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Rojas-Carabali W, Cifuentes-González C, Gutierrez-Sinisterra L, Heng LY, Tsui E, Gangaputra S, Sadda S, Nguyen QD, Kempen JH, Pavesio CE, Gupta V, Raman R, Yan MC, Lee B, de-la-Torre A, Agrawal R. Managing A Patient with Uveitis in The Era of Artificial Intelligence: Current Approaches, Emerging Trends, And Future Perspectives. Asia Pac J Ophthalmol (Phila) 2024:100082. [PMID: 39019261 DOI: 10.1016/j.apjo.2024.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/30/2024] [Accepted: 07/04/2024] [Indexed: 07/19/2024] Open
Abstract
The integration of artificial intelligence (AI) with healthcare has opened new avenues for diagnosing, treating, and managing medical conditions with remarkable precision. Uveitis, a diverse group of rare eye conditions characterized by inflammation of the uveal tract, exemplifies the complexities in ophthalmology due to its varied causes, clinical presentations, and responses to treatments. Uveitis, if not managed promptly and effectively, can lead to significant visual impairment. However, its management requires specialized knowledge, which is often lacking, particularly in regions with limited access to care. AI's capabilities in pattern recognition, data analysis, and predictive modelling offer significant potential to revolutionize uveitis management. AI can classify disease outcomes, analyze multimodal imaging data, and identify new therapeutic targets. However, transforming these AI models into clinical applications and meeting patient expectations involves overcoming challenges like acquiring extensive, annotated datasets, ensuring algorithmic transparency, and validating these models in real-world settings. This review delves into the complexities of uveitis and the current AI landscape, discussing the development, opportunities, and challenges of AI from theoretical models to bedside application. It also examines the epidemiology of uveitis, the global shortage of uveitis specialists, and the disease's socioeconomic impacts, underlining the critical need for AI-driven approaches. Furthermore, it explores the integration of AI in diagnostic imaging and future directions in ophthalmology, aiming to highlight emerging trends that could transform management of a patient with uveitis and suggesting collaborative efforts to enhance AI applications in clinical practice.
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Affiliation(s)
- William Rojas-Carabali
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapor3.
| | - Carlos Cifuentes-González
- Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapor3.
| | - Laura Gutierrez-Sinisterra
- Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapor3.
| | - Lim Yuan Heng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - Edmund Tsui
- Stein Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA.
| | - Sapna Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Srinivas Sadda
- Doheny Eye Institute, David Geffen of Medicine at UCLA, Los Angeles, California, USA.
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA.
| | - John H Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School; and Schepens Eye Research Institute; Boston, MA, USA; Department of Ophthalmology, Myungsung Medical College/MCM Comprehensive Specialized Hospital, Addis Abeba, Ethiopia; Sight for Souls, Bellevue, WA, USA.
| | | | - Vishali Gupta
- Advanced Eye Centre, Post- graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Rajiv Raman
- Department of Ophthalmology, Sankara Nethralaya, Chennai, India.
| | - Miao Chun Yan
- School of Computer Science and Engineering at Nanyang Technological University, Singapore.
| | - Bernett Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia.
| | - Rupesh Agrawal
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapor3; Singapore Eye Research Institute, Singapore; Duke NUS Medical School, Singapore.
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Sánchez Sevila JL, Rosas Gómez de Salazar J, Seguí Crespo M. Work Productivity and Activities of Daily Living in Working Patients with Uveitis. Ocul Immunol Inflamm 2024:1-8. [PMID: 38652637 DOI: 10.1080/09273948.2024.2343071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE To assess self-reported impairment of work productivity and activities of daily living and the indirect costs of absenteeism in a sample of working patients with uveitis and to examine their association with sociodemographic, occupational, and clinical variables. METHODS We conducted a cross-sectional, cross-association study. Participants completed the self-administered Work Productivity and Activity Impairment Questionnaire uveitis 2.0 to assess absenteeism, presenteeism, overall work impairment, and impairment in activities of daily living. Clinical data were collected from the patients' medical records or instruments used to evaluate clinical parameters in practice. Indirect costs of absenteeism were assessed by the "lost wages method." Two clinical groups were established for this study. Bivariate and multivariate analyses were performed to assess the associations between variables. RESULTS The final sample comprised 60 participants. Factors significantly associated with increased overall work impairment in the multivariate linear regression analysis were active uveitis (coefficient, 31.5; 95% confidence interval [CI], 16.1 to 46.9; p < 0.001) and presence of ocular comorbidities (coefficient for absence, -16.4; 95% CI, -31.1 to -1.8; p = 0.03). Factors significantly associated with increased impairment in activities of daily living were active uveitis (coefficient, 32.1; 95% CI, 18.2 to 46.0; p < 0.001), presence of ocular comorbidities (coefficient for absence, -23.5; 95% CI, -36.1 to -11.0; p < 0.001), and absence of nonocular comorbidities (coefficient 16.1; 95% CI, 3.9 to 28.3; p = 0.01). CONCLUSIONS Active uveitis and ocular comorbidities are significantly associated with increased overall work impairment and impairment in activities of daily living in working patients with uveitis.
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Affiliation(s)
| | | | - Mar Seguí Crespo
- Department of Optics, Pharmacology and Anatomy, University of Alicante, Alicante, Spain
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Marshall RF, Berkenstock M. Factors influencing treatment and time spent with physicians in patients with uveitis compared to other ophthalmology subspecialties in the National Ambulatory Medical Care Survey. Eye (Lond) 2024:10.1038/s41433-024-03071-8. [PMID: 38605075 DOI: 10.1038/s41433-024-03071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 03/12/2024] [Accepted: 04/05/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Cases of uveitis can necessitate long-term treatment resulting in recurrent follow-up appointments. Analysing the demographic distribution and patient factors influencing treatment and time spent with physicians in this population compared to other subspecialties of ophthalmology using the National Ambulatory Medical Care Survey (NAMCS) has not previously been studied. METHODS Data were extracted from the NAMCS database, a large, nationally representative survey of office-based specialists, entered between 2012-2016 and 2018. Demographics, time with physician, and payor types were compared between patients with a uveitis-related diagnosis codes versus all other ophthalmic subspecialty diagnoses. RESULTS Overall, 12,870 ophthalmic patients were included of which 300 had uveitis-related diagnosis codes. Uveitis patients were more likely to be non-Caucasian (p < 0.0001 to p = 0.022), visiting the physician's office due to flare of or treatment for a chronic medical problem (p < 0.0001 to p = 0.022). Adjusted for age, sex, race, and ethnicity, uveitis patients spent a significantly longer time (mean 27.5 min) compared to comprehensive ophthalmology patients (mean 25.5 min) with their physician (p = 0.0041). Among the uveitis patient population, African American patients (p = 0.0053), Hispanic or Latino (p = 0.034), and Medicaid (p = 0.035) patients had increased office visit times. CONCLUSIONS Those with uveitis spent more time with the physician than comprehensive patients. Race, ethnicity, payor type, and the major reason for the visit all significantly impacted uveitis office visit times. In order to manage their schedules, providers should be aware of the additional support and time needed by these patients during office visits.
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Affiliation(s)
| | - Meghan Berkenstock
- Division of Ocular Immunology, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Chattopadhyay A, Rathinam SR, Gonzales JA, Kelly NK, Thundikandy R, Kanakath A, Murugan SB, Vedhanayaki R, Lim LL, Suhler EB, Al-Dhibi HA, Doan T, Ebert CD, Porco TC, Acharya NR. Association between Quality of Life and Visual Acuity in a Randomized Clinical Trial of Patients with Uveitis Taking Antimetabolites. Ocul Immunol Inflamm 2024; 32:301-309. [PMID: 36749914 PMCID: PMC10404633 DOI: 10.1080/09273948.2023.2169714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE To evaluate how changes in visual acuity are associated with changes in quality of life (QoL) among patients with non-infectious uveitis taking antimetabolites. METHODS This secondary analysis of the multicenter First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial involves 216 participants randomized to methotrexate or mycophenolate mofetil. Vision-related (NEI-VFQ and IND-VFQ) and health-related (PCS and MCS SF-36v2) QoL and visual acuity were measured at baseline and 6-month primary endpoint. RESULTS Visual acuity was significantly associated and correlated with all QoL measures (Spearman correlation coefficients = 0.5, 0.5, 0.3, and 0.4 for NEI-VFQ, IND-VFQ, SF-36v2 MCS and PCS, respectively). All observed changes in QoL met or exceeded the minimal clinically important difference definition on each scale. Treatment group was not significantly associated with any QoL measure. CONCLUSION By adding insight beyond visual acuity, QoL provides a more comprehensive picture of the patient experience during uveitis treatment.Abbreviations and Acronyms: QoL = quality of life; VR-QoL = vision-related quality of life; HR-QoL = health-related quality of life; FAST = First-line Antimetabolites as Corticosteroid Sparing Treatment; NEI-VFQ = National Eye Institute Visual Functioning Questionnaire; IND-VFQ = Indian Visual Functioning Questionnaire; SF-36v2 = Medical Outcomes Study 36-Item Short Form Survey; PCS = physical component score; MCS = mental component score; 95% CI = 95% confidence interval; MCID = minimal clinically important difference.
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Affiliation(s)
- Aheli Chattopadhyay
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
| | - S R Rathinam
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - John A Gonzales
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Nicole K Kelly
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Radhika Thundikandy
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - Anuradha Kanakath
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Coimbatore, India
| | - S Bala Murugan
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Pondicherry, India
| | - R Vedhanayaki
- Uvea Services, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, India
| | - Lyndell L Lim
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Eric B Suhler
- Casey Eye Institute, Oregon Health and Science University, OHSU-PSU School of Public Health, and Portland Veterans' Affairs Health Care System, Portland, Oregon, USA
| | - Hassan A Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Thuy Doan
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Caleb D Ebert
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Travis C Porco
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
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Patel VP, Davis M, Li J, Hwang S, Johnson S, Kondejewski J, Croft D, Rood K, Simhan HN. Workplace Productivity Loss and Indirect Costs Associated With Preterm Birth in the United States. Obstet Gynecol 2024; 143:23-34. [PMID: 37851518 PMCID: PMC10715688 DOI: 10.1097/aog.0000000000005404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To estimate workplace productivity loss and indirect costs in the year after birth among individuals who deliver preterm in the United States. METHODS This retrospective, observational cohort study estimated workplace productivity loss and indirect costs for individuals aged 18-55 years with an inpatient delivery between January 1, 2016, and September 30, 2021, using data from the Merative MarketScan Commercial Claims and Encounters database and the Health and Productivity Management database. Workdays lost and costs attributable to medical-related absenteeism, workplace absenteeism (defined as sick leave, leave, recreational leave, Family Medical Leave Act); disability (defined as short-term and long-term disability), and aggregate workplace productivity loss, a combined outcome measure, were compared between propensity-score-matched birth cohorts: preterm birth (before 37 weeks of gestation) and full-term birth (at or after 37 weeks of gestation). Outcomes were also compared between the full-term birth cohort and preterm birth subgroups (before 32 weeks of gestation and before 34 weeks of gestation). Estimations of indirect costs assumed an 8-hour workday. Costs were inflated to December 2021 U.S. dollars. RESULTS In total, 37,522 individuals were eligible for medical-related absenteeism, 1,028 for workplace absenteeism, 7,880 for disability, and 396 for aggregate workplace productivity loss after propensity score matching. Compared with full-term birth, preterm birth was associated with more workdays lost and costs in the year after childbirth attributable to medical-related absenteeism (differences of 4.2 days and $1,045, P <.001) and disability (differences of 2.8 days and $422, P <.001). Preterm birth was not associated with workplace absenteeism (differences of 1.4 days and $347, P =.787) and aggregate workplace productivity loss (differences of 5.2 days [ P =.080] and $1,021 [ P =.093]). Numerical differences were greater in magnitude and inversely related to gestational age at birth across outcomes. CONCLUSION Preterm birth was associated with medical-related absenteeism, disability claims, and indirect costs in the year after birth compared with full-term birth.
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Affiliation(s)
- Vanessa Perez Patel
- Organon, Jersey City, New Jersey; Medicus Economics LLC, Milton, Massachusetts; Snell Medical Communication, Montreal, Quebec, Canada; The Ohio State University, Columbus, Ohio; and the University of Pittsburgh, Pittsburgh, Pennsylvania
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Pleyer U, Al-Mutairi S, Murphy CC, Hamam R, Hammad S, Nagy O, Szepessy Z, Guex-Crosier Y, Julian K, Habot-Wilner Z, Androudi S. Impact of adalimumab in patients with active non-infectious intermediate, posterior, and panuveitis in real-life clinical practice: HOPE study. Br J Ophthalmol 2023; 107:1892-1899. [PMID: 36261259 DOI: 10.1136/bjo-2021-320770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM This study evaluated real-life adalimumab impact in patients with active non-infectious intermediate, posterior, or panuveitis (NIIPPU). METHODS Adults with active NIIPPU received adalimumab in this prospective, observational study (06/2017-04/2020). Patients were evaluated at baseline (V0) and four follow-up visits over 12 months (V1-V4). PRIMARY ENDPOINT proportion of patients achieving quiescence (anterior chamber (AC) cells grade and vitreous haze (VH) grade≤0.5+ in both eyes, no new active chorioretinal lesions) at any follow-up visit. Secondary endpoints: proportion of patients achieving quiescence at each visit; proportion of patients maintaining response; and proportion of patients with flares. Workability, visual function, healthcare resource utilisation, and safety were evaluated. RESULTS Full analysis set included 149 patients. Quiescence at any follow-up visit was achieved by 129/141 (91%) patients. Quiescence at individual visits was achieved by 99/145 (68%), 110/142 (77%), 102/131 (78%), and 99/128 (77%) patients at V1-V4, respectively. Number of patients in corticosteroid-free quiescence increased from 51/147 (35%; V1) to 67/128 (52%; V4; p<0.05). Proportion of patients with maintained response increased from 89/141 (63%; V2) to 92/121 (76%; V4; p<0.05) and proportion of patients with flare decreased from 25/145 (17%; V1) to 13/128 (10%; V4; p=0.092). Workability and visual function improved throughout the study. Proportion of patients with medical visits for uveitis decreased from 132/149 (89%; V0) to 27/127 (21%; V4). No new safety signals were observed. CONCLUSION These results demonstrated adalimumab effectiveness in improving quality of life while reducing economic burden of active NIIPPU.
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Affiliation(s)
- Uwe Pleyer
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Salem Al-Mutairi
- Al-Bahar Ophthalmology Center - Al-Sabah Hospital, Kuwait City, Kuwait
| | - Conor C Murphy
- Ophthalmology, Royal Victoria Eye an Ear Hospital, Dublin, Ireland
| | - Rola Hamam
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Yan Guex-Crosier
- Department of Ophthalmology, University of Lausanne, Lausanne, Switzerland
| | - Karina Julian
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine of CWRU, Cleveland, Ohio, USA
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sofia Androudi
- Department of Medicine, University of Thessaly, Larissa, Greece
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Felfeli T, Eshtiaghi A, Rhee J, Balas M, Tai F, Kaplan AJ, Christakis PG, Dzulynsky K, Monson H, Mandelcorn ED, Rubin LA, Bakshi NK, Derzko-Dzulynsky LA. Clinical characteristics of non-infectious uveitis treated with and without systemic immunomodulatory therapy. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00308-3. [PMID: 37972648 DOI: 10.1016/j.jcjo.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To compare the patient characteristics and long-term outcomes for those treated with and without systemic immunomodulatory therapy (IMT) for non-infectious uveitis (NIU). DESIGN Retrospective cohort study. PARTICIPANTS All consecutive adults with NIU receiving care at 5 uveitis subspecialty tertiary care clinics between 2010 and 2021. METHODS Clinical outcomes were evaluated on initial presentation and at the last available follow-up. The main outcome measures were baseline characteristics and final visual acuity. RESULTS A total of 914 NIU patients (418 IMT, 496 non-IMT) with a median age of 51.0 years and 57.4% female were identified. Over half the patients had bilateral disease, with a significantly higher proportion of bilateral cases in the IMT group compared with the non-IMT group (p < 0.001). The IMT group was more likely to have chronic uveitis (p < 0.001), with a higher proportion of patients experiencing cataracts and cystoid macular edema (p < 0.001 for both). A significantly higher proportion of non-IMT patients had anterior uveitis and an idiopathic etiology (p < 0.001). Overall, visual acuity improved significantly from baseline to last follow-up in the entire cohort (p < 0.001), with a slightly better improvement in the IMT group. Multivariable linear regression analysis suggested that baseline visual acuity and panuveitis were significant predictors of final visual acuity (p < 0.001 for both). CONCLUSIONS NIU patients on IMT are often younger, suffer from bilateral and chronic uveitis, and are more likely to have ocular complications. Those in the non-IMT group are more likely to have anterior idiopathic NIU. Baseline visual acuity and panuveitis are the main predictors of final vision outcomes among patients with NIU.
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Affiliation(s)
- Tina Felfeli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Institute of Health Policy, Management and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, ON; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON.
| | - Arshia Eshtiaghi
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON
| | - Jess Rhee
- Faculty of Medicine, Schulich School of Medicine and Dentistry, London, ON
| | - Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON
| | - Felicia Tai
- Division of Ophthalmology, McMaster University, Hamilton, ON
| | - Alexander J Kaplan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Department of Ophthalmology, Toronto Western Hospital, University Health Network, Toronto, ON; Kensington Vision and Research Centre, Kensington Health Institute, Toronto, ON
| | - Panos G Christakis
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Kensington Vision and Research Centre, Kensington Health Institute, Toronto, ON
| | - Kira Dzulynsky
- Faculty of Engineering, McGill University, Montreal, Que
| | - Hayley Monson
- Faculty of Mathematics, McMaster University, Hamilton, ON
| | - Efrem D Mandelcorn
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Department of Ophthalmology, Toronto Western Hospital, University Health Network, Toronto, ON; Kensington Vision and Research Centre, Kensington Health Institute, Toronto, ON
| | - Laurence A Rubin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON; Division of Rheumatology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON
| | - Nupura K Bakshi
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Kensington Vision and Research Centre, Kensington Health Institute, Toronto, ON; Department of Ophthalmology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON; Department of Ophthalmology, Mount Sinai Hospital, Toronto, ON
| | - Larissa A Derzko-Dzulynsky
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Kensington Vision and Research Centre, Kensington Health Institute, Toronto, ON; Department of Ophthalmology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON
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Beltrán Catalán E, Brito García N, Pato Cour E, Muñoz Fernández S, Gómez Gómez A, Díaz Valle D, Hernández Garfella M, Francisco Hernández FM, Trujillo Martín MDM, Silva Fernández L, Villanueva G, Suárez Cuba J, Blanco R. SER recommendations for the treatment of uveitis. REUMATOLOGIA CLINICA 2023; 19:465-477. [PMID: 37839964 DOI: 10.1016/j.reumae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/12/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis. METHODS Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed. RESULTS Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus. CONCLUSIONS Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.
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Affiliation(s)
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - Santiago Muñoz Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía. Universidad Europea de Madrid, Madrid, Spain
| | | | - David Díaz Valle
- Unidad de Inflamación Ocular, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | - Lucía Silva Fernández
- Servicio de Reumatología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Julio Suárez Cuba
- Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Ricardo Blanco
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Cantabria, Spain
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Moll-Udina A, Hernanz I, Sainz-de-la-Maza M, Pelegrín L, Coelho-Borges AI, Pazos M, Adán A, Llorenç V. Intravitreal fluocinolone acetonide 0.19 mg (ILUVIEN®) in patients with non-infectious uveitis: real-world effectiveness and safety outcomes at 12 months. Int Ophthalmol 2023; 43:4181-4195. [PMID: 37698661 PMCID: PMC10520169 DOI: 10.1007/s10792-023-02828-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/27/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE This study assessed the effectiveness of the 0.19-mg fluocinolone acetonide (FAc) implant by multimodal measurements in patients with non-infectious uveitis (NIU) in a real-world setting in Spain. METHODS A prospective study of patients who had NIU including uveitic macular oedema (UME) with ≥ 12 months follow-up was done. Exclusion criteria include infectious uveitis and uncontrolled glaucoma or ocular hypertension requiring more than 2 medications. Effectiveness was assessed using a multicomponent outcome measure that included nine outcomes. Effectiveness was defined as all components being met at every timepoint. Secondary outcome measures were onset or progression of glaucoma and investigator-reported adverse events. RESULTS Twenty-six eyes from 22 patients were included, with 96.2% having an indication including UME. During the 12-month study, the FAc implant was effective in 15 (57.7%) eyes, reaching effectiveness as soon as 2 weeks post-implantation. Mean best-corrected visual acuity and mean central macular thickness (CMT) were significantly improved vs. baseline at all timepoints (all comparisons p < 0.01). During the 12-month study, inflammation markers (anterior chamber cells and vitreous haze) had also significantly declined. Factors predicting effectiveness at month 12 were systemic corticosteroid dose pre-FAc, higher immunomodulatory therapy (IMT) load at baseline and thicker retinal nerve fibre layer (RNFL) at baseline (all p < 0.05). Factors predicting failure were male gender, thinner RNFL at baseline and treatment ineffectiveness at 1 month (all p < 0.05). In parallel, corticosteroid and IMT use also declined significantly. No significant increase in IOP was detected. CONCLUSION The FAc implant is safe and effective at treating NIU over 12 months in a real-world setting in Spain.
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Affiliation(s)
- Aina Moll-Udina
- Facultat de Medicina, University of Barcelona, Barcelona, Spain.
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain.
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | | | - Maite Sainz-de-la-Maza
- Facultat de Medicina, University of Barcelona, Barcelona, Spain
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Pelegrín
- Facultat de Medicina, University of Barcelona, Barcelona, Spain
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Marta Pazos
- Facultat de Medicina, University of Barcelona, Barcelona, Spain
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Alfredo Adán
- Facultat de Medicina, University of Barcelona, Barcelona, Spain
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Victor Llorenç
- Facultat de Medicina, University of Barcelona, Barcelona, Spain
- Clínic Institute of Ophthalmology, Clínic Hospital of Barcelona, Sabino de Arana Str., 1, 2Nd Floor (Maternity Hospital), 08028, Barcelona, PC, Spain
- August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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10
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Tan Yip Ming C, Rojas-Carabali W, Cifuentes-González C, Agrawal R, Thorne JE, Tugal-Tutkun I, Nguyen QD, Gupta V, de-la-Torre A, Agrawal R. The Potential Role of Large Language Models in Uveitis Care: Perspectives After ChatGPT and Bard Launch. Ocul Immunol Inflamm 2023:1-5. [PMID: 37562028 DOI: 10.1080/09273948.2023.2242462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Affiliation(s)
- Collin Tan Yip Ming
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - William Rojas-Carabali
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Carlos Cifuentes-González
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Rajdeep Agrawal
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jennifer E Thorne
- Department of Ophthalmology, Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimor, Maryland, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Eye Protection Foundation Bayrampasa Eye Hospital, Istanbul, Turkey
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Vishali Gupta
- Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Rupesh Agrawal
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
- Singapore Eye Research Institute, The Academia, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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11
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Alawneh KM, Saleh OA, Smadi MM, Ababneh FK, Ali Mahmoud IH, Smadi AM, Alawneh D. Pattern of Uveitis in a Tertiary Hospital in North Jordan and the Impact of Behcet's Disease. J Ophthalmol 2023; 2023:2076728. [PMID: 37588519 PMCID: PMC10427226 DOI: 10.1155/2023/2076728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023] Open
Abstract
Aim The purpose of this study is to assess the prevalence of autoimmune-mediated uveitis in relation to other diseases and to describe the clinical patterns of uveitis in a single tertiary hospital in north Jordan. Methods A cross-sectional retrospective review was performed. We included all patients diagnosed with uveitis in King Abdullah University Hospital (KAUH) ophthalmology clinic and/or patients referred to KAUH rheumatology clinics for evaluation of suspected autoimmune mediated uveitis or for difficult to treat uveitis. This included patients from January 2015 to January 2019. Data collected about patients' age, sex, anatomical location of the disease, etiology, treatment, complications, and outcomes on vision loss were analyzed. Results A total of 221 patients were included in our study. The mean (±SD) age was 36 (±16) years. A total of 111 patients were female and 110 were male with a ratio of 1 : 1. Noninfectious uveitis was found to be more common than infectious uveitis (95% vs. 5% respectively). Autoimmune-mediated uveitis accounted for 40% of the total cases. The most common causes of autoimmune-mediated uveitis included Behcet's disease (n = 41, 19%) and seronegative spondyloarthropathy (n = 29, 13%). The majority of patients (n = 207, 94%) were treated with ophthalmic eye drops, cDMARDs (n = 101, 46%), biologics (n = 33, 15%), and colchicine (n = 30, 14%). Conclusion Autoimmune-mediated uveitis, most commonly associated with Behcet's disease and seronegative spondyloarthropathy, represents a high percentage of uveitis in our area. This implies the need for a high index of suspicion at the time of evaluation.
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Affiliation(s)
- Khaldoon M. Alawneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Department of Internal Medicine, King Abdullah University Hospital, Irbid, Jordan
| | - Omar A. Saleh
- Department of Ophthalmology, Jordan University of Science and Technology, Irbid, Jordan
| | - Mahmoud M. Smadi
- Department of Mathematics and Statistics, Jordan University of Science and Technology, Irbid, Jordan
| | - Fatima Kamel Ababneh
- Department of Internal Medicine, King Abdullah University Hospital, Irbid, Jordan
| | | | - Areje M. Smadi
- Jordan University of Science and Technology, Irbid, Jordan
| | - Diala Alawneh
- Division of Rheumatology, University of Illinois at Chicago, Chicago, IL, USA
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12
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Ambrosino CM, Kaleem MA, Berkenstock MK. Referral to Vision Rehabilitation Services for Uveitis Patients: Referral Criteria and Barriers. Ocul Immunol Inflamm 2023:1-5. [PMID: 37433132 DOI: 10.1080/09273948.2023.2231543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Despite the benefits of vision rehabilitation services (VRS) for uveitis patients, limited literature has examined issues in VRS access within uveitis. We surveyed American Uveitis Society members regarding VRS referral practices, criteria, and barriers. METHODS Survey responses were collected from November 2022 to January 2023. Analysis summarized responses and compared response patterns of frequently-referring and infrequently-referring providers through Fisher's exact tests and logistic regression. RESULTS Most of the 33 respondents completed 1 to 5 monthly referrals using criteria of visual acuity loss, visual field loss, and difficulty performing vision-related activities. Key referral barriers included cost of services and insufficient patient-provider communication regarding vision loss. The practice of speaking to patients about vision loss during clinic visits was correlated with higher VRS referral rates (P = 0.047). CONCLUSIONS Greater patient-provider communication about vision loss may represent an opportunity to increase access to VRS.
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Affiliation(s)
| | - Mona A Kaleem
- Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Meghan K Berkenstock
- Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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Wan GJ, Niewoehner J, Hayes K. Acthar Gel (RCI): A Narrative Literature Review of Clinical and Economic Evidence. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:499-512. [PMID: 37397803 PMCID: PMC10312382 DOI: 10.2147/ceor.s410082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
Acthar® Gel (repository corticotropin injection [RCI]) is a naturally sourced complex mixture of adrenocorticotropic hormone analogs and other pituitary peptides used to treat patients with serious and rare inflammatory and autoimmune conditions. This narrative review summarizes the key clinical and economic findings among 9 indications: infantile spasms (IS), multiple sclerosis (MS) relapses, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), dermatomyositis and polymyositis (DM/PM), ocular inflammatory diseases (primarily uveitis and severe keratitis), symptomatic sarcoidosis, and proteinuria in nephrotic syndrome (NS). Key studies of clinical efficacy and healthcare resource utilization and cost from 1956 to 2022 are discussed. Evidence supports the efficacy of RCI across all 9 indications. RCI is recommended as first-line treatment for IS and is associated with improved outcomes for the other 8 indications, including increased recovery rates in MS relapse; improved disease control in RA, SLE, and DM/PM; real-world effectiveness in patients with uveitis and severe keratitis; improved lung function and reduced corticosteroid use in symptomatic sarcoidosis; and increased rates of partial remission of proteinuria in NS. For many indications, RCI may improve clinical outcomes during exacerbations or when conventional treatments have failed to show a benefit. RCI is also associated with a reduction in the use of biologics, corticosteroids, and disease-modifying antirheumatic drugs. Economic data suggest RCI is a cost-effective, value-based treatment option for MS relapse, RA, and SLE. Other economic benefits have been demonstrated for IS, MS relapses, RA, SLE, and DM/PM, including reduced hospitalizations, lengths of stay, inpatient and outpatient services, and emergency department visits. RCI is considered safe and effective and features economic benefits for numerous indications. Its ability to control relapse and disease activity makes RCI an important nonsteroid treatment option that could help preserve functioning and well-being among patients with inflammatory and autoimmune conditions.
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Affiliation(s)
- George J Wan
- Mallinckrodt Pharmaceuticals, Bridgewater, NJ, USA
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals, Bridgewater, NJ, USA
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14
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Pohlmann D, Zur Bonsen L, Rübsam A, Pleyer U. [Noninfectious posterior uveitis : Clinical aspects, diagnostics, management and treatment]. DIE OPHTHALMOLOGIE 2023; 120:443-458. [PMID: 37022476 DOI: 10.1007/s00347-023-01833-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 04/07/2023]
Abstract
Noninfectious posterior uveitis (NPU) comprises a heterogeneous group of vision-threatening, immune-mediated ocular and systemic diseases. It is predominantly bilateral and recurrent and, if not treated properly, leads to severe tissue damage that threatens the eyesight. In industrialized countries ca. 10-20% of all cases of blindness are caused by NPU. An NPU can occur at any age but is most common between the ages of 20 and 50 years. Laboratory diagnostic and imaging procedures enable an increasingly better differentiation of the disease spectrum. This makes it possible to better assess the course and prognosis of individual disease entities. An increasing repertoire of systemic and intravitreal forms of treatment has already led to more favorable long-term treatment outcomes. It can be expected that further progress can be achieved with better knowledge of the pathophysiology of the different clinical disorders and appropriate, targeted treatment.
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Affiliation(s)
- Dominika Pohlmann
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Lynn Zur Bonsen
- Universitäts-Augenklinik, Charité, Campus CBF - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - Anne Rübsam
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Uwe Pleyer
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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15
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Tipton CW, Reilly GR, Chen K, Chang E, Ackert JM, Liberman P, Berkenstock MK. Analyzing the demographics of patients with uveitis in an indigent, urban population. BMC Ophthalmol 2023; 23:140. [PMID: 37020208 PMCID: PMC10077706 DOI: 10.1186/s12886-023-02888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
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.
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Affiliation(s)
| | - Grace R Reilly
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Kevin Chen
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Eileen Chang
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | | | - Paulina Liberman
- Departamento de Oftalmología, Escuela de Medicina. Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Meghan K Berkenstock
- Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 N. Wolfe Street Maumenee 3rd Floor, Baltimore, MD, 21087, USA.
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16
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Gómez-Gómez A, Madrid-Garcia A, Borrego-Sanz L, Álvarez-Hernández P, Arriola-Villalobos P, Pérez-Sancristobal I, Benítez Del Castillo JM, Mendez-Fernandez R, Pato-Cour E, Díaz-Valle D, Rodriguez-Rodriguez L. Therapeutic Response After Immunosuppressive Drug Prescription in Non-infectious Uveitis: A Survival Analysis. Ophthalmol Ther 2023; 12:139-153. [PMID: 36266560 PMCID: PMC9834496 DOI: 10.1007/s40123-022-00587-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/23/2022] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION To identify factors affecting the response rate to immunosuppressive drugs (ISDs) in patients with non-infectious uveitis (NIU). METHODS This longitudinal retrospective cohort study included patients from the Hospital Clinico San Carlos Uveitis Clinic diagnosed with NIU from 1992 to 2016. Subjects were followed up from ISD prescription until the achievement of good therapeutic response (GTR), ISD treatment change, or up to 12 months. GTR was defined as the complete resolution of the eye inflammatory manifestations with a corticosteroid dose ≤ 10 or ≤ 5 mg per day of prednisone or equivalent (GTR10 and GTR5, respectively) maintained for at least 28 days. Kaplan-Meier curves were estimated for GTR. Demographic, clinical, and treatment-related factors were analyzed using Cox robust regression. RESULTS A total of 73 patients (100 episodes of ISD prescription) were analyzed. In 44 and 41 episodes, GTR10 and GTR5 were achieved, respectively. A lower hazard for both GTRs was associated with uveitic macular edema at prescription and with a higher "highest oral corticosteroid dose prescribed in the year before ISD prescription". GTR10 was higher if cyclosporine was prescribed (compared to other ISDs), and if a higher number of ISDs had been previously prescribed. GTR5 hazard was lower for patients with posterior uveitis or if the ISDs were prescribed before 2008, and higher if periocular corticosteroids had been administered before ISD prescription, or if the duration of the posterior segment activity was shorter. CONCLUSIONS Factors associated with GTR to ISDs may help to identify patients with NIUs who could benefit from a thorough follow-up.
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Affiliation(s)
- Alejandro Gómez-Gómez
- School of Medicine, Universidad Complutense de Madrid, Plaza Ramón y Cajal, s/n, 28040, Madrid, Spain
- Rheumatology Department, Hospital Universitario Vall d'Hebron, Passeig de la Vall d'Hebron 119, 08035, Barcelona, Spain
| | - Alfredo Madrid-Garcia
- Musculoskeletal Pathology Group, Rheumatology Department, Health Research Institute (IdISSC), Hospital Clínico San Carlos, c\ Prof. Martín Lagos, s/n, 20840, Madrid, Spain
| | - Lara Borrego-Sanz
- Ophthalmology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Paula Álvarez-Hernández
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Pedro Arriola-Villalobos
- Ophthalmology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Inés Pérez-Sancristobal
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - José M Benítez Del Castillo
- Ophthalmology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Rosalía Mendez-Fernandez
- Ophthalmology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Esperanza Pato-Cour
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - David Díaz-Valle
- Ophthalmology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Calle Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Luis Rodriguez-Rodriguez
- Musculoskeletal Pathology Group, Rheumatology Department, Health Research Institute (IdISSC), Hospital Clínico San Carlos, c\ Prof. Martín Lagos, s/n, 20840, Madrid, Spain.
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Ross BX, Habhab S, Syeda S, Baiyasi A, Benchaala I, Okeagu C, Barbosa J, Im J, Le K, Lin X. Patient Clinical Outcomes in Standalone Versus a Combined Ophthalmology-rheumatology Uveitis Clinic. J Ophthalmic Inflamm Infect 2022; 12:36. [PMID: 36344850 PMCID: PMC9640525 DOI: 10.1186/s12348-022-00314-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/13/2022] [Accepted: 10/22/2022] [Indexed: 11/09/2022] Open
Abstract
Background To evaluate uveitis care outcomes in standalone versus a combined ophthalmology-rheumatology clinic. Methods Participants were patients aged 18 years and older with a minimum 12-month history of chronic uveitis prior to being referred to the combined uveitis clinic at Kresge Eye Institute and who were treated in the combined clinic for at least 6 months. Best corrected visual acuity (BCVA), objective markers of inflammation, and achieving targeted dose of immunomodulatory therapy (IMT) were compared in the cohort of uveitis patients 6 months prior to and after the initial evaluation in the combined clinic. Results Sixty-six percent of study participants were female with a mean age of 51.5 years. BCVA improved from 0.58 logMAR (Snellen: ~20/74) at the initial combined clinic visit to 0.50 logMAR (Snellen: ~20/63) 6 months after the first combined visit (p = 0.0137). The establishment of the combined uveitis clinic led to higher frequency of patients at target dose of IMT: an increase from 49.0% at 6 months prior to the combined visit to 70.1.4% and 79.8% at the initial combined visit and 6 months after the combined visit, respectively. Conclusion A combined model of management for chronic uveitis patients wherein rheumatological services are coupled with ophthalmic care leads to improvement in patient clinical outcomes and achieving target therapy.
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18
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Prieto del Cura MDM, Gonzalez-Guijarro JJ. Impact of Ocular Complications on Visual Outcomes in Adult Patients With Uveitis. Cureus 2022; 14:e21370. [PMID: 35070586 PMCID: PMC8765332 DOI: 10.7759/cureus.21370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background In this study, we aimed to assess the impact of ocular complications on visual outcomes in uveitis. Methodology We conducted a retrospective cohort study of 474 uveitis patients (655 eyes) with a mean age of 52.4 years who were followed for a median of 32 months (range: 8-80 months). Results At least one ocular complication was found in 317 eyes (48.4%), 161 of which were present at the time of diagnosis (prevalent complication). Although having an ocular complication was associated with a mean loss of 1.7 Early Treatment Diabetic Retinopathy Study (ETDRS) lines, the best-corrected visual acuity increased at the end of the study. Complications causing a decrease of ≥2 ETDRS lines were prevalent macular and peripheral retinal diseases, as well as new-onset corneal lesions, intraocular pressure alterations, and peripheral retinal diseases. Conclusions The impact of the most frequent complications (cataract and macular edema) did not reach two ETDRS lines. Macular diseases at presentation were the main risk factor for visual loss at the end of follow-up.
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19
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Zeng S, Yang L, Bai F, Liu T, Liu X. Intravitreal dexamethasone implant for noninfectious uveitis in Chinese patients. Int Ophthalmol 2022; 42:2063-2069. [PMID: 34984627 DOI: 10.1007/s10792-021-02204-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the effectiveness and safety of the dexamethasone intravitreal implant (DEX-I) in Non-Infectious Uveitis (NIU) in Chinese patients. METHODS Ninety-one eyes of 77 patients (56 men, 21 women) receiving 130 implant injections for NIU were included. Treatment indication, uveitis diagnosis, best-corrected visual acuity (BCVA), central retinal thickness (CRT), vitreous haze score, intraocular pressure, phakic status, number of injections, time to reinjection, and systemic treatments were collected at baseline, 1 week, 1 month, 3 and 6 months after treatment. RESULTS All patients were followed for at least 12 weeks and had a mean follow-up period of 5.1 months (range, 3-14 months) after the first implant. The main treatment indications were macular edema (ME), retinal vasculitis, retinal vasculitis with ME. Sixty-one eyes (67.03%) received only one injection, while 31 eyes (32.97%) received two or more. In eyes that received 2 injections, the mean time to the second injection was 3.83 months and in those that received 3 injections, the mean time to the third injection was 7.5 months. BCVA and CRT significantly improved at 1 week, 1 month, 3 months, and 6 months after treatment. When compared to baseline, the mean prednisone (or equivalent) dosage significantly decreased at 3- and 6-month follow-up evaluations after DEX implantation.14.29% of eyes developed a transient increase in intraocular pressure, and a cataract was removed from 1 phakic eye. CONCLUSIONS DEX implants, either alone or in combination with common adjunctive NIU treatments, is safe and effective in the treatment of NIU in Chinese patients.
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Affiliation(s)
- Shun Zeng
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Li Yang
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Feng Bai
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Tao Liu
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Xiaoli Liu
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China.
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20
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Hariprasad SM, Joseph G, Gagnon-Sanschagrin P, Serra E, Bhattacharyya S, Bédard J, Guérin A, Albini TA. Healthcare costs among patients with macular oedema associated with non-infectious uveitis: a US commercial payer's perspective. BMJ Open Ophthalmol 2021; 6:e000896. [PMID: 34786486 PMCID: PMC8587681 DOI: 10.1136/bmjophth-2021-000896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/23/2021] [Indexed: 11/03/2022] Open
Abstract
Objective To describe patient characteristics and healthcare costs associated with uveitic macular oedema (UME) in US clinical practices from a commercial payer's perspective. Methods and analysis The IBM MarketScan Commercial Subset (1 October 2015-31 March 2020) was used to identify patients with non-infectious uveitis (NIU), with or without UME. Patients with UME at any time were further classified into subgroups of patients who received a UME diagnosis during the study period and those who received a UME diagnosis and local steroid injection (LSI) during the study period. Demographic and clinical characteristics, NIU-related treatments and healthcare costs were described for each cohort and subgroup during the most recent 12 months of continuous health plan enrolment. Healthcare costs were also described by vision status among all patients with NIU. Results A total of 36 322 patients with NIU were identified, of whom 3 301 (9.1%) had UME and 33 021 (90.9%) had no UME. Patients with UME more frequently received NIU-related treatment compared with those without UME (64.6% vs 45.0%), particularly LSI treatment (12.5% vs 0.7%). Mean total all-cause healthcare costs per-patient-per-year (PPPY) were higher among patients with UME ($19 851) than patients without UME ($16 188) and were especially high among those with bilateral UME ($24 162). Further, vision loss was more commonly observed in those with UME versus those without UME (5.7% vs 2.2%) and a trend of increasing healthcare costs with increasing vision loss was observed. Conclusion NIU is associated with substantial clinical and economic burden, particularly when UME is present.
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Affiliation(s)
- Seenu M Hariprasad
- Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois, USA
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21
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Yalçındağ FN, Çakar Özdal P, Özyazgan Y, Batıoğlu F, Tugal-Tutkun İ. Comparison of Sociodemographic Features Between Behçet Uveitis and Other Non-infectious Uveitis. Turk J Ophthalmol 2021; 51:206-211. [PMID: 34461696 PMCID: PMC8411281 DOI: 10.4274/tjo.galenos.2020.28485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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 analyze and compare sociodemographic features between Behçet uveitis and other non-infectious uveitis. Materials and Methods: The data of adults with non-infectious uveitis in the nationwide uveitis database were analyzed and the sociodemographic features of patients with and without Behçet disease were compared. Results: This study included data of 4,978 eyes of 3,363 patients from 33 centers. The mean age at presentation was 38.7±13.3 (17- 87) years. The mean age was 34.3±10.5 years in the Behçet uveitis group and 41.1±14.0 years in the other non-infectious uveitis group (p<0.001). Male predominance was seen in the Behçet uveitis group (67.7% vs. 32.3%) while female patients were more common in the other non-infectious uveitis group (54.4% vs. 45.6%, p<0.001). Regarding education level, the proportion of patients with low education was higher in the Behçet uveitis group than the other non-infectious uveitis group (49.6% vs. 43.4% in males, p=0.004; 61.5% vs. 59.2% in females, p=0.021). Having a low-income job or being currently unemployed, indicators of poor income, were more frequent in the Behçet uveitis group than in the other non-infectious uveitis group (32.0% vs. 22.8%, p<0.001). In the comparison of places of residence, the proportion of patients who lived in cities with low gross national product was 37.0% in the Behçet uveitis group and 31.1% in the other non-infectious uveitis group (p<0.001). Conclusion: Patients with Behçet disease had lower education level and socioeconomic status than patients with other non-infectious uveitis entities.
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Affiliation(s)
- F Nilüfer Yalçındağ
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Pınar Çakar Özdal
- University of Health Sciences Turkey Faculty of Medicine, Department of Ophthalmology, Ankara Ulucanlar Göz SUAM, Ankara, Turkey
| | - Yılmaz Özyazgan
- İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - Figen Batıoğlu
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - İlknur Tugal-Tutkun
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
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22
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Signature of Circulating Biomarkers in Recurrent Non-Infectious Anterior Uveitis. Immunomodulatory Effects of DHA-Triglyceride. A Pilot Study. Diagnostics (Basel) 2021; 11:diagnostics11040724. [PMID: 33921773 PMCID: PMC8072877 DOI: 10.3390/diagnostics11040724] [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: 04/11/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 12/11/2022] Open
Abstract
The purpose of this study was to identify circulating biomarkers of recurrent non-infectious anterior uveitis (NIAU), and to address the anti-inflammatory effects of triglyceride containing docosahexaenoic acid (DHA-TG). A prospective multicenter study was conducted in 72 participants distributed into: patients diagnosed with recurrent NIAU in the quiescence stage (uveitis group (UG); n = 36) and healthy controls (control group (CG); n = 36). Each group was randomly assigned to the oral supplementation of one pill/day (+) containing DHA-TG (n = 18) or no-pill condition (−) (n = 17) for three consecutive months. Data from demographics, risk factors, comorbidities, eye complications and therapy were recorded. Blood was collected and processed to determine pro-inflammatory biomarkers by bead-base multiplex assay. Statistical processing with multivariate statistical analysis was performed. The mean age was 50, 12 (10, 31) years. The distribution by gender was 45% males and 55% females. The mean number of uveitis episodes was 5 (2). Higher plasma expression of interleukin (IL)-6 was detected in the UG versus the CG (p = 5 × 10−5). Likewise, significantly higher plasma levels were seen for IL-1β, IL-2, INFγ (p = 10−4), and TNFα (p = 2 × 10−4) in the UG versus the CG. Significantly lower values of the above molecules were found in the +DHA-TG than in the -DHA-TG subgroups, after 3 months of follow-up, TNFα (p = 10−7) and IL-6 (p = 3 × 10−6) being those that most significantly changed. Signatures of circulating inflammatory mediators were obtained in the quiescent stage of recurrent NIAU patients. This 3-month follow-up strongly reinforces that a regular oral administration of DHA-TG reduces the inflammatory load and may potentially supply a prophylaxis-adjunctive mediator for patients at risk of uveitis vision loss.
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23
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Leal I, Romão VC, Mano S, Khmelinskii N, Campanilho-Marques R, Ponte C, Macieira C, Oliveira-Ramos F, Vieira-Sousa E, Rosa CM, Rodrigues W, Abegão Pinto L, Marques-Neves C, Fonseca JE. A Non-Infectious Uveitis Multidisciplinary Clinic in a Tertiary Referral Center: Clinical Impact and Added Value. J Multidiscip Healthc 2021; 14:695-704. [PMID: 33790568 PMCID: PMC7997415 DOI: 10.2147/jmdh.s292981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/29/2021] [Indexed: 12/17/2022] Open
Abstract
Non-infectious uveitis (NIU) is a group of sight-threatening diseases that generates significant burden for the healthcare systems due to its adverse outcomes, irreversible structural complications in the eye with loss of visual function, limited clinical expertise and low-grade evidence for best practice. The usefulness of multidisciplinary care, specifically close collaboration between Rheumatologists and Ophthalmologists in NIU, has been emphasized in the literature. In this paper, the assessment tools and protocols used in our clinic are depicted and an overview of our activity with a brief description of the patients included in our registry, between 2018 and 2020 is provided. The cohort of 290 patients assessed in our NIU clinic, their demographics, sources of referral, details about immunosuppression treatment, and internal and external collaborations is described. This experience-based manuscript aims to describe the general functioning of our multidisciplinary NIU clinic, highlighting the benefits and drawbacks of multidisciplinary team management in patients with NIU, ultimately initiating a dialogue on what an NIU clinic should be and providing information for newly NIU clinics start-up. In conclusion, establishing a standardized and multidisciplinary clinic in NIU allows to systematically observe and follow-up this infrequent disease at a tertiary hospital level, thus improving quality of care delivery and research avenues.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Univeristário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Clínica Universitária de Oftalmologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vasco C Romão
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sofia Mano
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Univeristário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Clínica Universitária de Oftalmologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Carla Macieira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Filipa Oliveira-Ramos
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Elsa Vieira-Sousa
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Carlos Miranda Rosa
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Walter Rodrigues
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Univeristário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Clínica Universitária de Oftalmologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Luís Abegão Pinto
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Univeristário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Clínica Universitária de Oftalmologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Carlos Marques-Neves
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Univeristário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Clínica Universitária de Oftalmologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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24
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Abstract
The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.
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Affiliation(s)
- Bryn M Burkholder
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Clinical Trials and Evidence Synthesis, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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25
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García-Otero X, Díaz-Tomé V, Varela-Fernández R, Martín-Pastor M, González-Barcia M, Blanco-Méndez J, Mondelo-García C, Bermudez MA, Gonzalez F, Aguiar P, Fernández-Ferreiro A, Otero-Espinar FJ. Development and Characterization of a Tacrolimus/Hydroxypropyl-β-Cyclodextrin Eye Drop. Pharmaceutics 2021; 13:pharmaceutics13020149. [PMID: 33498753 PMCID: PMC7911614 DOI: 10.3390/pharmaceutics13020149] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 02/03/2023] Open
Abstract
Uveitis is a vision inflammatory disorder with a high prevalence in developing countries. Currently, marketed treatments remain limited and reformulation is usually performed to obtain a tacrolimus eye drop as a therapeutic alternative in corticosteroid-refractory eye disease. The aim of this work was to develop a mucoadhesive, non-toxic and stable topical ophthalmic formulation that can be safely prepared in hospital pharmacy departments. Four different ophthalmic formulations were prepared based on the tacrolimus/hydroxypropyl-β-cyclodextrin (HPβCD) inclusion complexes’ formation. Phase solubility diagrams, Nuclear Magnetic Resonance (NMR) and molecular modeling studies showed the formation of 1:1 and 1:2 tacrolimus/HPβCD inclusion complexes, being possible to obtain a 0.02% (w/v) tacrolimus concentration by using 40% (w/v) HPβCD aqueous solutions. Formulations also showed good ophthalmic properties in terms of pH, osmolality and safety. Stability studies proved these formulations to be stable for at least 3 months in refrigeration. Ex vivo bioadhesion and in vivo ocular permanence showed good mucoadhesive properties with higher ocular permanence compared to the reference pharmacy compounding used in clinical settings (t1/2 of 86.2 min for the eyedrop elaborated with 40% (w/v) HPβCD and Liquifilm® versus 46.3 min for the reference formulation). Thus, these novel eye drops present high potential as a safe alternative for uveitis treatment, as well as a versatile composition to include new drugs intended for topical ophthalmic administration.
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Affiliation(s)
- Xurxo García-Otero
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, Faculty of Pharmacy, University of Santiago de Compostela (USC), 15705 Santiago de Compostela, Spain; (X.G.-O.); (V.D.-T.); (R.V.-F.); (J.B.-M.)
- Molecular Imaging Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Victoria Díaz-Tomé
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, Faculty of Pharmacy, University of Santiago de Compostela (USC), 15705 Santiago de Compostela, Spain; (X.G.-O.); (V.D.-T.); (R.V.-F.); (J.B.-M.)
- Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (M.G.-B.); (C.M.-G.)
| | - Rubén Varela-Fernández
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, Faculty of Pharmacy, University of Santiago de Compostela (USC), 15705 Santiago de Compostela, Spain; (X.G.-O.); (V.D.-T.); (R.V.-F.); (J.B.-M.)
- Clinical Neurosciences Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Manuel Martín-Pastor
- Nuclear Magnetic Resonance Unit, Research Infrastructures Area, University of Santiago de Compostela (USC), 15782 Santiago de Compostela, Spain;
| | - Miguel González-Barcia
- Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (M.G.-B.); (C.M.-G.)
| | - José Blanco-Méndez
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, Faculty of Pharmacy, University of Santiago de Compostela (USC), 15705 Santiago de Compostela, Spain; (X.G.-O.); (V.D.-T.); (R.V.-F.); (J.B.-M.)
- Paraquasil Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Cristina Mondelo-García
- Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (M.G.-B.); (C.M.-G.)
| | - Maria A. Bermudez
- Physiology Department–CIMUS, University of Santiago de Compostela (USC), 15782 Santiago de Compostela, Spain;
| | - Francisco Gonzalez
- Ophthalmology Department, Clinical University Hospital Santiago de Compostela (SERGAS), 15706 Santiago de Compostela, Spain;
- Department of Surgery and Medical-Surgical Specialties and CIMUS, University of Santiago de Compostela (USC), 15782 Santiago de Compostela, Spain
| | - Pablo Aguiar
- Molecular Imaging Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Correspondence: (P.A.); (A.F.-F.); (F.J.O.-E.); Tel.: +34-881814878 (F.J.O.-E.)
| | - Anxo Fernández-Ferreiro
- Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (M.G.-B.); (C.M.-G.)
- Correspondence: (P.A.); (A.F.-F.); (F.J.O.-E.); Tel.: +34-881814878 (F.J.O.-E.)
| | - Francisco J. Otero-Espinar
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, Faculty of Pharmacy, University of Santiago de Compostela (USC), 15705 Santiago de Compostela, Spain; (X.G.-O.); (V.D.-T.); (R.V.-F.); (J.B.-M.)
- Paraquasil Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Correspondence: (P.A.); (A.F.-F.); (F.J.O.-E.); Tel.: +34-881814878 (F.J.O.-E.)
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26
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Tugal-Tutkun I, Çakar Özdal P. Behçet's disease uveitis: is there a need for new emerging drugs? Expert Opin Emerg Drugs 2020; 25:531-547. [PMID: 33147420 DOI: 10.1080/14728214.2020.1847271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Behçet's disease uveitis (BDU) is a potentially blinding disorder. Systemic treatment with disease-modifying anti-rheumatic drugs (DMARDs) is mandatory in patients with intraocular inflammation involving the posterior segment of the eye. Areas covered: This article discusses existing systemic treatment with corticosteroids and conventional and biologic DMARDs as well as adjunctive local therapy in BDU. An overview is provided for a wide range of biologic DMARDs that have shown promise or investigated in clinical trials. Most recently introduced biologic DMARDs and targeted synthetic DMARDs are also reviewed for their potential in the treatment of BDU. Expert opinion: The prognosis of patients with BDU has remarkably improved after the introduction of biologic DMARDs. An expanding therapeutic armamentarium will allow treatment of most refractory cases. The ultimate goal is to provide drug-free remission with preservation of 20/20 vision.
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Affiliation(s)
- Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University , Istanbul, Turkey
| | - Pinar Çakar Özdal
- Department of Ophthalmology, University of Health Sciences, Ulucanlar Eye Education and Research Hospital , Ankara, Turkey
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27
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Berkenstock MK, Mir TA, Khan IR, Burkholder BM, Chaon BC, Shifera AS, Thorne JE. Effectiveness of the Dexamethasone Implant in Lieu of Oral Corticosteroids in Intermediate and Posterior Uveitis Requiring Immunosuppression. Ocul Immunol Inflamm 2020; 30:741-749. [PMID: 33021854 DOI: 10.1080/09273948.2020.1826534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate dexamethasone intravitreal implant effectiveness in lieu of high-dose oral prednisone for short-term treatment of noninfectious intermediate and posterior uveitis in patients requiring immunosuppression. METHODS This is a proof-of-concept, open-label, non-comparative clinical trial with 12-month follow-up. The primary outcome was uveitis control without additional prednisone at 6 and 12 months. Secondary outcomes were need for multiple implants or additional prednisone, and safety data. RESULTS 20 patients (28 eyes) were enrolled- 16 eyes had control by 6 months; 20 by 12 months. No patients required high-dose prednisone. 6 patients enrolled on prednisone: 2 stopped; 4 tapered to 7.5 mg daily or less by 12 months. 16 eyes required multiple implants; five required cataract surgery; 12 required drops to control IOP; 2 underwent glaucoma surgery. CONCLUSIONS The dexamethasone implant was effective in lieu of high-dose prednisone although the majority required multiple implants. All patients decreased or discontinued prednisone during follow-up.
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Affiliation(s)
- Meghan K Berkenstock
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tahreem A Mir
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Irfan R Khan
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bryn M Burkholder
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin C Chaon
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amde Selassie Shifera
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer E Thorne
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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28
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Espinosa G, Herreras JM, Muñoz-Fernández S, García Ruiz de Morales JM, Cordero-Coma M. Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis. Med Clin (Barc) 2020; 155:220.e1-220.e12. [PMID: 32199631 DOI: 10.1016/j.medcli.2019.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience. METHODS A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines. CONCLUSIONS In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
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Affiliation(s)
- Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, España
| | - José M Herreras
- IOBA (Instituto Universitario de Oftalmobiología), Universidad de Valladolid, Valladolid, España; Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Santiago Muñoz-Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España; Universidad Europea, San Sebastián de los Reyes, Madrid, España
| | - José M García Ruiz de Morales
- Unidad de Uveítis, Servicio de Inmunología, Complejo Asistencial Universitario de León, León, España; Instituto de Biomedicina, Universidad de León (IBIOMED), León, España
| | - Miguel Cordero-Coma
- Instituto de Biomedicina, Universidad de León (IBIOMED), León, España; Unidad de uveítis, Servicio de Oftalmología, Complejo Asistencial Universitario de León, León, España.
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29
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Gómez-Gómez A, Loza E, Rosario MP, Espinosa G, de Morales JMGR, Herrera JM, Muñoz-Fernández S, Rodríguez-Rodríguez L, Cordero-Coma M. Efficacy and safety of immunomodulatory drugs in patients with non-infectious intermediate and posterior uveitis, panuveitis and macular edema: A systematic literature review. Semin Arthritis Rheum 2020; 50:1299-1306. [PMID: 33065425 DOI: 10.1016/j.semarthrit.2020.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/30/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Non-infectious non-anterior uveitis (NINA) is a sight-threatening condition that often requires immunomodulatory drugs (IMDs) for its management. OBJECTIVES To evaluate the published evidence regarding the use of IMDs in adult patients with NINA uveitis including intermediate (IU) and posterior uveitis (PU), panuveitis (PanU) and macular edema (ME). METHODS We performed a systematic literature review. Search strategies were designed for Medline, Embase, and Cochrane Libraries for articles up to 2019 to evaluate the efficacy and safety of the IMDs. A quality assessment was performed using the Jadad Scale. RESULTS Nineteen randomized clinical trials were selected from the 1,103 articles retrieved. Characteristics of patients, treatment dosages and outcome measures were heterogeneous. The outcomes most frequently analyzed were visual acuity (VA), macular thickness and vitreous haze (VH). Different IMDs were used at their usual dosages. Methotrexate (MTX), micophenolate mofetil, cyclosporine A (CsA), tacrolimus, adalimumab and sarilumab were effective in NINA uveitis. Rituximab combined with MTX was effective in PU. Interferon-β was superior to MTX, albeit with more adverse events in IU with ME. CsA was similar to cyclophosphamide (Cyc) in Behçet uveitis. Tacrolimus was safer and similar to CsA. Cyc was effective in serpiginoid choroiditis, but when combined with azathioprine in PU, but did not improve VA. Secukinumab did not prevent NINA uveitis recurrences, although intravenously it showed a higher response rate than when used subcutaneously. Daclizumab did not show any benefits in Behçet NINA uveitis. CONCLUSION Several IMDs and their combinations can be useful in treating NINA uveitis. The available studies were heterogeneous regarding patient characteristics and outcomes.
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Affiliation(s)
- Alejandro Gómez-Gómez
- Medicine Department, Universidad Complutense de Madrid, Spain; Rheumatology Department, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Estíbaliz Loza
- Instituto de Salud Musculoesquelética (INMUSC), Madrid, Spain
| | | | - Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clinic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Spain
| | - José M García Ruiz de Morales
- Immunology unit, Complejo Asistencial Universitario e Instituto de Biomedicina Universidad de León (IBIOMED), León, Spain
| | - José M Herrera
- Instituto Universitario de Oftalmobiología (IOBA), University of Valladolid, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Hospital Clínico Universitario de Valladolid, Spain
| | - Santiago Muñoz-Fernández
- Medicine Department, Universidad Complutense de Madrid, Spain; Universidad Europea de Madrid, Madrid, Spain
| | - Luis Rodríguez-Rodríguez
- Medicine Department, Universidad Complutense de Madrid, Spain; Rheumatology department, Hospital Clínico San Carlos, Madrid, Spain
| | - Miguel Cordero-Coma
- Uveitis unit, Complejo Asistencial Universitario e Instituto de Biomedicina University of León (IBIOMED), León, Spain.
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Valenzuela RA, Flores I, Urrutia B, Fuentes F, Sabat PE, Llanos C, Cuitino L, Urzua CA. New Pharmacological Strategies for the Treatment of Non-Infectious Uveitis. A Minireview. Front Pharmacol 2020; 11:655. [PMID: 32508634 PMCID: PMC7250389 DOI: 10.3389/fphar.2020.00655] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Non-infectious uveitis (NIU) is a group of disorders characterized by intraocular inflammation at different levels of the eye. NIU is a leading cause of irreversible blindness in working-age population in the developed world. The goal of uveitis treatment is to control inflammation, prevent recurrences, and preserve vision, as well as minimize the adverse effects of medications. Currently, the standard of care for NIU includes the administration of corticosteroids (CS) as first-line agents, but in some cases a more aggressive therapy is required. This includes synthetic immunosuppressants, such as antimetabolites (methotrexate, mycophenolate mofetil, and azathioprine), calcineurinic inhibitors (cyclosporine, tacrolimus), and alkylating agents (cyclophosphamide, chlorambucil). In those patients who become intolerant or refractory to CS and conventional immunosuppressive treatment, biologic agents have arisen as an effective therapy. Among the most evaluated treatments, TNF-α inhibitors, IL blockers, and anti-CD20 therapy have emerged. In this regard, anti-TNF agents (infliximab and adalimumab) have shown the strongest results in terms of favorable outcomes. In this review, we discuss latest evidence concerning to the effectiveness of biologic therapy, and present new therapeutic approaches directed against immune components as potential novel therapies for NIU.
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Affiliation(s)
- Rodrigo A Valenzuela
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Department of Chemical and Biological Sciences, Faculty of Health, Universidad Bernardo O Higgins, Santiago, Chile
| | - Iván Flores
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Beatriz Urrutia
- Rheumatology Service, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - Francisca Fuentes
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Pablo E Sabat
- Department of Ophthalmology, University of Chile, Santiago, Chile.,Department of Ophthalmology, Clínica las Condes, Santiago, Chile
| | - Carolina Llanos
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Loreto Cuitino
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Servicio de Oftalmología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Cristhian A Urzua
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Department of Ophthalmology, University of Chile, Santiago, Chile.,Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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31
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Callanan D, Nguyen QD, Suhler EB, Paggiarino D, Riedel GE. Withdrawn: Reduced Risk of Recurrence of Noninfectious Posterior Segment Uveitis After 0.18-mg Fluocinolone Acetonide Insert: Randomized Trial. Am J Ophthalmol 2020:S0002-9394(20)30064-7. [PMID: 32087143 DOI: 10.1016/j.ajo.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/14/2020] [Accepted: 02/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- David Callanan
- Texas Retina Associates, Arlington, Texas, USA; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA; Department of Public Health, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA; Ophthalmology Service, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | | | - Gerard E Riedel
- EyePoint Pharmaceuticals, Inc, Watertown, Massachusetts, USA
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de Parisot A, Jamilloux Y, Kodjikian L, Errera MH, Sedira N, Heron E, Pérard L, Cornut PL, Schneider C, Rivière S, Ollé P, Pugnet G, Cathébras P, Manoli P, Bodaghi B, Saadoun D, Baillif S, Tieulie N, André M, Chiambaretta F, Bonin N, Bielefeld P, Bron A, Mouriaux F, Bienvenu B, Amamra N, Guerre P, Decullier E, Sève P. Evaluating the cost-consequence of a standardized strategy for the etiological diagnosis of uveitis (ULISSE study). PLoS One 2020; 15:e0228918. [PMID: 32059021 PMCID: PMC7021300 DOI: 10.1371/journal.pone.0228918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/25/2020] [Indexed: 12/02/2022] Open
Abstract
MAIN OBJECTIVE To prospectively assess the cost-consequence of a standardized diagnostic strategy as to compared to an open one for the etiological diagnosis of uveitis. DESIGN This was a prospective, non-inferiority, multicentre, randomized controlled trial. METHODS We included all consecutive patients with uveitis who had visited at least one of the Departments of Ophthalmology. In the standardized group, patients had a minimal work-up regardless of the type of uveitis (including evaluation of the CBC, ESR, C-reactive protein, tuberculin skin test, syphilis serology and chest X-ray). Depending on ophthalmological findings, further investigations could be performed. In the open strategy, ophthalmologists were free to order any kind of investigation. The main outcome was the mean cost per patient of each strategy. RESULTS 903 uveitis patients were included from January, 2010 to May, 2013. The mean cost per patient of the standardized strategy was 182.97 euros [CI 95% (173.14; 192.80)], and the mean cost per patient of the open strategy was 251.75 euros [CI 95% (229.24; 274.25)]. Therefore, the mean cost per patient of the standardized strategy was significantly lower than the mean cost per patient of the open strategy (p<0.001). There were significantly fewer visits (p<0.001), fewer radiological procedures (p<0.004) and fewer laboratory investigations (p<0.001) in the standardized group. CONCLUSION A standardized strategy is a cost-saving approach for the etiological diagnosis of uveitis.
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Affiliation(s)
- Audrey de Parisot
- Department of Internal Medicine, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | | | - Neila Sedira
- Department of Internal Medicine, Quinze-Vingts Hospital, Paris, France
| | - Emmanuel Heron
- Department of Internal Medicine, Quinze-Vingts Hospital, Paris, France
| | - Laurent Pérard
- Department of Internal Medicine, Edouard-Herriot Hospital, Lyon, France
| | | | - Christelle Schneider
- Department of Ophthalmology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Sophie Rivière
- Department of Internal Medicine, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Priscille Ollé
- Department of Ophthalmology, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Grégory Pugnet
- Department of Internal Medicine, Purpan University Hospital, Toulouse, France
| | - Pascal Cathébras
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Étienne, France
| | - Pierre Manoli
- Department of Ophthalmology, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Étienne, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
| | - David Saadoun
- Department of Internal Medicine, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphanie Baillif
- Department of Ophthalmology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Nathalie Tieulie
- Department of Internal Medicine, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marc André
- Department of Internal Medicine, Gabriel-Montpied Hospital, Clermont-Ferrand, France
| | | | - Nicolas Bonin
- Department of Ophthalmology, Gabriel-Montpied Hospital, Clermont-Ferrand, France
| | - Philip Bielefeld
- Department of Internal Medicine, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Alain Bron
- Department of Ophthalmology, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Frédéric Mouriaux
- Department of Ophthalmology, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Boris Bienvenu
- Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | | | | | - Pascal Sève
- Department of Internal Medicine, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
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Pepose JS, Sarda SP, Cheng WY, McCormick N, Cheung HC, Bobbili P, Joseph C, Duh MS. Direct and Indirect Costs of Infectious Conjunctivitis in a Commercially Insured Population in the United States. Clin Ophthalmol 2020; 14:377-387. [PMID: 32103884 PMCID: PMC7023864 DOI: 10.2147/opth.s233486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/20/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the direct and indirect costs of infectious conjunctivitis and quantify medical costs due to conjunctivitis transmission in families. Methods In this retrospective claims analysis from the OptumHealth Care Solutions, Inc. database (1998–2016), beneficiaries with or without at least one diagnosis of infectious conjunctivitis were identified. Direct and indirect costs (in 2016 US$) during the 60 days post conjunctivitis diagnosis (or imputed date for controls) were compared using cost differences in linear regressions. For transmission cost analysis, the total cost of each conjunctivitis episode was the sum of the primary episode (seed patient) and the secondary episode (infected family members) costs. A generalized estimating equation model adjusted for seed patient characteristics was used to assess the impact of number and rate of transmissions on episode cost. Results Health care resource utilization and direct costs were significantly higher for patients with conjunctivitis (n=1,002,188) versus controls (n=4,877,210): 1.67 all-cause visits per person per month (PPPM) versus 0.79 visits PPPM, respectively; total mean direct cost of $396.04 PPPM versus $289.63 PPPM, respectively. The cost of medically related absenteeism was $105.42 (95% confidence interval [CI], $104.18–$106.75) higher for patients with conjunctivitis than for controls. Episode cost, without transmission due to seed patient, was $669.43 (95% CI, $654.67–$684.85); it increased with each additional infected family member and with increased infection transmission time between family members. Conclusion Conjunctivitis was associated with a notable economic burden in terms of direct medical costs and medically related absenteeism. Family health care costs increased with transmission time and with each family member infected with conjunctivitis.
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Affiliation(s)
- Jay S Pepose
- Pepose Vision Institute, Chesterfield, MO, USA.,Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Niemeyer KM, Gonzales JA, Doan T, Browne EN, Rao MM, Acharya NR. Time Trade-off Utility Values in Noninfectious Uveitis. Am J Ophthalmol 2019; 208:47-55. [PMID: 31201795 DOI: 10.1016/j.ajo.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE To investigate time trade-off (TTO) utility values in patients with noninfectious uveitis and determine whether patient demographics and clinical characteristics are associated with utility scores. DESIGN Time trade-off utility analysis. METHODS Setting: A tertiary care uveitis center in San Francisco, California, USA. PATIENT POPULATION One hundred and four consecutive adults with noninfectious uveitis, enrolled between November 2016 and February 2017. MAIN OUTCOME MEASURES TTO utility values, as collected by an interviewer-guided survey. Information regarding general health, ocular symptoms, and religion was also collected and medical record review was conducted to record anatomic location of uveitis, disease activity, visual acuity, and treatments. Multivariable regression analysis with backward selection was used to identify variables associated with TTO values. RESULTS Median TTO score was 0.975 (interquartile range [IQR]: 0.8-1.0), corresponding to trading a median 1.28 years of remaining life for healthy eyes (IQR: 0-6.29). Regression analysis revealed that worse eye visual acuity, >6 months of oral corticosteroid use, and current antidepressant use were associated with lower TTO scores (P = .008, P = .006, P = .008, respectively), controlling for age and sex. In particular, patients who had been taking oral corticosteroids for more than 6 months, regardless of dose, were 10.5 times more likely to trade 20% or more years of remaining life (TTO ≤0.8) than patients not taking oral corticosteroids (95% confidence interval: 2.3, 48.1; P = .002). CONCLUSIONS Patients with noninfectious uveitis had measurable, though modest, reductions in quality of life, as assessed by TTO, and these decreases were significantly associated with visual acuity in the worse eye and long-term oral corticosteroid use.
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Affiliation(s)
- Katherine M Niemeyer
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
| | - John A Gonzales
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Thuy Doan
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Erica N Browne
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
| | - Maya M Rao
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA; Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA.
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Gómez-Gómez A, García-González J, Peiteado D, Borrego-Sanz L, Arriola-Villalobos P, Esteban-Ortega M, Martín-López M, Ventura-Hidalgo M, Perez-Blazquez E, Pato E, Díaz-Valle D, Muñoz-Fernández S, Rodriguez-Rodriguez L. Inflammatory Relapses after Immunosuppressive Drug Discontinuation in Uveitis Patients: A Survival Analysis. Ocul Immunol Inflamm 2019; 29:376-387. [PMID: 31710514 DOI: 10.1080/09273948.2019.1681469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To estimate the incidence rate (IR) and identify risk factors associated to inflammatory relapse after immunosuppressive drug (ISD) discontinuation in noninfectious uveitis patients.Methods: Multicenter longitudinal retrospective study, including patients from four uveitis clinics followed-up until December 2018. Hazard ratios for different variables were estimated using multivariable Cox models.Results: 32 patients (34 episodes of ISD discontinuation) were analyzed (median and maximum follow-up time: 2.4 and 19.2 years, respectively). Fourteen patients presented at least one relapse: anterior (8 patients), intermediate (5) and posterior (8). IR (95% confidence interval) of the first relapse was 14.3 (8.6-23.8) episodes per 100 patient-years (median survival time: 4.8 years). Early use of ISDs, panuveitis, and higher oral corticosteroid dosage at discontinuation were associated with higher hazards of relapse in multivariable analysis.Conclusions: Relapse is a frequent and early event after ISD discontinuation. Identifying relapse risk factors could support the physician's decision regarding ISD discontinuation.
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Affiliation(s)
- Alejandro Gómez-Gómez
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Rheumatology Department, Hospital Universitario Infanta Sofía, Madrid, Spain
| | | | - Diana Peiteado
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Lara Borrego-Sanz
- Ophthalmology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Mar Esteban-Ortega
- Ophthalmology Department, Hospital Universitario Infanta Sofía, Madrid, Spain.,Medicine Department, Universidad Europea, Madrid, Spain
| | - María Martín-López
- Rheumatology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Esperanza Pato
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - David Díaz-Valle
- Ophthalmology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Luis Rodriguez-Rodriguez
- Rheumatology Department and Health Research Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
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Predictors of High-cost Patients With Noninfectious Inflammatory Eye Diseases. Clin Ther 2019; 41:2331-2342. [PMID: 31607561 DOI: 10.1016/j.clinthera.2019.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 09/17/2019] [Accepted: 09/20/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Noninfectious inflammatory eye diseases (NIIEDs), such as uveitis, is a general term used to describe a complex mix of acute, chronic, allergic, and inflammatory disorders. Prior literature has established that, in addition to severe clinical burden, NIIEDs is associated with significant economic burden for US payers; however, no literature provides a current estimate of the economic burden associated with patients with high-cost NIIEDs. This study aimed to better understand the cost and resource use distribution and predictors of patients with high-cost NIIEDs. METHODS This retrospective cohort study selected adult patients with NIIEDs from a large US administrative claims database between 2006 and 2015. Among the included patients, total all-cause health care costs were calculated for a randomly selected 12-month period. Patients in the top 20% of total all-cause health care costs were identified as high-cost patients; the remaining patients were identified as lower-cost patients. Patient demographic characteristics, clinical characteristics, cost, and health care resource utilization (HRU) were compared. Logistic regression models were used to determine characteristics associated with high-cost patients. FINDINGS Patients with NIIEDs (n = 14,879) were categorized into 2976 high-cost and 11,903 lower-cost patients. High-cost patients with NIIEDs were significantly more likely to experience blindness, cataract, cystoid macular degeneration, retinal detachment, and visual disturbances during the follow-up period than the lower-cost patients (all P < 0.05). The high-cost patients accounted for ~77% of the total all-cause health care spend. High-cost patients incurred an average annual total health care cost of $59,873, and the top 1 percentile incurred $349,967 during the follow-up period. Hospitalization was a key cost driver among the high-cost patients, accounting for 50% of the total cost among the top 1 percentile of patients. High-cost patients were more likely to have specific autoimmune diseases, inpatient admission, and use of biologic and immunosuppressant agents. IMPLICATIONS A small segment of patients with NIIEDs consumed most resources. This study identified several predictors based on patient characteristics and HRU that may help inform the profile of patients with NIIEDs with the highest health care needs. As such, patients with a given profile can be selected for targeted interventions by clinicians to potentially help improve quality of care and to reduce costs.
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Pleyer U, Pohlmann D, Kardeş E, Poddubnyy D, Rademacher J. Emerging drugs for the treatment of noninfectious uveitis. Expert Opin Emerg Drugs 2019; 24:173-190. [PMID: 31498689 DOI: 10.1080/14728214.2019.1663823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Uveitis is a leading cause of visual impairment and a significant burden of blindness. Although corticosteroids and conventional immunosuppressive agents have been successfully used, these are non-specific, and their long-term use may induce significant adverse effects. Areas covered: This article discusses existing local and systemic applied treatments for ocular inflammation including corticosteroids, non-biologic, and biologic disease-modifying anti-rheumatic drugs (DMARD). Potential drugs being studied in clinical trials are introduced for both local and systemic use. Expert opinion: Treatment options for uveitis continue to expand. Still, more efforts and research are needed to better understand the mechanisms potentially leading to clinical trials.
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Affiliation(s)
- Uwe Pleyer
- Department of Ophthalmology, Campus Virchow, Charité , Berlin , Germany
| | - Dominika Pohlmann
- Department of Ophthalmology, Campus Virchow, Charité , Berlin , Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health , Berlin , Germany
| | - Esra Kardeş
- Department of Ophthalmology, University of Health Sciences, Umraniye Training and Research Hospital , Istanbul , Turkey
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology , Berlin , Germany.,Epidemiology Unit, German Rheumatism Research Centre , Berlin , Germany
| | - Judith Rademacher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health , Berlin , Germany.,Department of Gastroenterology, Infectiology and Rheumatology , Berlin , Germany
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38
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Gray CF, Quill S, Compton M, McAvoy CE, Williams MA. Epidemiology of Adult Uveitis in a Northern Ireland Tertiary Referral Centre. THE ULSTER MEDICAL JOURNAL 2019; 88:170-173. [PMID: 31619852 PMCID: PMC6790633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 11/03/2022]
Abstract
Uveitis is inflammation of the middle layer of the eye, called the uveal tract. It can be classified by anatomic location of the focus of inflammation inside the eye: intermediate, posterior or pan-uveitis. These types are less common than anterior uveitis (iritis), but more often have underlying aetiologies that require identification. Some aetiologies are infective, while others require systemic immunosuppression. Underlying aetiologies vary in different regions in the world, and so local data is important to guide clinicians. This study describes the aetiology of 255 cases of intermediate, posterior and pan-uveitis in adults. The most common non-infectious causes, after idiopathic, were sarcoid, Birdshot chorioretinopathy, demyelination-related and Behçet's, whereas toxoplasmosis and herpes simplex and zoster related retinitis were the common infectious causes. Neither age nor sex of the patient were related to aetiology.
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Affiliation(s)
- CF Gray
- Northern Ireland Medical and Dental Training Agency
| | - S Quill
- School of Medicine, National University of Ireland, Galway
| | - M Compton
- Department of Ophthalmology, Belfast Health and Social Care Trust
| | - CE McAvoy
- Department of Ophthalmology, Belfast Health and Social Care Trust
| | - MA Williams
- Department of Ophthalmology, Belfast Health and Social Care Trust,Centre for Medical Education, Queen’s University of Belfast,Corresponding author: Dr Michael Williams E-mail:
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Scott AT, Pecen PE, Palestine AG. Ophthalmic medication price variation across the United States: Anti-inflammatory medications. Ther Adv Ophthalmol 2019; 11:2515841419863638. [PMID: 31360908 PMCID: PMC6640056 DOI: 10.1177/2515841419863638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Cost-related nonadherence to medication can impact ophthalmic treatment outcomes. We aimed to determine whether medication prices vary between US cities and between different types of pharmacies within one city. Methods: We conducted a phone survey of eight nationwide and five independent pharmacies in five cities across the United States: Boston, Massachusetts; Charlotte, North Carolina; Denver, Colorado; Detroit, Michigan; and Seattle, Washington. A researcher called each pharmacy asking for price without insurance for four common anti-inflammatory ophthalmic medications: prednisolone acetate, prednisolone sodium phosphate, difluprednate (Durezol™), and loteprednol etabonate (Lotemax™). Results: Prednisolone sodium phosphate price could only be obtained by a small subset of pharmacies (45.2%) and was excluded from additional analysis; however, preliminary data demonstrated lower cost of prednisolone sodium phosphate over prednisolone acetate. Three-way analysis of variance revealed no interaction between pharmacy type (chain versus independent), city, and drug (F = 0.40, p = 0.92). A significant interaction was identified between pharmacy type and drug (F = 5.0, p = 0.008), but not city and pharmacy type (F = 0.66, p = 0.62) or city and drug (F = 0.27, p = 0.97). Average drug prices were lower at independent pharmacies compared with chain pharmacies for difluprednate (US$211.36 versus US$216.85, F = 1.09, p = 0.297) and significantly lower for loteprednol etabonate (US$255.49 versus US$274.86, F = 14.7, p < 0.001). Prednisolone acetate was cheaper at chain pharmacies, but not statistically significantly cheaper (US$48.82 versus US$51.61, F = 0.34, p = 0.559). Conclusions: Medication prices do not differ significantly between US cities. High variation of drug prices within the same city demonstrates how comparison shopping can provide cost savings for patients and may reduce cost-related nonadherence.
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Affiliation(s)
- Anthony T Scott
- Department of Ophthalmology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Paula E Pecen
- Department of Ophthalmology, School of Medicine, University of Colorado, Rocky Mountain Lions Eye Institute, 1675 Aurora Court, Mailstop F731, Aurora, CO 80045, USA
| | - Alan G Palestine
- Department of Ophthalmology, School of Medicine, University of Colorado, Aurora, CO, USA
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Cabahug VLO, Uy HS, Yu-Keh E, Sapno KJD. Outcomes of treatment with sirolimus for non-infectious uveitis: a meta-analysis and systematic review. Clin Ophthalmol 2019; 13:649-669. [PMID: 31114144 PMCID: PMC6478489 DOI: 10.2147/opth.s198401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Uveitis is a group of intraocular inflammatory diseases whose primary treatment involves immunosuppression. Although corticosteroids (CSs) remain the mainstay therapy, sirolimus is among the recently studied immunomodulatory drugs for treating noninfectious uveitis (NIU). Objective The aim of this review was to assess and summarize the updated evidence on the outcomes of treatment with sirolimus for NIU. Materials and methods Two reviewers conducted a systematic search on November 5, 2018, of electronic databases (EMBASE, MEDLINE, and The Cochrane Library) and clinical trial registers having no restrictions on language or publication date. The primary outcome was uveitis activity as measured by vitreous haze (VH), while the secondary outcomes included central macular thickness (CMT), best-corrected visual acuity (BCVA), CS-sparing effect, IOP elevation, and other adverse events. A meta-analysis was conducted on selected studies with appropriate clinical and methodological homogeneity. Results Seven studies were included and reviewed. Four randomized clinical trials were eligible for meta-analysis: SAVE 2013, One-year outcomes of the SAVE study, SAVE 2 2016, SAKURA 2016. The pooled proportions of inflammation control (VH improvement) were 38% (95% CI 16.19%-62.66%) during a 6-month follow-up and 49.97% (95% CI 16.19%-83.03%) during a 6- to 12-month follow-up with the latter showing a significantly higher response rate (p=0.0472). BCVA improvement was 62.2% (95% CI 33.17%-87.11%) during a 6-month follow-up and 56.86% (95% CI 20.91%-89.05%) during a 6- to 12-month follow-up with no significant difference between the two (p=0.3705). Increased IOP remained at 7.11% (95% CI 3.46%-12.68%) for both a 6-month follow-up and up to a 12-month follow-up duration. The CS-sparing effect of sirolimus was also well demonstrated. A reduction in CMT was observed, and only minor drug-related adverse events were reported in all the studies reviewed. Conclusion This review provided evidence that sirolimus is a promising treatment option for controlling inflammatory activity, improving visual acuity, and sparing CS use with minor adverse events for NIU.
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Affiliation(s)
| | - Harvey S Uy
- St Luke's Medical Center, Quezon City, Philippines, .,University of the Philippines, Manila, Philippines
| | - Ellen Yu-Keh
- St Luke's Medical Center, Quezon City, Philippines,
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Albini TA, Rice JB, White AG, Johnson M, Reiff J, Lima AF, Bartels-Peculis L, Ciepielewska G, Nelson WW. Economic Burden of Non-Infectious Inflammatory Eye Disease (NIIED) in a Commercially-Insured Population in the United States. Ocul Immunol Inflamm 2019; 28:164-174. [PMID: 30794006 DOI: 10.1080/09273948.2018.1560476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To assess the economic burden of non-infectious inflammatory eyedisease (NIIED) in a commercially-insured population in the United StatesMethods: Adult patients with a NIIED diagnosis between 2006 and 2015 were selected from a de-identified, privately insured claims database and were matched 1:1 to a non-NIIED control. Ophthalmologic complications, direct healthcare resource use and costs, and indirect work loss (from the payer perspective) were calculated for a 12-month period and compared across the 2 cohorts.Results: Among the 14 876 matched pairs, NIIED patients were significantly more likely than controls to experience ocular complications, including glaucoma and cataracts (p < 0.001). NIIED patients had significantly higher healthcare resource utilization and costs compared with matched controls (relative difference 40%, p < 0.001). NIIED patients missed 12.2 days of work ($2925 annual work-loss costs), 46% more than non-NIIED patients (p < 0.001).Conclusion: NIIED imposes a significant clinical and economic burden, suggesting an unmet need for expanded access to alternative treatment options.
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Affiliation(s)
- Thomas A Albini
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA
| | | | | | | | - Julie Reiff
- Analysis Group Inc., Boston, Massachusetts, USA
| | - Antonio Flavio Lima
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Laura Bartels-Peculis
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Gosia Ciepielewska
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Winnie W Nelson
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
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Rice JB, White AG, Scarpati LM, Wan GJ, Nelson WW. The burden of non-infectious intraocular inflammatory eye diseases: a systematic literature review. Curr Med Res Opin 2018; 34:2095-2103. [PMID: 30112931 DOI: 10.1080/03007995.2018.1512961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Non-infectious inflammatory eye diseases (IEDs), although rare, are complex and varied and may result in detrimental effects. A systematic literature review was conducted on the clinical outcome and economic burden of IED. METHODS The Ovid search platform (Wolters Kluwer) was used to access scientific literature databases, including MEDLINE, Embase, Cochrane libraries, Health Technology Assessment and the NHS Economic Evaluation database. The search strategy targeted clinical and economic outcomes research in 2009-2016. Titles and abstracts resulting from inclusion criteria were screened, and two reviewers independently extracted relevant information from the selected full-text articles. RESULTS Thirty-nine papers met the inclusion criteria - 21 clinical trials, 7 database analyses, 6 non-systematic literature reviews with expert commentary, 3 chart reviews, and 2 surveys - which assessed steroids, immunosuppressants, implants and biologics. Patients experienced considerable morbidity, much of which was associated with corticosteroid use. The average annual healthcare costs of patients with IED were $13,728 to $32,268 in 2009 US dollars, which amounted to 3.1 to 8.3 times that of patients without IED. Steroid-releasing intraocular implants were associated with higher up-front costs, close monitoring requirements, potential for implant removal and increased rates of adverse ocular events than systemic steroids. CONCLUSIONS IEDs are rare and complex conditions that threaten eyesight and impose considerable morbidity as well as a substantial economic burden. This review confirms that further research is needed to more fully explore the burden of IED and treatment-related adverse events, as well as appropriate means for clinicians to intensify treatment.
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Affiliation(s)
| | | | | | - George J Wan
- b Mallinckrodt Pharmaceuticals , Bedminster , NJ , USA
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Lindholm JM, Laine I, Hippala H, Ylinen P, Tuuminen R. Improving eye care services with a lean approach. Acta Ophthalmol 2018; 96:724-728. [PMID: 29461675 DOI: 10.1111/aos.13703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 12/14/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Effective provision of eye care services in government-financed hospitals is essential to balance the discrepancy between growing demand and limited resources. We aimed to improve efficiency of the treatment protocol for Nd:YAG laser posterior capsulotomy. Predetermined quality targets were a patient-oriented and patient-safe approach and the development of a clinical care process with purposeful use of competences. METHODS We utilized a lean process improvement methodology to develop a streamlined Nd:YAG laser posterior capsulotomy treatment protocol. A total of 206 patient visits were evaluated, where the lean-oriented treatment protocol was utilized in 158 of the visits and the conventional (CONV) protocol was followed in 48 of the visits. RESULTS All baseline variables were comparable between the study groups. Compared to the CONV protocol, implementation of new operational principles shortened the total reception time per patient from 55:36 ± 30:23; 12-136 min to 44:40 ± 4:49; 37-54 min (mean ± SD; range, p = 0.040). The per hour number of patients and eyes treated in the operation room improved from 4.7 ± 1.6; 2.6-8.4 patients and 5.5 ± 2.0; 3.5-11.3 eyes to 16.3 ± 2.3; 14.3-19.4 patients (p < 0.001) and 18.0 ± 1.6; 16.8-20.4 eyes (p < 0.001). The time spent by the operating physician reduced from 8:19 ± 3:06; 3:57-14:30 min to 3:01 ± 1:00; 1:34-6:38 min in unilateral procedure (p < 0.001) and from 8:45 ± 3:55; 5:52-14:10 min to 4:40 ± 2:03; 2:38-10:14 min in bilateral procedure (p < 0.006). Furthermore, the overall patient satisfaction grade improved from 17.3 ± 1.04; 15-18 points to 17.8 ± 0.61; 15-18 points (p = 0.001). CONCLUSIONS The lean approach improved the treatment protocol for Nd:YAG laser posterior capsulotomy with substantial reductions in lead times without compromising patient satisfaction.
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Affiliation(s)
- Juha-Matti Lindholm
- Unit of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
| | - Ilkka Laine
- Unit of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Automation and Electrical Engineering; Aalto University; Helsinki Finland
| | - Heli Hippala
- Unit of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
| | - Petteri Ylinen
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Raimo Tuuminen
- Unit of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Patient Insurance Centre; Helsinki Finland
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Thorne JE, Sugar EA, Holbrook JT, Burke AE, Altaweel MM, Vitale AT, Acharya NR, Kempen JH, Jabs DA. Periocular Triamcinolone vs. Intravitreal Triamcinolone vs. Intravitreal Dexamethasone Implant for the Treatment of Uveitic Macular Edema: The PeriOcular vs. INTravitreal corticosteroids for uveitic macular edema (POINT) Trial. Ophthalmology 2018; 126:283-295. [PMID: 30269924 DOI: 10.1016/j.ophtha.2018.08.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To evaluate the comparative effectiveness of 3 regional corticosteroid injections for uveitic macular edema (ME): periocular triamcinolone acetonide (PTA), intravitreal triamcinolone acetonide (ITA), and the intravitreal dexamethasone implant (IDI). DESIGN Multicenter, randomized clinical trial. PARTICIPANTS Patients with uveitic ME. METHODS Patients were randomized 1:1:1 to receive 1 of the 3 therapies. Patients with bilateral ME were assigned the same treatment for both eyes. MAIN OUTCOME MEASURES The primary outcome was the proportion of baseline (PropBL) central subfield thickness (CST) at 8 weeks (CST at 8 weeks/CST at baseline) assessed with OCT by masked readers. Secondary outcomes included ≥20% improvement and resolution of ME, best-corrected visual acuity (BCVA), and intraocular pressure (IOP) events over 24 weeks. RESULTS All treatment groups demonstrated improved CST during follow-up. At 8 weeks, each group had clinically meaningful reductions in CST relative to baseline (PropBL: 0.77, 0.61, and 0.54, respectively, which translates to reductions of 23%, 39%, and 46% for PTA, ITA, and IDI, respectively). Intravitreal triamcinolone acetonide (PropBL ITA/PropBL PTA, hazard ratio [HR], 0.79; 99.87% confidence interval [CI], 0.65-0.96) and IDI (PropBL IDI/PropBL PTA, HR, 0.69; 99.87% CI, 0.56-0.86) had larger reductions in CST than PTA (P < 0.0001). Intravitreal dexamethasone implant was noninferior to ITA at 8 weeks (PropBL IDI/PropBL ITA, HR, 0.88; 99.87% CI, 0.71-1.08). Both ITA and IDI treatments also were superior to PTA treatment in improving and resolving uveitic ME. All treatment groups demonstrated BCVA improvement throughout follow-up. Both ITA and IDI groups had improvements in BCVA that was 5 letters greater than in the PTA group at 8 weeks (P < 0.004). The risk of having IOP ≥24 mmHg was higher in the intravitreal treatment groups compared with the periocular group (HR, 1.83; 95% CI, 0.91-3.65 and HR, 2.52; 95% CI, 1.29-4.91 for ITA and IDI, respectively); however, there was no significant difference between the 2 intravitreal treatment groups. CONCLUSIONS Intravitreal triamcinolone acetonide and the IDI were superior to PTA for treating uveitic ME with modest increases in the risk of IOP elevation. This risk did not differ significantly between intravitreal treatments.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Center for Clinical Trials and Data Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
| | - Elizabeth A Sugar
- Center for Clinical Trials and Data Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Center for Clinical Trials and Data Synthesis, Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Janet T Holbrook
- Center for Clinical Trials and Data Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Alyce E Burke
- Center for Clinical Trials and Data Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael M Altaweel
- The Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Albert T Vitale
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah
| | - Nisha R Acharya
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Department of Epidemiology, University of California, San Francisco, San Francisco, California
| | - John H Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Eye Unit, MyungSung Christian Medical Center and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Douglas A Jabs
- Center for Clinical Trials and Data Synthesis, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
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Chirikov VV, Shah R, Kwon Y, Patel D. Oral corticosteroid exposure and increased risk of related complications in patients with noninfectious intermediate, posterior, or panuveitis: Real-world data analysis. Ophthalmic Epidemiol 2018; 26:27-46. [DOI: 10.1080/09286586.2018.1513042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - Ruchit Shah
- Real-World Evidence, Pharmerit International, Bethesda, MD, USA
| | - Youngmin Kwon
- Real-World Evidence, Pharmerit International, Bethesda, MD, USA
| | - Dipen Patel
- Real-World Evidence, Pharmerit International, Bethesda, MD, USA
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Leal I, Rodrigues FB, Sousa DC, Romão VC, Duarte GS, Carreño E, Dick AD, Marques-Neves C, Costa J, Fonseca JE. Efficacy and safety of intravitreal anti-tumour necrosis factor drugs in adults with non-infectious uveitis - a systematic review. Acta Ophthalmol 2018; 96:e665-e675. [PMID: 29577629 DOI: 10.1111/aos.13699] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 12/09/2017] [Indexed: 12/29/2022]
Abstract
Anti-tumour necrosis factor (TNF) drugs have been extensively used in non-infectious uveitis (NIU), when corticosteroids or conventional immunosuppressive drugs cannot adequately control inflammation or intolerable side-effects occur. However, systemic anti-TNF therapies are also associated with a myriad of side-effects. Therefore, intravitreal administration of anti-TNF biologics has been employed to minimize patient morbidity and systemic adverse effects, while maintaining therapeutic effectivity. We undertook a systematic review to determine evidence of efficacy and safety of intravitreal administration of anti-TNF drugs in adults with NIU. We conducted this systematic review according to the PRISMA guidelines. The protocol was registered with PROSPERO (CRD42016041946). We searched CENTRAL, MEDLINE and EMBASE, from inception to April 2017, as well as clinical trial registries and grey literature. The qualitative analysis included all studies of adult patients with a diagnosis of NIU and who received intravitreal anti-TNF drugs with a 4-week minimum follow-up. A total of 4840 references were considered for title and abstract screening. Seven full texts were screened, and five studies were considered for analysis. All studies were open-label, single-centre, prospective, non-randomized, interventional case series with a follow-up between 4 and 26 weeks, employing either adalimumab in two studies and infliximab in three. Three studies showed a treatment effect of anti-TNF intravitreal injections, while one study revealed short-term improvement and one study revealed no efficacy of anti-TNF intravitreal therapy. None of the studies reported ocular adverse effects but only two studies included electrophysiological assessment in the safety analysis and no study assessed systemic human anti-drug antibodies. The available evidence is not sufficiently robust to conclude about the clinical effectivity of intravitreal anti-TNF in NIU and so no recommendation can be made. In conclusion, intravitreal injection of anti-TNF antibodies remains a possible treatment option to be explored through robust clinical investigation.
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Affiliation(s)
- Inês Leal
- Department of Ophthalmology; Hospital de Santa Maria-CHLN; Lisbon Academic Medical Centre; Lisboa Portugal
- Department of Ophthalmology; Faculdade de Medicina; Universidade de Lisboa; Lisboa Portugal
- Centro de Estudos das Ciências da Visão; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Clinical Pharmacology Unit; Instituto de Medicina Molecular; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Huntington's Disease Centre; University College London; London UK
| | - David Cordeiro Sousa
- Department of Ophthalmology; Hospital de Santa Maria-CHLN; Lisbon Academic Medical Centre; Lisboa Portugal
- Department of Ophthalmology; Faculdade de Medicina; Universidade de Lisboa; Lisboa Portugal
- Centro de Estudos das Ciências da Visão; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Vasco C Romão
- Department of Rheumatology; Hospital de Santa Maria-CHLN; Lisbon Academic Medical Centre; Lisbon Portugal
- Rheumatology Research Unit; Instituto de Medicina Molecular; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Clinical Pharmacology Unit; Instituto de Medicina Molecular; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Ester Carreño
- Clinical Research Unit; Bristol Eye Hospital NHS Foundation Trust; Bristol UK
| | - Andrew D Dick
- Clinical Research Unit; Bristol Eye Hospital NHS Foundation Trust; Bristol UK
- School of Clinical Sciences; Faculty of Medicine and Dentistry; University of Bristol; Bristol UK
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology; London UK
| | - Carlos Marques-Neves
- Department of Ophthalmology; Hospital de Santa Maria-CHLN; Lisbon Academic Medical Centre; Lisboa Portugal
- Department of Ophthalmology; Faculdade de Medicina; Universidade de Lisboa; Lisboa Portugal
- Centro de Estudos das Ciências da Visão; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Clinical Pharmacology Unit; Instituto de Medicina Molecular; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Evidence Based Medicine Centre; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
- Portuguese Collaborating Centre of the Cochrane Iberoamerican Network; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - João Eurico Fonseca
- Department of Rheumatology; Hospital de Santa Maria-CHLN; Lisbon Academic Medical Centre; Lisbon Portugal
- Rheumatology Research Unit; Instituto de Medicina Molecular; Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
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Nguyen QD, Merrill PT, Sepah YJ, Ibrahim MA, Banker A, Leonardi A, Chernock M, Mudumba S, Do DV. Intravitreal Sirolimus for the Treatment of Noninfectious Uveitis: Evolution through Preclinical and Clinical Studies. Ophthalmology 2018; 125:1984-1993. [PMID: 30060978 DOI: 10.1016/j.ophtha.2018.06.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/31/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022] Open
Abstract
In recent decades, the treatment paradigm for noninfectious intermediate uveitis, posterior uveitis, and panuveitis, a group of intraocular inflammatory diseases, has included systemic and local (periocular or intraocular) corticosteroids, biologics, and other steroid-sparing immunomodulatory therapy agents. Recently, an intravitreal formulation of sirolimus, an immunosuppressant that inhibits the mammalian target of rapamycin, a key regulator of cell growth in the immune system, was developed. On the basis of this mechanism and the local method of delivery, it was hypothesized that intravitreal sirolimus can improve ocular inflammation in patients with noninfectious intermediate uveitis, posterior uveitis, and panuveitis, with minimal systemic exposure and systemic adverse events (AEs). This review summarizes the pharmacokinetics, efficacy, and safety results of intravitreal sirolimus from 3 preclinical studies and 4 phase 1-3 clinical studies. Preclinical studies in rabbits showed that 22 to 220 μg intravitreal sirolimus results in sustained release of sirolimus in the vitreous for 2 months or more, with systemic concentrations below the threshold for systemic immunosuppression (approximately 8 ng/ml). Subsequently, 2 phase 1 studies (n = 50 and n = 30) established that intravitreal sirolimus improves ocular inflammation in humans. Further investigation in phase 2 and 3 studies (n = 24 and n = 347, respectively) suggested that 440 μg has the best benefit-to-risk profile. In the phase 3 study, the proportion of patients who showed complete resolution of ocular inflammation at month 5 was significantly higher in the 440-μg group than in the 44-μg group (22.8% vs. 10.3%; P = 0.025, Fisher exact test). In addition, 47 of 69 patients (68.1%) who were treated with systemic corticosteroids at baseline discontinued corticosteroid use at month 5. No sirolimus-related systemic AEs were reported in phase 1-3 studies. Collectively, these preclinical and clinical study data of intravitreal sirolimus support the therapeutic rationale of treating noninfectious uveitis with a local mammalian target of rapamycin inhibitor and suggest that 440 μg intravitreal sirolimus has the potential to be an effective and well-tolerated anti-inflammatory and corticosteroid-sparing treatment for noninfectious intermediate uveitis, posterior uveitis, and panuveitis.
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Affiliation(s)
- Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California.
| | - Pauline T Merrill
- Department of Ophthalmology, Rush University Medical Center, Chicago, Illinois
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Mohamed A Ibrahim
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; Ocular Imaging Research and Reading Center (OIRRC), Menlo Park, California
| | - Alay Banker
- Banker's Retina Clinic and Laser Center, Navrangpura, Ahmedabad, India
| | - Andrea Leonardi
- Department of Neuroscience, Ophthalmology Unit, University of Padua, Padua, Italy
| | | | | | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
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Jabs DA. Immunosuppression for the Uveitides. Ophthalmology 2018; 125:193-202. [PMID: 28942074 PMCID: PMC5794515 DOI: 10.1016/j.ophtha.2017.08.007] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/21/2017] [Accepted: 08/07/2017] [Indexed: 12/19/2022] Open
Abstract
The uveitides are a collection of more than 30 diseases characterized by intraocular inflammation. Many cases of juvenile idiopathic arthritis-associated uveitis, many cases of intermediate uveitis, and most cases of posterior and panuveitides requiring treatment are treated with corticosteroids and immunosuppression. Disease-specific, time-updated modeling of clinical data for several uveitides suggests superior prevention of ocular complications and visual outcomes with immunosuppression. These studies also suggest that oral corticosteroids at doses low enough for safe long-term therapy (i.e., <7.5 mg/day) are ineffective, implying that immunosuppression should be part of the initial regimen. The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study was a randomized comparative effectiveness trial comparing systemic therapy with oral corticosteroids and immunosuppression with regional corticosteroid treatment. It demonstrated that, when used properly, oral corticosteroids and immunosuppression can be given safely for up to 7 years with no evident increased risk of systemic side effects compared with regional corticosteroid therapy, except for greater antibiotic use for infections. The Systemic Treatment for Eye Diseases (SITE) Cohort Study suggested long-term safety for this approach, when the immunosuppressive agents were antimetabolites or calcineurin inhibitors. Thus, oral corticosteroids and immunosuppression may be a preferred initial therapy for many noninfectious, intermediate, posterior, and panuveitides. Nonalkylating-agent immunosuppression has a low rate of sustained, drug-free remissions, <10%/year. Nonalkylating-agent immunosuppression for >3 years with control of the inflammation for >2 years is associated with a decreased risk of relapse after discontinuing immunosuppression. Alkylating agents can induce sustained drug-free remissions but likely increase the lifetime risk of cancer. Biologics, which target specific cytokines and pathways, hold promise for the future. Monoclonal antibodies directed against tumor necrosis factor (TNF)-α have been studied most often, and one, adalimumab, is U.S. Food and Drug Administration approved for the treatment of noninfectious, intermediate, posterior, and panuveitides.
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Affiliation(s)
- Douglas A Jabs
- Departments of Ophthalmology and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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Leitlinie Nr. 24b der DOG und BVA. Ophthalmologe 2017; 114:1122-1134. [DOI: 10.1007/s00347-017-0582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Espinosa G, Muñoz-Fernández S, García Ruiz de Morales JM, Herreras JM, Cordero-Coma M. Treatment recommendations for non-infectious anterior uveitis. Med Clin (Barc) 2017; 149:552.e1-552.e12. [PMID: 28911893 DOI: 10.1016/j.medcli.2017.06.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVE To develop recommendations on the use of immunodepressors in patients with non-infectious, non-neoplastic anterior uveitis (AU) based on best evidence and experience. MATERIAL AND METHODS A multidisciplinary panel of five experts was established, who, in the first nominal group meeting defined the scope, users, and chapters of the document. A systematic literature review was performed to assess the efficacy and safety of immunosuppressors in patients with non-infectious, non-neoplastic AU. All the above was discussed in a second nominal group meeting and 33 recommendations were generated. Through the Delphi methodology, the degree of agreement with the recommendations was tested also by 25 more experts. Recommendations were voted on from one (total disagreement) to 10 (total agreement). We defined agreement if at least 70% voted ≥7. The level of evidence and degree of recommendation was assessed using the Oxford Centre for Evidence-based Medicine's Levels of Evidence. RESULTS The 33 recommendations were accepted. They include specific recommendations on patients with non-infectious, non-neoplastic AU, as well as different treatment lines. CONCLUSIONS In patients with non-infectious, non-neoplastic AU, these recommendations on the use of immunosuppressors might be a guide in order to help in the treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
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Affiliation(s)
- Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Institut Clinic de Medicina i Dermatologia, Hospital Clínic, Barcelona, España
| | - Santiago Muñoz-Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España; Universidad Europea, San Sebastián de los Reyes, Madrid, España
| | - José M García Ruiz de Morales
- Unidad de Uveítis, Servicio de Inmunología, Complejo Asistencial Universitario de León, León, España; Instituto de Biomedicina, Universidad de León (IBIOMED), León, España
| | - José M Herreras
- IOBA (Instituto Universitario de Oftalmobiología), Universidad de Valladolid, Valladolid, España; Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Miguel Cordero-Coma
- Instituto de Biomedicina, Universidad de León (IBIOMED), León, España; Unidad de uveítis, Servicio de Oftalmología, Complejo Asistencial Universitario de León, León, España.
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