Seronegative spondyloarthropathies and the eye

Ocular manifestations in Iranian patients referred to rheumatology clinics from 2018 to 2020

AIM

Autoimmune diseases are presented with many signs and symptoms. Eyes are commonly involved in these diseases. This study aimed to estimate the prevalence of different ophthalmological complications in patients with and without immune-mediated rheumatological diseases.

METHODS

Patients who were referred to Kermanshah's rheumatologic clinics by an ophthalmologist from 2018 to 2020 for a rheumatologist visit were included. A checklist for extracting data from medical files; containing symptoms, organ involvement, ocular diseases diagnosed by an ophthalmologist, rheumatologic diseases diagnosed by a rheumatologist, lab tests, and disease progression was created. After we evaluated the medical data, we found that 54 patients out of 106 were diagnosed to have immune-mediated rheumatological diseases. Patients were divided into two groups; the first group included patients with diagnosed immune-mediated rheumatologic disease and ophthalmic complications; patients with no known immune-mediated rheumatological disease were considered the second group. The obtained information was analyzed using statistical tests.

RESULTS

One hundred and six patients participated in this study, 67% of whom were females. The most common ocular symptom was blurred vision (49%). Involvement of both eyes (43.4%) was more common than single left or right eye involvement. The most common ophthalmic disease was anterior uveitis (35.8%). The most common rheumatologic disease was Behçet's disease (21.7%). Hypertension and hypothyroidism were the most common comorbidities; 36.7% of the patients had skin and mucous involvement, and 37.7% had joint involvement. In follow-up of the ophthalmic symptoms, most patients were controlled partially. Ophthalmic diseases, laboratory tests, joint involvement, skin and mucous involvement, and lung involvement were associated with rheumatologic diseases.

CONCLUSION

Early diagnosis of ocular involvement in rheumatologic diseases is crucial to prevent adverse complications. The results can be beneficial for a better perception of ophthalmic symptoms and diseases among patients with autoimmune diseases.

[Differential diagnosis of anterior uveitis]

Anterior uveitis is a potentially sight-threatening disease, which affects either one or both eyes. Although the etiology is not fully understood, important associations with systemic diseases and infections have been established. A thorough clinical investigation with the slit lamp may reveal important findings leading to diagnosis and therapy. Additional diagnostic procedures are usually required only with the occurrence of relapses. Most anterior uveitis cases with an underlying autoimmune etiology respond very well to topical steroids and mydriasis while systemic treatment is rarely needed. In contrast, infectious causes typically require systemic medication. Anterior uveitis has a good prognosis if treated adequately despite some complications like cataract, macular edema, or increase of intraocular pressure, which cannot be prevented in all cases.

Bilateral sacroiliitis and uveitis comorbidity: brucellosis? Ankylosing spondylitis?

We present a rare case of a comorbidity of sacroiliitis and brucellosis infection. A 28-year-old woman received irregular medication due to ongoing backache and hip pain for 5 years. The patient presented to our hospital for evaluation of visual loss and was diagnosed with uveitis. Sacroiliac MRI was performed to investigate the inflammatory backache and hip pain, and the aetiology of the uveitis, revealing the presence of sacroiliitis. The patient's blood test results were as follows: positive brucellosis Rose Bengal test and positive tube agglutination test with a titre of 1/640. The patient was treated with doxycycline and rifampicin for 8 weeks for the brucellosis infection, and with acemetacin for the ankylosing spondylitis. The patient's back and hip pain decreased significantly 8 weeks later; however, the uveitis was not controlled by the treatment. Therefore, anti-tumour necrosis factor (infliximab) treatment was started.

Difluprednate 0.05% versus prednisolone acetate 1% for endogenous anterior uveitis: a phase III, multicenter, randomized study

PURPOSE

Endogenous anterior uveitis (AU), when untreated, may lead to vision loss. This study compared the safety and efficacy of difluprednate versus prednisolone acetate for the treatment of this condition.

METHODS

This phase III, double-masked, noninferiority study randomized patients with mild to moderate endogenous AU to receive difluprednate 0.05% (n = 56) four times daily, alternating with vehicle four times daily, or prednisolone acetate 1% (n = 54) eight times daily. The 14-day treatment period was followed by a 14-day dose-tapering period and a 14-day observation period. The primary efficacy end point was change in anterior chamber cell grade (range, 0 for ≤1 cell to 4 for >50 cells) from baseline to day 14.

RESULTS

At day 14, the mean change in anterior chamber cell grade with difluprednate was noninferior to that with prednisolone acetate (-2.2 vs. -2.0, P = 0.16). The proportions of difluprednate-treated patients versus prednisolone acetate-treated patients demonstrating complete clearing of anterior chamber cells at day 3 were 13.0% vs. 2.1% (P = 0.046) and at day 21 were 73.9% vs. 63.8% (P = 0.013). A significant between-group difference in the mean IOP increase was seen at day 3 (2.5 mm Hg for difluprednate-treated patients and 0.1 mm Hg for prednisolone acetate-treated patients, P = 0.0013) but not at other time points. The mean IOP values in both groups remained less than 21 mm Hg throughout the study.

CONCLUSIONS

Difluprednate 0.05% four times daily is well tolerated and is noninferior to prednisolone acetate 1% eight times daily for the treatment of endogenous AU. (ClinicalTrials.gov number, NCT01201798.).

Cutting-edge issues in autoimmune uveitis

Autoimmune uveitis (AIU) is among the leading causes of preventable blindness. It can be isolated, precede, or appear in the course of a systemic autoimmune inflammatory disease. When suspected, AIU should be promptly referred to an ophthalmologist for proper anatomic classification and local treatment. In recurrent and chronic forms, systemic treatment should be started, usually with corticosteroids and immunesuppressors. In cases of lack of efficacy or intolerance, biologic agents such as monoclonal antibodies anti-TNF (infliximab and adalimumab) and others (abatacept and tocilizumab) are being used. The clinical diseases associated to AIU and the experimental models have helped in the understanding of the pathogenic mechanism. The treatment schemes have improved, and recent advances in basic knowledge are leading to even more effective targeted therapies.

Impact of IL-1 signalling on experimental uveitis and arthritis

BACKGROUND

Uveitis, or inflammatory eye disease, is a common extra-articular manifestation of many systemic autoinflammatory diseases involving the joints. Anakinra (recombinant interleukin (IL)-1 receptor antagonist (Ra)) is an effective therapy in several arthritic diseases; yet, few studies have investigated the extent to which IL-1 signalling or IL-1Ra influences the onset and/or severity of uveitis.

OBJECTIVE

To seek possible links between arthritis and uveitis pathogenesis related to IL-1 signalling.

METHODS

The eyes of IL-1Ra-deficient BALB/c mice were monitored histologically and by intravital videomicroscopy to determine if uveitis developed along with the expected spontaneous arthritis in ankles and knees. Expression levels of IL-1R and its negative regulators (IL-1Ra, IL-1RII, IL-1RAcP and single Ig IL-1R-related molecule) in eye and joint tissues were compared. Differences in uveitis induced by intraocular injection of lipopolysaccharide (LPS) in mice lacking IL-1R or IL-1Ra were assessed.

RESULTS

Deficiency in IL-1Ra predisposes to spontaneous arthritis, which is exacerbated by previous systemic LPS exposure. The eye, however, does not develop inflammatory disease despite the progressive arthritis or LPS exposure. Organ-specific expression patterns for IL-1Ra and negative regulators of IL-1 activity were observed that appear to predict predisposition to inflammation in each location in IL-1Ra knockout mice. The eye is extremely sensitive to locally administered LPS, and IL-1Ra deficiency markedly exacerbates the resulting uveitis.

CONCLUSION

This study demonstrates that IL-1Ra plays an important role in suppressing local responses in eyes injected with LPS and that there is discordance between murine eyes and joints in the extent to which IL-1Ra protects against spontaneous inflammation.

Demographic, clinical, laboratory and treatment characteristics of spondyloarthritis patients with and without acute anterior uveitis

CONTEXT AND OBJECTIVE

Acute anterior uveitis is a common extra-articular manifestation in spondyloarthritis patients. The aim of this study was to compare demographic, clinical, laboratory and treatment data among spondyloarthritis patients with and without acute anterior uveitis.

DESIGN AND SETTING

This was a cross-sectional analytical study at the Rheumatology Outpatient Clinic of the Evangelical University Hospital, Curitiba, Brazil.

METHODS

Spondyloarthritis patients with without acute anterior uveitis were compared regarding demographic data, spondyloarthritis subtype, peripheral arthritis, enthesitis, disease activity, functional index, physical examination, radiological involvement, HLA-B27 and treatment.

RESULTS

Presence of acute anterior uveitis was not found to have any relationship with functional index, degree of radiological involvement, peripheral arthritis or enthesitis. Acute anterior uveitis showed a negative association with skin manifestations (P = 0.04) and a trend towards higher disease activity (P = 0.06).

CONCLUSION

In the study sample, it could not be shown that AAU had any association with the functional and radiological prognoses. The patients with spondyloarthritis with and without acute anterior uveitis did not differ clinically except for a higher proportion of ankylosing spondylitis and smaller presence of skin involvement in those with uveitis.

Retrospective study on the effects of immunosuppressive therapy in uveitis associated with rheumatic diseases in Korea

This retrospective study of 432 patients was conducted between 2000 and 2009 to compare immunosuppressive therapy responses in uveitis accompanied or unaccompanied by rheumatic diseases. We divided patients into two groups: uveitis related or unrelated to rheumatic diseases. The clinical improvement after treatment was measured at the end of the observation period. Of the 432 patients with uveitis, 33 (7.6%) patients suffered from associated rheumatic diseases and 399 (92.4%) patients did not. The groups showed similar clinical features, but the mean age at onset of uveitis was lower in the rheumatic disease group (44.06 ± 2.13 years vs. 48.23 ± 0.81 years). The rheumatic diseases included spondyloarthropathy (31%), Behcet's disease (27%), rheumatoid arthritis (18%), systemic lupus erythematosus (15%), Sjogren's syndrome (6%), and mixed connective tissue disease (3%). Erythrocyte sedimentation rate and C-reactive protein level were increased in uveitis associated with rheumatic diseases, whereas ocular complications were not. The response to immunosuppressive therapy was significantly increased in cases of uveitis associated with rheumatic diseases (P < 0.05). Therefore, during early treatment, uveitis accompanied by rheumatic diseases showed better response to immunosuppressive therapy and less frequent complications.

TNF-α antagonists beyond approved indications: stories of success and prospects for the future

Tumour necrosis factor alpha (TNF-α) is a key molecule of the inflammatory response and data derived from studies in experimental animal models and humans suggest that TNF-α may be implicated in the pathogenesis of various autoimmune and non-infectious inflammatory conditions. Over the past decade pharmaceutical agents directed against TNF-α (infliximab, adalimumab and etanercept) have been widely and successfully employed for the management of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis, psoriatic arthritis, juvenile idiopathic arthritis and inflammatory bowel disease, whereas two novel anti-TNF-α agents, golimumab and certolimumab pegol, recently entered the market for the treatment of RA, AS, Crohn's disease and psoriasis. Encouraged by the positive results obtained from the use of TNF-α antagonists in terms of efficacy and safety and due to the increasingly accumulating evidence regarding the implication of TNF-α in the pathogenesis of numerous disorders, anti-TNF-α agents have been considered for the management of diseases other than the ones they were initially approved for. Although in the case of multiple sclerosis and chronic heart failure the outcome from the administration of TNF-α blockers had been less than favourable, in other cases of non-infectious inflammatory conditions the response to TNF-α inhibition had been fairly beneficial. More specifically, according to well-documented clinical trials, anti-TNF-α agents exhibited favourable results in Behçet's disease, non-infectious ocular inflammation, pyoderma gangrenosum and hidradenitis suppurativa. In this review we discuss the successful outcomes as well as the prospects for the future from the off-label use of TNF-α antagonists.

Alopecia areata during etanercept therapy

PURPOSE

To report a case of alopecia areata occurring during anti-tumor necrosis factor therapy.

METHODS

Observational case report.

RESULTS

The authors describe a 44-year-old man with ankylosing spondylitis who developed 6 months of patchy hair loss consistent with alopecia areata while undergoing treatment with etanercept.

CONCLUSIONS

Although anti-TNF agents are expected to impede autoimmune-related processes such as alopecia areata, these drugs have been found to be causally related to the development of alopecia areata. Ophthalmologists who are increasing involved in using these biologic agents should be aware of possible side effects.

Association of various inflammatory diseases with human leukocyte antigens B27, B7, Bw4 and Bw6 in patients with SSA

Seronegative spondyloarthropathies (SSA) are a group of inflammatory disorders, which clinically involve the axial skeleton and the sacroiliiac and shoulder joints. The aim of the present study was to study the association of HLA B27, B7, Bw4 and Bw6 with some inflammatory diseases, in SSA patients in our area. A total of 220 SSA patients were studied and HLA typing for these antigens were done by the complement-mediated microcytotoxicity method. The total positivity of B27 was found to be 68.64% in SSA patients. Tubercular infection (chi(2) = 8.06) and acute anterior uveitis (chi(2) = 6.19) were found to be statistically significant (P < 0.05) in B27-positive SSA patients. Tuberculosis was also found to be significantly (chi(2) = 6.40) associated with Bw4. In SSA urinary tract infection, gastrointestinal infection and streptococcal infection were not significantly associated with B27, B7, Bw4 or Bw6 antigens. Our study concludes that microbial infections do have some pathogenic role in causing SSA.