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Intravitreal Dexamethasone Implants for Refractory Macular Edema in Eyes with Noninfectious Uveitis. J Clin Med 2021; 10:jcm10173762. [PMID: 34501209 PMCID: PMC8432099 DOI: 10.3390/jcm10173762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022] Open
Abstract
Macular edema (ME) is a common cause of visual loss among eyes with uveitis, and its management can be challenging. Steroids are an effective treatment for ME, and intravitreal dexamethasone (DEX) implants provide sustained steroid release. The purpose of this study is to evaluate intravitreal DEX implant on refractory ME in eyes with noninfectious uveitis. A retrospective study including 52 eyes of 37 patients with refractory uveitic ME was conducted from January 2011 through August 2017 at Linkou Chang Gung Memorial Hospital in Taiwan. Patients’ demographic characteristics were collected. In addition, clinical information, including corrected visual acuity (VA), intraocular pressure (IOP), and central retinal thickness (CRT) on optical coherence tomography, was recorded and analyzed. During the study period, affected eyes received a total of 110 intravitreal DEX implants (range, one to six in each eye). After the first DEX implant injection in all eyes, VA significantly improved at one and two months. CRT significantly decreased one month after a single DEX implant, and the effect lasted for six months and waned over time. Patients receiving multiple DEX implants still showed significant decreases in CRT one month after the first implant. Increases in IOP were noted one month after the DEX implant, but the IOP could be medically controlled. Intravitreal DEX implants can effectively treat refractory uveitic ME, improving both VA and CRT with an acceptable safety profile. Further studies are necessary to evaluate the effect of multiple implants and long-term outcomes.
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Hasanreisoğlu M, Özdemir HB, Özkan K, Yüksel M, Aktaş Z, Atalay HT, Özdek Ş, Gürelik G. Intravitreal Dexamethasone Implant in the Treatment of Non-infectious Uveitis. Turk J Ophthalmol 2020; 49:250-257. [PMID: 31650791 PMCID: PMC6823586 DOI: 10.4274/tjo.galenos.2019.81594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives: To evaluate the long-term results of intravitreal dexamethasone implant (DEX) for noninfectious uveitis. Materials and Methods: The study included 62 eyes of 44 patients treated with DEX implant due to noninfectious uveitis and followed up for at least a year. Best-corrected visual acuity (BCVA), central foveal thickness, intraocular pressure (IOP), vitreous haze score, indications, immunomodulatory therapy and steroid usage before/after injection, number of injections, and adverse events were analyzed retrospectively. Results: Average follow-up was 20 months (range 12-64 months). The female/male ratio was 29/15. Mean age was 50 years (range 22-75 years). The most frequent uveitis etiologies were idiopathic (25 patients, 40.3%) and Behçet’s uveitis. (17 patients, 27.4%) The signedmost common indication for DEX injection was cystoid macular edema together with resistant vitreous haze (26 eyes, 41.9%). Twenty-two eyes (30%) received more than one DEX injection. Mean BCVA was improved from 0.55 logMAR at baseline to 0.38, 0.32, and 0.35 after 1, 3, and 6 months, respectively (p<0.001 for each). Mean CFT was decreased from 386 μm at baseline to 288, 311, and 302 μm after 1, 3, and 6 months, respectively (p<0.001 for each). Mean IOP did not change significantly during follow-up. Five eyes (8%) received topical anti-glaucoma medication (IOP ≥25 mmHg). Eighteen (46%) of 39 phakic eyes underwent cataract surgery during follow-up. Similar efficacy of the DEX implant was observed in eyes that received multiple injections. Systemic immunomodulatory therapy did not change significantly during follow-up. Conclusion: Intravitreal DEX injection does not alter systemic immunomodulatory therapy, but may facilitate the management of noninfectious uveitis by suppressing local intraocular inflammation. Multiple injections yielded comparable visual and anatomical outcomes to single injections. Follow-up for ocular hypertension and cataract formation are important, especially in eyes receiving multiple injections.
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Affiliation(s)
- Murat Hasanreisoğlu
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Hüseyin Baran Özdemir
- University of Health Sciences, Ulucanlar Eye Training and Research Hospital, Ophthalmology Clinic, Ankara, Turkey
| | - Kaan Özkan
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Murat Yüksel
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Zeynep Aktaş
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Hatice Tuba Atalay
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Şengül Özdek
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Gökhan Gürelik
- Gazi University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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The Anti-Inflammatory Effects of Angiogenin in an Endotoxin Induced Uveitis in Rats. Int J Mol Sci 2020; 21:ijms21020413. [PMID: 31936482 PMCID: PMC7014170 DOI: 10.3390/ijms21020413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
Angiogenin (ANG) is involved in the innate immune system and inflammatory disease. The aim of this study is to evaluate the anti-inflammatory effects of ANG in an endotoxin induced uveitis (EIU) rat model and the pathways involved. EIU rats were treated with balanced salt solution (BSS), a non-functional mutant ANG (mANG), or wild-type ANG (ANG). The integrity of the blood-aqueous barrier was evaluated by the infiltrating cell and protein concentrations in aqueous humor. Histopathology, Western blot, and real-time qRT-PCR of aqueous humor and ocular tissue were performed to analyze inflammatory cytokines and transcription factors. EIU treated with ANG had decreased inflammatory cells and protein concentrations in the anterior chamber. Compared to BSS and mANG, ANG treatment showed reduced expression of IL-1β, IL-8, TNF-α, and Myd88, while the expression of IL-4 and IL-10 was increased. Western blot of ANG treatment showed decreased expression of IL-6, inducible nitric oxide synthase (iNOS), IL-1β, TNF-α, and phosphorylated NF-κB and increased expression of IL-10. In conclusion, ANG seems to reduce effectively immune mediated inflammation in the EIU rat model by reducing the expression of proinflammatory cytokines, while increasing the expression of anti-inflammatory cytokines through pathways related to NF-κB. Therefore, ANG shows potential for effectively suppressing immune-inflammatory responses in vivo.
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You C, Sahawneh HF, Ma L, Kubaisi B, Schmidt A, Foster CS. A review and update on orphan drugs for the treatment of noninfectious uveitis. Clin Ophthalmol 2017; 11:257-265. [PMID: 28203051 PMCID: PMC5298311 DOI: 10.2147/opth.s121734] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Uveitis, a leading cause of preventable blindness around the world, is a critically underserved disease in regard to the medications approved for use. Multiple immunomodulatory therapy (IMT) drugs are appropriate for uveitis therapy but are still off-label. These IMT agents, including antimetabolites, calcineurin inhibitors, alkylating agents, and biologic agents, have been designated as “orphan drugs” and are widely used for systemic autoimmune diseases or organ transplantation. Area covered The purpose of this paper is to comprehensively review and summarize the approved orphan drugs and biologics that are being used to treat systemic diseases and to discuss drugs that have not yet received approval as an “orphan drug for treating uveitis” by the US Food and Drug Administration (FDA). Our perspective IMT, as a steroid-sparing agent for uveitis patients, has shown promising clinical results. Refractory and recurrent uveitis requires combination IMT agents. IMT is continued for a period of 2 years while the patient is in remission before considering tapering medication. Our current goals include developing further assessments regarding the efficacy, optimal dose, and safety in efforts to achieve FDA approval for “on-label” use of current IMT agents and biologics more quickly and to facilitate insurance coverage and expand access to the products for this orphan disease.
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Affiliation(s)
- Caiyun You
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA; Department of Ophthalmology, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Haitham F Sahawneh
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA
| | - Lina Ma
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA
| | - Buraa Kubaisi
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA
| | - Alexander Schmidt
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham; Ocular Immunology and Uveitis Foundation, Weston, MA, USA; Harvard Medical School, Boston, MA, USA
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Fardeau C, Champion E, Massamba N, LeHoang P. Uveitic macular edema. Eye (Lond) 2016; 30:1277-1292. [PMID: 27256304 DOI: 10.1038/eye.2016.115] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/23/2016] [Indexed: 02/06/2023] Open
Abstract
Macular edema (ME) may complicate anterior, intermediate, and posterior uveitis, which may be because of various infectious, neoplastic or autoimmune etiologies. BRB breakdown is involved in the pathogenesis of Uveitic ME (UME). Optical coherence tomography has become a standard tool to confirm the diagnosis of macular thickening, due to its non-invasive, reproducible, and sensitive features. Retinal fluorescein and indocyanine green angiography is helpful to study the macula and screen for associated vasculitis, detect ischemic areas and preretinal, prepapillary or choroidal neovascular complications, and it may provide information about the etiology and be needed to assess the therapeutic response. UME due to an infection or neoplastic infiltration may require a specific treatment. If it remains persistent or occurs in other etiologies, immunomodulatory treatments may be needed. Intravitreal, subconjunctival, or subtenon corticosteroids are widely used. Their local use is contraindicated in glaucoma patients and limited by their short-lasting action. In case of bilateral sight-threatening chronic posterior uveitis, systemic treatments are usually needed, and corticosteroids are used as the standard first-line therapy. In order to reduce the daily steroid dose, immunosuppressive or immunomodulatory agents may be added, some of them being now available intravitreally. Ongoing prospective studies are assessing biotherapies and immunomodulators to determine their safety and efficacy in this indication.
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Affiliation(s)
- C Fardeau
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - E Champion
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - N Massamba
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - P LeHoang
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
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Cordero-Coma M, Salazar-Méndez R, Yilmaz T. Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues. Expert Opin Drug Saf 2015; 14:1353-71. [PMID: 26118392 DOI: 10.1517/14740338.2015.1061992] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive (IS) drugs in selected cases. This may be particularly challenging in certain patients with associated conditions, which may increase the risk of side effects or modify guidelines for the use of such drugs. Chronic viral and mycobacterial infections in the setting of non-infectious uveitis create a number of diagnostic but also therapeutic dilemmas to clinicians because they can be exacerbated by IS therapies with detrimental effects. AREAS COVERED In this review, we will focus on very specific chronic infections that can be affected by IS therapies: human immunodeficiency virus infection, chronic hepatitis virus infection and tuberculosis. The main aim of this review is to provide an updated and comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with non-infectious uveitis affected by the aforementioned infectious conditions. EXPERT OPINION Clinicians should be aware of the risk of viral and mycobacterial reactivation of an underlying infection during IS therapy. However, most of these conditions do not represent an absolute contraindication if one were able to apply an appropriate prior screening and close monitoring of such therapy.
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Affiliation(s)
- Miguel Cordero-Coma
- a 1 University of León, Instituto Biomedicina (IBIOMED), University Hospital of León , León, Spain +34 654403609 ; +34 987 233322 ;
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Cordero-Coma M, Salazar-Méndez R, Yilmaz T. Treatment of severe non-infectious uveitis in high-risk conditions (Part I): pregnancy and malignancies, management and safety issues. Expert Opin Drug Saf 2015; 14:1071-86. [DOI: 10.1517/14740338.2015.1044969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Sepah YJ, Michelle EH, Metcalf B, Khwaja A, Channa R, Ibrahim M, Hatef E, Heo J, Hee JL, Rentiya ZS, Do DV, Nguyen QD. Voclosporin: a potentially promising therapeutic agent for noninfectious uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Schewitz-Bowers LP, Lee RWJ, Dick AD. Immune mechanisms of intraocular inflammation. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.09.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Chu DS, Johnson SJ, Mallya UG, Davis MR, Sorg RA, Duh MS. Healthcare costs and utilization for privately insured patients treated for non-infectious uveitis in the USA. J Ophthalmic Inflamm Infect 2013; 3:64. [PMID: 24195808 PMCID: PMC3830557 DOI: 10.1186/1869-5760-3-64] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/07/2013] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of this study was to describe comorbidities, healthcare costs, and resource utilization among patients with chronic non-infectious uveitis initiating corticosteroid, immunosuppressants, or biologics. In this retrospective cohort study, patients with a non-infectious uveitis diagnosis and continuous insurance coverage during a 6-month baseline were selected from a privately insured claims database with 80.7 million enrollees. Index dates were defined as the first prescription/administration of a corticosteroid, immunosuppressant, or biologic between 2003 and 2009. Comorbidities, healthcare costs, and utilization were analyzed in a per-member-per-month (PMPM) framework to account for varying between-patient treatment periods, defined as continuous medication use within the same class. Wilcoxon rank-sum and chi-square tests were used for comparisons of costs and categorical outcomes. Results Patients on corticosteroids (N = 4,568), immunosuppressants (N = 5,466), and biologics (N = 1,694) formed the study population. Baseline PMPM inpatient admission rates were 0.029 for patients on corticosteroids, 0.044 for patients on immunosuppressants, and 0.045 for patients on biologics (p < 0.001 immunosuppressants or biologics versus corticosteroids); during treatment, PMPM inpatient admissions increased to 0.044 and 0.048 for patients taking corticosteroids and immunosuppressants, respectively, but decreased to 0.024 for patients taking biologics (p < 0.001 versus corticosteroids and p = 0.003 versus immunosuppressants). Baseline average PMPM costs for patients taking corticosteroids, immunosuppressants, and biologics were US$935, US$1,738, and US$1,439 (p < 0.001 between groups), while on-treatment PMPM costs excluding drug costs increased to US$1,129 for patients taking corticosteroids but lowered to US$1,592 for patients taking immunosuppressants, and US$918 for patients taking biologics (p < 0.001 versus corticosteroids or immunosuppressants). Conclusions There is significant economic burden associated with existing treatments of uveitis. Corticosteroids may be overused as a treatment for uveitis.
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Affiliation(s)
- David S Chu
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, 90 Bergen Street, Suite 6100, Newark, NJ 07960, USA.
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Abstract
The purpose of this article is to highlight evidence about the medical and surgical management of intermediate uveitis (IU). Updated understandings of the immunopathology of IU were reviewed in this retrospective literature review. Literature selection for this review was based on the PubMed database (National Library of Medicine) and OVID database (Wolters Kluwer). Articles deemed relevant were selected and highlighted. Intermediate uveitis is most often a benign form of uveitis. Since intermediate uveitis has been described in association with different systemic disorders, the initial diagnostic evaluation should serve to exclude masquerade syndromes and infectious diseases in which immunosuppression may be ineffective or contraindicated. Although the pathogenesis of intermediate uveitis is not fully understood, identification of proinflammatory molecules involved in the IU has contributed to the development and implementation of new therapies. Studies about the use of various immunosuppressants, biological agents and surgical treatment on IU have provided more evidence for managing IU. Nevertheless, corticosteroids remain the mainstay of treatment. The treatment options of intermediate uveitis are evolving, with the development of various immunosuppressants and biological agents. The management of intermediate uveitis should be tailored individually, based on specific causes of the disease and associated complications.
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Affiliation(s)
- Frank H P Lai
- From the Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, The People's Republic of China
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Shrestha S, Thapa M, Shah DN. Pattern of intraocular pressure fluctuation in uveitic eyes treated with corticosteroids. Ocul Immunol Inflamm 2013; 22:110-5. [PMID: 24131295 DOI: 10.3109/09273948.2013.824106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine IOP fluctuation in uveitic eyes treated with corticosteroids. DESIGN Prospective Observational Study. METHOD Study of 116 consecutive new uveitis patients visiting Uveitis clinic, BPKLCOS. IOP was meticulously monitored. Data was analyzed in SPSS-16 using paired samples 't-test'. RESULTS The mean IOP in all patients at presentation, at 1 week, 3 weeks and 6 weeks were respectively 14.66 mmHg, 14.72 mmHg, 14.75 mmHg and 14.93 mmHg. This progressive IOP rise was not statistically significant. Ocular hypertension was seen in 20% eyes; 64.5% were due to corticosteroids. Steroid-induced ocular hypertension was seen in 37.03% of oral group, 14.28% of posterior subtenon group, 8.57% of topical group. Antiglaucoma medications were started in 61.2% of the cases with raised IOP. None had to undergo glaucoma filtering surgery. CONCLUSION Incidence of ocular hypertension in uveitic eyes was 20% in this study. Majority of them was corticosteroid induced. Timely medical treatment averted the necessity of surgical intervention for IOP control.
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Affiliation(s)
- Sneha Shrestha
- BP Koirala Lions Centre for Ophthalmic Studies, Maharajgunj , Kathmandu , Nepal
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Abstract
Uveitis is underappreciated as a sight-threatening cause of blindness. There are two broad causative classes of uveitis: infectious and non-infectious. Non-infectious uveitis is considered a prototypical autoimmune disorder based mainly on data from experimental models in the mouse. Several different experimental models exist that reflect the different types of uveitis in man (anterior, intermediate, and posterior uveitis). These models have demonstrated that uveitis is predominantly a Th1/Th17 mediated disease, although innate immune cells play a significant role both in induction of disease and in tissue damage. Most experimental models of uveitis rely on activation of the innate immune system by use of adjuvants that activate a range of pathogen recognition receptors (PRRs). This begs the question of the underlying role of initial and/or persistent infection, including latent infection, in immune-mediated uveitis in which active infection cannot be demonstrated. This further raises the possibility of pathogenic mechanisms such as antigenic cross-reactivity and molecular mimicry. Alternatively, residual/latent antigen from infectious agents may act as "endogenous" adjuvants for induction of immune reactions to damaged/altered self antigen, suggesting a commonality in pathogenesis for both infectious and non-infectious uveitis in man.
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Affiliation(s)
- John V Forrester
- Ocular Immunology Laboratory, Section of Immunology and Infection, Division of Applied Medicine, Institute of Medical Sciences, University of Aberdeen, Scotland.
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Therapeutic dosing of fingolimod (FTY720) prevents cell infiltration, rapidly suppresses ocular inflammation, and maintains the blood-ocular barrier. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 180:672-81. [PMID: 22119714 DOI: 10.1016/j.ajpath.2011.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 09/14/2011] [Accepted: 10/11/2011] [Indexed: 01/23/2023]
Abstract
Fingolimod (FTY720) is an FDA-approved therapeutic drug with efficacy demonstrated in experimental models of multiple sclerosis and in phase III human multiple sclerosis trials. Fingolimod prevents T-cell migration to inflammatory sites by decreasing expression of the sphingosine-1 phosphate receptor normally required for egress from secondary lymphoid tissue. As a preclinical model of human uveitis, experimental autoimmune uveoretinitis permits assessment of immunotherapeutic efficacy. Murine experimental autoimmune uveoretinitis is induced by activation of retinal antigen-specific CD4(+) T cells that infiltrate the eye. High-dose fingolimod treatment administered before disease onset reduces ocular infiltration within hours of administration and suppresses clinicopathologic expression of experimental autoimmune uveoretinitis. In the present investigation of the efficacy of fingolimod treatment for established disease, single-dose treatment was effective and immunosuppressive ability was maintained through a dose range, demonstrating significant and rapid reduction in CD4(+) cell infiltration at clinically relevant therapeutic doses of fingolimod. A repeated-treatment regimen using a dose similar to that in current multiple sclerosis patient protocols significantly reduced infiltration within 24 hours of administration; importantly, repeated doses did not compromise the vascular integrity of the blood-ocular barrier. On withdrawal of fingolimod, drug-induced remission was lost and recrudescence of clinical disease was observed. These results support a strong therapeutic potential for fingolimod as an acute rescue therapy for the treatment of ocular immune-mediated inflammation.
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Lee RWJ, Dick AD. Current concepts and future directions in the pathogenesis and treatment of non-infectious intraocular inflammation. Eye (Lond) 2011; 26:17-28. [PMID: 21960067 DOI: 10.1038/eye.2011.255] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The blockbuster drug paradigm is under increasing scrutiny across the biopharmaceutical industry. Intraocular inflammation poses particular challenges to this, given the heterogeneity of conditions in the uveitis spectrum, and the increasing acknowledgement of individual patient and disease variance in underlying immune responses. This need has triggered a drive towards personalised and stratified medicine, supported and enabled as a result of continued development of both experimental models and molecular biological techniques and improved clinical classification. As such we have the ability now to systematically appraise at a genomic, transcriptomic, and proteomic level individual immunophenotype, and the promise that in the eye this can be augmented by in vivo immune imaging to identify individual immunopathology. With such advances all running in parallel, we are entering an era of experimental medicine that will facilitate early diagnosis, generate biomarkers for accurate prognostication, and enable the development of individualised and targeted therapies, which can progress rapidly into clinical practice.
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Affiliation(s)
- R W J Lee
- School of Clinical Sciences, University of Bristol, Bristol, UK
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Lyon F, Gale RP, Lightman S. Recent developments in the treatment of uveitis: an update. Expert Opin Investig Drugs 2010; 18:609-16. [PMID: 19388878 DOI: 10.1517/14728220902852570] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The management of complex uveitis is often based around the use of oral corticosteroids. To spare the side effects of corticosteroids, second-line oral immunosuppressant drugs are used. Newer systemic immunosuppressive drugs, including biologics, and locally delivered treatments are being evaluated. This article reviews current conventional treatments, discusses their limitations and evaluates newer treatment strategies. Current theories about the pathogenesis of uveitis and potential targets for treatment are discussed in this context. We are still in search of a low-risk, where possible, locally delivered and targeted treatment for uveitis.
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Affiliation(s)
- Fiona Lyon
- Academic Unit of Ophthalmology, York Hospital, Wigginton Road, York YO318HE, UK
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Abstract
Pediatric non-infectious uveitis remains a rare but potentially sight-threatening group of diseases. However, early screening and treatment can improve outcomes. No single agent has proven to be efficacious in all cases. A wide variety of long-term immunomodulatory treatments are available; these agents differ in both their potency and side effect profiles. Corticosteroids remain an extremely valuable form of treatment in the short-term management of uveitis. Other major groups of immunomodulatory treatments include the calcineurin inhibitors and antimetabolites such as methotrexate, which is frequently used as the first-line agent. The biologics, including anti-tumor necrosis factor agents and interferons, are newer and potentially very useful therapies although side effects limit their use. Successful outcomes may be achieved with appropriate immunosuppressant therapy given early in the disease, although clinical trials are required to define the true efficacy of this strategy.
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Kim JC, Ham DI. Clinical Characteristics and Treatments of Intermediate Uveitis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2009. [DOI: 10.3341/jkos.2009.50.1.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jin Chul Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Don Il Ham
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Teoh SC, Hogan AC, Dick AD, Lee RW. Mycophenolate mofetil for the treatment of uveitis. Am J Ophthalmol 2008; 146:752-60, 760.e1-3. [PMID: 18455143 DOI: 10.1016/j.ajo.2008.03.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2008] [Revised: 02/29/2008] [Accepted: 03/03/2008] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the efficacy and tolerance of mycophenolate mofetil (MMF) for the treatment of noninfectious uveitis using the methods of analysis advocated by the Standardization of Uveitis Nomenclature (SUN) Working Group, and to compare this with other SUN-compliant reports of immunosuppression in ocular inflammation. DESIGN Retrospective case series. MEDHODS: A predefined data set was retrospectively obtained from the case notes of 100 consecutive uveitis patients treated with MMF at a single academic referral center between April 1, 2000 and August 1, 2006. These data were then analyzed in accordance with SUN recommendations. The main outcome measures were: 1) rate of tapering oral prednisone to 10 mg daily, 2) requirement for alternative second-line immunosuppressive therapy, and 3) rate of MMF dose discontinuation because of side effects. RESULTS In this large cohort with noninfectious persistent, chronic, or recurrent uveitis, there was an 84.6% probability of achieving a prednisone dose of < or =10 mg daily after one year of MMF treatment. Alternative second-line immunosuppressive therapy was introduced at a rate of 0.18 per patient-year (PY) and MMF was discontinued because of intolerance at a rate of 0.09/PY, predominantly because of gastrointestinal upset. This corroborates the findings of the only previous SUN-compliant study of MMF in ocular inflammation and is comparable to the rates of treatment success and intolerance we have recently reported for tacrolimus. CONCLUSION This data generates concordant evidence with other SUN-compliant studies supporting the use of MMF in uveitis.
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Trittibach P, Barker SE, Broderick CA, Natkunarajah M, Duran Y, Robbie SJ, Bainbridge JWB, Smith AJ, Sarra GM, Dick AD, Ali RR. Lentiviral-vector-mediated expression of murine IL-1 receptor antagonist or IL-10 reduces the severity of endotoxin-induced uveitis. Gene Ther 2008; 15:1478-88. [PMID: 18580969 DOI: 10.1038/gt.2008.109] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Uveitis is a sight threatening inflammatory disorder that remains a significant cause of visual loss. We investigated lentiviral gene delivery of interleukin 1 receptor antagonist (IL-1ra) or interleukin (IL)-10 to ameliorate murine endotoxin-induced uveitis (EIU). An human immunodeficiency virus-1-based vector containing the mIL-1ra or mIL-10 cDNA demonstrated high expression of biologically active cytokine. Following administration of Lenti.GFP into the anterior chamber, transgene expression was observed in corneal endothelial cells, trabecular meshwork and iris cells. To treat EIU, mice were injected with Lenti.IL-1ra, Lenti.IL-10 or a combination of these. EIU was induced 14 days after vector administration and mice were culled 12 h following disease induction. Lenti.IL-1ra or Lenti.IL-10-treated eyes showed significantly lower mean inflammatory cell counts in the anterior and posterior chambers compared with controls. The aqueous total protein content was also significantly lower in treated eyes, demonstrating better preservation of the blood-ocular barrier. Furthermore, the treated eyes showed less in vivo fluorescein leakage from inner retinal vessels compared with controls. The combination of both IL-1ra and IL-10 had no additive effect. Thus, lentiviral gene delivery of IL-1ra or IL-10 significantly reduces the severity of experimental uveitis, suggesting that lentiviral-mediated expression of immunomodulatory genes in the anterior chamber offers an opportunity to treat uveitis.
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Affiliation(s)
- P Trittibach
- Division of Molecular Therapy, Institute of Ophthalmology, University College London, London, UK
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