Vision-related Quality of Life in Patients with Non-infectious Uveitis: A Cross-sectional Study

Psychosocial Well-Being and Quality of Life in Uveitis: A Review

PURPOSE

As a potentially sight-threatening disease with ocular, systemic, and treatment-related complications, uveitis diminishes quality of life (QOL) and affects psychosocial well-being. This review summarizes the existing tools for evaluating psychosocial well-being and/or QOL in patients with uveitis, explores the biological and non-biological factors affecting psychosocial well-being and/or QOL, and proposes future directions for incorporating these tools into clinical practice.

METHODS

A systematic search of the MEDLINE, Embase, and Cochrane databases from inception to June 8, 2022 was conducted, screening for articles focused on psychosocial well-being and/or QOL in patients with uveitis. Both quantitative and qualitative analyses were performed.

RESULTS

In uveitis research, the most frequently studied patient-reported outcome measures were vision-related QOL (e.g. Visual Function Questionnaire [VFQ-25]) and health-related QOL (e.g. Short Form Survey [SF-36]), followed by mental health indicators including depression and anxiety. Instruments have also been developed specific to the pediatric population (e.g. Effects of Youngsters' Eyesight on Quality of Life [EYE-Q]). Generally, studies report worse psychosocial outcomes and QOL in patients with uveitis compared to the general population. Contributory factors include both clinical (e.g. visual impairment, ocular comorbidities) and patient-related (e.g. older age, female sex) factors.

CONCLUSION

Given the heterogeneity of instruments used, it is worth considering standardization across large uveitis studies and trials. Beyond research, given the biopsychosocial effects on patients with uveitis, there are benefits to incorporating QOL and psychosocial assessments into clinical practice. Simplification of questionnaires into abridged forms, focusing on the most clinically relevant aspects of patient care, may be considered.

Work Productivity and Activities of Daily Living in Working Patients with Uveitis

PURPOSE

To assess self-reported impairment of work productivity and activities of daily living and the indirect costs of absenteeism in a sample of working patients with uveitis and to examine their association with sociodemographic, occupational, and clinical variables.

METHODS

We conducted a cross-sectional, cross-association study. Participants completed the self-administered Work Productivity and Activity Impairment Questionnaire uveitis 2.0 to assess absenteeism, presenteeism, overall work impairment, and impairment in activities of daily living. Clinical data were collected from the patients' medical records or instruments used to evaluate clinical parameters in practice. Indirect costs of absenteeism were assessed by the "lost wages method." Two clinical groups were established for this study. Bivariate and multivariate analyses were performed to assess the associations between variables.

RESULTS

The final sample comprised 60 participants. Factors significantly associated with increased overall work impairment in the multivariate linear regression analysis were active uveitis (coefficient, 31.5; 95% confidence interval [CI], 16.1 to 46.9; p < 0.001) and presence of ocular comorbidities (coefficient for absence, -16.4; 95% CI, -31.1 to -1.8; p = 0.03). Factors significantly associated with increased impairment in activities of daily living were active uveitis (coefficient, 32.1; 95% CI, 18.2 to 46.0; p < 0.001), presence of ocular comorbidities (coefficient for absence, -23.5; 95% CI, -36.1 to -11.0; p < 0.001), and absence of nonocular comorbidities (coefficient 16.1; 95% CI, 3.9 to 28.3; p = 0.01).

CONCLUSIONS

Active uveitis and ocular comorbidities are significantly associated with increased overall work impairment and impairment in activities of daily living in working patients with uveitis.

Vision-related quality of life in patients treated for ocular syphilis

Multiple studies have showed negative impact of non-infectious uveitis on quality of life (QoL). Less is understood regarding life experiences in patients with infectious uveitis. We investigated vision-related QoL in individuals who had recovered from ocular syphilis. 32 adults treated for ocular syphilis at a uveitis service in Brazil completed the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), and a comprehensive ophthalmic examination was performed. Medical records were reviewed to confirm resolution of ocular inflammation for 3 months pre-enrolment, and collect clinical data. The NEI VFQ-25 composite score was low overall (75.5 ± 19.8, mean ± standard deviation), and subscale scores varied from relative lows of 59.1 ± 39.6 (driving) and 60.9 ± 24.5 (mental health), to relative highs of 84.8 ± 21.8 (ocular) and 89.1 ± 21.0 (color vision). Adults aged over 40 years and those with a final visual acuity of 20/50 or worse had significantly lower mean composite and subscale scores. Other clinical characteristics-including gender, HIV co-infection, and type of uveitis-did not significantly influence scores. Our findings, taken in context with previous observations that prompt recognition achieves better vision outcomes, suggest early treatment may improve QoL after recovery from ocular syphilis.

A review of patient-reported outcome measures used in uveitis

We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.

Tear and Plasma Levels of Cytokines in Patients with Uveitis: Search for Active Disease Biomarkers

Uveitis accounts for up to 20% of blindness in Europe, making the development of new non-invasive biomarkers which could help in its management a field of interest. It has been hypothesised that tear levels of cytokines and chemokines could be used as a potential biomarker in patients with anterior uveitis, and this could be correlated with their concentration in plasma. Therefore, we measured twelve cytokines/chemokines in tear and plasma samples of 22 patients diagnosed with active anterior uveitis. Levels of these molecules in tears and plasma were compared and associated with the degree of activity of the uveitis. It is notable that the percentage of tear interleukin (IL)-6 detection was significantly reduced in the inactive phase (p < 0.05). However, the tear concentration in epidermal growth factor (EGF), fractalkine, IL-8, IL-1RA, interferon-inducible protein (IP)-10/CXCL10, vascular endothelial growth factor (VEGF) and IL-6, comparing the active and inactive period, was not statistically different. Apart from the tear VEGF levels, the cytokine/chemokine concentration in tears in the active/inactive phase was statistically different (p < 0.05) from the counterpart levels in plasma. In conclusion, no isolated cytokine/chemokine in the tears has been found in a concentration which could be used as a potential biomarker of disease activity and treatment response.

Efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis: a protocol for a multicentre, randomised, parallel three arms, active-controlled, phase III open label with blinded outcome assessment study

INTRODUCTION

Non-infectious uveitis include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than and as safe as their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet.

METHODS AND ANALYSIS

The Combination THerapy with mEthotrexate and adalImumAb for uveitis (CoTHEIA) study is a phase III, multicentre, prospective, randomised, single-blinded with masked outcome assessment, parallel three arms with 1:1:1 allocation, active-controlled, superiority study design, comparing the efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis. We aim to recruit 192 subjects. The duration of the treatment and follow-up will last up to 52 weeks, plus 70 days follow-up with no treatment. The complete and maintained resolution of the ocular inflammation will be assessed by masked evaluators (primary outcome). In addition to other secondary measurements of efficacy (quality of life, visual acuity and costs) and safety, we will identify subjects' subgroups with different treatment responses by developing prediction models based on machine learning techniques using genetic and proteomic biomarkers.

ETHICS AND DISSEMINATION

The protocol, annexes and informed consent forms were approved by the Reference Clinical Research Ethic Committee at the Hospital Clínico San Carlos (Madrid, Spain) and the Spanish Agency for Medicines and Health Products. We will elaborate a dissemination plan including production of materials adapted to several formats to communicate the clinical trial progress and findings to a broad group of stakeholders. The promoter will be the only access to the participant-level data, although it can be shared within the legal situation.

TRIAL REGISTRATION NUMBER

2020-000130-18; NCT04798755.

Healthcare costs among patients with macular oedema associated with non-infectious uveitis: a US commercial payer's perspective

Objective

To describe patient characteristics and healthcare costs associated with uveitic macular oedema (UME) in US clinical practices from a commercial payer's perspective.

Methods and analysis

The IBM MarketScan Commercial Subset (1 October 2015-31 March 2020) was used to identify patients with non-infectious uveitis (NIU), with or without UME. Patients with UME at any time were further classified into subgroups of patients who received a UME diagnosis during the study period and those who received a UME diagnosis and local steroid injection (LSI) during the study period. Demographic and clinical characteristics, NIU-related treatments and healthcare costs were described for each cohort and subgroup during the most recent 12 months of continuous health plan enrolment. Healthcare costs were also described by vision status among all patients with NIU.

Results

A total of 36 322 patients with NIU were identified, of whom 3 301 (9.1%) had UME and 33 021 (90.9%) had no UME. Patients with UME more frequently received NIU-related treatment compared with those without UME (64.6% vs 45.0%), particularly LSI treatment (12.5% vs 0.7%). Mean total all-cause healthcare costs per-patient-per-year (PPPY) were higher among patients with UME ($19 851) than patients without UME ($16 188) and were especially high among those with bilateral UME ($24 162). Further, vision loss was more commonly observed in those with UME versus those without UME (5.7% vs 2.2%) and a trend of increasing healthcare costs with increasing vision loss was observed.

Conclusion

NIU is associated with substantial clinical and economic burden, particularly when UME is present.

Structure-Function Relationship and Vision-Related Quality of Life in Glaucoma Secondary to Anterior Uveitis: Comparison with Open Angle Glaucoma

Purpose: The aim of this study is to investigate the structure–function characteristics and vision-related quality of life (VR-QoL) in uveitic glaucoma (UG) compared with open-angle glaucoma (OAG). Method: The study included 69 patients with UG and 138 patients with primary open angle glaucoma, normal-tension glaucoma. A 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) was used to evaluate the patients’ VR-QoL. The retinal nerve fiber layer thickness (RNFLT) was measured using optical coherence tomography, and the integrated visual field (IVF) was determined using the best location method. Results: There were no significant differences in the binocular IVF and mean deviation (MD) of the affected eye between the OAG and UG group, whereas the average RNFLT was significant thinner in the OAG group (p = 0.008). The patients with UG showed a significantly lower composite score and five subscales of the VFQ-25, compared with those with OAG (p < 0.05, for all, general linear model). Multivariate linear regression analyses showed that the composite score showed the strongest associations with the whole IVF (β = 1.240, p < 0.001) in the OAG group, whereas in the UG group, a significant association was seen only with the inferior VF of the affected eye (β = 0.596, p = 0.038). Conclusions: The eyes with UG exhibited distinctive structure–function characteristics and worse VR-QoL that differentiated them from OAG eyes.

Non-infectious uveitis burden on quality of life and work impairment assessed through different psychometric questionnaires

BACKGROUND

The purpose of this study was to evaluate the association between a novel psychometric 12-item questionnaire (U-qest) and other validated questionnaires to assess quality of life and work impairment in patients with non-infectious uveitis.

METHODS

Data were collected at baseline and 3 months postbaseline using U-qest and two other validated questionnaires: The National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) and the 12-Item Short-Form Health Survey (SF-12).

RESULTS

A total of 136 patients (52.2% female) aged 47.9 ± 14.8 years (mean ± SD) were enrolled in 14 uveitis referral centres. U-qest correlated moderately with VFQ-25 and SF-12 at baseline and at 3 months. Both U-qest and VFQ-25 scores improved as disease improved; however, U-qest also detected improvement in patients for whom VFQ-25 scores did not improve. Disease activity was shown to significantly affect activity impairment. Patients and physicians expressed positive perceptions regarding the use and benefit of this instrument. U-qest showed very good reliability in terms of internal consistency (Cronbach's alpha = 0.91).

CONCLUSIONS

U-qest can be considered a useful tool to assess the burden of uveitis on quality of life.

Long-term prognosis for glaucoma in patients with Posner-Schlossman syndrome

BACKGROUND

The aim of this study is to investigate the long-term prognosis for glaucoma in patients with Posner-Schlossman syndrome (PSS).

METHODS

In this retrospective case series study, a total of 98 patients with PSS from January 2014 to February 2019 were included in this study. Initial presentations and follow-up data were obtained from medical records. Vision-related quality of life (VR-QoL) was assessed using the 25-item National Eye Institute Visual Functioning Questionnaire.

RESULTS

Of the 98 patients included in the study, 66 (67%) presented with glaucoma, and among them, 21 (32%) required glaucoma surgery. The mean follow-up time was 50.1 months (range 1-263 months). Iris involvement was noted in 46 (46.9%) eyes; 26 (26.5%) had sectoral iris changes and 20 (20.4%) showed diffuse iris changes. Eyes with iris involvement had a significantly higher number of acute attacks of uveitis than those without (p = 0.010). The 5-year glaucoma surgery-free interval was 77.8% according to Kaplan-Meier analysis. Significant predictors of glaucoma surgery included iris involvement (hazard ratio [HR] = 5.215; confidence interval [CI] = 1.387-19.610), highest number of anti-glaucoma agents (HR = 5.069; CI = 1.848-13.905), baseline average retinal nerve fiber layer thickness (RNFLT) thickness (HR = 0.949; CI = 0.917-0.982), and disease duration (HR = 0.977; CI = 0.957-0.996). Overall complete surgical success and qualified success at 2 years was 35.3% and 75.5%, respectively. Patients with iris involvement, glaucoma surgery, and thinner average RNFLT had significantly poorer VR-QoL (all, p < 0.05).

CONCLUSIONS

Patients with PSS and glaucoma required glaucoma surgery in a high rate. Iris involvement increased the probability of surgical treatment and lowered the VR-QoL of PSS patients.

Ocular syphilis

Multiple studies around the world suggest that syphilis is re-emerging. Ocular syphilis - with a wide range of presentations, most of which are subtypes of uveitis - has become an increasingly common cause of ocular inflammation over the past 20 years. Its rising incidence, diagnostic complexity, and manifestations that have only recently been characterized make ocular syphilis relevant from the public health, clinical, and scientific perspectives. We review the demographics, epidemiology, clinical features, ocular imaging findings, diagnosis, and medical management of this condition.

Quality of life in patients with uveitis: data from the ULISSE study (Uveitis: cLInical and medico-economic evaluation of a Standardised Strategy for the Etiological diagnosis)

AIMS

To assess vision-related (VR-QOL) and health-related quality of life (HR-QOL) in a large series of patients with de novo uveitis at baseline and 6-month follow-up.

METHODS

Non-inferiority, prospective, multicentre, cluster randomised controlled trial registered under the Unique Identifier: NCT01162070. VR-QOL and HR-QOL were assessed by the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) and the Medical Outcomes Study 36-item Short Form Survey (SF-36).

RESULTS

At inclusion, 466 patients completed the VFQ-25. The mean composite score was 80.0 (±16.7). In multivariate analysis, higher age, female sex and insidious onset were significantly associated with lower QOL. At 6 months, 138 patients completed the VFQ-25, with a significantly higher mean composite score of 82.6 (±16.7). SF-36 mental component was 42.9 (±11.3) and physical component was 47.2 (±8.5) at inclusion (n=425). HR-QOL improvement at 6 months was not clinically significant.

CONCLUSION

QOL seems relatively well preserved in this cohort; only VR-QOL improved significantly at 6 months, especially in patients with low initial visual acuity.

Economic Hardship, Ocular Complications, and Poor Self-reported Visual Function are Predictors of Mental Problems in Patients with Uveitis

PURPOSE

To characterize the quality of life and mental health status of patients with uveitis and investigate predictors of psychological problems.

METHODS

A total of 245 patients and 105 controls were enrolled in this cross-sectional study. Quality of life, psychological status, socio-demographic and clinical data were obtained from questionnaires and medical records. Multivariate regression analyses and Receiver Operating Characteristic (ROC) were applied to obtain the model predicting psychological problems of patients.

RESULTS

Of 245 patients, 16.7% and 26.5% (P < .0001) screened positive for anxiety and depression, respectively. The model predicting anxiety was comprised of low annual household income and poor self-reported visual function (P = .029, P < .0001, respectively), with an AUC of ROC of 0.744. The model predicting depression was comprised of poor self-reported visual function and ocular complications (P < .0001, P = .012, respectively), with an AUC of 0.78.

CONCLUSIONS

Economic hardship, ocular complications, and poor self-reported visual function are predictors of mental problems in patients with uveitis.

Self-Reported Quality of Life in Patients with Long-Standing Vogt-Koyanagi-Harada Disease

Purpose: To assess health-related (HR-) and vision-related (VR-) quality of life (QoL) in patients with long-standing Vogt-Koyanagi-Harada disease (VKHD).Methods: Cross-sectional study of 49 patients with disease duration ≥12 months followed at Uveitis Service, Universidade de São Paulo, BR, for at least 12 months. HR- and VR-QoL were evaluated using SF-36 and NEI VFQ-25 questionnaires, respectively. Demographic, clinical and visual function data were compared with questionnaire scores.Results: After generalized linear models, lower mensal household income was associated with lower scores in both questionnaires while unemployment was associated with SF-36 questionnaire only. Treatment with peri-/intraocular medications and ocular surgery were associated with higher scores on SF-36 questionnaire. Worse visual acuity (VA), ocular complications and no ocular surgery were related to lower scores on NEI VFQ-25 questionnaire.Conclusions: On HR- and VR-QoL questionnaires difficulties perceived by patients with long-standing VKHD were mainly associated with socio-economic aspects, VA, local treatment and ocular complications.

Time Trade-off Utility Values in Noninfectious Uveitis

PURPOSE

To investigate time trade-off (TTO) utility values in patients with noninfectious uveitis and determine whether patient demographics and clinical characteristics are associated with utility scores.

DESIGN

Time trade-off utility analysis.

METHODS

Setting: A tertiary care uveitis center in San Francisco, California, USA.

PATIENT POPULATION

One hundred and four consecutive adults with noninfectious uveitis, enrolled between November 2016 and February 2017.

MAIN OUTCOME MEASURES

TTO utility values, as collected by an interviewer-guided survey. Information regarding general health, ocular symptoms, and religion was also collected and medical record review was conducted to record anatomic location of uveitis, disease activity, visual acuity, and treatments. Multivariable regression analysis with backward selection was used to identify variables associated with TTO values.

RESULTS

Median TTO score was 0.975 (interquartile range [IQR]: 0.8-1.0), corresponding to trading a median 1.28 years of remaining life for healthy eyes (IQR: 0-6.29). Regression analysis revealed that worse eye visual acuity, >6 months of oral corticosteroid use, and current antidepressant use were associated with lower TTO scores (P = .008, P = .006, P = .008, respectively), controlling for age and sex. In particular, patients who had been taking oral corticosteroids for more than 6 months, regardless of dose, were 10.5 times more likely to trade 20% or more years of remaining life (TTO ≤0.8) than patients not taking oral corticosteroids (95% confidence interval: 2.3, 48.1; P = .002).

CONCLUSIONS

Patients with noninfectious uveitis had measurable, though modest, reductions in quality of life, as assessed by TTO, and these decreases were significantly associated with visual acuity in the worse eye and long-term oral corticosteroid use.

Ophthalmic medicine regulatory approvals through the European Centralised Procedure, 1999-2017: Clinical efficacy considerations

OBJECTIVES

Regulatory approval of new medicines requires a thorough assessment of the potential clinical benefits and risks. Study end-points are expected to demonstrate a clinically relevant treatment effect that will translate into direct patient benefits. This study sought to review the ophthalmic medicines with European Union-wide approval granted via the Centralised Procedure and characterise the key efficacy end-points underpinning the demonstration of clinical benefit.

METHODS

This study was a retrospective review of published data pertaining to the European regulatory authorisation of centrally approved ophthalmic products between 1999 and 2017, inclusive. All sources and data consulted are in the public domain. European Public Assessment Reports published by the European Medicines Agency were consulted for data concerning the pivotal clinical efficacy studies supporting the applications. Data analyses were descriptive.

RESULTS

The European Medicines Agency have authorised 30 products via the Centralised Procedure between 1999 and 2017. For these products, a total of 24 additional approvals for line extensions or additional therapeutic indications were granted. Four products have been approved for orphan indications, including one approval 'under exceptional circumstances' and one 'Conditional Marketing Authorisation'. Approvals for products in retina (36%) and glaucoma (28%) indications together accounted for the majority of authorisations, with trial end-points predominantly based on visual acuity and intraocular pressure parameters, respectively. Products were also approved for indications in ocular surface disease, inflammation, optic neuropathy and surgical adjuncts, with a range of functional and anatomical end-points.

CONCLUSION

Approvals for ophthalmic medicines have been granted for a range of clinical indications, representing a considerable portion of available major therapeutics for practitioners. Benefit-risk assessments rely on clinical trial data demonstrating a clearly relevant patient benefit.