Behçet disease

Optimizing glucocorticoid therapy for Behçet's uveitis: efficacy, adverse effects, and advances in combination approaches

Behçet's uveitis (BU) is a debilitating manifestation of Behçet's disease, often requiring prompt and aggressive treatment to prevent vision loss. Glucocorticoids (GCS) serve as a first-line therapy for BU; however, their long-term, high-dose use can result in significant adverse effects. This review summarizes the efficacy, adverse effects, and advances in combination therapy involving GCS for the management of BU. We discuss the benefits and drawbacks of various GCS administration routes, including periocular and intravitreal injections, intravitreal sustained-release devices, and systemic therapy, highlighting the role of fluocinolone acetonide and dexamethasone as primary sustained-release formulations. Moreover, we underscore the importance of combining GCS with immunosuppressive drugs and biological agents to minimize adverse reactions and optimize therapeutic outcomes. The review concludes that, while GCS remain a crucial component of BU treatment, careful consideration of their administration and combination with other therapies is essential to achieve long-term remission and improved visual outcomes for patients with BU.

[Association of the different forms of uveitis with inflammatory rheumatic diseases and their treatment]

The etiology of uveitis greatly varies worldwide, whereby in industrial nations noninfectious causes occur relatively more frequently. In Germany, 44% of all cases of uveitis are due to systemic diseases. In rheumatology, uveitis or other kinds of ocular inflammation, such as scleritis or retinal vasculitis, most commonly occur in spondylarthritis, vasculitis and sarcoidosis. Vice versa, ophthalmologists often ask rheumatologists about an underlying rheumatic disease in patients with uveitis. It is of utmost importance to differentiate between the different forms of uveitis. This review article presents the associations with inflammatory rheumatic diseases as well as treatment options from the point of view of both ophthalmologists and rheumatologists.

[Association of the different forms of uveitis with inflammatory rheumatic diseases and their treatment]

The etiology of uveitis greatly varies worldwide, whereby in industrial nations noninfectious causes occur relatively more frequently. In Germany, 44% of all cases of uveitis are due to systemic diseases. In rheumatology, uveitis or other kinds of ocular inflammation, such as scleritis or retinal vasculitis, most commonly occur in spondylarthritis, vasculitis and sarcoidosis. Vice versa, ophthalmologists often ask rheumatologists about an underlying rheumatic disease in patients with uveitis. It is of utmost importance to differentiate between the different forms of uveitis. This review article presents the associations with inflammatory rheumatic diseases as well as treatment options from the point of view of both ophthalmologists and rheumatologists.

A 10-year follow-up of infliximab monotherapy for refractory uveitis in Behçet's syndrome

Infliximab (IFX) was the first biologic introduced for refractory uveitis treatment in Behçet’s syndrome (BS). However, there have been few reports on the safety and efficacy of IFX monotherapy over follow-up periods of more than 10 years. This retrospective study evaluated the 10-year safety and efficacy of IFX monotherapy compared to IFX combination therapies with colchicine or corticosteroid for refractory uveitis in BS patients. Monotherapy was performed in 30 eyes of 16 patients while combination therapies were performed in 20 eyes of 11 patients. Continuation of IFX occurred in 70.3% of enrolled patients for 10 years without any significant difference noted in the retention rate between the monotherapy and combination therapies (p = 0.86). Reduction of ocular inflammatory attacks and improvement of best corrected visual acuity occurred in the monotherapy group after 10 years, which was equivalent to that for the combination therapies. Although adverse events (AEs) or therapy discontinuation occurred during the initial 5 years in both therapies, no AEs were observed for either therapy after 6 years. Our results suggested that IFX monotherapy proved to be effective and not inferior to combination therapies over a 10-year follow-up. Although loss of response and AEs may be noticed during the initial 5-year period, a safe and effective continuation can be expected thereafter.

Long-term efficacy of early infliximab-induced remission for refractory uveoretinitis associated with Behçet's disease

BACKGROUND

To evaluate long-term efficacy of infliximab (IFX) in refractory uveoretinitis associated with Behçet's disease (BD) depending on uveoretinitis duration.

METHODS

Records of 16 patients with BD (32 eyes) followed for >5 years after starting IFX, were retrospectively reviewed. Long-term efficacy was compared between patients with short duration (≤18 months, n=7) versus long duration (>18 months, n=9) of their uveoretinitis prior to starting IFX.

RESULTS

The median follow-up after starting IFX was 132 months (76-146 months). Mean frequency of attacks and the 1-year Behçet's Disease Ocular Attack Score 24 decreased significantly over 10 years. Overall, the percentage of eyes with a best-corrected visual acuity (BCVA) ≥1.0 increased from 47% at baseline to 59% at 5 years; the percentage of eyes with a BCVA ≤0.1 was 19% at both baseline and 5 years. The frequency of ocular attacks decreased similarly in both short duration and long duration groups; however, the percentage of eyes with a BCVA ≥1.0 at 5 years was 100% in the short duration group versus 28% in the long duration group. IFX was discontinued in four patients with an excellent response to IFX therapy; all were young male patients in the short duration group with good BCVA bilaterally, and none had inflammatory recurrences over a median follow-up of 56 months off IFX.

CONCLUSION

Initiation of IFX therapy in patients with BD within 18 months of their uveoretinitis onset was more effective in maintaining good BCVA than after 18 months.

Long-term efficacy of infliximab on background vascular leakage in patients with Behçet's disease

PURPOSE

To evaluate the effect of infliximab over the initial 4 years of treatment on inflammatory ocular attacks and background retinal/disc vascular leakage in patients with refractory uveoretinitis associated with Behçet's disease.

METHODS

Clinical records of nine patients were retrospectively reviewed. The main outcomes analyzed were frequency of ocular inflammatory attacks, background retinal and disc vascular leakage as assessed by fluorescein angiography during periods of clinical quiescence, best-corrected visual acuity, and adverse effects.

RESULTS

The median follow-up on infliximab was 50 months (range 48-58 months). Mean frequency of attacks decreased significantly in years 1, 2, 3, and 4 compared with the baseline 1-year period before infliximab use. Mean background retinal and disc vascular leakage scores also decreased significantly at the end of each 1-year period compared with baseline. Visual acuity improved or was unchanged at the end of 4 years in 17 of 18 eyes. No serious adverse effects were observed.

CONCLUSION

Infliximab reduced the mean frequency of ocular attacks and mean background retinal/disc vascular leakage in a long-term sustained manner over 4 years of treatment in Behçet's disease patients.

Behçet's Uveitis

Behçet's disease is a multisystem inflammatory disorder that is most common in countries along the ancient “Silk Road”. The eye is the most commonly involved vital organ in Behçet's patients and the typical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Uveitis is the initial manifestation of the disease in 10-15% of the patients. Anterior uveitis is always nongranulomatous. Diffuse vitritis, retinal infiltrates, sheathing of predominantly retinal veins, and occlusive vasculitis are the typical signs of posterior segment inflammation. Spontaneous resolution of acute inflammatory signs is a diagnostic feature. Fundus fluorescein angiography is the gold standard in monitoring inflammatory activity. Laser flare photometry is a useful noninvasive tool since flare readings correlate with fluorescein angiographic leakage. The most common complications are cataract, maculopathy, and optic atrophy. Male patients have a more severe disease course and worse visual prognosis. Immunomodulatory therapy is indicated in all patients with posterior segment involvement. Corticosteroids combined with azathioprine and/or cyclosporine is used initially. Biologic agents, including interferon alfa and infliximab, are used in resistant cases. Visual prognosis has improved in recent years with an earlier and more aggressive use of immunomodulatory therapy and the use of biologic agents in resistant cases.

Current approach in the diagnosis and management of panuveitis

Panuveitis is a generalized inflammation of not only the whole of the uveal tract but also involves the retina and vitreous humor. It differs from other anatomical sites of inflammation in terms of causes as well as distribution. The common causes of panuveitis in our population are tuberculosis, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, Behcet's disease and sarcoidosis. A large number of cases still remain idiopathic. A stepwise approach is essential while evaluating these patients to be able to identify and treat the disease timely and correctly. Ancillary tests can be appropriately applied once the anatomic site of inflammation is identified. An exhaustive approach comprising a full battery of tests is obsolete. Only specific tailored investigations are ordered as suggested by the preliminary clinical and ocular examination. The mainstay of the treatment of uveitis is corticosteroids. Immunosuppressive agents are administered if the inflammation is not adequately controlled with corticosteroids. One of the recent breakthroughs in the treatment of refractory uveitis includes the introduction of immunomodulating drugs: Tumor necrosis factor-alpha antagonist and Interferon-alpha. Vitrectomy has been used in uveitis for over a few decades for diagnostic and therapeutic purposes. When compared to other anatomical sites of inflammation, panuveitis has poor visual outcome due to more widespread inflammation. The side-effects of the chronic treatment that these patients receive cannot be overlooked and should be specifically monitored under the supervision of an internist with special interest in inflammatory diseases.

Clinical characteristics of Behçet's disease in China

To evaluate the prevalence of clinical findings in Behçet's disease (BD) in Chinese population. The clinical data of 170 consecutive BD patients were, retrospectively, analyzed and compared with previous reports. The mean age at onset was 34.4 years (range 6-72) and the mean age of diagnosis was 39.1 years (range 8-72). Mean delay in diagnosis was 5.7 years. The male to female ratio was 1.3:1. Recurrent aphthous ulceration (64.7%), skin lesion (18.2%), and genital ulceration (8.2%) were the commonest onset-presentations of the disease. During the disease course, the commonest presenting features were oral ulcer (100%), cutaneous involvement (68.2%), genital ulcer (63.5%), arthritis (37.1%), and ocular lesion (14.1%). As for the minor clinical manifestations, gastrointestinal lesion (10.0%), vascular lesion (8.8%), and cardiac lesion (4.7%) occurred occasionally. The pathergy skin test showed positive in 63.5% of the patients and revealed a higher positive rate in the females (76.7%) than in the males (53.6%). Less ocular lesion and genital ulcer were present in Chinese BD patients.