Diagnosis and ophthalmological features of Behçet's disease

JAK-STAT Signaling Pathway in Non-Infectious Uveitis

Non-infectious uveitis (NIU) refers to various intraocular inflammatory disorders responsible for severe visual loss. Cytokines participate in the regulation of ocular homeostasis and NIU pathological processes. Cytokine receptors transmit signals by activating Janus kinase (JAK) and signal transducer and activator of transcription (STAT) proteins. Increasing evidence from human NIU and experimental models reveals the involvement of the JAK-STAT signaling pathway in NIU pathogenesis. Several small-molecule drugs that potentially inhibit multiple cytokine-dependent pathways are under investigation for treating autoimmune diseases, implicating possible applications for NIU treatment. This review summarizes the current understanding of the diverse roles of the JAK-STAT signaling pathway in ocular homeostasis and NIU pathology, providing a rationale for targeting JAKs and STATs for NIU treatment. Moreover, available evidence for the safety and efficacy of JAK inhibitors for refractory uveitis and potential approaches for treatment optimization are discussed.

Outcome of surgical management for rhegmatogenous retinal detachment in Behçet's disease

BACKGROUND

The purpose of the current study is to evaluate the surgical outcome for rhegmatogenous retinal detachment (RD) associated with Behçet's disease (BD).

METHODS

The current retrospective study included all patients operated for rhegmatogenous RD associated with BD in our institution from June 2007 to June 2012. Surgical repair was done either by scleral buckling (SB) or pars plana vitrectomy (PPV) according to the topography and clinical criteria of the detachment.

RESULTS

The current study included 7 eyes of 7 patients (6 males and one female). The mean age was 34.3 ± 4.9 years and all patients showed systemic features of BD. In 3 eyes, intravitreal triamcinolone acetonide (IVTA) was injected within 8 weeks prior to the occurrence of rhegmatogenous RD. Five eyes were treated with SB (segmental buckle in 4 cases and encircling buckle in one case) and 2 cases were treated by PPV. One case was initially treated by SB but showed recurrence of RD which was surgically repaired by PPV with successful closure of the retinal break. The retina was successfully reattached in all cases at the end of follow up period (22.0 ± 6.7 months).

CONCLUSIONS

Rhegmatogenous RD in BD can be effectively treated by scleral buckling in selected cases and PPV in more complex cases. Intravitreal injections may be a precipitating factor for rhegmatogenous RD.

The skin pathergy test: innately useful?

Pathergy is the term used to describe hyper-reactivity of the skin that occurs in response to minimal trauma. A positive skin pathergy test (SPT), characterised by erythematous induration at the site of the needle stick with a small pustule containing sterile pus at its centre, is among the criteria required for a diagnosis of Behçet's disease (BD) and in certain population has been shown to be highly specific for this condition. Problems with standardising the induction manoeuvre for the SPT as well as the method of assessment of the response have limited the usefulness of the SPT in the clinical setting. Extensive investigation into histopathological and immunological aspects of pathergy has led to a number of hypotheses relating to the aetiology of the skin pathergy reaction and the disease itself, but the cause is considered to be unknown. Pathergy lesions, the development of new skin lesions or the aggravation of existing ones following trivial trauma, are also reported in pyoderma gangrenosum and has been noted in other neutrophilic dermatoses such as Sweet's syndrome. The response of such patient groups to the systematic application of the SPT has not been described. We propose that a new way of considering the pathergy reaction is to see it as an aberration of the skin's innate reactivity from a homeostatic reactive mode closely coupled to tissue healing to an abnormal destructive/inflammatory mode. Our understanding of BD and other similar conditions would profit by more detailed mechanistic knowledge of skin homeostasis to minimal trauma in both health and disease through a more structured and systematic use of the SPT.

Long-term efficacy and safety of low-dose interferon alpha2a therapy in severe uveitis associated with Behçet disease

PURPOSE

To investigate long-term responsiveness of patients with severe uveitis associated with Behçet disease to interferon alpha2a (IFN-alpha2a).

DESIGN

Retrospective study.

METHODS

Thirty-two patients with sight-threatening uveitis associated with Behçet disease who relapsed despite corticosteroids and immunosuppressive agents were included. IFN-alpha2a was administered subcutaneously (three million units thrice a week). Ophthalmologic examination and fluorescein angiography associated with laboratory tests were performed at regular intervals. Main outcome measures were visual acuity and recurrence of uveitis attacks before, during, and after initiation of IFN-alpha2a therapy.

RESULTS

Control of inflammation was achieved in 28 of 32 patients (88%). Mean observation period of the 28 responder patients was 70.6 months (range, 30.3 to 129.2 months). Median visual acuity improved from 0.52 to 0.33 (logarithm of the minimum angle of resolution units; P = .005) two years after initiation of IFN-alpha2a therapy. The relapse rate decreased significantly during IFN-alpha2a treatment from 1.68 +/- 1.22 relapses/patient/year to 0.11 +/- 0.20 relapses/patient/year (P < .0001). IFN-alpha2a was discontinued in 19 of 28 patients (68%) after 32 months of treatment (range, 16 to 50 months). Mean follow-up after IFN-alpha2a discontinuation was 43 months (range, 11 to 84 months). After IFN-alpha2a discontinuation, the relapse rate increased from 0.08 +/- 0.21 relapse/person/year to 0.74 +/- 1.40 relapse/person/year (P = 0.04).

CONCLUSIONS

IFN-alpha2a is efficient and safe for the long-term management of severe uveitis associated with Behçet disease. Meanwhile it seems to be a suspensive therapeutic strategy, even though long-term remission is possible in some patients.

Complex aphthosis: A large case series with evaluation algorithm and therapeutic ladder from topicals to thalidomide

BACKGROUND

Recurrent aphthous stomatitis is a common problem with 20% to 50% of the population having experienced simple aphthous lesions (ie, canker sores). Complex aphthosis is the diagnosis given to patients with almost constant >3 oral aphthae or recurrent oral and genital aphthae in the absence of Behcet's disease.

METHODS

Eighty-one patients were referred to the Wake Forest University School of Medicine, Department of Dermatology from 1995 to 2001 with the diagnosis of presumptive Behcet's disease. After exclusion of patients with simple recurrent aphthous stomatitis or non-aphthous oral disease, 64 patients remained. Ten of the patients met criteria for Behcet's disease. The remaining 54 patients were evaluated and treated as patients with the diagnosis of complex aphthosis.

RESULTS

The 54 patients with complex aphthosis became the subject of this study. Twelve patients had secondary complex aphthosis with 10/12 having inflammatory bowel disease. The remaining 42 patients had primary (ie, idiopathic) complex aphthosis. The therapeutic ladder for these patients ranged from topical therapy through oral colchicine and combination oral colchicine and oral dapsone therapy to oral thalidomide therapy.

CONCLUSION

Complex aphthosis is an important condition to distinguish from Behcet's disease. Appropriate patient evaluation algorithms and treatment therapeutic ladders are proposed.

Complex aphthosis and Behçet's disease

Complex aphthosis is a disorder in which patients develop recurrent oral and genital aphthous ulcers or almost constant, multiple oral aphthae, without manifestations of systemic disease. Behçet's disease is a multisystem disease characterized clinically by oral and genital aphthae, arthritis, cutaneous lesions, and ocular, gastrointestinal, and neurologic manifestations. This article reviews both disorders, including their clinical and histologic presentations, factors in pathogenesis, and includes an overview of therapeutic modalities.

Posterior segment involvement in ocular Behçet's disease

PURPOSE

Posterior segment involvement, which can lead to blindness with recurrent inflammatory attacks, has a very important prognostic value in ocular Behçet's disease (BD). This study evaluated the frequency and characteristics of posterior segment involvement and the causes of visual impairment in patients with ocular BD.

METHODS

We retrospectively evaluated 257 eyes of the 131 patients who were followed from 1993 to 2001 in the Uveitis and BD division of SSK Ankara Eye Hospital, Turkey.

RESULTS

The mean follow-up was 49.2 +/- 27.4 months. Thirty-one of the palents were female (23.6%) and 100 male (76.4%). The mean age was 25.1 +/- 7.9. Fundus changes were observed in 213 (82.9%) eyes and were bilateral in 87%, and vitritis was present in 239 (93%) eyes. The most frequent fundus changes were vascular sheathing in 61 eyes (23.7%), optic atrophy in 46 (17.9%), macular edema in 29 (11.3%), retinal hemorrhage in 23 (9%), macular scar in 21 (8.2%), optic disc paleness in 19 (7.4%), retinal edema in 17 (6.6%), branch retinal vein occlusion in 15 (5.8%). The most common fluorescein angiography findings were diffuse vascular leakage in 98 (38%), hyperfluorescence of the optic disc in 38 (14.8%) and hyperfluorescence of the macula in 29 eyes (11.3%). Visual acuity was <1/10 in 85 (33%) of the eyes. Optic atrophy was the main cause (54.1%) of permanent visual impairment.

CONCLUSIONS

Posterior segment involvement is the most serious ocular complication of BD, leading to blindness with recurrent attacks. Following patients closely, performing fluorescein angiography in all patients diagnosed as BD even they have no clinical ocular involvement, and early treatment are very important in the prognosis of the disease.

Central retinal artery occlusion associated with ocular Behçet's disease

PURPOSE

To report a case of central retinal artery occlusion associated with ocular Behçet's disease (BD) and briefly discuss retinal vasculitis due to BD.

CASE REPORT

A 52-year-old man, diagnosed as BD 22 years ago and followed up with ocular involvement for six years presented with sudden loss of vision. The clinical diagnosis was central retinal artery occlusion.

RESULTS

No other associated systemic diseases were found and the case was classified as a complication of retinal vasculitis due to BD.

CONCLUSIONS

Although the arteries are rarely affected in retinal vasculitis due to BD, it has to be considered in the differential diagnosis of retinal arterial occlusions especially in countries where the disease is prevalent. To our knowledge, this is the first reported case of ocular BD complicated with central retinal artery occlusion.

Inflammatory conditions of the eye associated with rheumatic diseases

Ocular inflammation occurs in many patients with systemic rheumatic disease. The best examples are rheumatoid arthritis, juvenile rheumatoid arthritis, temporal arteritis, systemic lupus erythematosus, Wegener's granulomatosis, polyarteritis nodosa, relapsing polychondritis, and Adamantiades-Behçet's disease. Ocular inflammation may precede the symptoms of the systemic disease and can be helpful in systemic diagnosis. After diagnosis, ocular inflammation can mark the severity of the systemic condition. Thus, prompt diagnosis and treatment of inflammatory conditions of the eye are warranted and may be sight- and life-saving.

Diagnosing the systemic associations of anterior uveitis

Up to one-half of patients with anterior uveitis suffer from related systemic diseases. The common associations are the seronegative arthropathies and, in children, juvenile chronic arthritis. Anterior uveitis may also occur in the context of sarcoidosis or Behçet's disease. Syphilis and tuberculosis remain a significant problem for specific populations and may be the cause of anterior uveitis in these groups. By thorough clinical history and the correct selection and interpretation of simple investigations, it is generally possible for the ophthalmologist to make or exclude a systemic diagnosis, predict the ocular prognosis and direct selected patients to the appropriate physician. Diseases that threaten the patient's wellbeing must certainly be recognized. In the present review we present a method for identifying the systemic associations of anterior uveitis.