Biologics for the treatment of noninfectious uveitis: current concepts and emerging therapeutics

Long-term outcomes of noninfectious uveitis treated with systemic immunomodulatory therapy: a retrospective case series

OBJECTIVE

To study the clinical characteristics and long-term outcomes of patients with noninfectious uveitis (NIU) who are treated with systemic immunomodulatory therapy (IMT).

DESIGN

Retrospective case series.

PARTICIPANTS

All consecutive cases of adults with NIU under the care of 5 uveitis subspecialty tertiary care clinics between 2010 to 2021 were included.

METHODS

Patient outcomes were assessed at initial presentation and at the latest available follow-up.

RESULTS

A total of 418 NIU patients receiving IMT therapy with a median age of 46.0 years and 59.3% female were identified. Each patient required an average of 1.4 agents until achieving an optimal response. Following initial treatment with prednisone, patients were most commonly initiated on methotrexate. The top 3 treatments with the highest proportion of optimal treatment response when taken alone or in combination with other agents were infliximab (79.3%), cyclosporine (75%), and adalimumab (70%). The strongest predictors for requiring a greater number of IMTs trialed were younger age, panuveitis, and a chronic or recurrent disease course. Multivariable linear regression analysis suggested that baseline visual acuity at diagnosis was the only significant predictor of final visual acuity (p < 0.001).

CONCLUSIONS

NIU patients on IMT are often trialed on multiple therapeutic agents before achieving an optimal treatment response. Visual acuity at diagnosis is a predictor of final visual outcomes, whereas chronic or recurrent disease course, younger age, and panuveitis are predictors of requiring multiagent treatment regimens.

Subconjunctival injection of rapamycin-loaded polymeric microparticles for effective suppression of noninfectious uveitis in rats

Noninfective uveitis is a major cause of vision impairment, and corticosteroid medication is a mainstay clinical strategy that causes severe side effects. Rapamycin (RAPA), a potent immunomodulator, is a promising treatment for noninfective uveitis. However, because high and frequent dosages are required, it is a great challenge to implement its clinical translation for noninfective uveitis therapy owing to its serious toxicity. In the present study, we engineered an injectable microparticulate drug delivery system based on biodegradable block polymers (i.e., polycaprolactone-poly (ethylene glycol)-polycaprolactone, PCEC) for efficient ocular delivery of RAPA via a subconjunctival injection route and investigated its therapeutic efficacy in an experimental autoimmune uveitis (EAU) rat model. RAPA-PCEC microparticles were fabricated using the emulsion-evaporation method and thoroughly characterized using scanning electron microscopy, fourier transform infrared spectroscopy, X-ray diffraction, and differential scanning calorimetry. The formed microparticles exhibited slow in vitro degradation over 28 days, and provided both in vitro and in vivo sustained release of RAPA over 4 weeks. Additionally, a single subconjunctival injection of PCEC microparticles resulted in high ocular tolerance. More importantly, subconjunctival injection of RAPA-PCEC microparticles significantly attenuated the clinical signs of EAU in a dose-dependent manner by reducing inflammatory cell infiltration (i.e., CD45+ cells and Th17 cells) and inhibiting microglial activation. Overall, this injectable microparticulate system may be promising vehicle for intraocular delivery of RAPA for the treatment of noninfective uveitis.

Fluocinolone Acetonide Implant for Uveitis: Dissecting Responder and Non-Responder Outcomes at a Tertiary Center

Macular edema (ME) remains a primary cause of visual deterioration in uveitis. Visual acuity (VA) can often be maintained using corticosteroid depot systems. This study evaluated the efficacy of a fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN®) in treating non-infectious uveitis using real-world data. This retrospective analysis included 135 eyes subdivided into responders and non-responders. Central retinal thickness (CRT), VA, and intraocular pressure (IOP) were followed over time. A significant decrease in CRT and an increase in VA were observed in all eyes throughout the follow-up period (p < 0.01). An IOP increase (p = 0.028) necessitated treatment in 43% of eyes by Month 6. Non-responders were older (p = 0.004) and had been treated with more dexamethasone (DEX) implants (p = 0.04); 89.3% had a defect in the external limiting membrane (ELM) and inner/outer segment (IS/OS) zone (p < 0.001). Immunomodulatory therapy had no impact on treatment response. Pars plana vitrectomy (PPV) patients had a mean CRT reduction of 47.55 µm and a reduced effect by Month 24 (p = 0.046) versus non-PPV patients. We conclude that the FAc implant achieves long-term control of CRT and improves VA. Increases in IOP were manageable. Eyes with a previous PPV showed milder results. Data showed a correlation between older age, a damaged ELM and IS/OS zone, frequent DEX inserts, and poorer outcome measures.

Janus Kinase Inhibitors as a Third-Line Therapy for Refractory Endogenous Noninfectious Uveitis

PURPOSE

Janus kinase (JAK) inhibitors have recently been used to treat patients with biologic refractory noninfectious uveitis (NIU). This narrative review updates the current evidence relevant for their application in patients with refractory NIU.

METHODS

A literature search was performed for articles published until October 2023 in the PubMed, Scopus, and CENTRAL databases using the key terms "noninfectious uveitis" and "Janus kinase inhibitor" or "JAK inhibitor" without any exclusion criteria. Published articles were selected based on their clinical focus, relevance for ocular disease, time since publication and study design reflecting their scientific soundness with a critical appraisal of drug safety aspects.

RESULTS

Janus kinases are transmembrane signaling proteins. Their inhibition has shown therapeutic potential experimentally and in patients with multiple immune-mediated diseases, including NIU. JAK inhibitors differ from biological agents in that they inhibit not one specific but multiple cytokines. These agents can be ingested orally and seem superior to adalimumab for most indications. While there is no doubt regarding their efficacy in treating immune-mediated inflammatory diseases, reports regarding their safety are increasing, and the findings are generally confusing and contradictory. Since substantiated information about their specific safety profiles in patients with inflammatory eye disease is lacking, their position in the therapeutic algorithm for uveitis has yet to be determined.

CONCLUSIONS

In the absence of evidence from controlled clinical trials, JAK inhibitor therapy is still rendered experimental and currently considered only for sight-threatening uveitis. JAK inhibitors may be considered for specific NIU entities for which there is insufficient response or secondary loss of response to conventional or biologic disease-modifying drugs.

AAV-mediated gene therapies for glaucoma and uveitis: are we there yet?

Glaucoma and uveitis are non-vascular ocular diseases which are among the leading causes of blindness and visual loss. These conditions have distinct characteristics and mechanisms but share a multifactorial and complex nature, making their management challenging and burdensome for patients and clinicians. Furthermore, the lack of symptoms in the early stages of glaucoma and the diverse aetiology of uveitis hinder timely and accurate diagnoses, which are a cause of poor visual outcomes under both conditions. Although current treatment is effective in most cases, it is often associated with low patient adherence and adverse events, which directly impact the overall therapeutic success. Therefore, long-lasting alternatives with improved safety and efficacy are needed. Gene therapy, particularly utilising adeno-associated virus (AAV) vectors, has emerged as a promising approach to address unmet needs in these diseases. Engineered capsids with enhanced tropism and lower immunogenicity have been proposed, along with constructs designed for targeted and controlled expression. Additionally, several pathways implicated in the pathogenesis of these conditions have been targeted with single or multigene expression cassettes, gene editing and silencing approaches. This review discusses strategies employed in AAV-based gene therapies for glaucoma and non-infectious uveitis and provides an overview of current progress and future directions.

Cytokines in Immune-mediated "Non-infectious" Uveitis

Uveitis is a significant cause of ocular morbidity and accounts for approximately 5 - 10% of visual impairments worldwide, particularly among the working-age population. Infections are the cause of ~ 50% cases of uveitis, but it has been suggested that infection might also be implicated in the pathogenesis of immune-mediated "non-infectious" uveitis. There is growing evidence that cytokines (i.e., interleukins, interferons, etc.) are key mediators of immune-mediated "non-infectious" uveitis. For example, activation of the interleukin-23/interleukin-17 signalling pathway is involved in immune-mediated "non-infectious" uveitis. Studies in animal models have been important in investigating the role of cytokines in uveitis. Recent studies of clinical samples from patients with uveitis have allowed the measurement of a considerable array of cytokines even from very small sample volumes (e.g., aqueous and vitreous humour). The identification of complex patterns of cytokines may contribute to a better understanding of their potential pathogenetic role in uveitis as well as to an improved diagnostic and therapeutic approach to treat these potentially blinding pathologies. This review provides further insights into the putative pathobiological role of cytokines in immune-mediated "non-infectious" uveitis.

Recent advances in uveitis therapy: focus on selected phase 2 and 3 clinical trials

INTRODUCTION

Uveitis is a heterogeneous group of ocular conditions characterized by inflammation of the uveal tract. It is a leading cause of blindness in developed countries and exerts significant psychological, social, and economic impact on both patients and the larger society. While there are numerous pharmacotherapy options, posterior segment noninfectious uveitis remains a significant challenge to treat due to its severity, chronicity, and high recurrence rates.

AREAS COVERED

The index review highlights the unmet needs of uveitis pharmacotherapy and its research and the shortcomings of existing ocular and systemic therapeutic options for noninfectious uveitis. The more promising novel ocular drug delivery methods and therapeutic targets/drugs are discussed, and evidence from the clinical trials is evaluated.

EXPERT OPINION

There has been incredible growth in the number of treatment options available to uveitis patients today, especially with the new generation of biologic drugs. Available evidence suggests that these newer options may be superior to conventional immunosuppressive therapies in terms of efficacy and side effect profiles. Further high-quality research and additional clinical trials will be needed to clarify their roles in the stepladder treatment approach of noninfectious uveitis.

[Analysis of adverse drug reactions (ADR) in fluorescein angiography (FAG) and indocyanine green angiography (ICGA) and indications before and during the COVID-19 pandemic at a university eye hospital]

BACKGROUND

This study was an analysis of fluorescein angiography (FAG) and indocyanine green angiography (ICGA) at a university eye hospital. The primary objective of the study was to analyze adverse drug reactions (ADRs) and their severity (mild, moderate, severe). The secondary objective was to investigate the indications of FAG and ICGA before and during the COVID-19 pandemic.

METHODS

A retrospective analysis of all FAG and ICGA at the University Eye Hospital in Würzburg from January 2016 to the end of December 2021 was performed. The ADRs, gender, age, examination time points and indications were evaluated. The ADRs were classified into mild, moderate, and severe, following the definition of Kornblau et al. [1] RESULTS: A total of 4900 examinations from 4193 patients were analyzed. An FAG was performed slightly more frequently in men (54.8%) than in women (45.2%) and the mean age was 63.2 ± 16.9 years (median: 65 years). The ADRs occurred in only 1.65% of all FAG, of which 1.27% were mild and 0.39% were moderate. No severe ADRs occurred. The most common ADR was nausea at 59.26%. No ADR occurred in ICGA. The annual number of FAGs averaged 816.7 ± 91.1 and was relatively constant throughout the period except for a significantly reduced number in 2016 (compared with 2018, 2019, and 2021). The most common indication for FAG was venous retinal occlusion at 22.93% (N = 774), showing a significant increase in 2021 compared to 2018-2020. An ICGA was performed in 4.18% of cases, with the most common indication being uveitis at 31.82% (N = 63).

CONCLUSION

Compared to other studies very few ADRs occurred and no life-threatening ADR occurred in any case. Venous retinal occlusions were very common indications for FAG, probably due to the frequent need for repeated examinations in this condition. Briefly, during the first lockdown (18 March-8 May 2020), a decrease in angiographies was observed, but over a longer period, no significant differences were seen compared with the prepandemic period.

Pathogenesis and current therapies for non-infectious uveitis

Non-infectious uveitis (NIU) is a disorder with various etiologies and is characterized by eye inflammation, mainly affecting people of working age. An accurate diagnosis of NIU is crucial for appropriate therapy. The aim of therapy is to improve vision, relieve ocular inflammation, prevent relapse, and avoid treatment side effects. At present, corticosteroids are the mainstay of topical or systemic therapy. However, repeated injections are required for the treatment of chronic NIU. Recently, new drug delivery systems that may ensure intraocular delivery of therapeutic drug levels have been highlighted. Furthermore, with the development of immunosuppressants and biologics, specific therapies can be selected based on the needs of each patient. Immunosuppressants used in the treatment of NIU include calcineurin inhibitors and antimetabolites. However, systemic immunosuppressive therapy itself is associated with adverse effects due to the inhibition of immune function. In patients with refractory NIU or those who cannot tolerate corticosteroids and immunosuppressors, biologics have emerged as alternative treatments. Thus, to improve the prognosis of patients with NIU, NIU should be managed with different drugs according to the response to treatment and possible side effects.

Noninfectious Uveitis in Rheumatology: Patterns, Treatment, and Outcomes

OBJECTIVES

The present study aimed to determine the pattern and cause of noninfectious uveitis in rheumatology practice. The secondary objective was to identify the pattern of treatment and outcomes.

MATERIALS AND METHODS

This retrospective cross-sectional study was conducted in the Department of Rheumatology, National Hospital and Medical Centre, Lahore, Pakistan. After receiving consent, electronic medical records (EMRs) of all patients with a diagnosis of noninfectious uveitis (NIU) from November 2019 to January 2023 were reviewed, and a total of 52 patients labeled as having noninfectious uveitis were identified. The collected data included age at diagnosis, anatomical location of uveitis, associated systemic disease, used medications, and outcomes. All cases had been diagnosed and assessed mutually by a rheumatologist and an ophthalmologist using the International Uveitis Study Group classification system to classify the pattern of uveitis by location, clinical course, and laterality and rule out the possibility of other ophthalmologic diseases. Disease activity was defined using the Standardization of Uveitis Nomenclature (SUN) guidelines. Data was analyzed on SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA).

RESULTS

The mean age of the patients in this study was 36.02 ± 43.31 years, with 31 (59.6%) male patients. Anterior uveitis was the most common type observed among the patients at 55.8%, panuveitis was found in 25%, intermediate uveitis and posterior uveitis were seen in 9.6% each. Based on laterality, unilateral eye involvement was identified in 53.8% of patients. Spondyloarthritis (SpA) and idiopathic uveitis were observed in 34.6% and 28.8%, respectively. In this study, 28 (54.9%) patients were on conventional disease-modifying antirheumatic drugs (cDMARDDs), and 23 (45.1%) were on biological DMARDs. In the biologics group, 82% of patients were in remission in comparison to 60% in the cDMARDs group.

CONCLUSION

To the best of our knowledge, this is the first report on noninfectious uveitis in the Pakistani population. The study concluded that anterior uveitis is the most common type of uveitis and is more common in males. Spondyloarthropathy is one of the most common underlying systemic diseases. Human leukocyte antigen (HLA)-B27 is associated more with uveitis. Biologics are more effective than cDMARDs in controlling the disease. Collaborative work between different specialties resulted in early diagnosis of underlying systemic disease, better management plans, and disease outcomes. To obtain further details on noninfectious uveitis, a population-based study is needed in Pakistan.

Successful treatment of idiopathic retinal vasculitis with rituximab in two patients

Purpose

To describe results of treatment of idiopathic retinal vasculitis with intravenous rituximab.

Observations

We present two patients with idiopathic retinal vasculitis who required steroid-sparing therapy and achieved steroid-free remission with intravenous rituximab. Rituximab was used as a first-line steroid-sparing agent after steroids in one patient and as a second-line steroid-sparing agent in the other patient. Both patients achieved steroid-free remission of disease with follow up of at least one year after rituximab initiation.

Conclusions and importance

Rituximab achieved steroid-free remission in two patients with idiopathic retinal vasculitis. It should be considered as a treatment option in these patients.

The multifunctional human ocular melanocortin system

Immune privilege in the eye involves physical barriers, immune regulation and secreted proteins that together limit the damaging effects of intraocular immune responses and inflammation. The neuropeptide alpha-melanocyte stimulating hormone (α-MSH) normally circulates in the aqueous humour of the anterior chamber and the vitreous fluid, secreted by iris and ciliary epithelium, and retinal pigment epithelium (RPE). α-MSH plays an important role in maintaining ocular immune privilege by helping the development of suppressor immune cells and by activating regulatory T-cells. α-MSH functions by binding to and activating melanocortin receptors (MC1R to MC5R) and receptor accessory proteins (MRAPs) that work in concert with antagonists, otherwise known as the melanocortin system. As well as controlling immune responses and inflammation, a broad range of biological functions is increasingly recognised to be orchestrated by the melanocortin system within ocular tissues. This includes maintaining corneal transparency and immune privilege by limiting corneal (lymph)angiogenesis, sustaining corneal epithelial integrity, protecting corneal endothelium and potentially enhancing corneal graft survival, regulating aqueous tear secretion with implications for dry eye disease, facilitating retinal homeostasis via maintaining blood-retinal barriers, providing neuroprotection in the retina, and controlling abnormal new vessel growth in the choroid and retina. The role of melanocortin signalling in uveal melanocyte melanogenesis however remains unclear compared to its established role in skin melanogenesis. The early application of a melanocortin agonist to downregulate systemic inflammation used adrenocorticotropic hormone (ACTH)-based repository cortisone injection (RCI), but adverse side effects including hypertension, edema, and weight gain, related to increased adrenal gland corticosteroid production, impacted clinical uptake. Compared to ACTH, melanocortin peptides that target MC1R, MC3R, MC4R and/or MC5R, but not adrenal gland MC2R, induce minimal corticosteroid production with fewer amdverse systemic effects. Pharmacological advances in synthesising MCR-specific targeted peptides provide further opportunities for treating ocular (and systemic) inflammatory diseases. Following from these observations and a renewed clinical and pharmacological interest in the diverse biological roles of the melanocortin system, this review highlights the physiological and disease-related involvement of this system within human eye tissues. We also review the emerging benefits and versatility of melanocortin receptor targeted peptides as non-steroidal alternatives for inflammatory eye diseases such as non-infectious uveitis and dry eye disease, and translational applications in promoting ocular homeostasis, for example, in corneal transplantation and diabetic retinopathy.

Perspectives of Therapeutic Drug Monitoring of Biological Agents in Non-Infectious Uveitis Treatment: A Review

Biological drugs, especially those targeting anti-tumour necrosis factor α (TNFα) molecule, have revolutionized the treatment of patients with non-infectious uveitis (NIU), a sight-threatening condition characterized by ocular inflammation that can lead to severe vision threatening and blindness. Adalimumab (ADA) and infliximab (IFX), the most widely used anti-TNFα drugs, have led to greater clinical benefits, but a significant fraction of patients with NIU do not respond to these drugs. The therapeutic outcome is closely related to systemic drug levels, which are influenced by several factors such as immunogenicity, concomitant treatment with immunomodulators, and genetic factors. Therapeutic drug monitoring (TDM) of drug and anti-drug antibody (ADAbs) levels is emerging as a resource to optimise biologic therapy by personalising treatment to bring and maintain drug concentration within the therapeutic range, especially in those patients where a clinical response is less than expected. Furthermore, some studies have described different genetic polymorphisms that may act as predictors of response to treatment with anti-TNFα agents in immune-mediated diseases and could be useful in personalising biologic treatment selection. This review is a compilation of the published evidence in NIU and in other immune-mediated diseases that support the usefulness of TDM and pharmacogenetics as a tool to guide clinicians’ treatment decisions leading to better clinical outcomes. In addition, findings from preclinical and clinical studies, assessing the safety and efficacy of intravitreal administration of anti-TNFα agents in NIU are discussed.

Antidrug Antibodies to Tumor Necrosis Factor α Inhibitors in Patients With Noninfectious Uveitis

Importance

Tumor necrosis factor inhibitors (TNFis) can induce antidrug antibody (ADA) formation and loss of therapeutic response. However, the utility of ADA testing and the association between ADAs and treatment response in patients with noninfectious uveitis (NIU) is not well understood.

Objective

To assess the frequency of ADAs and their association with drug levels and clinical response in patients with NIU treated with adalimumab or infliximab.

Design, Setting, and Participants

This retrospective cross-sectional study included patients diagnosed with NIU who received adalimumab or infliximab and underwent testing for serum drug level and ADAs at the National Eye Institute from September 2017 to July 2021.

Exposures

Serum drug level testing with reflex testing for ADA levels was performed.

Main Outcomes and Measures

The main outcome was the association between drug levels and ADAs, clinical response, and concurrent antimetabolite use in patients treated with TNFis for NIU.

Results

Of 54 patients included in the study, 42 received adalimumab (mean [SD] age, 43.6 [19.6] years; 25 [59.5%] female) and 12 received infliximab (mean [SD] age, 42.7 [20.4] years; 7 [58.3%] male). In the adalimumab group, mean (SD) drug level was 9.72 (6.82) μg/mL, mean (SD) ADA level was 84.2 (172.9) arbitrary units/mL, and ADA frequency was 35.7% (15 of 42 patients). Mean drug level was lower in those with ADAs compared with those without ADAs (mean [SD], 2.8 [2.6] μg/mL vs 13.6 [5.2] μg/mL; difference: 10.8 μg/mL; 95% CI, 8.3-13.2 μg/mL; P < .001). There was a higher mean drug level with concurrent antimetabolite use compared with monotherapy (mean [SD], 11.0 [7.3] μg/mL vs 6.8 [4.5] μg/mL; difference: -4.2 μg/mL; 95% CI, -8.7 to 0.2 μg/mL; P = .06). Multivariable modeling showed that a 1-arbitrary unit increase in ADAs was associated with a -0.02 μg/mL (95% CI, -0.01 to -0.34 μg/mL) difference in mean drug level (P < .001). Favorable clinical response was associated with a threshold drug level above 2.7 μg/mL or an antibody level below 15.2 μg/mL. The mean (SD) drug level in the infliximab group was 27.02 (18.15) μg/mL, and no ADAs were detected.

Conclusions and Relevance

In this study, 35.7% of adalimumab-treated patients with NIU had ADAs. The presence of ADAs was associated with lower drug levels, and higher ADA levels were associated with increased risk of TNFi treatment failure. Although limited by the retrospective design, our results suggest that therapeutic drug monitoring may be considered among patients experiencing therapy failure to help exclude ADAs as a potential cause of treatment failure.

Anti-TNF vs tocilizumab in refractory uveitic cystoid macular edema due to Behcet's disease. Multicenter study of 49 patients

OBJECTIVE

To compare the efficacy of TNF inhibitors (adalimumab (ADA) and infliximab (IFX)) vs tocilizumab (TCZ) in patients with refractory cystoid macular edema (CME) due to Behçet's disease (BD).

METHODS

Multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. We analyzed the evolution of macular thickness (main outcome), best-corrected visual acuity (BCVA) and intraocular inflammation (Tyndall and vitritis) from baseline up to 4 years in the 3 groups mentioned.

RESULTS

49 patients and 72 eyes with CME were included. ADA was used in 25 patients (40 eyes), IFX in 15 (21 eyes) and TCZ in 9 (11 eyes). No statistically significant baseline differences were observed between the 3 groups except for a lower basal BCVA in TCZ group and a higher basal degree of intraocular inflammation in ADA group. Most patients from all groups had received several conventional immunosuppressive drugs. In addition, most patients in the group of TCZ had also received anti-TNF agents. Biological therapy was used in monotherapy (n=8) or combined with conventional immunosuppressive drugs (n=41). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory intraocular remission was achieved in all groups.

CONCLUSION

Refractory CME associated with BD uveitis can be effectively treated either with ADA, IFX or TCZ. Furthermore, TCZ is effective in patients resistant to anti-TNF therapy.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Anti-CD20 therapy for multiple sclerosis associated uveitis: a case series

BACKGROUND

About 1% of patients with multiple sclerosis (MS) suffer from uveitis, but data on the effects of immunotherapies for MS on MS-associated uveitis are scarce.

OBJECTIVE

To investigate the ophthalmological outcomes in patients with MS-associated uveitis treated with anti-CD20 therapy.

METHODS

Retrospective study of 12 eyes of 6 patients with MS-associated uveitis, refractory to previous immunotherapies. Uveitis activity was assessed before initiation of anti-CD20 therapy and at regular follow-up visits. Primary outcome measures were vitreous haze score, retinal vasculitis score determined on fluorescein angiography images, macular edema as quantified by central retinal thickness (CRT) on optical coherence tomography, and visual acuity. Secondary outcomes included the number of annualized uveitis or MS relapses, disease activity on cerebral magnetic resonance imaging (cMRI) and the expanded disability status scale (EDSS).

RESULTS

After a median (IQR) treatment time of 28.5 (8-43) months, anti-CD20 therapy was associated with an improvement of vitreous haze score (p=0.002), retinal vasculitis score (p=0.001), CRT (p=0.002), and visual acuity (p=0.007). The median (IQR) annualized uveitis relapse rate declined from 0.59 (0.56-0.94) before to 0 (0-0.49) after the start of anti-CD20 therapy. The median (IQR) annualized MS relapse rate declined from 0.62 (0.26-2.84) before to 0 (0-0) after the start of anti-CD20 therapy. After initiation of anti-CD20 therapy, there was no disease activity on cMRI and the EDSS improved (n=2) or remained stable (n=4). No severe adverse events were observed.

CONCLUSION

These findings suggest that anti-CD20 therapy may be a valuable treatment option for MS-associated uveitis.

Single subcutaneous injection of the minocycline nanocomposite-loaded thermosensitive hydrogel for the effective attenuation of experimental autoimmune uveitis

Autoimmune uveitis induces a serious pathological and inflammatory response in the retina/choroid and results in vision impairment and blindness. Here, we report a minocycline (Mino) nanocomposite-loaded hydrogel offering a high drug payload and sustained drug release for the effective control of ocular inflammation via a single subcutaneous injection. In the presence of divalent cations (i.e., Ca²⁺), Mino was found to co-assemble with a phosphorylated peptide (i.e., NapGFFpY) via electrostatic interaction and consequently generating Mino nanocomposite. The drug entrapment efficiency (EE) of the Mino nanocomposite varied from 29.93±0.76% to 67.90±6.57%, depending on different component concentrations. After incorporation into 30 wt% poly (D,L-lactide)-b-poly (ethylene glycol)-b-poly (D,L-lactide) (PDLLA-PEG-PDLLA) thermosensitive hydrogel, the resulting Mino nanocomposite-loaded hydrogel provided a sustained drug release over 21 days. In the experimental autoimmune uveitis (EAU) rat model, a single subcutaneous injection of the Mino nanocomposite-loaded hydrogel effectively alleviated ocular inflammation in a dose-dependent manner. As indicated by optical coherence tomography (OCT) and electroretinogram (ERG) measurements, the Mino nanocomposite-loaded hydrogel treatment not only remarkably reduced destruction of the retina by EAU, but also greatly rescued retinal functions. Moreover, the proposed Mino nanocomposite-loaded hydrogel exerted its therapeutic effect on EAU primarily through a significant reduction of the influx of leukocytes and Th17 cells as well as suppression of microglia activation and apoptosis in the retina. Overall, the proposed Mino nanocomposite-loaded hydrogel might be a promising strategy for the clinical management of EAU.

Management Strategies of Juvenile Idiopathic Arthritis-Associated Chronic Anterior Uveitis: Current Perspectives

Juvenile idiopathic arthritis (JIA) is the most common extraocular disease associated with pediatric uveitis. Despite the growing knowledge about the pathogenetic and clinical characteristics of the disease, it still remains a challenge for both the pediatric rheumatologist and ophthalmologist. Since uveitis is asymptomatic in most cases, it is generally detected by parents in a late phase of the disease when complications have occurred with consequent severe vision loss. Improvement in attentive screening and early treatment initiation to suppress inflammation has considerably reduced the sight-threatening outcomes of JIA-associated chronic anterior uveitis (JIA-CAU). Initial treatment with topical steroids is effective in most cases. However, more severe cases require the use of periocular or systemic corticosteroids, possibly leading to long-term complications. These include growth retardation, cataract and glaucoma. Systemic immunosuppressive agents are then employed in patients resistant to first-line therapy or to reduce steroid-associated complications. In this review, we will discuss the immunosuppressant agents currently employed for the treatment of the disease, including anti-tumor necrosis factor (TNF)α biologics approved or not by the regulatory agencies. We will also highlight how new therapeutic options like biologic targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4) co-stimulatory molecule, interleukin-6 receptor (IL-6R) or B lymphocytes might represent exciting new options for patients resistant to conventional therapy. Finally, the potential use of janus kinase (JAK) inhibitors recently approved for the treatment of several inflammatory rheumatic diseases in adults will be also discussed.

The Trend of Drug Therapy on Uveitic Macular Edema: A Bibliometric Analysis of the 100 Most Cited Articles

Background

Macular edema is the most common cause of impaired vision due to uveitis. Although various medications are available, not all uveitis patients with macular edema are satisfied with the treatment results. Therefore, solving this gap becomes the utmost concern worldwide. This study attempted to use bibliometric analysis to compare the valuable information in the top 100 highly cited studies in the field of drug therapy for uveitic macular edema (UME) and then determine the research hot spots and trends in this field.

Methods

In this study, the Science Citation Index Expanded (SCIE) of Web of Science (WOS) was used to collect the top 100 most cited studies on UME and analyze the literature from different countries/regions, institutions, and journals. The visualization knowledge maps is generated by VOSviewer and Citespace software.

Results

The top 100 highly cited studies are from 34 countries/regions. The United States has the largest number of publications, followed by the England, Spain and Germany. The top three institutions publishing highly cited literature are all from the England: University of London, University College London, and Moorfields Eye Hospital NHS Foundation Trust. Ophthalmology is the most widely published journal with 14 papers. The total number of citations is 1,371, meaning that Ophthalmology is the most authoritative journal in the field of UME drug therapy. The top two articles with the most cited times are from the United States, accounting for 36.5% of the total cited times of the top 10 articles. Keywords were divided into three clusters: the corticosteroid administration pathway, biological agents, and clinical trials. Uveitis, cystoid macular edema, efficacy, dexamethasone, and triamcinolone acetonide appeared more frequently in keywords. Researches on local and long-acting drug has gradually becoming the hot spots and trends.

Conclusion

This study concludes that bibliometric analysis can intuitively and quickly obtain the frontiers and hot spots of research in the field of UME drug therapy. Corticosteroid administration, biological agents, and clinical trials are considered the potential focus of future research.

An Introduction to Biosimilars for the Treatment of Retinal Diseases: A Narrative Review

Biological therapies have revolutionized the treatment of disease across a number of therapeutic areas including retinal diseases. However, on occasion, such treatments may be relatively more expensive compared to small molecule therapies. This can restrict patient access and treatment length leading to suboptimal clinical outcomes. Several biosimilar candidates of ranibizumab and aflibercept are currently in development and the first biosimilar of ranibizumab received EMA approval in August and FDA approval in September 2021. Biosimilars are biological medicines that are highly similar to an already-approved biological medicine (reference product). The physicochemical and clinical similarity of a biosimilar is determined by a rigorous analytical and clinical program, including extensive pharmacokinetic and pharmacodynamic analysis with phase III equivalence studies where appropriate. These phase III studies are carried out in a patient population that is representative of all of the potential approved therapeutic indications of the originator product and the most sensitive for detecting potential differences between the biosimilar and the reference product. Biosimilars have been used successfully across a wide range of therapeutic areas for the past 15 years where they have achieved substantial cost savings that can be reinvested into healthcare systems without affecting the quality of patient care. The current review provides an introduction to biosimilars with the aim of preparing retinal specialists for discussing these products with their patients.

Anti-inflammatory Effects of GTE in Eye Diseases

Ocular inflammation is a common complication of various eye diseases with wide consequences from irritations to potentially sight-threatening complications. Green tea is a popular beverage throughout the world. One of the proven health benefits of consuming green tea extract (GTE) is anti-inflammation. Catechins are the biologically active constituents of GTE. In in vitro and in vivo studies, GTE and catechins present inhibition of inflammatory responses in the development of ocular inflammation including infectious, non-infectious or autoimmune, and oxidative-induced complications. Research on the ocular inflammation in animal models has made significant progress in the past decades and several key disease mechanisms have been identified. Here we review the experimental investigations on the effects of GTE and catechins on various ocular inflammation related diseases including glaucoma, age-related macular degeneration, uveitis and ocular surface inflammation. We also review the pharmacokinetics of GTE constituents and safety of green tea consumption. We discuss the insights and perspectives of these experimental results, which would be useful for future development of novel therapeutics in human.

Ocular Manifestations of Behçet's Disease: An Update on Diagnostic Challenges and Disease Management

Behçet's disease is a systemic vasculitis that affects multiple organs. The most common manifestations are oral and genital ulcerations and recurrent uveitis. Uveitis can be an initial symptom in 10-20% of cases and leads to blindness in 16-25% of patients. The management of this disease is evolving due to the clinical phenotypes recently described in the literature and increasing focus on the detection of subclinical inflammation to enable correct therapeutic decisions. The first line treatment is azathioprine, followed by various immunosuppressive and biological agents as alternatives in severe or refractory cases. This review summarizes scientific articles about the etiology of, diagnostic tools for and treatment of the ocular manifestations of Behçet's disease available in the PubMed database from 1 January 2016 to 1 May 2021. A multidisciplinary approach is necessary to effectively prevent permanent damage and thus improve the life quality of the patients. Therefore, it is crucial to raise awareness of the common clusters of symptoms, use of modern imaging methods, such as ocular computed tomography and fluorescein angiography, and novelty treatment algorithms to enable early diagnosis and appropriate management.

Clinical characteristics and treatment of pars planitis: an adalimumab experience

PURPOSE

This study aims to investigate the clinical and demographic characteristics, treatment outcomes and complications of patients with pars planitis.

METHODS

This retrospective study included patients diagnosed with pars planitis between 1998 and 2019 and followed for at least 6 months. Demographics, best-corrected visual acuity (BCVA), anterior segment and fundus examination findings, intraocular pressure (IOP) values at baseline and final examination, treatments used during the follow-up, surgeries and complications were noted from medical records of the patients. The percentage of patients given adalimumab (ADA), the reasons for treatment switch and response to ADA were investigated.

RESULTS

One hundred fifteen eyes of 59 patients were included in the study. Forty-seven percent of patients were female. The median age of the patients was 10 (4-44) years. The median follow-up time was 33 (6-252) months. The median BCVA at admission was 0.20 (0.00-2.00) logMAR. The most common complications were cystoid macular oedema, cataract, epiretinal membrane and inferior peripheral retinoschisis. Prophylactic laser photocoagulation for peripheral retinoschisis was the most common surgical intervention, followed by cataract surgery and pars plana vitrectomy. Approximately 80% of patients received immunosuppressive and corticosteroid therapy for initial treatment. ADA was initiated in 23 patients (38.9%) due to refractory uveitis and adverse effects to the corticosteroid and helped control intraocular inflammation and decrease the use of systemic steroids/immunosuppressives in 22 of 23 (95%) of patients who received ADA. The median BCVA at final examination increased to 0.00 (0.00-2.00) logMAR.

CONCLUSIONS

Pars planitis is a chronic, progressive and insidious disease with several ocular complications and requires early and aggressive treatment. ADA appeared to be effective especially in patients' refractory to conventional treatment.

Efficacy and Safety of Immunosuppressant Therapy for Noninfectious Uveitis: A Systematic Review and Meta-Analysis

Objective

To analyze efficacy and safety of immunosuppressant therapy for noninfectious uveitis.

Methods

A network search of PubMed, ResearchGate, and EMBASE databases was conducted for relative literature and studies from the inception of each database to April 2021. Primary outcomes were efficacy and time to treatment failure of immunosuppressant for noninfectious uveitis. Secondary outcome was incidence of adverse events (AEs). Cochrane risk of bias tool was used to assess risk of bias of included studies. Fixed effects model or random effects model was implemented to assess statistical heterogeneity. Subgroup analysis was employed to analyze heterogeneous sources.

Results

Eight studies were deemed eligible for inclusion with a total of 848 patients. Six studies were randomized controlled trials (RCTs). Among them, a single-blind RCT had relatively high measurement bias and performance bias. Immunosuppressant presented favorable efficacy for noninfectious uveitis than placebo, and RR was 1.43 (95% CI: 1.12-1.82). Immunosuppressant for noninfectious uveitis prolonged the time before failure, and HR was 0.43 (95% CI: 0.32-0.54). AEs increased after immunosuppressant was applied. Compared with immunosuppressant, RR of AEs with placebo was 0.88 (95% CI: 0.71-1.08).

Conclusion

Immunosuppressant contributed to controlling progression of noninfectious uveitis to some extent. Compared with placebo, it increased incidence of AEs. More studies with low heterogeneity are warranted for stronger evidence in clinical.

Biological Therapy in Noninfectious Pediatric Uveitis: A Systematic Review

Purpose

Noninfectious pediatric uveitis is a potentially blinding disease often associated with systemic conditions. In cases of chronic anterior uveitis without adequate response to steroids and immunosuppressants, biological response modifiers would be viable therapeutic options. Still, evidence is lacking on the safety of the long-term use of these drugs in children. Therefore, this study aimed to evaluate the efficacy and safety of biological therapy to treat noninfectious pediatric uveitis.

Methods

A systematic review was performed to identify original studies involving biological therapy for children diagnosed with noninfectious uveitis. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification system.

Results

Nine studies involving 526 children were eligible. Adalimumab was superior to placebo in reducing inflammatory activity (risk ratio (RR) 3.21 [95% confidence interval (CI) 1.65–6.27]; P = 0.0006; I² = 0%) and steroid use (RR 2.27 [95% CI 1.03–4.99]; P = 0.04; I² = 0%, low-certainty evidence). There was no difference between adalimumab and placebo in the occurrence of systemic adverse events (RR 2.51 [95% CI 0.74–8.54]; P = 0.14; I² = 48%) and local events (RR 1.15 [95% CI 0.46–2.88]; P= 0.76; I² = 1%). There was no difference between adalimumab and infliximab in response to treatment (RR 1.18 [95% CI 0.69–2.03]; P= 0.55; I² = 91%, very low-certainty evidence) and in the occurrence of adverse effects (RR 0.84 [95% CI 0.41–1.73]; P= 0.64; I² = 18%, low-certainty evidence).

Conclusion

There is low to very-low evidence that biological therapy is effective and safe in managing noninfectious pediatric uveitis. Future large randomized trials may provide more substantial evidence to confirm these results.

Juvenile Idiopathic Arthritis-Associated Chronic Uveitis: Recent Therapeutic Approaches

Pediatric patients with early onset (before the age of 6 years), antinuclear antibody positive, oligoarticular or polyarticular juvenile idiopathic arthritis (JIA), and some children with no arthritis may develop chronic, anterior uveitis. Recent recommendations insist on the need to perform slit lamp examination every 3 months for at least 5 years in early onset JIA patients in order to diagnose uveitis before complications develop. Local steroid therapy is usually the first-line treatment. However, in patients requiring steroid eye drops for several months, systemic immunomodulatory therapy is indicated. Methotrexate (MTX) is then prescribed in most cases; however, some patients also need anti-tumor necrosis factor alpha monoclonal antibody therapy and, in some cases, other biologics to control uveitis and avoid long-term ocular damage. Expert ophthalmologists and pediatricians must be involved in taking care of such patients. Immunomodulatory treatment must not be too easily interrupted and may even be intensified in some cases, particularly if there is a need for optimal disease control before ophthalmologic surgery. In good responders to MTX and/or biologics, treatment must be maintained at least 1 year, possibly even 2 years after achieving remission before tapering treatment intensity.

The Efficacy of Adalimumab as an Initial Treatment in Patients with Behçet's Retinal Vasculitis

Background: No study has evaluated the effectiveness of Adalimumab (ADA) as first-line in treatment-naïve patients with retinal vasculitis due to Behçet’s Uveitis (BU).

Objective: To compare the efficacy of ADA plus conventional therapy and conventional therapy alone as initial treatments in naïve BU patients characterized by retinal vasculitis.

Methods: Medical records of BU patients characterized by retinal vasculitis treated with conventional therapy (CT, refers to glucocorticoid and immunosuppressive agents) alone or ADA plus conventional therapy with at least 6 months of follow-up between February 2015 and June 2020 were analyzed. Only patients who were first diagnosed with BU without previous systemic treatment were reviewed. The retinal vasculitis score based on fluorescein angiography (FA), best-corrected visual acuity, glucocorticoid-sparing effect, the number of relapses and ocular complications were evaluated.

Results: A total of 45 patients (87 eyes) were included. Twenty-four patients (55.33%) in the CT group were treated with conventional therapy and 21 patients (46.67%) in the ADA group were treated with ADA plus conventional therapy. The inflammatory parameters improved in both groups. FA scores showed significantly greater improvement in ADA group than CT group (p < 0.001). The median number of relapses was significantly lower, and the duration of remission was longer in ADA group than CT group (p < 0.001). At the last visit, a significantly better BCVA improvement (p = 0.024), better inflammation control (anterior chamber inflammation p = 0.017 and vitritis p < 0.001) and lower daily glucocorticoid dosage (p = 0.005) were identified in patients received ADA therapy. In CT group, 1 patient suffered hepatitis B and tuberculosis, 1 had growth retardation, 1 patient had with osteoporosis, then followed by other mild AEs (mostly respiratory upper tract infections); while in ADA group, 1 patient experienced a mild pneumonia (n = 1) while milder AEs were represented mostly by respiratory upper tract infections followed by gastrointestinal discomfort.

Conclusion: ADA plus conventional therapy achieved superiority over conventional therapy as initial treatment in naïve BU patients with retinal vasculitis.

A Review of the Various Roles and Participation Levels of B-Cells in Non-Infectious Uveitis

Non-infectious uveitis is an inflammatory disorder of the eye that accounts for severe visual loss without evident infectious agents. While T cells are supposed to dominate the induction of inflammation in non-infectious uveitis, the role of B cells in the pathogenesis of this disease is obscure. Therefore, this review aimed to discuss diverse B-cell participation in different non-infectious uveitides and their roles in the pathogenesis of this disease as well as the mechanism of action of rituximab. Increasing evidence from experimental models and human non-infectious uveitis has suggested the participation of B cells in non-infectious uveitis. The participation levels vary in different uveitides. Furthermore, B cells play multiple roles in the pathogenic mechanisms. B cells produce autoantibodies, regulate T cell responses via antibody-independent functions, and constitute ectopic lymphoid structures. Regulatory B cells perform pivotal anti-inflammatory functions in non-infectious uveitis. Rituximab may work by depleting pro-inflammatory B cells and restoring the quantity and function of regulatory B cells in this disease. Identifying the levels of B-cell participation and the associated roles is beneficial for optimizing therapy. Diversified experimental model choices and emerging tools and/or methods are conducive for future studies on this topic.

Interleukins and cytokine biomarkers in uveitis

Interleukins and cytokines are involved in the pathogenesis of uveitis of heterogeneous origin. Understanding the basics of the ocular immune privilege is a fulcrum to discern their specific role in diverse uveitis to potentially translate as therapeutic targets. This review attempts to cover these elements in uveitis of infectious, noninfectious and masquerade origin. Insights of the molecular targets in novel therapy along with the vision of future research are intriguing.

Recent advances in the treatment of juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis-associated uveitis has an estimated prevalence of 10-20% in patients with juvenile idiopathic arthritis, making it the most common cause of chronic anterior uveitis in children. Prompt treatment is important to prevent development of ocular complications and permanent vision loss. In this review, we will discuss the use of immunosuppression in treatment of juvenile idiopathic arthritis-associated uveitis. This will include the use of conventional immunosuppressants, such as methotrexate, biologic anti-tumor necrosis factor agents, such as adalimumab, as well as other anti-tumor necrosis factor agents, including infliximab and golimumab. In addition, we will discuss medications currently in clinical trials or under consideration for juvenile idiopathic arthritis-associated uveitis, including interleukin-6 inhibitors (tocilizumab) and Janus kinase inhibitors (tofacitinib, baricitinib).

Comparative study of adalimumab versus conventional therapy in sight-threatening refractory Behçet's uveitis with vasculitis

BACKGROUND

Anti-tumor necrosis factor-alpha was regarded as an option in treatment of non-infectious uveitis. However, few studies in the far easter region have concentrated on this therapy and current studies have not emphasized the elimination of retinal vasculitis. To compare the effectiveness of adalimumab (ADA) plus conventional therapy (CT) versus CT alone in treating patients with retinal vasculitis (RV) due to refractory Behçet's uveitis (BU).

DESIGN

Retrospective cohort study.

METHODS

Clinical records of BU patients with previously treated but poorly controlled RV were analyzed. Patients were allocated into two groups depending on ADA use. Each group was treated for no less than 6 months between February 2015 and September 2020. The primary outcome parameter was the RV score. Best-corrected visual acuity (BCVA), number of relapses, macular thickness and ocular complications were considered concomitantly.

RESULTS

Forty-two patients (72 eyes) were included; 21 patients were in CT group, and 21 patients were in ADA group. Inflammatory parameters improved in both groups. The improvement in the fluorescein angiography (FA) score and anterior chamber inflammation were significantly better in ADA group than in CT group (P < 0.05). The relapse time was significantly lower in ADA group than in CT group (P = 0.01). Daily glucocorticoid dose tapers were more evident in ADA group than in CT group (P < 0.05). Adverse events were detected in 7 patients (5 had upper respiratory tract infection and 2 had gastrointestinal discomfort) in ADA group; in CT group, upper respiratory infection and recurrent gum swelling were observed in 1 patient each.

CONCLUSION

Our results indicate that ADA plus CT outperforms CT alone in patients with RV due to refractory BU. More agile ADA use in these patients should be considered to achieve optimal treatment.

A Review of Local Therapy for the Management of Cystoid Macular Edema in Uveitis

ABSTRACT

Uveitic macular edema is a significant cause of visual impairment in most uveitis types. Treatment options of uveitis have advanced remarkably in recent years. Up to now, corticosteroids remain the mainstay of treatment. Nonsteroidal immunomodulators, and recently the biologic agents, which can reinforce efficacy and enable discontinuation or reduction of steroids to maintenance doses, are becoming increasingly popular in the management of uveitic macular edema. Several medications can be used in intraocular delivery and more and more sustained releasing implants are being developed. This review will briefly focus on the review of local therapy for the management of cystoid macular edema in uveitis, as many of these novel approaches are currently being evaluated in clinical trials.

Systemic immunosuppressive therapies for uveitis in developing countries

There are multiple approaches to inhibit inflammatory molecules and pathways in noninfectious uveitis. The cornerstone of local and systemic anti-inflammatory treatment is corticosteroid therapy. Corticosteroids remain the most potent and efficacious drugs for treating intraocular inflammation. However, their long-term use is limited by their medium- and long-term side effects, which are a major concern. The approach taken to limit corticosteroid side effects is to introduce steroid-sparing agents that suppress the inflammatory pathways and immune response differently than corticosteroids. There are several classes of such drugs that are affordable, effective, and generally well-tolerated. Relatively recently, an increasing range of biologic agents has become available to treat intraocular inflammation. However, the relatively expensive cost of these therapies limits their use in the developing world. This systemic review aimst to discuss the use of corticosteroids and different immunosuppressive regimens in the management of various uveitides.

A review of ocular adverse events of biological anti-TNF drugs

The recent introduction of biological agents has revolutionized the treatment of chronic immune-inflammatory diseases; however, this new therapy did not come without significant side effects.Through large controlled studies indicating decrease in the number of uveitis flares, the role of TNF inhibitors therapy for non-infectious uveitis gained more ground. Paradoxically to its therapeutic effect, there are reports associating these drugs with the onset or recurrence of inflammatory eye disease.A number of studies have suggested possible roles for anti-TNF-α agents in precipitating or worsening an underlying inflammatory process, including the hypothesis of a disequilibrium in cytokine balance, but to date the mechanisms responsible for these adverse events are not fully understood.A PubMed literature search was performed using the following terms: ophthalmic complication, uveitis, inflammatory eye disease, optic neuritis, neuropathy, adverse events, anti-TNF, TNF alpha inhibitor, infliximab, etanercept, adalimumab, golimumab, certolizumab, and biologics. The data presented in this study was mainly derived from the use of TNF inhibitors in rheumatology, essentially because these drugs have been used for a longer period in this medical field.Many of the ocular adverse events reported on this review may be considered a paradoxical effect of anti-TNF therapy. We found a variety of data associating new onset of uveitis with anti-TNF therapy for rheumatic conditions, predominantly under etanercept.In conclusion, although there is increasing data on ocular adverse events, it remains to be seen whether the suggested link between TNF inhibitors and the onset of ocular inflammation is substantiated by more quality data. Nevertheless, the awareness of potential treatment side effects with anti-TNF should be highlighted.

Cytokine Profiling in Aqueous Humor Samples From Patients With Non-Infectious Uveitis Associated With Systemic Inflammatory Diseases

Non-infectious uveitis are intraocular inflammatory conditions caused by dysregulated activation of the immune response without any detectable infectious agents. The aim of this study was to explore potential markers and therapeutic targets for two distinct types of non-infectious uveitis associated with Behçet's disease (BD) and Vogt Koyanagi Harada (VKH) disease. Concentrations of 27 cytokines were investigated in aqueous humor (AH) samples from patients with active uveitis vs. healthy controls (HC) (n = 10 patients with BD-associated uveitis; n = 10 patients with VKH-associated uveitis; n = 10 HC) using the Bio-Plex Pro^TM human cytokine group I panel. Additionally, leukocytes in AH samples were counted with hemocytometers and characterized by flow cytometry. Eleven cytokines were differentially expressed between patients with uveitis and HC with a median concentration greater than 10 pg/ml. IL-6, IP-10, G-CSF, and IFNγ showed higher concentrations in AH samples from both BD and VKH patients while IL-2, IL-8, IL-13, TNFα, eotaxin, IL-1ra showed statistically significant higher concentrations only in AH samples from BD patients. GM-CSF was the sole cytokine with an opposite profile showing decreased levels in AH samples from BD patients. IL-1ra and IL-6 were detected at higher frequencies in AH samples from BD and VKH patients compared with those from HC while IFNγ and TNFα were not detected in HC. The concentrations of IL-6, IL-8, IP-10, G-CSF, IFNγ, TNFα, eotaxin, IL-1ra positively correlated with the concentrations of leukocytes in AH, suggesting that such cytokines can be produced by immune cells and/or attract and/or promote proliferation and survival of immune cells in these types of uveitis. The correlation matrix of cytokine concentrations in AH samples revealed that IFNγ, TNFα, eotaxin, IL-6, G-CSF highly correlated each other. The ratios of cytokine concentrations between AH and plasma intra-individuals showed that IL-2, IL-6, IP-10, GM-CSF were increased intraocularly. In conclusion, AH sampling followed by multiplex analysis of cytokines should be fostered in non-infectious uveitis to identify cytokines dysregulated intraocularly in each individual laying the groundwork for precision medicine.

Tackling HTLV-1 infection in ophthalmology: a nationwide survey of ophthalmic care in an endemic country, Japan

INTRODUCTION

Japan is the most endemic of the developed nations in terms of human T-lymphotropic virus type 1 (HTLV-1) infection. Japan has been tackling HTLV-1 infection and has made remarkable progress. In ophthalmology, awareness of the association between HTLV-1 infection and uveitis has been increasing since the 1990s, when the relationship was first established. Here, we describe a nationwide survey and analysis of the current state of medical care for HTLV-1-associated uveitis (HAU) at ophthalmic facilities in Japan.

METHODS

A questionnaire survey covered all university hospitals in Japan that were members of the Japanese Ophthalmological Society and all regional core facilities that were members of the Japanese Ocular Inflammation Society. Survey data were collected, and nationwide data on the state of medical care for HAU were tallied and analysed.

RESULTS

Of the 115 facilities, 69 (60.0%) responded. HAU was most commonly diagnosed 'based on blood tests and characteristic ophthalmic findings'. Overall, 86.8% of facilities perform testing for HTLV-1 antibodies during medical care for diagnosing uveitis, with 58.3% routinely performing testing. Facilities with experience in providing medical care for HAU accounted for 67.6%. The survey also revealed that 85.5% of facilities had seen no decrease in the number of patients with HAU.

CONCLUSIONS

In the two decades since the establishment of HAU as a pathological entity, the majority of facilities in Japan have started performing testing for HTLV-1 antibodies when considering differential diagnoses for uveitis. Our data suggest that providing information on HTLV-1 infection to ophthalmologists in Japan has been successfully implemented.

A C-terminal peptide from type I interferon protects the retina in a mouse model of autoimmune uveitis

Experimental autoimmune uveitis (EAU) in rodents recapitulates many features of the disease in humans and has served as a useful tool for the development of therapeutics. A peptide from C-terminus of interferon α1, conjugated to palmitoyl-lysine for cell penetration, denoted as IFNα-C, was tested for its anti-inflammatory properties in ARPE-19 cells, followed by testing in a mouse model of EAU. Treatment with IFNα-C and evaluation by RT-qPCR showed the induction of anti-inflammatory cytokines and chemokine. Inflammatory markers induced by treatment with TNFα were suppressed when IFNα-C was simultaneously present. TNF-α mediated induction of NF-κB and signaling by IL-17A were attenuated by IFNα-C. Differentiated ARPE-19 cells were treated with TNFα in the presence or absence IFNα-C and analyzed by immmunhistochemistry. IFNα-C protected against the disruption integrity of tight junction proteins. Similarly, loss of transepithelial resistance caused by TNFα was prevented by IFNα-C. B10.RIII mice were immunized with a peptide from interphotoreceptor binding protein (IRBP) and treated by gavage with IFNα-C. Development of uveitis was monitored by histology, fundoscopy, SD-OCT, and ERG. Treatment with IFNα-C prevented uveitis in mice immunized with the IRBP peptide. Splenocytes isolated from mice with ongoing EAU exhibited antigen-specific T cell proliferation that was inhibited in the presence of IFNα-C. IFNα-C peptide exhibits anti-inflammatory properties and protects mice against damage to retinal structure and function suggesting that it has therapeutic potential for the treatment of autoimmune uveitis.

Retinal Function in Patients with Adalimumab Treatment: Long-term Follow-up with Microperimetry

Purpose: To examine the effects of a biological treatment (adalimumab) on visual function in patients with ankylosing spondylitis and in uveitic patients without macular edema during one-year treatment with adalimumab.Methods: Sixteen eyes of eight consecutive Caucasian patients treated with adalimumab were followed up using microperimetry (MAIA; CenterVue, Padova, Italy). Five patients had ankylosing spondylitis without uveitis, three patients had panuveitis without macular edema. Macular sensitivity and macular integrity were recorded.Results: During six-month follow-up, the average threshold did not change significantly (p = .649). Macular integrity was stable (p = .225). The macular sensitivity point analysis showed no significant effects (examination F(3,56) = 0.494 and p = .688; point*examination F(108,2016) = 0.688 and p = .994) during the follow-up.Conclusions: During one-year follow-up, adalimumab did not affect macular function, unlike the well-established maculopathy induced by hydroxychloroquine. Microperimetry may be considered when following-up macular function in patients undertaking adalimumab.