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Systemic Immunosuppression for the Treatment of Pediatric Uveitis. Int Ophthalmol Clin 2022; 62:155-175. [PMID: 34965233 DOI: 10.1097/iio.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Paulbuddhe V, Addya S, Gurnani B, Singh D, Tripathy K, Chawla R. Sympathetic Ophthalmia: Where Do We Currently Stand on Treatment Strategies? Clin Ophthalmol 2021; 15:4201-4218. [PMID: 34707340 PMCID: PMC8542579 DOI: 10.2147/opth.s289688] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 01/05/2023] Open
Abstract
Sympathetic ophthalmia is a rare bilateral diffuse granulomatous panuveitis that usually results from surgical or penetrating trauma to one eye. The symptoms range from impaired near vision to pain, photophobia, and loss of visual acuity. Anterior segment manifestations include bilateral acute uveitis with mutton-fat keratic precipitates and posterior segment findings include vitritis, multifocal neurosensory retinal detachment, choroiditis, optic nerve edema, and Dalen-Fuchs nodules. The diagnosis is clinical. Ancillary investigations include fundus fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), ultrasound B scan, and autofluorescence imaging. The management options include corticosteroids (topical and systemic) as the first line along with immunomodulatory therapy started at the presentation of the disease. Recent advances include imaging with OCT-angiography, enhanced depth imaging-OCT (EDI-OCT, choroidal vascular index/CVI), targeting IL-23/IL-17 pathway, and use of biologics for the management of this rare entity. Recent advances in early diagnosis and prompt treatment has led to improved final visual outcomes in both the sympathizing and exciting eye. This review is aimed at giving a comprehensive overview of sympathetic ophthalmia along with a special emphasis on current treatment strategies and recent advances.
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Affiliation(s)
- Vivek Paulbuddhe
- Department of Vitreoretina, ASG Eye Hospital, Guwahati, 781006, Assam, India
| | - Sujit Addya
- Department of Vitreoretina, ASG Eye Hospital, Guwahati, 781006, Assam, India
| | - Bharat Gurnani
- Department of Cornea, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, 605007, Puducherry, India
| | - Dheerendra Singh
- Department of Retina, ASG Eye Hospital, Bhopal, 462016, Madhya Pradesh, India
| | - Koushik Tripathy
- Department of Vitreoretina, ASG Eye Hospital, Kolkata, 700058, West Bengal, India
| | - Rohan Chawla
- Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, 110029, India
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Hassan M, Karkhur S, Bae JH, Halim MS, Ormaechea MS, Onghanseng N, Nguyen NV, Afridi R, Sepah YJ, Do DV, Nguyen QD. New therapies in development for the management of non-infectious uveitis: A review. Clin Exp Ophthalmol 2020; 47:396-417. [PMID: 30938012 DOI: 10.1111/ceo.13511] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/16/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
Uveitis is a spectrum of inflammatory disorders characterized by ocular inflammation and is one of the leading causes of preventable visual loss. The main aim of the treatment of uveitis is to control the inflammation, prevent recurrences of the disease and preserve vision while minimizing the adverse effects associated with the therapeutic agents. Initial management of uveitis relies heavily on the use of corticosteroids. However, monotherapy with high-dose corticosteroids is associated with side effects and cannot be maintained long term. Therefore, steroid-sparing agents are needed to decrease the burden of steroid therapy. Currently, the therapeutic approach for non-infectious uveitis (NIU) consists of a step-ladder strategy with the first-line option being corticosteroids in various formulations followed by the use of first-, second- and third-line agents in cases with suboptimal steroid response. Unfortunately, the agents currently at our disposal have limitations such as having a narrow therapeutic window along with their own individual potential side-effect profiles. Therefore, research has been targeted to identify newer drugs as well as new uses for older drugs that target specific pathways in the inflammatory response. Such efforts are made in order to provide targeted and safer therapy with reduced side effects and greater efficacy. Several specially designed molecular antibodies are currently in various phases of investigations that can potentially halt the inflammation in patients with NIU. In the review, we have provided a comprehensive overview of the current and upcoming therapeutic options for patients with NIU.
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Affiliation(s)
- Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Samendra Karkhur
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Jeong H Bae
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Maria S Ormaechea
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Nam V Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Rubbia Afridi
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Quan D Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California
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Ormaechea MS, Hassan M, Onghanseng N, Park JH, Mahajan S, Al-Kirwi KY, Uludag G, Halim MS, Schlaen A, Sepah YJ, Do DV, Nguyen QD. Safety of systemic therapy for noninfectious uveitis. Expert Opin Drug Saf 2019; 18:1219-1235. [PMID: 31801415 DOI: 10.1080/14740338.2019.1692810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: The treatment strategies for noninfectious uveitis (NIU) aim to achieve disease remission, prevention of recurrences, and preserving vision, while minimizing the side effects associated with the therapies used.Areas covered: The index review aims to provide a detailed overview of the adverse events and safety parameters associated with the systemic therapies for the management of the NIU.Expert opinion: Despite being the cornerstone of management of acute cases of NIU, long-term corticosteroid use is associated with multi-system side effects, requiring the use of steroid-sparing agents. Adalimumab was recently approved by the FDA for the management of NIU based on the results of VISUAL studies. Similarly, newer drugs targeting various aspects of the inflammatory cascade are being developed. However, until we completely understand the molecular pathways of the inflammatory diseases, the therapeutic profile of these newer agents needs to be broad enough to suppress inflammatory cascade and narrow enough to spare normal cellular processes. Another strategy that has shown some potential in decreasing the systemic side effects is to provide local drug delivery. Therefore, the future of management of NIU is very bright with many novel therapeutic agents and strategies of drug delivery on the horizon.
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Affiliation(s)
- Maria Soledad Ormaechea
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina.,Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Jung Hyun Park
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Khalid Yusuf Al-Kirwi
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Imamein Khadhimein Medical City University Hospital, Baghdad, Iraq
| | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Ariel Schlaen
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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5
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Heiligenhaus A, Minden K, Tappeiner C, Baus H, Bertram B, Deuter C, Foeldvari I, Föll D, Frosch M, Ganser G, Gaubitz M, Günther A, Heinz C, Horneff G, Huemer C, Kopp I, Lommatzsch C, Lutz T, Michels H, Neß T, Neudorf U, Pleyer U, Schneider M, Schulze-Koops H, Thurau S, Zierhut M, Lehmann HW. Update of the evidence based, interdisciplinary guideline for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Semin Arthritis Rheum 2018; 49:43-55. [PMID: 30595409 DOI: 10.1016/j.semarthrit.2018.11.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized. METHODS Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure). RESULTS Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of ≥ 2 years of uveitis inactivity. CONCLUSIONS An interdisciplinary, evidence-based treatment guideline for JIAU is presented.
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Affiliation(s)
- A Heiligenhaus
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany.
| | - K Minden
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Tappeiner
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H Baus
- The Participation of the Following Bodies: Parents' Group for Children with Uveitis and their Families, Germany
| | - B Bertram
- Professional Association of Ophthalmologists (BVA), Germany
| | - C Deuter
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - I Foeldvari
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - D Föll
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Frosch
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - G Ganser
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Gaubitz
- German Society of Rheumatology (DGRh), Germany
| | - A Günther
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Heinz
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - G Horneff
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Huemer
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - I Kopp
- Association of the Scientific Medical Societies in Germany (AWMF), Germany
| | - C Lommatzsch
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - T Lutz
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - H Michels
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - T Neß
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - U Neudorf
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - U Pleyer
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Schneider
- German Society of Rheumatology (DGRh), Germany
| | | | - S Thurau
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Zierhut
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H W Lehmann
- The Society for Paediatric Rheumatology (GKJR), Germany
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Kapoor Y, Dixon P, Sekar P, Chauhan A. Incorporation of drug particles for extended release of Cyclosporine A from poly-hydroxyethyl methacrylate hydrogels. Eur J Pharm Biopharm 2017; 120:73-79. [DOI: 10.1016/j.ejpb.2017.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/06/2017] [Accepted: 08/14/2017] [Indexed: 10/19/2022]
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Sood AB, Angeles-Han ST. An Update on Treatment of Pediatric Chronic Non-Infectious Uveitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:1-16. [PMID: 28944162 PMCID: PMC5604477 DOI: 10.1007/s40674-017-0057-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are no standardized treatment protocols for pediatric non-infectious uveitis. Topical corticosteroids are the typical first-line agent, although systemic corticosteroids are used in intermediate, posterior and panuveitic uveitis. Corticosteroids are not considered to be long-term therapy due to potential ocular and systemic side effects. In children with severe and/or refractory uveitis, timely management with higher dose disease-modifying antirheumatic drugs (DMARDs) and biologic agents is important. Increased doses earlier in the disease course may lead to improved disease control and better visual outcomes. In general, methotrexate is the usual first-line steroid-sparing agent and given as a subcutaneous weekly injection at >0.5 mg/kg/dose or 10-15 mg/m2 due to better bioavailability. Other DMARDs, for instance mycophenolate, azathioprine, and cyclosporine are less common treatments for pediatric uveitis. Anti-tumor necrosis factor-alpha agents, primarily infliximab and adalimumab are used as second line agents in children refractory to methotrexate, or as first-line treatment in those with severe complicated disease at presentation. Infliximab may be given at a minimum of 7.5 mg/kg/dose every 4 weeks after loading doses, up to 20 mg/kg/dose. Adalimumab may be given up to 20 or 40 mg weekly. In children who fail anti-tumor necrosis factor-alpha agents, develop anti-tumor necrosis factor-alpha antibodies, experience adverse effects, or have difficulty with tolerance, there is less data available regarding subsequent treatment. Promising results have been noted with tocilizumab infusions every 2-4 weeks, abatacept monthly infusions and rituximab.
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Abstract
Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.
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Affiliation(s)
- Sirichai Pasadhika
- Vitreoretinal and Uveitis Service, Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA.
| | - James T Rosenbaum
- Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA
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Abstract
Intermediate uveitis is a form of intraocular inflammation in which the vitreous body is the major site of inflammation. Intermediate uveitis is primarily treated medicinally and systemic corticosteroids are the mainstay of therapy. When recurrence of uveitis or side effects occur during corticosteroid therapy an immunosuppressive treatment is required. Cyclosporine A is the only immunosuppressive agent that is approved for therapy of uveitis in Germany; however, other immunosuppressive drugs have also been shown to be effective and well-tolerated in patients with intermediate uveitis. In severe therapy-refractory cases when conventional immunosuppressive therapy has failed, biologics can be used. In patients with unilateral uveitis or when the systemic therapy is contraindicated because of side effects, an intravitreal steroid treatment can be carried out. In certain cases a vitrectomy may be used.
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Affiliation(s)
- D Doycheva
- Universitäts-Augenklinik Tübingen, Schleichstr. 12-16, 72076, Tübingen, Deutschland,
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Pilly B, Heath G, Tschuor P, Lightman S, Gale RP. Overview and recent developments in the medical management of paediatric uveitis. Expert Opin Pharmacother 2013; 14:1787-95. [DOI: 10.1517/14656566.2013.816677] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Heiligenhaus A, Michels H, Schumacher C, Kopp I, Neudorf U, Niehues T, Baus H, Becker M, Bertram B, Dannecker G, Deuter C, Foeldvari I, Frosch M, Ganser G, Gaubitz M, Gerdes G, Horneff G, Illhardt A, Mackensen F, Minden K, Pleyer U, Schneider M, Wagner N, Zierhut M. Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int 2011; 32:1121-33. [DOI: 10.1007/s00296-011-2126-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 08/22/2011] [Indexed: 12/14/2022]
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Durrani K, Zakka FR, Ahmed M, Memon M, Siddique SS, Foster CS. Systemic Therapy With Conventional and Novel Immunomodulatory Agents for Ocular Inflammatory Disease. Surv Ophthalmol 2011; 56:474-510. [DOI: 10.1016/j.survophthal.2011.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 05/18/2011] [Accepted: 05/24/2011] [Indexed: 12/19/2022]
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Peng CC, Chauhan A. Extended cyclosporine delivery by silicone-hydrogel contact lenses. J Control Release 2011; 154:267-74. [PMID: 21745507 DOI: 10.1016/j.jconrel.2011.06.028] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/22/2011] [Accepted: 06/18/2011] [Indexed: 11/15/2022]
Abstract
Cyclosporine A (CyA) is effective in treating chronic dry eyes and contact lens mediated dry eyes. CyA is delivered through eye drops of an oil-in-water emulsion, which has a small residence time in the eyes, leading to low bioavailability. Here we explore delivery of CyA from contact lenses to provide controlled and extended drug delivery with an increased bioavailability due to enhanced ocular residence time. Loading and release profiles of CyA from commercial contact lenses are presented to show that 1-DAY ACUVUE® releases CyA for about a day and extended wear silicone hydrogel (SiH) lenses release CyA for about 2-weeks. The longer duration from SiH lenses compared to the 1-DAY ACUVUE®lens is due to larger partition coefficients in the gel. A novel approach is presented for increasing release duration from the SiH lenses to the desired 1-month through incorporation of Vitamin E. The results show that Vitamin E loaded lenses can provide CyA release within the therapeutic window for a period of about a month. This pilot study demonstrates the promising potential of delivering CyA from contact lens for treatment of chromic dry eyes and contact lens mediated dry eyes.
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Affiliation(s)
- Cheng-Chun Peng
- Department of Chemical Engineering, University of Florida, Gainesville, FL 32611, USA
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Pato E, Muñoz-Fernández S, Francisco F, Abad MA, Maese J, Ortiz A, Carmona L. Systematic Review on the Effectiveness of Immunosuppressants and Biological Therapies in the Treatment of Autoimmune Posterior Uveitis. Semin Arthritis Rheum 2011; 40:314-23. [DOI: 10.1016/j.semarthrit.2010.05.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 05/17/2010] [Accepted: 05/20/2010] [Indexed: 12/14/2022]
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Abstract
INTRODUCTION Uveitis is a challenging disease covering both infectious and noninfectious conditions. The current treatment strategies are hampered by the paucity of randomized controlled trials and trials comparing the efficacy of different agents. AREAS COVERED This review describes the current and future treatments of uveitis. A literature search was performed in PUBMED from 1965 to 2010 on drugs treating ocular inflammation with emphasis placed on more recent, larger studies. Readers should gain a basic understanding of current treatment strategies beginning with corticosteroids and transitioning to steroid sparing agents. Steroid sparing agents include antimetabolites such as methotrexate, azathioprine and mycophenolate mofetil; calcineurin inhibitors which include cyclosporine, tacrolimus; alkylating agents which include cyclophosphamide and chlorambucil; and biologics which include the TNF-α inhibitors infliximab, adalimumab and etanercept and daclizumab, IFN-α(2a) and rituximab. EXPERT OPINION Newer agents are typically formulated from existing drugs or developed based on new advances in immunology. Future treatment will require a better understanding of the mechanisms involved in autoimmune diseases and better delivery systems in order to provide targeted treatment with minimal side effects.
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Affiliation(s)
- Theresa Larson
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA.
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17
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Quinones K, Choi JY, Yilmaz T, Kafkala C, Letko E, Foster CS. Pars Plana Vitrectomy versus Immunomodulatory Therapy for Intermediate Uveitis: A Prospective, Randomized Pilot Study. Ocul Immunol Inflamm 2010; 18:411-7. [DOI: 10.3109/09273948.2010.501132] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Yeh S, Nussenblatt RB, Levy-Clarke GA. Emerging biologics in the treatment of uveitis. Expert Rev Clin Immunol 2010; 3:781-96. [PMID: 20477028 DOI: 10.1586/1744666x.3.5.781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The pathogenic mechanisms underlying uveitis syndromes continue to be evaluated using animal models and in the clinical setting. As the complex interactions between ocular immune cells, proinflammatory cytokines, chemokines and cellular adhesion molecules are uncovered, targeted therapies directed against these immune mediators will continue to be developed. Traditional immunosuppressive medications, such as corticosteroids and steroid-sparing immunomodulatory agents, have demonstrated efficacy in the treatment of uveitic syndromes, but side effects and drug toxicities often limit the use of these medications. The biologic agents, a newer class of medications, target specific immune pathways and have demonstrated efficacy in rheumatologic, dermatologic and neurologic conditions. Biologic therapies (e.g., TNF-alpha inhibitors and IL-2 receptor inhibitor) targeting ocular immune cell surface receptors, cytokines and chemokines continue to be developed and have shown promise in the treatment of uveitis and ocular inflammatory diseases. Clinical and basic aspects of monoclonal antibody therapy for uveitis are presented in this review. Additional studies are needed to further evaluate the role of monoclonal antibodies in the therapeutic armamentarium for uveitis.
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Affiliation(s)
- Steven Yeh
- National Eye Institute/National Institutes of Health, Laboratory of Immunology, MSC 1857, 10 Center Dr., Bethesda, MD 20892-1857, USA.
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Simonini G, Cantarini L, Bresci C, Lorusso M, Galeazzi M, Cimaz R. Current therapeutic approaches to autoimmune chronic uveitis in children. Autoimmun Rev 2010; 9:674-83. [PMID: 20553975 DOI: 10.1016/j.autrev.2010.05.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 05/19/2010] [Indexed: 01/01/2023]
Abstract
Uveitis is an inflammatory disorder involving inflammation of the uveal tract. It is classified as anterior, intermediate, posterior or panuveitis, depending on the part of eye affected by the inflammatory process. In children, non-infectious, chronic uveitis is a relatively uncommon but serious disease, with the potential for significant long-term complications and possible blindness. Although frequently associated with an underlying systemic disease, e.g. juvenile idiopathic arthritis (JIA), a significant number of cases in children show no associated signs or symptoms, and are labelled as idiopathic. Taking into account this evidence, an anti-inflammatory therapy based on an immuno-modulatory approach seems a reasonable strategy for non-infectious chronic uveitis, in children as well as in adults. Due to a lack of controlled studies regarding uveitis in children, immunosuppressive drugs are supported only at evidence level III. The aim of this review is to report currently available medical strategies for treatment of childhood sight-threatening chronic uveitis; in addition, a step-by-step approach to the use of immunosuppressants in this context is suggested.
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Affiliation(s)
- Gabriele Simonini
- Department of Paediatrics, Anna Meyer Children's Hospital, University of Florence, Italy.
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Cuchacovich M, Solanes F, Díaz G, Cermenati T, Avila S, Verdaguer J, Verdaguer JI, Carpentier C, Stopel J, Rojas B, Traipe L, Gallardo P, Sabugo F, Zanoli M, Merino G, Villarroel F. Comparison of the Clinical Efficacy of Two Different Immunosuppressive Regimens in Patients with Chronic Vogt-Koyanagi-Harada Disease. Ocul Immunol Inflamm 2010; 18:200-7. [DOI: 10.3109/09273941003587541] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaçmaz RO, Kempen JH, Newcomb C, Daniel E, Gangaputra S, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Jabs DA, Levy-Clarke GA, Foster CS. Cyclosporine for ocular inflammatory diseases. Ophthalmology 2010; 117:576-84. [PMID: 20031223 DOI: 10.1016/j.ophtha.2009.08.010] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/02/2009] [Accepted: 08/04/2009] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate the clinical outcomes of cyclosporine treatment for noninfectious ocular inflammation. DESIGN Retrospective cohort study. PARTICIPANTS A total of 373 patients with noninfectious ocular inflammation managed at 4 tertiary ocular inflammation clinics in the United States observed to use cyclosporine as a single noncorticosteroid immunosuppressive agent to their treatment regimen, between 1979 and 2007 inclusive. METHODS Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics, including dosage of cyclosporine and main outcome measures, were obtained for every eye of every patient at every visit via medical record review by trained expert reviewers. MAIN OUTCOME MEASURES Control of inflammation, sustained control after reducing corticosteroid dosages, and discontinuation of therapy because of toxicity. RESULTS Of the 373 patients (681 eyes) initiating cyclosporine monotherapy, 33.4% by 6 months and 51.9% by 1 year gained sustained, complete control of inflammation over at least 2 visits spanning at least 28 days. Approximately 25% more improved to a level of slight inflammatory activity by each of these time points. Corticosteroid-sparing success (completely controlled inflammation for at least 28 days with prednisone < or = 10 mg/day) was achieved by 22.1% by 6 months and 36.1% within 1 year. Toxicity led to discontinuation of therapy within 1 year by 10.7% of the population. Patients aged more than 55 years were more than 3-fold more likely to discontinue therapy because of toxicity than patients aged 18 to 39 years. Doses of 151 to 250 mg/day tended to be more successful than lower doses and were not associated with a higher discontinuation for toxicity rate; higher doses did not seem to offer a therapeutic advantage. CONCLUSIONS Cyclosporine, with corticosteroid therapy as indicated, was modestly effective for controlling ocular inflammation. Our data support a preference for cyclosporine adult dosing between 151 and 250 mg/day. Although cyclosporine was tolerated by the majority of patients, toxicity was more frequent with increasing age; alternative agents may be preferred for patients aged more than 55 years.
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Affiliation(s)
- R Oktay Kaçmaz
- Department of Ophthalmology, The Mount Sinai School of Medicine, New York, New York, USA
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Kapoor Y, Chauhan A. Ophthalmic delivery of Cyclosporine A from Brij-97 microemulsion and surfactant-laden p-HEMA hydrogels. Int J Pharm 2008; 361:222-9. [DOI: 10.1016/j.ijpharm.2008.05.028] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 05/22/2008] [Accepted: 05/26/2008] [Indexed: 10/22/2022]
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Cunningham MA, Austin BA, Li Z, Liu B, Yeh S, Chan CC, Anglade E, Velagaleti P, Nussenblatt RB. LX211 (voclosporin) suppresses experimental uveitis and inhibits human T cells. Invest Ophthalmol Vis Sci 2008; 50:249-55. [PMID: 18708627 DOI: 10.1167/iovs.08-1891] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To test the therapeutic effectiveness of voclosporin against experimental autoimmune uveoretinitis (EAU) in rats and to evaluate its effect on human T cells. METHODS EAU was induced by immunization with a uveitogenic protein. Voclosporin administration, by subcutaneous injection, began on day (d) 0 or d7 after immunization. Treatment effectiveness was evaluated in vivo using clinical EAU scoring (d7-d13) and histopathologic evaluation of enucleated eyes after experimental termination. Rodent lymphocytes were harvested from lymph nodes on d14 for antigen-specific proliferation assays. The effect of voclosporin on human T-cell proliferation and cytokine secretion was examined in vitro. RESULTS Voclosporin prevented EAU development in rats receiving medium and high preventive doses, whereas high-dose voclosporin administration effectively treated EAU. Lymphocytes from animals treated with voclosporin had decreased antigen-specific proliferation in vitro compared with lymphocytes from untreated animals. No evidence of abnormal ocular histopathology was found in the eyes from animals that received high doses of therapeutic voclosporin. Using human T cells, voclosporin inhibited human T-cell proliferation up to 100-fold. Furthermore, voclosporin treatment of human T cells significantly reduced pan T-cell effector responses. CONCLUSIONS Voclosporin effectively suppressed uveoretinitis in an animal model that imitates the human inflammatory ocular disease by inhibiting lymphocyte proliferation. In addition, voclosporin effectively inhibited human T-cell proliferation and function in vitro. The authors report the first evidence supporting the application of voclosporin to treat intraocular inflammation.
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Affiliation(s)
- Matthew A Cunningham
- National Eye Institute, National Institutes of Health, Bethesda, Maryland 20892-1857, USA
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Limited value of cyclosporine A for the treatment of patients with uveitis associated with juvenile idiopathic arthritis. Eye (Lond) 2008; 23:1192-8. [PMID: 18551142 DOI: 10.1038/eye.2008.174] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIMS Juvenile idiopathic arthritis (JIA) is often associated with severe chronic anterior uveitis (CAU), and immunosuppressive therapy may be required. In this study, the value of cyclosporine A (CsA) as monotherapy or as combination therapy for treating uveitis was studied in a large cohort of JIA children. METHODS Multicentre retrospective study including 82 JIA children (girls n=60) suffering from unilateral or bilateral (n=55) CAU. The indication for CsA was active uveitis, although patients were on topical or systemic corticosteroids, MTX, or other immunosuppressive drugs. RESULTS Inactivity of uveitis during the entire treatment period (mean 3.9 years) was obtained with CsA monotherapy in 6 of 25 (24%) patients, but more often when CsA was combined with the immunosuppressives (35/72 patients; 48.6%, P=0.037), or MTX (18/37 patients, 48.6%, P=0.065), which had already been given. With CsA (mean dosage 2.9 mg/kg), systemic immunosuppressive drugs and steroids could be reduced by >or=50% (n=19) or topical steroids reduced to <or=2 drops/eye/day (n=40) in selected patients. Pre-existing cystoid macular oedema did not resolve under CsA treatment in any of the patients. In nine patients (11%), CsA was discontinued because of systemic hypertension (n=1), elevated creatinine levels (n=3), or other adverse effects (n=5). CONCLUSIONS These observations suggest that CsA has limited value as a second-line immunosuppressive drug for the treatment of JIA-associated CAU. The efficacy was better as the combination therapy in patients not responding to other immunosuppressives (eg, MTX) than the systemic monotherapy.
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Drug and surfactant transport in Cyclosporine A and Brij 98 laden p-HEMA hydrogels. J Colloid Interface Sci 2008; 322:624-33. [DOI: 10.1016/j.jcis.2008.02.028] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 02/21/2008] [Accepted: 02/22/2008] [Indexed: 11/21/2022]
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Advances in the diagnosis and immunotherapy for ocular inflammatory disease. Semin Immunopathol 2008; 30:145-64. [PMID: 18320151 DOI: 10.1007/s00281-008-0109-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 02/04/2008] [Indexed: 02/07/2023]
Abstract
Significant advances in the diagnosis and therapy for uveitis have been made to improve the quality of care for patients with ocular inflammatory diseases. While traditional ophthalmic examination techniques, fluorescein angiography, and optical coherence tomography continue to play a major role in the evaluation of patients with uveitis, the advent of spectral domain optical coherence tomography and fundus autofluorescence into clinical practice provides additional information about disease processes. Polymerase chain reaction and cytokine diagnostics have also continued to play a greater role in the evaluation of patients with inflammatory diseases. The biologic agents, a group of medications that targets cytokines and other soluble mediators of inflammation, have demonstrated promise in targeted immunotherapy for specific uveitic entities. Their ophthalmic indications have continued to expand, improving the therapeutic armentarium of uveitis specialists.
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Anglade E, Yatscoff R, Foster R, Grau U. Next-generation calcineurin inhibitors for ophthalmic indications. Expert Opin Investig Drugs 2007; 16:1525-40. [DOI: 10.1517/13543784.16.10.1525] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gallagher M, Quinones K, Cervantes-Castañeda RA, Yilmaz T, Foster CS. Biological response modifier therapy for refractory childhood uveitis. Br J Ophthalmol 2007; 91:1341-4. [PMID: 17556427 PMCID: PMC2000999 DOI: 10.1136/bjo.2007.124081] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the use of biological response modifiers (BRM) in the treatment of refractory childhood uveitis. DESIGN Retrospective non-comparative case series of pediatric patients with uveitis treated with BRM. PARTICIPANTS 23 pediatric patients. METHODS All children (18 years or younger) who received a BRM were assessed for visual changes, time to control inflammation, and any associated adverse side effects. Thirteen patients were treated with infliximab, five with adalimumab, and five with daclizumab. All patients had bilateral eye involvement. Diagnoses of the participants included juvenile idiopathic arthritis, keratouveitis, sarcoid panuveitis, Adamantiades-Behcets disease, and idiopathic panuveitis. MAIN OUTCOME MEASURES Inflammation and visual acuity. RESULTS In the infliximab group 16 of 26 eyes (62%), and 10 of 13 patients (77%) demonstrated an improvement in visual acuity. Twenty of 26 eyes (77%) demonstrated an improvement in the degree of inflammation. In the adalimumab group, four of 10 eyes (40%) demonstrated an improvement in visual acuity, with five of 10 eyes (50%) demonstrating an improvement in inflammation. Four of 10 eyes (40%) in the daclizumab group demonstrated an improvement in vision with eight of 10 eyes (80%) demonstrating an improvement in inflammation. CONCLUSION BRM appear to be safe to use in children, and represent a useful therapeutic adjunctive drug group for treating recalcitrant childhood uveitis.
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Affiliation(s)
- Michael Gallagher
- Massachusetts Eye Research and Surgery Institute, 5 Cambridge Center, 8th Floor, Cambridge, MA 02142, USA
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Schatz CS, Uzel JL, Leininger L, Danner S, Terzic J, Fischbach M. Immunosuppressants used in a steroid-sparing strategy for childhood uveitis. J Pediatr Ophthalmol Strabismus 2007; 44:28-34. [PMID: 17274332 DOI: 10.3928/01913913-20070101-03] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To review, with respect to etiology, the efficacy and complications of different immunosuppressants used in a steroid-sparing strategy for children with uveitis. PATIENTS AND METHODS Forty children with uveitis were observed during a 5-year period, from 1997 to 2002. After complete ocular and physical assessment, routine and specific laboratory investigations were conducted along with radiologic examination. All cases underwent local therapy. Systemic corticosteroids were necessary in 75% of cases. Pediatric staff determined the need for initial association or sequential relay with immunosuppressants, depending on the severity of the uveitis. A steroid-sparing strategy was developed. RESULTS The average age was 6.5 years (range, 3 months to 14 years), with a male-to-female ratio of 23 to 17. Uveitis was anterior in 55% of cases, intermediate in 2.5%, posterior in 42.5%, and bilateral in 62.5%. A positive etiology was found in 47.5% of cases, and articular symptoms were present in 25%. Overall, the improvement in visual acuity was 62.2%. Where corticotherapy was associated with azathioprine, a 61% improvement was achieved. Corticosteroid therapy associated with mycophenolate mofetil resulted in a 94% improvement. No complications were present in 42.5% of cases. Ocular complications were present in 57.5% of cases and systemic complications were present in 12.5% of cases, none being directly related to the use of steroids. CONCLUSION The association of systemic corticotherapy and immunosuppressants in pediatric relapsing or steroid-dependent uveitis allows good recovery of visual acuity, fewer complications, and a minimization of side effects, especially those related to systemic corticosteroids. It requires close collaboration between the ophthalmologist and a fully involved pediatrician.
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Affiliation(s)
- Claude Speeg Schatz
- Strasbourg University Eye Hospital, BP 426 1 place de l'Hôpital, 67091 Strasbourg, France
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Okada AA. Immunomodulatory therapy for ocular inflammatory disease: a basic manual and review of the literature. Ocul Immunol Inflamm 2006; 13:335-51. [PMID: 16419419 DOI: 10.1080/09273940590951034] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Corticosteroids are used as first-line treatment for many ocular inflammatory conditions. The risk of adverse effects, however, necessitates conversion to steroid-sparing immunomodulatory therapy (IMT) for disease that is recurrent, chronic, or poorly responsive to treatment. Combination drug treatments with multiple agent 'recipes' are also considered. Immunomodulatory agents include the broad categories of antimetabolites (azathioprine, methotrexate, mycophenolate mofetil), alkylating agents (cyclophosphamide, chlorambucil), T-cell inhibitors (cyclosporine, tacrolimus), and cytokines (interferon alfa). This article reviews and summarizes the evidence for IMT agent use in the treatment of various forms of ocular inflammation.
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Affiliation(s)
- Annabelle A Okada
- Department of Ophthalmology, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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Hesselink DA, Baarsma GS, Kuijpers RWAM, van Hagen PM. Experience with cyclosporine in endogenous uveitis posterior. Transplant Proc 2004; 36:372S-377S. [PMID: 15041371 DOI: 10.1016/j.transproceed.2004.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment with cyclosporine (CsA) has considerably improved the visual prognosis of patients suffering from endogenous posterior uveitis (EPU). However, the therapeutic benefits of CsA are partially outweighed by its many side effects, most notably nephrotoxicity and hypertension. Low-dose CsA regimens have reduced toxicity but have not been able to completely eliminate this problem. New therapeutic approaches, such as anti-tumor necrosis factor alpha treatment or immunosuppression with drugs including tacrolimus, sirolimus, and interleukin-2 receptor antibodies, are currently under evaluation. Hopefully such strategies will further reduce the morbidity of EPU and minimize the adverse effects associated with conventional therapies.
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Affiliation(s)
- D A Hesselink
- Department of Internal Medicine, Renal Transplant Unit, Erasmus Medical Center, Rotterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW Uveitis is an important cause of functional visual loss and blindness in the developed world. Immunosuppressive drugs may be required to treat severe noninfectious uveitis successfully, but the efficacy and safety of such treatments are often limited by the small numbers of patients enrolled in clinical trials or studied retrospectively, the absence of control participants, and the variable natural course of some types of uveitis. This review was undertaken to highlight recent clinical advances in the treatment of severe noninfectious uveitis. RECENT FINDINGS A literature search emphasizing the research published since 2001 was undertaken. The role of previously available immunosuppressives such as antimetabolites, calcineurin inhibitors, and alkylating agents continues to develop. In recent years, more specific drugs, collectively known as biologics, have been used in the treatment of uveitis. A persistent limitation of the published literature remains the general lack of randomized, controlled clinical trials. The long-term risks of most immunosuppressive drugs and the risk of relapse after discontinuation of therapy are also not well established. Tumor necrosis factor-alpha antagonists are promising but extremely expensive, and they may be more effective for rheumatologic and nonocular autoimmune disorders than for uveitis. SUMMARY The number of options available for the treatment of severe noninfectious uveitis has expanded in the past few years. While promising, the new drugs are expensive, and their long-term efficacy and safety are not known; consequently, older immunosuppressive drugs still play an important role in the treatment of uveitis.
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Affiliation(s)
- James P Dunn
- Department of Ophthalmology, Division of Ocular Immunology, The Wilmer Eye Institute, The Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA.
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Abstract
Retinal vasculitis represents a group of diseases characterized by inflammation affecting the retinal vasculature. It is an uncommon disorder that may occur as an isolated disease or more commonly in association with other ocular diseases or a variety of systemic diseases. With a wide variety of disease associations, a search for an underlying etiology should be undertaken based on a meticulous history, review of systems, and physical examination. The laboratory evaluation of patients with retinal vasculitis is an essential component of the work-up to facilitate detection of any underlying disease or to establish a limited differential diagnosis. The management of infectious causes of retinal vasculitis consists of antimicrobial therapy while noninfectious retinal vasculitis is managed with corticosteroids and/or immunosuppressive agents. Because retinal vasculitis is an uncommon disease, there are only a limited number of publications over the past year related to this topic.
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Affiliation(s)
- R Christopher Walton
- Department of Ophthalmology, University of Tennessee College of Medicine, Memphis, 38163, USA.
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Lau CH, Comer M, Lightman S. Long-term efficacy of mycophenolate mofetil in the control of severe intraocular inflammation. Clin Exp Ophthalmol 2004; 31:487-91. [PMID: 14641155 DOI: 10.1046/j.1442-9071.2003.00704.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE To assess whether the previously demonstrated short-term efficacy of the immunosuppressant mycophenolate mofetil (MMF; CellCept, Roche) is maintained in the long-term management of refractory uveitis. METHODS The study was an open-label, non-comparative retrospective series of 14 patients with refractory uveitis and treated with MMF for a mean of >33 months. Mycophenolate mofetil was given at a dosage of 1 g (oral) twice daily. Indications included prednisolone reduction, additive agent with cyclosporin, or replacement therapy (azathioprine or methotrexate). The intraocular inflammatory response, side-effects, and toxicity were monitored. RESULTS Intraocular inflammation remained under control in 10 patients, unchanged in three and deteriorated in one patient. Transient side-effects included tiredness, headache and dizziness (one patient each, lasting less than 2 weeks from the time of MMF introduction). Mycophenolate mofetil was stopped in one patient because of absence of prolonged clinical improvement. Vision improved in 25% (7 eyes), did not change in 50% (14 eyes), but was reduced in 25% (7 eyes). CONCLUSIONS Mycophenolate mofetil is safe for long-term usage and is recommended for treatment of refractory panuveitis or posterior uveitis with uncontrolled inflammation despite high prednisolone maintenance dosage (>15 mg/day) or toxicity or lack of efficacy of other immuno-suppressive agents. However, MMF is less effective for refractory uveitis unresponsive to azathioprine.
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Affiliation(s)
- Chun H Lau
- Department of Clinical Ophthalmology, Institute of Ophthalmology and Moorfields Eye Hospital, City Road, London EC1V 2PD, UK
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Abstract
PURPOSE OF REVIEW This review summarizes current patterns in the use of immunosuppressive agents in patients with uveitis. RECENT FINDINGS A number of immunosuppressive agents are currently available for the treatment of uveitis. Reports of safety and efficacy, although numerous, have been largely nonrandomized and performed without controls, limiting, to some extent, the strength and generalizability of their conclusions. Nonetheless, the volume of case reports and case series provides compelling evidence that immunosuppressive agents are effective at providing long-term control in patients with moderate to severe chronic or recurrent uveitis. The choice of immunosuppressive agent is complex, and depends on the cause and severity of the patient's underlying inflammation, the presence or absence of associated systemic inflammation, and the patient's prior response to immunosuppressive treatments. SUMMARY Although corticosteroids remain the primary initial treatment for patients with uveitis, use of noncorticosteroid immunosuppressive agents in selected patients with uveitis allows for improved control and decreased risk of corticosteroid-induced side effects.
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Affiliation(s)
- Marc J Lustig
- Department of Ophthalmology, New York University School of Medicine, and Manhattan Eye, Ear, and Throat Hospital, New York, 10021, USA
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Abstract
Uveitis associated with juvenile rheumatoid arthritis is the most common form of ocular inflammation in children. Prevention of permanent visual damage by this silent disease requires heightened awareness from pediatric rheumatologists and ophthalmologists. Early prediction of severity and prognosis will aid in the identification of those patients requiring more aggressive management. Generally, reports using immunosuppressives in this population are small, uncontrolled, and retrospective. Large-scale collaborative studies have been proposed and are underway. Hopefully, collaborations between pediatricians, pediatric rheumatologists, and ophthalmologists will allow the development of straightforward treatment guidelines for children suffering from chronic uveitis and its related complications.
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Affiliation(s)
- Lucila M A Agle
- Division of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Abstract
In the treatment of uveitis, corticosteroids are usually included in first-line therapy due to its rapid onset of action and excellent safety profile. Systemic immunosuppressive agents also play an important role in the management of posterior uveitis. The purpose of this study was to review systemic agents for treating uveitis: prednisone, methotrexate, cyclosporine, and azathioprine. This study was a review of the literature using Medline. Thirty-eight references were incorporated. Immunosuppressants take several weeks for their full effect and are considered when long-term therapy is anticipated. When long-term therapy is anticipated, immunosuppressant agents may be added, which allows for the reduction and eventual discontinuation of prednisone. Combination therapy of various immunosuppressants also allows for long-term therapy, which reduces the relapse rate. However, immunosuppressives can be associated with serious side-effects. The use of immunosuppressants requires careful monitoring.
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Affiliation(s)
- Julia Song
- Duke University Medical Center, Durham, NC 27710, USA.
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Holland GN, Stiehm ER. Special considerations in the evaluation and management of uveitis in children. Am J Ophthalmol 2003; 135:867-78. [PMID: 12788128 DOI: 10.1016/s0002-9394(03)00314-3] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To review issues related to the diagnosis, examination, and treatment of children with uveitis that are important for ophthalmologists. DESIGN Literature review. METHOD A review was made of pertinent reports from the medical literature, with commentary based on the authors' experiences and on discussions at an international workshop. RESULTS There are differences between children and adults in the differential diagnosis and manifestations of uveitis that should be considered during evaluation. There may be a higher risk of some ocular complications such as uveitic glaucoma, and the presence of other unique complications, such as amblyopia, in young patients during follow-up. With regard to treatment, children with uveitis may have unique dosing requirements and drug-associated risks such as growth retardation with systemic corticosteroids that must be considered. Examination and treatment may also be more difficult with children because of problems with patient cooperation. CONCLUSIONS There are unique patient care issues associated with uveitis in children that must be considered by care providers. Attention to these issues will improve the well-being of this patient population.
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Affiliation(s)
- Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Los Angeles, California 90095-7003, USA.
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Milojevic DS, Ilowite NT. Treatment of rheumatic diseases in children: special considerations. Rheum Dis Clin North Am 2002; 28:461-82. [PMID: 12380365 DOI: 10.1016/s0889-857x(02)00009-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The goals of treatment of rheumatic diseases in children are to control the disease process while ensuring normal nutrition, growth, and development. The choice of antirheumatic drugs is similar in children and adults, but the doses, treatment schedules, and susceptibility to toxicity can differ considerably. In addition to differences between adult and pediatric diseases themselves, it is important for the rheumatologist who treats children to be cognizant of the impact of nutritional, developmental, and growth issues and differential susceptibility to toxicity of various treatments.
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Affiliation(s)
- Diana S Milojevic
- Division of Pediatric Rheumatology, Schneider Children's Hospital, Albert Einstein College of Medicine, 269-01 76th Avenue, Room CH191, New Hyde Park, NY 11040, USA
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Abstract
Uveitis refers to inflammation involving the uvea or middle coat of the eye. This condition occurs uncommonly, particularly in persons aged <or=16 years. However, pediatric uveitis deserves special consideration for reasons that include the relatively poor prognosis, unique systemic associations, and various age-related treatment considerations. Accurate diagnosis requires history from both patient and parents, a complete ophthalmic examination that may require general anesthesia, and carefully selected investigations. Infections and masquerade syndromes, such as leukemia and retinoblastoma, must be excluded before treatment is commenced with immunosuppressive agents. Noninfectious anterior uveitis generally responds to topical corticosteroid and mydriatic therapy. Although used frequently in adults with posterior uveitis, periocular corticosteroid injections may require a general anesthetic, and systemic corticosteroids may cause serious adverse effects, including growth retardation, in pediatric patients. Consequently, in children, one or more corticosteroid-sparing immunosuppressive drugs are usually employed for vision-threatening noninfectious posterior eye inflammation. Methotrexate is the most commonly used systemic immunosuppressive agent for pediatric uveitis. It is effective in small retrospective clinical series, generally well tolerated, easy to administer, and inexpensive. Cyclosporin has also been used successfully in children with uveitis, being associated with a low risk of renal toxicity when used at standard doses. Although prescribed for severe ocular inflammation in adults, alkylating agents are generally contraindicated in children owing to risks including secondary malignancy, sterility and bone marrow suppression. Drugs that inhibit tumor necrosis factor-alpha have recently been used successfully to treat children with uveitis; however, in some patients there may be a risk of potentiating the ocular inflammation. Randomized clinical trials would provide valuable information about the relative efficacy of the various available treatment options.
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Affiliation(s)
- Justine R Smith
- Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon 97201-4197, USA.
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Gerloni V, Cimaz R, Gattinara M, Arnoldi C, Pontikaki I, Fantini F. Efficacy and safety profile of cyclosporin A in the treatment of juvenile chronic (idiopathic) arthritis. Results of a 10-year prospective study. Rheumatology (Oxford) 2001; 40:907-13. [PMID: 11511760 DOI: 10.1093/rheumatology/40.8.907] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This open prospective trial was performed in order to assess the efficacy and safety of cyclosporin A in the treatment of patients with juvenile chronic arthritis (JCA). METHODS Thirty-four of the patients enrolled were affected by systemic-onset disease and seven by chronic anterior uveitis associated with JCA. The cyclosporin dose was usually 3-5 mg/kg per day. The average duration of therapy was 1.4 yr, with a maximum of 7.2 yr. RESULTS The efficacy of treatment was mainly evident in terms of control of fever and reduction of steroid therapy. The benefits with respect to arthritis, laboratory parameters and uveitis seemed to be less clear-cut. Side-effects were frequent but usually mild or reversible. Sixty-six per cent of the study population withdrew from therapy because of inefficacy or side-effects. Eight systemic patients withdrew from therapy owing to complete remission. CONCLUSION Cyclosporin can be used in the treatment of JCA, its main benefits being the control of fever and a steroid-sparing effect.
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Affiliation(s)
- V Gerloni
- Rheumatology Department, University of Milan, Centre for Rheumatic Children, Gaetano Pini Institute, Milan, Italy
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Jabs DA, Rosenbaum JT, Foster CS, Holland GN, Jaffe GJ, Louie JS, Nussenblatt RB, Stiehm ER, Tessler H, Van Gelder RN, Whitcup SM, Yocum D. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol 2000; 130:492-513. [PMID: 11024423 DOI: 10.1016/s0002-9394(00)00659-0] [Citation(s) in RCA: 640] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To provide recommendations for the use of immunosuppressive drugs in the treatment of patients with ocular inflammatory disorders. PARTICIPANTS A 12-person panel of physicians with expertise in ophthalmologic, pediatric, and rheumatologic disease, in research, and in the use of immunosuppressive drugs in patient care. EVIDENCE Published clinical study results. Recommendations were rated according to the quality and strength of available evidence. PROCESS The panel was convened in September of 1999 and met regularly through May 2000. Subgroups of the panel summarized and presented available information on specific topics to the full panel; recommendations and ratings were determined by group consensus. CONCLUSIONS Although corticosteroids represent one of the mainstays in the management of patients with ocular inflammation, in many patients, the severity of the disease, the presence of corticosteroid side effects, or the requirement for doses of systemic corticosteroids highly likely to result in corticosteroid complications supports the rationale for immunosuppressive drugs (for example, antimetabolites, T-cell inhibitors, and alkylating agents) being used in the management of these patients. Because of the potential for side effects, treatment must be individualized and regular monitoring performed. With careful use of immunosuppressive drugs for treatment of ocular inflammatory disorders, many patients will benefit from them either with better control of the ocular inflammation or with a decrease in corticosteroid side effects.
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Affiliation(s)
- D A Jabs
- Wilmer Eye Institute and the Departments of Ophthalmology and Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Lyle WA, Jin GJ. Interface fluid associated with diffuse lamellar keratitis and epithelial ingrowth after laser in situ keratomileusis. J Cataract Refract Surg 1999; 25:1009-12. [PMID: 10404381 DOI: 10.1016/s0886-3350(99)00083-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We report a case in which diffuse interface keratitis began 1 week after bilateral uneventful laser in situ keratomileusis (LASIK). A layer of fluid in the interface with epithelial ingrowth was noted in the left eye 20 days postoperatively. The same complication occurred in the right eye 5 months after LASIK. Dry-eye syndrome and steroid-induced intraocular pressure elevation occurred in this patient with pre-existing ocular hypertension. A long course of interface inflammation was resistant to topical steroids. Surgical removal of the epithelial ingrowth and drainage of the fluid, combined with medical treatment, resulted in resolution of the inflammation. The cytopathologic examination of the fluid showed epithelial cells without signs of inflammation. The clinical features of this case represent a new complication of LASIK.
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Affiliation(s)
- W A Lyle
- Eye Institute of Utah, Salt Lake City, USA
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