients with Behçet's disease (BD) have an activated immune system, probably mediated by soluble factors in the circulation. The purpose of our study was to examine the roles of plasma interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R) in the pathogenesis of BD. Thirty-two patients with BD diagnosed according to the Criteria of the International Study Group for Behçet's Disease and 20 age-matched healthy persons were included in the study. The plasma levels of cytokines were measured by ELISA. Plasma levels of IL-2 and sIL-2R were increased in BD over controls, but the differences were not statistically significant. sIL-2R levels in patients with active disease were significantly higher than in either patients with inactive disease (p < 0.001) or the control group (p < 0.05). Our results suggest that the level of sIL-2R in BD seems to be related to disease activity.

Behçet's disease: an immune-mediated vasculitis involving vessels of all sizes

Behçet's disease is an immune-mediated vasculitis affecting both small and large vessels. Small-vessel vasculitis is the pathological basis of the multiorgan involvement that results in protean clinical features. However, relapsing aphthous ulcers in the mouth are considered the clinical hallmark and are often also observed over the genitalia. Both manifestations, in association with uveitis, form the typical clinical triad. In addition, skeletal muscles, joints, gastrointestinal, cardiopulmonary, and central nervous systems can be involved. Heterogeneity in incidence, clinical manifestations, course, and severity are observed according to ethnic background. The natural course is chronic with relapses and remissions, gradually abating over the years, but the illness can also be life or sight threatening. Its origin and cause are still obscure: genetic, infectious, environmental, and immunological factors have been proposed. Owing to the lack of a specific test, diagnosis still relies on recognition of the typical clinical pattern. Treatment usually includes corticosteroids and immunosuppressive drugs. A better understanding of the pathogenesis will hopefully improve both diagnosis and therapy. In addition, the development of tests aimed at monitoring disease activity and response to therapy is certainly desirable.

Blood serum interleukin-1 receptor antagonist in pars planitis and ocular Behçet disease

PURPOSE

To determine the levels of interleukin-1 receptor antagonist (IL-1ra) in the blood serum of patients with idiopathic bilateral pars planitis and Behçet disease.

METHODS

Five milliliters of blood was with-drawn from the cubital vein of 91 patients (58 with the ocular type and five with the combined type of Behçet disease; 28 with pars planitis) and 36 volunteers. Serum was separated from these samples and stored at -70 C until assayed. Interleukin-1 receptor antagonist levels were determined by human IL-1ra enzyme-linked immunosorbent assay kits. In patients not receiving any systemic medication, one serum sample was obtained before initiating treatment and another when the patients had been under full medical treatment for 6 weeks or more.

RESULTS

Pretreatment mean +/- SD serum IL-1ra levels were 320 +/- 32 pg/ml for the patients with pars planitis, 380 +/- 54 pg/ml for patients with Behçet disease, and 271 +/- 29 pg/ml for the control subjects (no statistical significance). During treatment, a mean serum level of 352 +/- 37 pg/ml was observed in patients with pars planitis (not significantly different from control subjects) and 538 +/- 79 pg/ml in patients with ocular Behçet disease (P = .0116 compared with control subjects). The greatest increase in IL-1ra levels was observed in patients with Behçet disease who received a combination of cyclosporine and corticosteroids.

CONCLUSIONS

Because IL-1ra is one of the natural immunomodulating molecules, the significant increase of serum IL-1ra levels, especially after combined treatment with cyclosporine and corticosteroids, could indicate that the therapeutic effects of this regimen may be mediated through its effects on this molecule.

Glaucoma associated with uveitis

Raised intraocular pressure is a common and frequently serious complication of anterior uveitis. The milieu of inflammatory cells, the mediators they release, and the corticosteroid therapy used to treat the uveitis can participate in the pathogenesis of uveitic glaucoma. These factors alter the normal anatomic structure of the anterior chamber and angle, influencing aqueous production and outflow. These changes act to disrupt the homeostatic mechanisms of intraocular pressure control. Structural changes in the angle can be acute, such as in secondary angle closure with pupillary block glaucoma, or chronic, such as combined steroid-induced and secondary open angle glaucoma. Management of uveitic glaucoma may be difficult because of the numerous mechanisms involved in its pathogenesis. Diagnostic and therapeutic decisions are guided by careful delineation of the pathophysiology of each individual case. The goal of treatment is to minimize permanent structural alteration of aqueous outflow and to prevent damage to the optic nerve head. This article reviews the pathogenesis of uveitic glaucoma, with specific attention to etiology. Medical and surgical therapies are also discussed, with emphasis on the more recent developments in each category.

Surgical aspects of Behçet's disease

Behçet's disease is an uncommon condition that is managed primarily by medical therapy. Nevertheless, the widespread manifestations of the disease mean that surgeons from many different subspecialties may be involved in the care of patients. This is especially so for the treatment of life-threatening complications. For this reason the surgeon needs to consider Behçet's disease in the differential diagnosis of many conditions and to be aware of the general principles underlying the surgical care of affected patients.