1
|
Schauwvlieghe PP, Van Calster J, Herbort CP, Kestelyn PA, de Vlam K. Efficacy and safety of abatacept to treat active birdshot uveitis: a prospective open label interventional proof-of-concept trial. Br J Ophthalmol 2024; 108:244-252. [PMID: 36585127 PMCID: PMC10850705 DOI: 10.1136/bjo-2022-321585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Birdshot uveitis (BU) is a chronic autoimmune posterior uveitis, mostly affecting middle-aged Caucasians. There is a strong association with HLA-A29 and T-cell activation. Safety and efficacy of abatacept, an inhibitor of T-cell costimulation, is tested in active BU. METHODS Fifteen patients with active BU were treated with monotherapy of weekly subcutaneous injections of abatacept 125 mg/mL. Time-to-treatment failure was evaluated as a primary outcome. The secondary objective was to evaluate the utility of different outcome measures to monitor disease activity. Safety was evaluated by adverse event reporting and serial blood analyses. RESULTS At the year-1 endpoint, there was significant improvement in vitreous haze grade (p=0.0014), central choroidal thickness (CCT) (p=0.0011), Fluorescein Angiography (FA) Score (p=0.0014), Indocyanine Green Angiography (ICGA) Score (p<0.001) and total dual FA-ICGA Score (p<0.001). Best corrected visual acuity (BCVA) (p=0.8354) and central retinal thickness (CRT) (p=0.3549) did not change significantly. There were no serious adverse events reported. In total, 4 out of 15 patients left the trial during year 1 of whom 2 experienced treatment failure. CONCLUSIONS Abatacept is very efficacious to treat both retinal vasculitis and choroiditis in patients with BU and is well tolerated. BCVA and CRT are inadequate to monitor disease activity. On the other hand, CCT is a promising non-invasive tool to detect treatment response in early active BU and dual FA-ICGA Score is very helpful to evaluate retinal vasculitis and choroiditis quantitatively. TRIAL REGISTRATION NUMBER NCT03871361.
Collapse
Affiliation(s)
- P P Schauwvlieghe
- Ophthalmology, University Hospitals Leuven, Leuven, Belgium
- Ophthalmology, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium
| | | | - Carl Peter Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Montchoisi Teaching Centre, Lausanne, Switzerland
| | | | - Kurt de Vlam
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Papasavvas I, Tugal-Tutkun I, Herbort CP. Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis. Pharmaceuticals (Basel) 2022; 15:ph15040398. [PMID: 35455395 PMCID: PMC9031533 DOI: 10.3390/ph15040398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 12/19/2022] Open
Abstract
Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.
Collapse
Affiliation(s)
- Ioannis Papasavvas
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Rue Charles-Monnard 6, CH-1003 Lausanne, Switzerland;
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34093, Turkey;
| | - Carl P. Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Rue Charles-Monnard 6, CH-1003 Lausanne, Switzerland;
- Correspondence:
| |
Collapse
|
3
|
Vidas Pauk S, Vukojević N, Jandroković S, Kalauz M, Tomić M, Masnec S, Škegro I, Mrazovac Zimak D. Bilateral juxtapapillary choroidal neovascularization secondary to Birdshot chorioretinopathy-case report. Clin Case Rep 2021; 9:e04601. [PMID: 34429993 PMCID: PMC8365546 DOI: 10.1002/ccr3.4601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022] Open
Abstract
Central vision loss, photopsia, floaters, and macular edema in a highly myopic patient can easily be misinterpreted as high myopia complications. In atypical cases, detailed examination and a thorough diagnostic workup are required to establish the proper diagnosis, which is often beyond the scope of diagnoses initially considered.
Collapse
Affiliation(s)
- Sania Vidas Pauk
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
| | - Nenad Vukojević
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | - Sonja Jandroković
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | - Miro Kalauz
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | - Martina Tomić
- Department of OphthalmologyVuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic DiseasesMerkur University HospitalZagrebCroatia
| | - Sanja Masnec
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | - Ivan Škegro
- Department of OphthalmologyZagreb University Hospital CenterZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | | |
Collapse
|
4
|
HLA-A29 Birdshot Retinochoroiditis in Its 5th Decade: Selected Glimpses into the Intellectual Meanderings and Progresses in the Knowledge of a Long-Time Misunderstood Disease. Diagnostics (Basel) 2021; 11:diagnostics11071291. [PMID: 34359373 PMCID: PMC8305470 DOI: 10.3390/diagnostics11071291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/17/2022] Open
Abstract
The appraisal of HLA-A29 birdshot retinochoroiditis (BRC) was fraught with pitfalls and misunderstandings. Progress in investigational methods has led to better knowledge and management of the disease. Our aim was to assess some of the steps that have led to better characterisation of the clinical entity of BRC. We performed a literature search analysing the relevant progress in disease origin, investigational and imaging methods, clinicopathology and classification, diagnostic criteria and management. Following developments were judged essential in the better appraisal and understanding of the disease: (1) new immunopathological hypotheses regarding the role of endoplasmic reticulum peptidases, (2) the essential importance of HLA testing, (3) relevant imaging modalities among which indocyanine green angiography is crucial, (4) diagnostic criteria that allow early diagnosis and (5) need of an early prolonged, as well as aggressive treatment combining more than one immunosuppressive agent. Based on these findings it is now possible to better define BRC, an indolent however severe disease, unlike thought before, involving the choroidal stroma and the retina independently and concomitantly that can be diagnosed early thanks to indocyanine green angiography and should be treated early and relentlessly.
Collapse
|
5
|
Espinosa G, Herreras JM, Muñoz-Fernández S, García Ruiz de Morales JM, Cordero-Coma M. Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis. Med Clin (Barc) 2020; 155:220.e1-220.e12. [PMID: 32199631 DOI: 10.1016/j.medcli.2019.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience. METHODS A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines. CONCLUSIONS In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
Collapse
Affiliation(s)
- Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, España
| | - José M Herreras
- IOBA (Instituto Universitario de Oftalmobiología), Universidad de Valladolid, Valladolid, España; Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Santiago Muñoz-Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España; Universidad Europea, San Sebastián de los Reyes, Madrid, España
| | - José M García Ruiz de Morales
- Unidad de Uveítis, Servicio de Inmunología, Complejo Asistencial Universitario de León, León, España; Instituto de Biomedicina, Universidad de León (IBIOMED), León, España
| | - Miguel Cordero-Coma
- Instituto de Biomedicina, Universidad de León (IBIOMED), León, España; Unidad de uveítis, Servicio de Oftalmología, Complejo Asistencial Universitario de León, León, España.
| |
Collapse
|
6
|
You C, Lasave AF, Kubaisi B, Syeda S, Ma L, Wai KCK, Diaz MH, Walsh M, Stephenson A, Montieth A, Foster CS. Long-term outcomes of systemic corticosteroid-sparing immunomodulatory therapy for Birdshot Retinochoroidopathy. Ocul Immunol Inflamm 2020; 28:966-974. [PMID: 31567006 DOI: 10.1080/09273948.2019.1641610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To report the visual prognosis, electroretinography (ERG) and perimetry outcomes of systemic corticosteroid-sparing immunomodulatory treatment (IMT) for birdshot retinochoroidopathy (BSRC). METHODS Retrospective non-comparative case series of 132 patients (264 eyes) with BSRC treated with IMT from Massachusetts Eye Research and Surgery Institution. RESULTS The average follow-up time was 60.1 months. After one year on IMT, 39.4% showed no clinically active inflammation. After 5 years of IMT, 78.0% had no signs of clinical inflammation. No significant differences were observed on best-corrected visual acuity (BCVA), ERG parameters, and perimetry parameters between baseline and subsequent visits on IMT. CONCLUSION Long-term systemic corticosteroid-sparing IMT was associated with a low rate of BSRC disease exacerbation. While differences were seen on testing parameters, they were not consistent trends and difference were attributed to variability of testing or fluctuation of inflammation that may be expected in the course of the disease.
Collapse
Affiliation(s)
- Caiyun You
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA.,Department of Ophthalmology, Tianjin Medical University General Hospital , Tianjin, China
| | - Andres F Lasave
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA.,Retina and Vitreous Department, Clinica Privada de Ojos, Mar del Plata , Buenos Aires, Argentina
| | - Buraa Kubaisi
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Sarah Syeda
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Lina Ma
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Kelvin Cheng Kah Wai
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA.,School of Medicine, University of Glasgow , Glasgow, United Kingdom
| | - Mikhail Hernandez Diaz
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Marisa Walsh
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Andrew Stephenson
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - Alyssa Montieth
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham, Massachusetts, USA.,Ocular Immunology and Uveitis Foundation , Weston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School , Boston, Massachusetts, USA
| |
Collapse
|
7
|
Retinal vasculitis: A framework and proposal for a classification system. Surv Ophthalmol 2020; 66:54-67. [PMID: 32450158 DOI: 10.1016/j.survophthal.2020.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.
Collapse
|
8
|
Visual acuity loss and development of ocular complications in white dot syndromes: a longitudinal analysis of 3 centers. Graefes Arch Clin Exp Ophthalmol 2019; 257:2505-2516. [DOI: 10.1007/s00417-019-04429-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022] Open
|
9
|
You C, Meese H, Stephenson A, Montieth A, Ma L, Hernandez M, Kubaisi B, Syeda S, Foster CS. Outcomes of "Early" Withdrawal of Corticosteroid Sparing Immunomodulatory Therapy for Birdshot Retinochoroidopathy. Ocul Immunol Inflamm 2018; 27:1165-1173. [PMID: 30207810 DOI: 10.1080/09273948.2018.1506040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To review early withdrawal of immunomodulatory therapy (IMT) for birdshot retinochoroidopathy (BSRC). Design: Retrospective case-series of sixteen patients with Human-leukocyte-antigen-A29-positive BSRC treated with IMT ≥ 1 year and discontinued prior to achieving durable remission, observed ≥ 6 months off IMT. Results: Mean duration on IMT was 42.4 months. At discontinuation, quiescence was achieved in 75.0% of eyes. Subjects off IMT for 6 months, 1 year, and 3 years showed quiescence in 75.0%, 77.8%, and 80.0% of eyes. No significantly decreased vision was found 6 or 12 months after discontinuation. One eye experienced significantly decreased vision following 3 years without IMT. Significantly decreased amplitude on electroretinography and worse deviation parameters in perimetry were found in patients 3 years after withdrawal that experienced early discontinuation when compared with those achieving durable remission on IMT > 2 years (p < 0.05). Conclusion: The possibility of electroretinography and perimetry results worsening after early IMT discontinuation remained if the patients couldn't achieve remission.
Collapse
Affiliation(s)
- Caiyun You
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA.,Department of Ophthalmology, Tianjin Medical University General Hospital , Tianjin , P.R. China
| | - Halea Meese
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Andrew Stephenson
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Alyssa Montieth
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Lina Ma
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Mikhail Hernandez
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Buraa Kubaisi
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - Sarah Syeda
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI) , Waltham , Massachusetts , USA.,Ocular Immunology and Uveitis Foundation , Weston , Massachusetts , USA.,Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts
| |
Collapse
|
10
|
Hafidi M, Loria O, Kodjikian L, Denis P, Ferrand MR, Broussolle C, Sève P. Efficacy of Methylprednisolone Pulse Followed by Oral Prednisone in Birdshot Chorioretinopathy. Ocul Immunol Inflamm 2016; 25:596-603. [DOI: 10.1080/09273948.2016.1178778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Meriem Hafidi
- Ophthalmology Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| | - Olivier Loria
- Ophthalmology Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| | - Laurent Kodjikian
- Ophthalmology Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| | - Philippe Denis
- Ophthalmology Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| | - Muriel R. Ferrand
- Biostatistics Department, Université Claude Bernard Lyon I, Lyon, France
| | - Christiane Broussolle
- Internal Medicine Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| | - Pascal Sève
- Internal Medicine Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Quai des Célestins, Lyon, France
| |
Collapse
|
11
|
Minos E, Barry RJ, Southworth S, Folkard A, Murray PI, Duker JS, Keane PA, Denniston AK. Birdshot chorioretinopathy: current knowledge and new concepts in pathophysiology, diagnosis, monitoring and treatment. Orphanet J Rare Dis 2016; 11:61. [PMID: 27175923 PMCID: PMC4866419 DOI: 10.1186/s13023-016-0429-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/17/2016] [Indexed: 11/15/2022] Open
Abstract
Birdshot chorioretinopathy (BCR) is a rare form of chronic, bilateral, posterior uveitis with a distinctive clinical phenotype, and a strong association with HLA-A29. It predominantly affects people in middle age. Given its rarity, patients often encounter delays in diagnosis leading to delays in adequate treatment, and thus risking significant visual loss. Recent advances have helped increase our understanding of the underlying autoimmune mechanisms involved in disease pathogenesis, and new diagnostic approaches such as multimodality imaging have improved our ability to both diagnose and monitor disease activity. Whilst traditional immunosuppressants may be effective in BCR, increased understanding of immune pathways is enabling development of newer treatment modalities, offering the potential for targeted modulation of immune mediators. In this review, we will discuss current understanding of BCR and explore recent developments in diagnosis, monitoring and treatment of this disease. Synonyms for BCR: Birdshot chorioretinopathy, Birdshot retinochoroiditis, Birdshot retino-choroidopathy, Vitiliginous choroiditis. Orphanet number: ORPHA179 OMIM: 605808.
Collapse
Affiliation(s)
- Evangelos Minos
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert J Barry
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Centre for Translational Inflammation Research, University of Birmingham, Birmingham, West Midlands, B15 2WB, UK
- Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Sue Southworth
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Birdshot Uveitis Society, London, UK
| | | | - Philip I Murray
- Academic Unit of Ophthalmology, Centre for Translational Inflammation Research, University of Birmingham, Birmingham, West Midlands, B15 2WB, UK
- Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Jay S Duker
- New England Eye Center, Tufts Medical Center, Tufts University School of Medicine, Boston, USA
| | - Pearse A Keane
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Alastair K Denniston
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Academic Unit of Ophthalmology, Centre for Translational Inflammation Research, University of Birmingham, Birmingham, West Midlands, B15 2WB, UK.
- Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK.
| |
Collapse
|
12
|
Rangel CM, Atencia C, Merayo-Lloves J, Fernandez-Vega Sanz A. Presumed latent ocular tuberculosis diagnosed with the positive quantiFERON-TB Gold In-Tube Test in a HLA-A29-positive patient. BMJ Case Rep 2015; 2015:bcr-2015-210206. [PMID: 26045521 DOI: 10.1136/bcr-2015-210206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old Hispanic woman presented with a 3-year history of floaters associated with bilateral reduced visual acuity. Her best-corrected visual acuity (BCVA) was 20/40. Both anterior segments were without inflammation, but fundoscopy showed mild vitreous inflammation and multiple inflammatory choroidal lesions. Tests for inflammatory and infectious diseases were negative except for human leucocyte antigen A29. The patient was diagnosed with birdshot choroidoretinopathy, and treatment was initiated with cyclosporine A 2.5 mg/kg/day. One year after treatment, the patient reported systemic symptoms with no improvement in visual acuity. Fundus findings remained with vitreal inflammation. QuantiFERON-TB Gold In-Tube Test was positive, and a diagnosis of presumed latent ocular tuberculosis (TB) was made. We initiated anti-TB treatment for 9 months. At 6 months of anti-TB therapy, there was no active inflammation. The patient was followed for 2 years with no medications and no active inflammation. Her final BCVA was 20/25.
Collapse
Affiliation(s)
- Carlos Mario Rangel
- Instituto Universitario Fernández-Vega, Universidad de Oviedo, Spain Fundación Oftalmológica de Santander, Universidad Autónoma de Bucaramanga, Colombia, Cartagena, Bolivar, Colombia
| | - Cesar Atencia
- Instituto Universitario Fernández-Vega, Universidad de Oviedo, Spain Clínica Oftalmológica de Cartagena, Universidad del Sinu, Cartagena, Colombia
| | | | | |
Collapse
|
13
|
Vitale AT. Birdshot retinochoroidopathy. J Ophthalmic Vis Res 2015; 9:350-61. [PMID: 25667738 PMCID: PMC4307660 DOI: 10.4103/2008-322x.143376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/25/2013] [Indexed: 01/14/2023] Open
Abstract
Birdshot retinochoroidopathy (BSRC) is an uncommon, but well-characterized chronic, bilateral posterior uveitis, which is uniquely associated with the human leukocyte antigen-A29 phenotype. The disease presents predominantly in middle-aged Caucasian females who complain of blurred vision, floaters, photopsias, paracentral scotomas and nyctalopia. While autoimmune mechanisms are thought to play an important role in the pathogenesis of BSRC, its etiology remains unknown. Important questions remain in our understanding of BSRC with respect to its pathogenesis, epidemiology, optimal treatment, and prognosis, including the determinants of remission and relapse, as well as the best strategy for monitoring disease activity, progression and response to therapy with electroretinographic and psychophysical testing, established and emerging imaging modalities, and peripheral cytokines profiles.
Collapse
Affiliation(s)
- Albert T Vitale
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, Salt Lake City, UT, USA
| |
Collapse
|
14
|
Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the non-biologic treatment of adult noninfectious uveitis: part I. Expert Opin Pharmacother 2014; 15:2141-54. [PMID: 25226529 DOI: 10.1517/14656566.2014.948417] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Treatment of adult, noninfectious uveitis remains a challenge for ophthalmologists around the world. The disease accounts for almost 10% of preventable blindness in the US and can be idiopathic or associated with infectious and systemic disorders. Strong evidence is still emerging to indicate that pharmacologic strategies presently used in rheumatologic or autoimmune disease may be translated to the treatment of intraocular inflammation. Corticosteroid monotherapy is widely regarded as wholly inappropriate, due to the unfavorable risk/benefit profile and poor long-term outcomes. Treatment plans have shifted away from low-dose, chronic corticosteroid therapy for maintenance, towards medium- to high-dose therapy for acute inflammation, followed immediately by initiation of immunomodulatory therapy. These therapies follow the 'stepladder approach', whereby least to more aggressive therapies are trialed to induce remission of inflammation, eventually without corticosteroids of any form (topical, local and systemic). AREAS COVERED This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment of ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. EXPERT OPINION The hazard of chronic corticosteroid use for the treatment of adult, noninfectious uveitis is well-documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted.
Collapse
Affiliation(s)
- Kyungmin Lee
- Massachusetts Eye Research and Surgery Institution , 5 Cambridge Center, 8th Floor, Cambridge, MA 02142 , USA +1 617 621 6377 ; +1 617 494 1430 ;
| | | | | | | | | | | |
Collapse
|
15
|
Doycheva D, Jägle H, Zierhut M, Deuter C, Blumenstock G, Schiefer U, Stingl K, Januschowski K, Voykov B, Stuebiger N. Mycophenolic acid in the treatment of birdshot chorioretinopathy: long-term follow-up. Br J Ophthalmol 2014; 99:87-91. [PMID: 25061107 DOI: 10.1136/bjophthalmol-2014-305535] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To assess the long-term efficacy and tolerability of both derivatives of mycophenolic acid, mycophenolate mofetil (MMF) and mycophenolate sodium (MPS), in the therapy of patients with birdshot chorioretinopathy (BSCR). METHODS Retrospective analysis of 24 patients (48 eyes) with BSCR, treated with MMF or MPS with a follow-up of at least 1 year. The main outcome measures included control of inflammation, steroid-sparing potential and side effects. Secondary outcome measure was the development of retinal function during the therapy measured by best-corrected visual acuity (BCVA), visual field and/or electroretinography (ERG). RESULTS Twelve patients (50%) were treated with MMF and 12 patients (50%) with MPS. Control of intraocular inflammation, defined as complete lack of clinical and angiographic signs of inflammatory activity, was achieved in 16 of 24 patients (67%). The angiographic signs of activity were significantly reduced during the follow-up (p<0.05). No significant difference was found in the mean BCVA, the visual field and the ERG parameters during the treatment compared with the baseline (p>0.05). In 20 out of 21 patients (95%) who received systemic corticosteroids, the corticosteroids could be tapered to a daily dose of ≤10 mg (rate 0.26/patient-year). Drug-related side effects occurred in 12 patients (50%, rate 0.16/patient-year). In four patients (17%), a therapy switch from MMF to MPS was undertaken due to gastrointestinal discomfort. CONCLUSIONS Derivatives of mycophenolic acid are effective and safe drugs for the treatment of BSCR. In cases with gastrointestinal side effects, a therapy switch from MMF to MPS should be considered.
Collapse
Affiliation(s)
- Deshka Doycheva
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Herbert Jägle
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany Department of Ophthalmology, University of Regensburg, Regensburg, Germany
| | - Manfred Zierhut
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Christoph Deuter
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tuebingen, Tuebingen, Germany
| | - Ulrich Schiefer
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany Competence Center "Vision Research", Study Course "Ophthalmic Optics/Audiology", University of Applied Sciences, Aalen, Germany
| | - Katarina Stingl
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Kai Januschowski
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Bogomil Voykov
- Centre for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Nicole Stuebiger
- Department of Ophthalmology, Charité, University Medicine Berlin, Berlin, Germany
| |
Collapse
|
16
|
Gender differences in birdshot chorioretinopathy and the white dot syndromes: do they exist? J Ophthalmol 2014; 2014:146768. [PMID: 24678412 PMCID: PMC3941241 DOI: 10.1155/2014/146768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/19/2013] [Accepted: 12/21/2013] [Indexed: 11/24/2022] Open
Abstract
Inflammatory conditions that affect the posterior pole are diverse. Specifically, birdshot chorioretinopathy and the white dot syndromes present with multiple white dots in the fundus. These diseases appear to affect similar age groups but there is question as to whether or not a difference exists between the genders. This review summarizes the current studies on birdshot chorioretinopathy and the white dot syndromes as they are related to gender, exploring the differences, if any, which may exist between prevalence, clinical presentation, and treatment response for these diseases. Though the specific etiology of these diseases remains unclear, future treatments may be guided as to how these diseases affect the sexes differently.
Collapse
|
17
|
A review of the inflammatory chorioretinopathies: the white dot syndromes. ISRN INFLAMMATION 2013; 2013:783190. [PMID: 24294536 PMCID: PMC3833360 DOI: 10.1155/2013/783190] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/18/2013] [Indexed: 11/18/2022]
Abstract
The white dot syndromes are a group of inflammatory chorioretinopathies of unknown etiology which have in common a unique and characteristic appearance of multiple yellow-white lesions affecting multiple layers of the retina, retinal pigment epithelium (RPE), choriocapillaris, and the choroid. They also have overlapping clinical features. We discuss acute retinal pigment epitheliopathy, multiple evanescent white dot syndrome, acute posterior multifocal placoid pigment epitheliopathy, multifocal choroiditis and panuveitis, acute zonal occult outer retinopathy, birdshot chorioretinopathy, and serpiginous choroidopathy. Some of these diseases are associated with a viral prodrome suggesting a possible viral/infectious etiology, while others are associated with a number of systemic processes suggesting an autoimmune etiology. We also review the presentation, evaluation/diagnosis, and treatment of these entities as well as the prognosis. Where applicable we discuss recent advancements in diagnosing and treating the white dot syndromes.
Collapse
|