Rheumatologists and Ophthalmologists Differ in Treatment Decisions for Ocular Behçet Disease

Analyzing the demographics of patients with uveitis in an indigent, urban population

PURPOSE

To study the types of uveitis examined in a hospital serving indigent populations in need of low-cost care.

METHODS

A retrospective chart review examined the electronic medical records of all patients with uveitis-related at Drexel Eye Physicians. Data collected included demographics, anatomic location of the uveitis, systemic disease associations, treatment modalities and insurance. Statistical analysis was performed using χ² or Fischer exact tests.

RESULTS

270 patients (366 eyes) were included for analysis, 67% of patients identified as African American. Most eyes (95.3%, N = 349) were treated with topical corticosteroid drops, and only 6 (1.6%) received an intravitreal implant. Immunosuppressive medications were started in 24 patients (8.9%). Nearly 80% depended to some extent on Medicare or Medicaid Assistance for treatment coverage. There was no association between insurance type and use of biologics or difluprednate.

CONCLUSION

We found no association between insurance type and the prescription of medications for uveitis that should be used at home. There was a minimal number of patients prescribed medications for implantation in the office. The adherence of use of medications at home should be investigated.

Epidemiology and treatment of Behçet's disease in the USA: insights from the Rheumatology Informatics System for Effectiveness (RISE) Registry with a comparison with other published cohorts from endemic regions

BACKGROUND

Behçet's disease (BD), a chronic systemic vasculitis, has distinct geographical and ethnic variation. Data regarding the epidemiology of patients with BD in the U.S. are limited; therefore, we sought to describe BD patient characteristics and medication use in the U.S., and compared them with data from patients from endemic regions.

METHODS

We conducted a cross-sectional study using data from the RISE registry (2014-2018). Patients aged ≥ 18 years with BD were included. Sociodemographic and treatment information was extracted. We compared patients from the RISE registry to data from other published studies of patients with BD from endemic areas.

RESULTS

One thousand three hundred twenty-three subjects with BD from the RISE registry were included. Mean age was 48.7 ± 16.3 years, female to male ratio was 3.8:1, and 66.7% were White. The most frequently used medications included glucocorticoids (67.6%) and colchicine (55.0%). Infliximab and adalimumab were the most used biologics (14.5% and 14.1%, respectively); 3.2% of patients used apremilast. The RISE registry had more women (79.3%), and patients were older compared to previously published BD studies from endemic areas. Methotrexate and TNFi were more commonly reported in RISE (21.8% and 29.4%) compared to studies from Egypt and Turkey. Colchicine, cyclosporine, and cyclophosphamide were more commonly used in cohorts from Egypt, Turkey, and Iran.

CONCLUSIONS

Findings from the largest BD dataset in the U.S. suggest that BD patients are predominantly female. Further research is needed to explore the reasons for the higher prevalence of BD among women in the U.S. and its possible impact on disease severity and management.

Multidisciplinary management of auto-immune ocular diseases in adult patients by ophthalmologists and rheumatologists

Purpose

Management of chronic vision threatening auto‐immune ocular diseases (AIOD, e.g. uveitis, scleritis) can be challenging. Guidelines recommend a multidisciplinary approach (MDA) with ophthalmologists and rheumatologists, to enhance the recognition of systemic diseases and guide the use of immunosuppressives. However, the indications and results of such an approach have not yet been studied.

Methods

A monocentre, retrospective chart review of all patients treated in a MDA between ophthalmologists and rheumatologists, in a Dutch tertiary center. The collaboration was twofold: a combined multidisciplinary team meeting every 2 weeks, and an ophthalmology‐dedicated rheumatology outpatient clinic. Primary endpoints of this descriptive study were as follows: indications for MDA, new diagnoses of systemic auto‐immune diseases and changes in systemic immunosuppression and prednisone dosages.

Results

In total, 157 adults (mean age 46 years, 57% female, median disease duration 19 months) were included, mainly with uveitis (74%) and scleritis (12%). Multidisciplinary approach (MDA)‐indications included diagnostic workup (32%), treatment support (44%), diagnostic‐and‐treatment support (10%) and side effects (8%). A systemic disease was newly diagnosed in eight and already present in 34 patients. At baseline, 54 patients used oral prednisone at >7.5 mg/day. Non‐corticoid immunosuppressives, mostly methotrexate, were started in 41% of the patients. During follow‐up, systemic prednisone was lowered to ≤7.5 mg/day in 68% of the patients.

Conclusion

This evaluation of an MDA‐programme in the management of AIOD demonstrated its added value. Mainly, it addressed the high demand for support in managing systemic immunosuppression, resulting in significant corticosteroid tapering. In addition, it resulted in the recognition of underlying systemic diseases.

A Cross-Sectional Online Survey Identifies Subspecialty Differences in the Management of Pediatric Cataracts Associated with Uveitis

Introduction

To determine if differences exist between pediatric ophthalmologists and uveitis ophthalmologists in the treatment of pediatric uveitic cataracts and placement of intraocular lenses.

Methods

Uveitis ophthalmologists and pediatric ophthalmologists were surveyed via an online poll regarding their therapeutic management of pediatric uveitic cataract and intraocular lens (IOL) placement.

Results

Sixty-two responses from uveitis ophthalmologists and 47 responses from pediatric ophthalmologists were recorded. According to 79% of all responses, uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation. Pediatric ophthalmologists were more likely to respond that the presence of chronic juvenile idiopathic arthritis-associated iridocyclitis, pars planitis, or recurrent acute anterior uveitis is a contraindication for primary IOL implantation in pediatric cases with full control of intraocular inflammation. There was no consensus within either specialty with regard to the preferred IOL material for lens implantation. Uveitis ophthalmologists were more likely to report the use of intravenous and intravitreal steroids for perioperative treatment. In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists (71%) than pediatric ophthalmologists (50%) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types.

Conclusions

Pediatric ophthalmologists and uveitis ophthalmologists have similar approaches to the management of pediatric uveitic cataract removal and IOL insertion, but several differences remain between these subspecialties. Continued collaboration between the subspecialties would be helpful to better develop consistent criteria to improve patient care.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00245-x) contains supplementary material, which is available to authorized users.

Therapeutic challenges in the treatment of systemic inflammatory disease in pregnancy

Background

Granulomatosis with polyangiitis and Behçet’s disease can occur during pregnancy and may be treated by ophthalmologists, rheumatologists, and obstetricians. We hypothesized that specialty training would affect the way physicians selected therapy.

Methods

Using an online questionnaire, 209 uveitis specialists, 853 rheumatologists, and 2500 obstetricians were surveyed. Respondents were given clinical vignettes containing a female patient who was contemplating pregnancy or in the first trimester and was diagnosed with granulomatosis with polyangiitis or Behçet’s disease.

Results

In the patient with granulomatosis with polyangiitis, therapy choice between specialties for biologic versus non-biologic systemic immunosuppressive medications was significantly different for both the non-pregnant and pregnant patient (p < 0.00001, p < 0.00003). In the non-pregnant patient diagnosed with Behçet’s disease, the therapy choice between biologic versus non-biologic medications was also significantly different (p < 0.0003).

Conclusions

Specialty training affects how physicians manage granulomatosis with polyangiitis and Behçet’s disease. Development of inter-specialty guidelines and treatment plans may improve outcomes, communication, and patient care.

Specialty management differences of syphilis and toxoplasmosis surrounding pregnancy: a prospective cross-sectional study

Background

Syphilis and toxoplasmosis are two infectious conditions that can occur during pregnancy. Both these diseases can have ocular manifestations and thus are treated by ophthalmologists and obstetricians. We hypothesized that specialty training would affect the way physicians selected therapy.

Results

A total of 209 uveitis specialists and approximately 2500 obstetricians across the USA were surveyed using an online questionnaire distributed via listserv and social media posts. Survey respondents were given a series of clinical vignettes containing case examples of a female patient who was either contemplating pregnancy or in the first trimester and was diagnosed with either syphilis or toxoplasmosis. The questionnaire included a total of four case scenarios with questions relating to the management of these diseases, as well as pregnancy counseling. For the syphilis vignette, a total of 97 physicians responded to the survey questions. Choices of therapy between physician specialty differed significantly (p = 0.0001); however, pregnancy status did not seem to affect therapy choice in syphilis. A total of 96 physicians responded to the survey questions pertaining to the toxoplasmosis vignette. For a non-pregnant patient diagnosed with toxoplasmosis, the differences in therapy choice between specialties were not significant; however, when the patient was pregnant, therapy choice was significantly different between specialties (p = 0.0001).

Conclusions

Differences exist between ophthalmologists and obstetricians concerning the therapy for syphilis and toxoplasmosis during pregnancy. Inter-specialty collaboration is needed to develop consistent criteria to improve the management of these patients.

Influence of corticosteroid therapy on IL-18 and nitric oxide production during Behçet's disease

BACKGROUND AND AIMS

Behçet's disease (BD) is a chronic multisystemic inflammatory disease with complex etiopathogenesis. Th1-proinflammatory cytokines seem to be involved in its pathogenesis. Our current study aims to evaluate interleukin-18 (IL-18) and nitric oxide (NO) involvement in the development of different clinical manifestations of BD as well as to investigate the corticosteroid therapy effect on this production in Algerian patients.

METHODS

For this purpose, we evaluated in vivo and ex vivo IL-18, interferon-γ (IFN-γ) levels using ELISA and NO production by the Griess' method in naïve-active and corticosteroid-treated BD patients with different clinical manifestations. Additionally, we assessed CD40/CD40L expression by flow cytometrics assay in these groups of patients.

RESULTS AND DISCUSSION

Our results indicate that IL-18 and nitrite levels were higher in naïve-active BD patients. Interestingly, this high production differed according to the clinical manifestations and was associated with an increased risk of mucocutaneous and vascular involvement. Concerning corticosteroid treated-active BD patients, no difference was observed in this production between each clinical subgroup. However, IFN-γ levels increased in all categories of active patients. Interestingly, corticosteroid therapy reduced significantly these inflammatory mediators regardless of the clinical manifestations studied. In addition, the CD40/CD40L expression differed according to the clinical presentations.

CONCLUSION

Collectively, our results suggest that concomitant high production of IL-18 and NO in naïve-active BD patients is related to an increased risk of mucocutaneous lesions and vascular involvement. Moreover, the relationship between these two inflammatory markers could constitute a predictable tool of BD clinical presentations and an early factor of therapy efficiency.

Uveitis Specialists and Rheumatologists Select Different Therapies for Idiopathic Non-necrotizing Anterior Scleritis

Introduction

Uveitis specialists and rheumatologists treat patients with anterior scleritis, but data from controlled trials to guide management are scarce, making differences in treatment paradigms possible.

Methods

1044 uveitis specialists and rheumatologists were surveyed regarding therapy for a patient with anterior scleritis. Respondents were asked to select first- and second-choice therapies and then reselect therapies assuming that the costs of all options were equal and that insurance approval was ensured. Fisher’s exact tests were employed to compare selections.

Results

Ninety-two respondents (8.6%) completed the survey. Methotrexate was the most-selected first-choice treatment before equalization of cost/insurance factors among uveitis specialists (44.4%) and rheumatologists (78.6%) (p < 0.009). Uveitis specialists selected mycophenolate at a higher rate (27.8%) than did rheumatologists (5.3%) (p < 0.015). Cost and insurance considerations were not significant.

Conclusions

Uveitis specialists and rheumatologists have different preferences in the treatment of anterior scleritis. The difference is impacted more by specialty practice than by cost/insurance.