New developments in uveitis associated with HLA B27

[Ocular manifestations of rheumatic diseases]

Rheumatic diseases are a large group of conditions of various origins, predominantly systemic in nature, with persistent or transient joint syndrome and involvement of other organs and systems, including the eyes. Many rheumatic diseases are characterized by specific types of ocular inflammation, which manifests through its localization, symmetry, and clinical features.

HLA-B27 positivity in a large miscegenated population of 5,389,143 healthy blood marrow donors in Brazil

BACKGROUND

The prevalence of HLA-B27 gene positivity in healthy Caucasian communities varies between 8 and 14%. However, there is a lack of information in countries with a high rate of miscegenation, such as Brazil.

AIM

To estimate the frequency of HLA-B27 in the Brazilian general population using a large national registry database.

METHODS

This is a cross-sectional ecological study using the Brazilian Registry of Volunteer Bone Marrow Donors (REDOME) database on HLA-B27 allelic frequency and proportion of positives of healthy donors (18-60 years old). Data were analyzed according to sex, age, race (by self-reported skin color recommended by the Brazilian Institute of Geography and Statistics - IBGE), and geographic region of residence.

RESULTS

From 1994 to 2022, a total of 5,389,143 healthy bone marrow donors were included. The overall positivity for HLA-B27 was 4.35% (CI 95% 4.32-4.37%), regardless of sex and age (57.2% were women, mean age was 41.7yo). However, there was a difference between races: 4.85% in Whites; 2.92% in Blacks; 3.76% in Pardos (Browns i.e. mixed races); 3.95% in Amarelos (Yellows i.e. Asian Brazilians); and 3.18% in Indigenous. There was also a difference regarding geographic region of residence (North: 3.62%; Northeast: 3.63%; Southeast: 4.29%; Midwest: 4.5% and 5.25% in South). The homozygosity rate for the HLA-B27 was 1.32% of all the positives and only 0.06% in the general population.

CONCLUSIONS

Our findings provide the first Brazilian national prevalence for HLA-B27 in 4.35%. There is a gradient gene positivity from North to South, suggesting that the genetic background related to the miscegenation due to colonization, slavery, and some later waves of immigration together with internal migratory flows, could explain our findings.

Study of the shared gene signatures of polyarticular juvenile idiopathic arthritis and autoimmune uveitis

Objective

To explore the shared gene signatures and potential molecular mechanisms of polyarticular juvenile idiopathic arthritis (pJIA) and autoimmune uveitis (AU).

Method

The microarray data of pJIA and AU from the Gene Expression Omnibus (GEO) database were downloaded and analyzed. The GEO2R tool was used to identify the shared differentially expressed genes (DEGs) and genes of extracellular proteins were identified among them. Then, weighted gene co-expression network analysis (WGCNA) was used to identify the shared immune-related genes (IRGs) related to pJIA and AU. Moreover, the shared transcription factors (TFs) and microRNAs (miRNAs) in pJIA and AU were acquired by comparing data from HumanTFDB, hTFtarget, GTRD, HMDD, and miRTarBase. Finally, Metascape and g: Profiler were used to carry out function enrichment analyses of previously identified gene sets.

Results

We found 40 up-regulated and 15 down-regulated shared DEGs via GEO2R. Then 24 shared IRGs in positivity-related modules, and 18 shared IRGs in negatively-related modules were found after WGCNA. After that, 3 shared TFs (ARID1A, SMARCC2, SON) were screened. And the constructed TFs-shared DEGs network indicates a central role of ARID1A. Furthermore, hsa-miR-146 was found important in both diseases. The gene sets enrichment analyses suggested up-regulated shared DEGs, TFs targeted shared DEGs, and IRGs positivity-correlated with both diseases mainly enriched in neutrophil degranulation process, IL-4, IL-13, and cytokine signaling pathways. The IRGs negatively correlated with pJIA and AU mainly influence functions of the natural killer cell, cytotoxicity, and glomerular mesangial cell proliferation. The down-regulated shared DEGs and TFs targeted shared DEGs did not show particular functional enrichment.

Conclusion

Our study fully demonstrated the flexibility and complexity of the immune system disorders involved in pJIA and AU. Neutrophil degranulation may be considered the shared pathogenic mechanism, and the roles of ARID1A and MiR-146a are worthy of further in-depth study. Other than that, the importance of periodic inspection of kidney function is also noteworthy.

Ocular Manifestations Related to Antibodies Positivity and Inflammatory Biomarkers in a Rheumatological Cohort

Purpose

Ocular involvement is frequent in autoimmune diseases and even can be the first manifestation. There are multiple descriptions in the literature around the world regarding this topic. However, we evidenced a lack of studies analyzing the relationship between the ocular manifestations and systemic biomarkers, especially in Latinamerica. Therefore, this study aimed to examine the relationship between the positivity of inflammatory biomarkers and the ocular manifestations in a Colombian cohort of rheumatological patients.

Patients and Methods

We conducted an observational, descriptive, non-comparative cross-sectional study in a rheumatology center, in Bogotá, Colombia, from 2013 to 2019. We calculated a sample size of 797 patients to assess the prevalence of ocular manifestations and inflammatory biomarkers. We performed univariate analyses for categorical and continuous variables and bivariate analyses using the Chi-square and Fisher’s exact test for categorical variables.

Results

Women represented 84% of the population, and the mean age was 54.61± 15.64 years. Of 797 patients, 21.45% reported one or more ophthalmological diagnoses, being keratoconjunctivitis sicca (KCS) the most common (15.93%), followed by uveitis, and cataract (1.38%, each one). Regarding ophthalmological symptoms, 35% presented at least one, being dry eye sensation (DE) the most common (30.86%), followed by ocular pain (2.76%), red eye, and decreased visual acuity (2.63%, each one). The antibodies or inflammatory biomarkers most frequently found were antinuclear antibodies (ANAs) (35.3%), C-reactive protein (28.7%), and rheumatoid factor (27.9%). We found statistical associations between consumption of complement 3, anti-CCP, anti-RO, and anti-LA antibodies with ocular manifestations such as photophobia, DE, conjunctivitis, KCS, uveitis, retinal vasculitis, and maculopathy.

Conclusion

Ocular manifestations are frequently found in patients with positive antibodies and inflammatory biomarkers. Our results suggest antibodies and inflammatory molecules could be biomarkers for ocular manifestations in patients with rheumatological diseases. This study provides the basis for future longitudinal studies.

Differences in the eyelid and buccal microbiome between open-angle glaucoma and uveitic glaucoma

PURPOSE

Microbiomes have immunoregulatory functions and may be involved in the pathophysiology of eye diseases. However, the effects of microbiomes on uveitic glaucoma (UG) and open-angle glaucoma (OAG) have not been sufficiently investigated. This study analysed differences in eyelid and buccal microbiomes between UG and OAG using metagenomic technology.

METHODS

Eyelid and buccal specimens were collected from 34 UG and 62 OAG patients. The taxonomic composition of the microbiome was determined via 16S rRNA gene sequencing, operational taxonomic unit analysis and diversity analysis. Differential gene expression analysis (DEG) and principal component analyses (PCoA) determined taxon differences between the microbiomes of the UG and OAG patients. Subgroup analysis according to age and baseline IOP was performed.

RESULTS

There was no significant difference in alpha-diversity between the microbiomes of UG and OAG patients. Further, PCoA revealed no differences in eyelid microbiome between the UG and OAG groups, but significant differences were found in buccal microbiome between the groups, especially in a subgroup of OAG patients with normal IOP. DEG analysis of the eyelid microbiome revealed various taxa differences, including the enrichment of Rhodococcus in UG samples over OAG samples. Taxa such as Lactobacillus and Proteus were significantly depleted (q-value = 9.98e^-6 and q-value = 1.38 × 10^-4 , respectively) in the buccal microbiome of UG patients, whereas Enterococcus was enriched (q-value = 5.26e^-5 ).

CONCLUSIONS

This study showed that the buccal microbiome in UG differs from that in OAG; reduced Lactobacillus was observed in UG. These results suggest that apart than OAG, microbiome composition may be a factor in the pathogenesis of UG.

The microbiomes of the eyelid and buccal area of patients with uveitic glaucoma

Background

The microbiome could trigger inflammation leading to epigenetic changes and is involved in the pathophysiology of eye diseases; however, its effect on uveitic glaucoma (UG) has not been fully investigated. This study analysed the differences in eyelid and buccal microbiomes in patients with UG using next-generation sequencing.

Methods

The eyelid and buccal specimens of 34 UG and 25 control patients were collected. The taxonomic composition of the microbiome was obtained via 16S ribosomal DNA sequencing. Diversity and differential gene expression analyses (DEG) determined taxon differences between the microbiomes of UG and control groups.

Results

In both the eyelid and buccal microbiomes, alpha-diversity was lower in UG patients than controls, while beta-diversity in patients with UG was higher than in controls. DEG analysis of the eyelid microbiome revealed various taxa differences, including enrichment of Paenibacillus and Dermacoccus (p-value, 1.31e⁻⁶ and 1.55e⁻⁷, respectively) and depletion of Morganella and Lactococcus (p-value, 6.26e⁻¹² and 2.55e⁻⁶, respectively) in patients with UG. In the buccal microbiome, taxa such as Lactococcus was significantly depleted (p-value, 1.31e⁻¹⁷), whereas Faecalibacterium was enriched in patients with UG (p-value, 6.12e⁻⁸).

Conclusions

The eyelid and buccal microbiomes in patients with UG differ from controls, which raises concerns surrounding environmental influences on the pathogenesis of UG. The reduced Lactococcus in the eyelid and buccal area suggest that microbiota dysbiosis is associated with UG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02395-x.

Targeted Medical History and Diagnostic Testing in Uveitis

Uveitis is a collective term for a variety of different intraocular inflammations. The underlying etiologies vary greatly depending on the uveitis subtype, and in particular the anatomical focus. The most common forms of anterior uveitis are acute fibrinous unilateral uveitis, often associated with the HLA-B27 haplotype, and granulomatous inflammation, typically associated with sarcoidosis or herpes infections. Intermediate uveitis is usually idiopathic in nature but can also be associated with multiple sclerosis or sarcoidosis, while vitreoretinal lymphoma must also be considered as a masquerade syndrome in patients aged over 45. Posterior uveitis, on the other hand, as well as retinal vasculitis and panuveitis, have a very broad variety of etiologies; these can, however, be narrowed down through a similar findings-centered approach. Retinitis, for example, is often associated with infections (Toxoplasma gondii and viruses of the herpes group), whereas chorioditis is frequently idiopathic, although infections such as tuberculosis may occur. Therefore, the medical history and laboratory diagnosis should be tailored in patients with uveitis based on the anatomic focus of inflammation (anterior, intermediate, or posterior uveitis, or panuveitis) and the clinical picture (e.g., granulomatous versus nongranulomatous).

Prevalence and risk factors for uveitis in spondyloarthritis

AIM

To determine the prevalence and risk factors for uveitis in spondyloarthritis (SpA) patients.

METHODS

A total of 225 patients who fulfilled Assessment of Spondyloarthritis International Society classification criteria for axial and peripheral SpA were enrolled. The diagnosis of uveitis was confirmed by an ophthalmologist. From medical records and from clinical evaluation associated information like disease duration, and human leukocyte antigen B27 was collected. Relevant laboratory tests were done and disease severity was assessed using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score - erythrocyte sedimentation rate and C-reactive protein. Characteristics of uveitis positive and uveitis negative groups were compared. Multivariate logistic regression analysis was done for the risk factors, and P values <.05 were considered significant.

RESULTS

Prevalence of uveitis was 18.7%. The disease duration was 9.3 ± 7 years and 5.4 ± 4.5 years in uveitis and no uveitis groups respectively (P ≤ .001). Family history of SpA was positive in 45.2% in the uveitis group (P ≤ .001). The frequency of axial SpA was 92.9% and 73.8% in the uveitis and no uveitis groups respectively (P ≤ .008). The mean BASDAI was 2.4 ± 1.9 and 3.3 ± 2.8 in uveitis and no uveitis groups respectively (P = .050). In multivariate logistic regression analysis, among the selected variables, family history of SpA (odds ratio [OR] =3.697; 95% CI =1.616-8.457; P = .002) and duration of disease (OR =1.089; 95% CI =1.004-1.181; P = .039) were independently associated with the occurrence of uveitis.

CONCLUSIONS

The prevalence of uveitis was 18.7%. The family history and the disease duration of SpA were independently associated with uveitis.

The risk of psoriasis in patients with uveitis: A nationwide population-based cohort study

Objective

To evaluate whether the risk of subsequent psoriasis and psoriatic arthritis development is increased in patients with uveitis.

Methods

In Taiwan’s national health insurance research database, we identified 195,125 patients with new-onset uveitis between 2001 and 2013. We randomly selected 390,250 individuals without uveitis who were matched 2:1 to uveitis cases based on age, sex and year of enrolment. The characteristics of the two groups were compared. Using multivariate Cox regression, hazard ratios (HRs) for psoriasis or psoriatic arthritis corresponding to uveitis were computed after adjustment for age, sex, insurance cost and comorbidities. In subgroup analyses, separate HRs for mild psoriasis, severe psoriasis and psoriatic arthritis were calculated.

Results

The mean age of the study cohort was 50.2 ± 17.2 years. Hypertension, diabetes, hyperlipidaemia and obesity were more prevalent in the uveitis group (all p < 0.0001). The hazard of psoriasis or psoriatic arthritis development was significantly greater in the uveitis group than in the non-uveitis group (p < 0.0001); this increased risk persisted after adjustment for confounders [adjusted HR = 1.41; 95% confidence interval (CI), 1.33–1.48]. Adjusted HRs showed an increasing trend from mild psoriasis (1.35; 95% CI, 1.28–1.44) to severe psoriasis (1.59; 95% CI, 1.30–1.94) and psoriatic arthritis (1.97; 95% CI, 1.60–2.42).

Conclusions

This nationwide population-based cohort study revealed that patients with uveitis have an increased risk of subsequent psoriasis or psoriatic arthritis development.

Uveitis: Molecular Pathogenesis and Emerging Therapies

The profound impact that vision loss has on human activities and quality of life necessitates understanding the etiology of potentially blinding diseases and their clinical management. The unique anatomic features of the eye and its sequestration from peripheral immune system also provides a framework for studying other diseases in immune privileged sites and validating basic immunological principles. Thus, early studies of intraocular inflammatory diseases (uveitis) were at the forefront of research on organ transplantation. These studies laid the groundwork for foundational discoveries on how immune system distinguishes self from non-self and established current concepts of acquired immune tolerance and autoimmunity. Our charge in this review is to examine how advances in molecular cell biology and immunology over the past 3 decades have contributed to the understanding of mechanisms that underlie immunopathogenesis of uveitis. Particular emphasis is on how advances in biotechnology have been leveraged in developing biologics and cell-based immunotherapies for uveitis and other neuroinflammatory diseases.

Complete blood count parameters and neutrophil-to-lymphocyte ratio values as markers for differentiation between systemic infectious and non-infectious uveitis

PURPOSE

To compare complete blood count (CBC) parameters and neutrophil/lymphocyte ratio (NLR) between patients with infectious uveitis (IU) and those with non-infectious uveitis (NIU) during the first acute uveitis attack (AUA).

METHODS

The records of 119 patients admitted with the first AUA between 2016 and 2019 and whose diagnosis was unknown at the time of admission were retrospectively reviewed. The patients were divided into two groups, IU and NIU according to diagnoses after ocular and systemic workup. The IU group was also divided into subgroups as uveitis associated with local ocular infections and systemic infections. The complete blood count and associated indices of patients calculated from samples taken during the attack were compared between the groups.

RESULTS

A total of 60 NIU cases (mean age: 43.5 ± 11.6 years) and 59 IU cases (43.3 ± 14.7 years) were examined. Twenty-six of the NIU cases were female and 34 were male, while 32 of the IU cases were female and 27 were male. The localization of uveitis was similar in the IU and NIU groups (anterior: 11 vs. 18, intermediate: 3 vs. 6, posterior: 28 vs. 14, panuveitis: 17 vs. 22). The NLR values were significantly increased in patients with IU compared to those with NIU (p = 0.047). When the NLR is compared between NIU and subgroups of IU, this value was only found significantly increased in uveitis due to a systemic infection (n = 12) (p < 0.001). The mean white blood cell (WBC) count (p < 0.001) and neutrophil values (p < 0.001) were also observed significantly higher in the uveitis associated with systemic infectious diseases when compared with uveitis associated with local ocular infections and NIU group.

CONCLUSION

In the current study, NLR values are compared with autoimmune uveitis and systemic infectious uveitis for the first time in patients with AUA. This ratio has been found significantly higher in uveitis associated with systemic infections. The use of CBC parameters and indices, especially the NLR, may be instrumental in assessing patients presenting with first AUA, particularly when there is no clear explanation or underlying cause.

Behcet's Disease Presenting With Bilateral Hypopyon Masquerading Post Cataract Surgery Endophthalmitis

Purpose

To report a case of Behcet’s disease presented with bilateral hypopyon after sequential cataract surgery masquerading delayed onset post-operative endophthalmitis.

Methods

A 53-year-old man with a history of sequential uneventful cataract surgeries came to our clinic with decreased vision (0.3 LogMAR) since 2 days ago and bilateral hypopyon in his both eyes. The primary diagnosis was chronic late-onset endophthalmitis.

Results

There was no lid edema or chemosis on the external examination. On slit-lamp examination, the cornea was clear, the pupil was well reactive with no posterior synechia, the intraocular lens was centered with good red reflex, however, bilateral hypopyon was detected in his both eyes which was more prominent in the left eye. The eyes were fairly calm and absence of vitreous reaction on slit-lamp examination, there was no pain and photophobia. Further, on physical examination, oral mucosal ulcerations were detected. His systemic workup revealed Behcet’s disease with HLA-B5 positive serology.

Conclusion

In cases with delayed onset hypopyon following cataract surgery, inflammatory diseases such as Behcet’s disease should be considered. Appropriate history taking and physical examinations in the context of serologic laboratory investigations may lead to the proper diagnosis.

Clinical Findings of Ankylosing Spondylitis With and Without Human Leukocyte Antigen (HLA)-B27 and HLA-B51

Introduction: Ankylosing spondylitis (AS) and Behçet’s disease are known to be associated with the human leukocyte antigen (HLA)-B27 and HLA-B51 genes, respectively. However, many of their clinical findings―including articular and extra-articular symptoms―are similar, making diagnosis a challenge in the early stage of the disease. The aim of this study was to investigate the differences in clinical findings of AS patients with and without the HLA-B27 gene. Materials and Methods: We performed a retrospective chart review of 151 AS patients. The following clinical findings were evaluated: oral ulcer, genital ulcer, skin manifestation, uveitis, peripheral arthritis; and gastrointestinal, cardiac and pulmonary involvement. Patients were divided into 4 groups based on absence or presence of the HLA-B27 and HLA-B51 genes. The number of patients with each clinical finding was subsequently examined in each group. Results: The incidence of uveitis was significantly higher in the HLA-B27-positive group (P = 0.004); however, other clinical findings did not differ significantly according to the absence or presence of the HLA-B27 gene. There were no significant differences in the clinical findings of patients with positive and negative HLA-B51. Conclusion: HLA-B27 was associated with the development of uveitis but not with other clinical findings or disease activity in AS patients. HLA-B51 was not associated with the clinical findings or disease activity of AS. Key words: Axial spondyloarthritis, Behçet’s disease, Uveitis

Diagnostic Value of Serum-Soluble Interleukin 2 Receptor Levels vs Angiotensin-Converting Enzyme in Patients With Sarcoidosis-Associated Uveitis

Importance

New and improved diagnostic tests for sarcoidosis-associated uveitis are needed because the currently available laboratory diagnostic biomarkers (eg, lysozyme and angiotensin-converting enzyme [ACE]) are lacking in high sensitivity and specificity.

Objective

To compare the value of soluble interleukin 2 receptor (sIL-2R) with ACE as diagnostic biomarkers of sarcoidosis in patients with uveitis.

Design, Setting, and Participants

A cross-sectional retrospective study was conducted using data collected from 249 consecutive patients with uveitis at the Erasmus University Medical Center uveitis outpatient clinic, Rotterdam, the Netherlands, from April 3, 2013, through November 25, 2015. Measurements of sIL-2R and ACE in serum samples and data extraction from patient files were conducted from December 2016 through February 2017, and analysis from April to May 2017.

Main Outcomes and Measures

Serum levels of sIL-2R and ACE and chest radiographic findings were assessed. Receiver operating characteristics analysis was used to determine the probability that individual tests correctly identified patients with sarcoidosis. The Youden Index was used to determine the optimal cutoff points for serum sIL-2R and ACE levels to define sarcoidosis in patients with uveitis.

Results

Data were analyzed from 249 patients with uveitis who had their serum sIL-2R and ACE levels determined and underwent chest radiography. Mean (SD) age at the time of sampling was 51 (16) years, 161 patients (64.7%) were women, and 191 (76.7%) were white. Although patients with sarcoidosis-associated uveitis had the highest mean (SD) serum sIL-2R (6047 [2533] pg/mL) and ACE (61 [38] U/L) levels, elevated serum sIL-2R levels were also found in patients with HLA-B27–associated (4460 [2465] pg/mL) and varicella-zoster virus–associated (5386 [1778] pg/mL) uveitis. Serum sIL-2R and ACE levels were significantly correlated (Pearson correlation coefficient, 0.205; P = .001, 2-sided), but no association was found between uveitis activity and sIL-2R (Spearman rank correlation coefficient [ρ], 0.070, P = .27) nor uveitis activity and ACE (ρ, −0.071; P = .27). The highest Youden index for sIL-2R alone was 0.45, corresponding to an optimal cutoff of 4000 pg/mL and providing 81% (95% CI, 74%-89%) sensitivity and 64% (95% CI, 56%-72%) specificity alone but combined with chest radiography yielded 92% sensitivity and 58% specificity. Chest radiography combined with sIL-2R at a cutoff of 6000 pg/mL resulted in 77% sensitivity and 73% specificity. Combined chest radiography and serum ACE levels at the standard cutoff of 68 U/L resulted in 70% sensitivity and 79% specificity.

Conclusions and Relevance

This cross-sectional study demonstrates that sIL-2R is a useful marker for diagnosing sarcoidosis in patients with uveitis and has slightly better diagnostic value than ACE.

[Uveitis in spondyloarthritis]

Acute anterior uveitis (AAU) is the most frequent uveitis subtype. It is often associated with HLA-B27 and with inflammatory rheumatic diseases, in particular with spondyloarthritis (SpA), which itself is strongly associated with HLA-B27. About 40-60% of patients with AAU have an associated spondyloarthritis, and 20-40% of patients with spondyloarthritis also have uveitis. The incidence of AAU in patients with SpA clearly correlates with disease duration. The AAU has an acute onset, usually affects only one eye at a time, and shows a tendency for recurrence. Early therapy of AAU with topical steroids is relevant for good visual outcomes. Minimum duration of therapy of flares of AAU is 6-8 weeks in order to prevent early recurrency. The rate of local complications correlates with the rate of AAU flares and the visual outcome is often good. Refractory uveitis and frequent recurrencies of AAU may be treated with conventional disease-modifying antirheumatic drugs (DMARDs, such as sulfasalazine and methotrexate) and biologicals (e.g. TNF-alpha inhibitors). Any first episode of AAU diagnosed by an ophthalmologist should prompt referral to rheumatology for suspected SpA, particularly if rheumatic symptoms are present.

Reclassifying Idiopathic Uveitis: Lessons From a Tertiary Uveitis Center

PURPOSE

Idiopathic uveitis is frequently the most common diagnosis in series from uveitis clinics. This study sought to determine the percentage of patients initially diagnosed as idiopathic, noninfectious uveitis referred to a tertiary uveitis center who were subsequently found to have an identifiable cause of uveitis.

DESIGN

Retrospective case series.

METHODS

We performed a computerized database analysis of 179 consecutive patients who were referred to our practice with the diagnosis of idiopathic, noninfectious uveitis between 2008 and 2016. Patients were evaluated by a thorough history and ophthalmic examination with selected laboratory testing targeted by clues from the history and examination. Standardization of Uveitis Nomenclature (SUN) criteria were used to better assess different types of uveitis.

RESULTS

Fifty-two out of 179 (29.0%) patients initially diagnosed with idiopathic uveitis were subsequently diagnosed with an underlying condition. Among patients referred with a diagnosis of idiopathic disease, female patients were most commonly affected (121/179; 67.6%). Among subsequent diagnoses, sarcoidosis was the most common (19/52 or 36.5%), followed by HLA-B27-associated uveitis (11/52, 21.1%), infectious uveitis (6/52, 11.5%), tubulointerstitial nephritis with uveitis (6/52, 11.5%), and juvenile idiopathic uveitis (4/52, 7.7%). Other diagnosable conditions included Behçet disease, multifocal choroiditis, panuveitis, Crohn disease, multiple sclerosis, and relapsing polychondritis. An underlying condition was not found in 127 of 179 (70.9%) patients.

CONCLUSIONS

We report that 29% of patients referred to our tertiary uveitis center diagnosed as "idiopathic" had an associated identifiable cause. Identifying an underlying condition associated with uveitis could be potentially lifesaving for some illnesses (eg, sarcoidosis with cardiac involvement) and is critical to management (eg, infection). Although we were able to use limited testing to classify many patients who had been previously incorrectly labeled with idiopathic uveitis, idiopathic uveitis remains the most common diagnosis in our uveitis clinic.

Lymphopaenia as a predictor of sarcoidosis in patients with a first episode of uveitis

Background/aims

The diagnostic properties of conventional diagnostic tests (ACE and chest radiography) for sarcoidosis-associated uveitis are not ideal. The diagnostic value of lymphopaenia for sarcoidosis-associated uveitis is investigated.

Methods

A retrospective study of 191 consecutive patients with a first uveitis episode visiting the ophthalmology department (Erasmus Medical Center, Rotterdam, The Netherlands). Receiver operating characteristics (ROC) analysis was performed and compared with known ROC values from literature of conventional diagnostic tests for sarcoidosis-associated uveitis. An ideal cut-off was determined for lymphopaenia by calculation of the highest Youden index.

Results

Out of all patients with first uveitis attack, 32/191 or 17% were subsequently diagnosed with biopsy-proven or radiological diagnosis of sarcoidosis. Lymphopaenia (<1.5×109/L) was significantly more often observed in patients with sarcoidosis-associated uveitis compared with patients with non-sarcoidosis-associated uveitis (p<0.05). The sensitivity and specificity of lymphopaenia was 75 % and 77 %, respectively. The optimal cut-off for lymphopaenia for diagnosing sarcoidosis-associated uveitis was 1.47 ×109/L. Lymphopaenia resulted in a 12.0 (95% CI 4.7 to 30.5 fold risk for having sarcoidosis, corrected for sex, race and age at onset of uveitis in patients with a first uveitis attack.

Conclusion

Lymphopaenia is a non-invasive and useful marker for diagnosing sarcoidosis-associated uveitis.

Relevance of erythrocyte sedimentation rate and C-reactive protein in patients with active uveitis

PURPOSE

To relate erythrocyte sedimentation rates (ESR) and C-reactive protein (CRP) values to different uveitis entisties.

METHODS

A retrospective study of patients with a first episode of active uveitis visiting the Erasmus University Medical Center, uveitis clinic, Rotterdam, the Netherlands, was performed. Levels of ESR and CRP were determined within 2 weeks and 1 week after onset of uveitis, respectively. Uveitis had to be of unknown origin at that moment. The specific etiologic groups were related to ESR and CRP values.

RESULTS

The majority of patients with uveitis had ESR and/or CRP values within the normal limits and no association of ESR and/or CRP with the specific cause of uveitis was observed. However, elevation of ESR ≥ 60 mm/h and/or CRP ≥ 60 mg/L was mostly seen in patients with systemic immune-mediated diseases (8/59, 14% of all with immune-mediated diseases) or systemic infectious causes (7/38, 18% of all infectious uveitis). Patients with ocular toxoplasmosis typically exhibited normal ESR and CRP (9/11, 82%) while patients with endogenous endophthalmitis had elevated ESR and/or CRP in 6/7, 86%. Sarcoidosis-associated uveitis showed predominantly elevated ESR (13/24, 54%; range 20-59 mm/h in 11/13, 85%). Human immunodeficiency virus-positive patients had more often elevated ESR values when compared to the remainder of patients (9/11, 82% vs. 64/163, 39%, 18%, P = 0.009). The cause of uveitis was established in 19/20 (95%) of patients with ESR ≥ 60 mm/h and/or CRP ≥ 60 mg/L.

CONCLUSIONS

The majority of patients with first attack of uveitis had ESR and CRP within the normal limits. Elevated levels of ESR and CRP reflected systemic involvement and high levels of both values were associated with established uveitis cause.

High-Dimensional Profiling Reveals Heterogeneity of the Th17 Subset and Its Association With Systemic Immunomodulatory Treatment in Non-infectious Uveitis

Background: Non-infectious uveitis (NIU) is a severe intra ocular inflammation, which frequently requires prompt systemic immunosuppressive therapy (IMT) to halt the development of vision-threatening complications. IMT is considered when NIU cannot be treated with corticosteroids alone, which is unpredictable in advance. Previous studies have linked blood cell subsets to glucocorticoid sensitivity, which suggests that the composition of blood leukocytes may early identify patients that will require IMT. Objective: To map the blood leukocyte composition of NIU and identify cell subsets that stratify patients that required IMT during follow-up. Methods: We performed controlled flow cytometry experiments measuring a total of 37 protein markers in the blood of 30 IMT free patients with active non-infectious anterior, intermediate, and posterior uveitis, and compared these to 15 age and sex matched healthy controls. Results from manual gating were validated by automatic unsupervised gating using FlowSOM. Results: Patients with uveitis displayed lower relative frequencies of Natural Killer cells and higher relative frequencies of memory T cells, in particular the CCR6+ lineages. These results were confirmed by automatic gating by unsupervised clustering using FlowSOM. We observed considerable heterogeneity in memory T cell subsets and abundance of CXCR3-CCR6+ (Th17) cells between the uveitis subtypes. Importantly, regardless of the uveitis subtype, patients that eventually required IMT in the course of the study follow-up exhibited increased CCR6+ T cell abundance before commencing therapy. Conclusion: High-dimensional immunoprofiling in NIU patients shows that clinically distinct forms of human NIU exhibit shared as well as unique immune cell perturbations in the peripheral blood and link CCR6+ T cell abundance to systemic immunomodulatory treatment.

Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) - Report 2: Pattern of Uveitis Investigations in Singapore

Purpose: To analyze the pattern of laboratory investigations of uveitis at a tertiary referral eye care center in Singapore.Methods: Retrospective analysis of 2040 uveitis cases from the Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) database over a 12-year period (2004 - 2015).Results: Patients with retinal vasculitis (RV) had the most tests utilized per patient (6.79), followed by intermediate uveitis (IU) (5.25), panuveitis (Pan) (5.12), posterior uveitis (PU) (4.17), anterior uveitis (AU) (2.75), and keratouveitis (KU) (1.10). The most frequently utilized test for infective etiology were the VDRL (41.3%), Syphilis IgG (29.5%), and T-SPOT.TB (24.6%). For autoimmune tests, ANA was most utilized (18.2%), followed by anti-dsDNA (14.8%), and HLA-B27 (12.4%).Conclusion: There was high utilization of autoimmune tests such as ANA, anti-dsDNA, RF, and ANCA, despite its limited yield. Rationalization of investigations in patients with ocular inflammation via a stepladder approach may help optimize the use of limited resources.

Autoimmunity, Autoinflammation, and Infection in Uveitis

PURPOSE

To review the pathogenesis of uveitis in light of recent advances in our understanding of innate and adaptive immune responses and their regulation.

DESIGN

Perspective.

METHODS

Methods included a review of prevailing views on the pathogenesis of uveitis and an analysis of developments in immunology that impact on its conceptual basis, particularly the concept of immunologic tolerance and its loss in autoimmunity. Importantly, the role of infection in the pathogenesis of uveitis is evaluated.

RESULTS

The results comprise a reappraisal of the pathogenesis of anterior vs posterior uveitis in the context of the blood-retinal barrier and its relation to autoimmune, autoinflammatory, and infectious uveitis. Autoimmunity is seen as a possible cause of certain forms of uveitis but definitive proof is lacking. Autoinflammatory disease, involving activated innate immune mechanisms, is considered causative in a second set of uveitis conditions. A place for infection in uveitis generally is proposed within a unifying concept for the pathogenesis of uveitis.

CONCLUSION

Infection may be implicated directly or indirectly in many forms of noninfectious or undifferentiated uveitis. In addition to the growing recognition that foreign antigen, including reactivatable infectious agents, might hide within ocular tissues, the possibility that a dysregulated microbiome might generate T cells that cause immune-mediated ocular inflammation has now been demonstrated experimentally. An uncontrolled, overexuberant host immune response may cause continuing irreversible tissue damage even after the infection has been cleared.

Why location matters - site-specific factors in rheumatic diseases

Rheumatic diseases follow a characteristic anatomical pattern of joint and organ involvement. This Review explores three interconnected mechanisms that might be involved in the predilection of specific joints for developing specific forms of arthritis: site-specific local cell types that drive disease; systemic triggers that affect local cell types; and site-specific exogenous factors, such as focal mechanical stress, that activate cells locally. The embryonic development of limbs and joints is also relevant to the propensity of certain joints to develop arthritis. Additionally, location-specific homeostasis and disease occurs in skin and blood vessels, thereby extending the concept of site-specificity in human diseases beyond rheumatology. Acknowledging the importance of site-specific parameters increases the complexity of current disease paradigms and brings us closer to understanding why particular disease processes manifest at a particular location.