Clinical Course before and after Cataract and Glaucoma Surgery under Systemic Infliximab Therapy in Patients with Behçet's Disease

Efficacy and safety of the optimisation of biological therapy in non-infectious uveitis: Systematic review

OBJECTIVE

To conduct a systematic critical review of the literature on the efficacy and safety of biological therapy (BT) optimisation in non-infectious uveitis (NIU).

METHODS

Searches were conducted (PubMed, Embase, Cochrane and conference abstracts) up to March 2021. The study population comprised patients with NIU in remission after BT. We analysed BT optimisation strategies. The main outcome measures were efficacy and safety. To assess the risk of bias, the ROBINS-1 tool was used. A qualitative review of the data was performed to assess heterogeneity and bias. Evidence tables (study characteristics and outcomes) were generated, and quantitative synthesis was performed if data were homogeneous.

RESULTS

We selected 11 studies (prospective and retrospective) including 513 patients. The studies were at moderate/high risk of bias and there was considerable variability between studies in sample size, underlying diseases, definitions and outcome variables. Criteria for starting optimisation were not uniform. All BTs optimised were TNF inhibitors. Optimisation could be attempted after 3-6 months in remission. Relapse occurred in 25-50% of patients but was controlled after dose re-escalation or BT switching. No safety issues were identified.

CONCLUSIONS

The optimization of BT (with TNF inhibitors) has been applied in patients with NIU in remission. There is no consensus on criteria for attempting BT optimisation and protocols are heterogeneous. There is a least moderate risk of bias, so no robust conclusions on efficacy and safety of optimization can be reached. Preliminary evidence suggests that relapses might be controlled using standard doses. Larger studies using uniform criteria are needed.

Management of cataract in uveitis patients

PURPOSE OF REVIEW

This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles.

RECENT FINDINGS

All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes.

SUMMARY

Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

Combined Ahmed valve and phacoemulsification with intraocular lens implantation under infliximab in refractory uveitic glaucoma

PURPOSE

To evaluate the outcome of combined Ahmed glaucoma valve (AGV) and phacoemulsification with posterior chamber intraocular lens implantation under infliximab in refractory uveitic glaucoma (UG).

METHODS

In this prospective interventional case series, 26 eyes of 26 patients with refractory UG underwent surgery under intravenous infliximab. The success rate was defined as intraocular pressure (IOP) 5 to 21 mm Hg with or without antiglaucoma medications (AGM), without additional glaucoma surgical intervention.

RESULTS

The mean IOP (37.8 ± 11.86 to 12.2 ± 2.8 mm Hg; p<0.0001) and mean number of AGM (3.4 ± 1.2 to 0.4 ± 0.1; p<0.001) were significantly reduced after surgery at 2 years. Kaplan-Meier survival analysis showed a cumulative probability of success for IOP control of 92% at 2 years of follow-up.

CONCLUSIONS

Combined AGV and phacoemulsification is an effective treatment for controlling refractory UG with complicated cataract under infliximab.

A Pilot Study on Ocular Safety and Efficacy of Infliximab as an Antifibrotic Agent After Experimental Glaucoma Filtration Surgery

Introduction

Tumor necrosis factor-α (TNF-α) is a multifunctional, proinflammatory cytokine that mediates pleiotropic biological functions, especially inflammation and immunoregulation. We hypothesized that blocking TNF-α with a monoclonal antibody would decrease inflammation and subconjunctival scarring in an animal model of experimental filtration surgery.

Methods

In a randomized, prospective, masked-observer study, 30 New Zealand albino rabbits underwent glaucoma filtration surgery. The animals were allocated to receive either intraoperative application of infliximab (group A) or mitomycin C (MMC) at a concentration of 0.2 mg/ml (group B) or balanced salt solution (BSS, control) (group C). Different infliximab doses, namely 1.0, 2.0, 3.0, 4.0, 5.0 mg in 0.1 ml, were applied. Bleb survival and characteristics were evaluated over a 30-day period. The animals were killed on postoperative day 15 or 30. Histology of the operated eyes was performed to evaluate and grade the amount of scarring in each group. Cellular density was evaluated in each case.

Results

Infliximab did not appear to improve outcomes in this model of glaucoma filtration surgery. Bleb survival was significantly higher in the MMC group compared to the other groups (p < 0.001 for both comparisons). Vascularity was also significantly lower in the MMC group compared to the other groups (p = 0.018 for both comparisons). There was a significant decrease in cellular density in the MMC group compared to the control (p = 0.0352) and the infliximab group (p < 001).

Conclusion

Our results have shown that trabeculectomies in the infliximab group failed faster and displayed more scarring, compared to the control and MMC groups. This outcome suggests that the infliximab doses used in this pilot study resulted in a subconjunctival TNF-α concentration, which acted as a stimulator to fibroblasts.

Herpetic Keratouveitis and Trabeculectomy Failure during Infliximab Therapy in a Patient with Behçet's Disease

A 51-year-old man was diagnosed with Behçet’s disease in 2001. The patient was resistant to all immunosuppressive therapies. After 6 months of infliximab therapy, he presented to our clinic with pain and blurred vision in his right eye. The visual acuity was 20/200 and the intraocular pressure was 35 mmHg in the right eye. Biomicroscopic examination revealed corneal dendritic ulcers and 2+ cells in the anterior chamber in the right eye. The herpetic keratouveitis attack was controlled with antiviral therapy but the patient needed another glaucoma surgery. Trabeculectomy with mitomycin C was performed about halfway through an eight-week interval between two doses of infliximab.

Infliximab reduces Zaprinast-induced retinal degeneration in cultures of porcine retina

Background

cGMP-degrading phosphodiesterase 6 (PDE6) mutations cause around 4 to 5% of retinitis pigmentosa (RP), a rare form of retinal dystrophy. Growing evidence suggests that inflammation is involved in the progression of RP. The aims of this study were to corroborate the presence of high TNFα concentration in the eyes of RP patients and to evaluate whether the blockade of TNFα with Infliximab, a monoclonal anti-TNFα antibody, prevented retinal degeneration induced by PDE6 inhibition in cultures of porcine retina.

Methods

Aqueous humor from 30 patients with RP and 13 healthy controls were used to quantify the inflammatory mediators IL-6, TNFα, IL-1β, IL-10 by a multiplex enzyme-linked immunosorbent assay (ELISA) system. Retinal explants from pig were exposed to Zaprinast, a PDE6 inhibitor, for 24 hours in the absence or the presence of Infliximab. Cell death was evaluated by TUNEL assay. The number and distribution of caspase-3 positive cells, indirect poly(ADP)ribose polymerase (PARP) activation and glial fibrillary acidic protein (GFAP) content were visualized by immunolabeling. Antioxidant total capacity, nitrites and thiobarbituric acid reactive substances (TBARS) formation were determined to evaluate antioxidant-oxidant status.

Results

IL-6 and TNFα concentrations were higher in the aqueous humor of RP patients than in controls. Infliximab prevented retinal degeneration, as judging by the reduced presence of TUNEL-positive cells, the reduction of caspase-3 activation and also reduction of glial activation, in an ex vivo model of porcine retina. Additionally, Infliximab partially reduced oxidative stress in retinal explants exposed to Zaprinast.

Conclusions

Inflammatory mediators IL-6 and TNFα were elevated in the aqueous humor of RP patients corroborating previous studies suggesting sustained chronic inflammation. Our study suggests that TNFα is playing an important role in cell death in an ex vivo model of retinal degeneration by activating different cell pathways at different cell layers of the retina that should be further studied.

Electronic supplementary material

The online version of this article (doi:10.1186/s12974-014-0172-9) contains supplementary material, which is available to authorized users.

Cataract surgery under systemic infliximab therapy in patients with refractory uveitis associated with Behcet disease

BACKGROUND AND OBJECTIVES

This study is to evaluate the outcome of cataract surgery in patients with refractory uveitis associated with Behçet disease (BD) treated with infliximab.

DESIGN AND SETTINGS

A retrospective study in a university-based tertiary referral center in the period between July 2003 and November 2011.

METHODS

This is a retrospective study of patients with refractory uveitis associated with BD who underwent phacoemulsification cataract surgery under systemic infliximab therapy between July 2003 and November 2011 at King Abdulaziz University Hospital, Riyadh, Saudi Arabia.

RESULTS

Six patients (9 eyes), 5 of which were male and 1 female, were identified in this study. The mean (SD) age and follow-up period were 26.2 (6.6) years (range, 16-36 years) and 51.6 (28.8) months (range, 12.84 months), respectively. All the patients underwent phacoemulsification with intraocular lens implantation. Postoperatively, visual acuity improved in all eyes and was 20/40 or better in 7 eyes (77.8%). In the immediate postoperative period, anterior chamber inflammation ranged from 2+ to 3+ cells. None of the patients developed inflammation relapse postoperatively. The most common postoperative complication was posterior capsular opacification in 5 eyes (55%), 4 of which were managed with neodymium:yttrium-aluminum garnet laser capsulotomy. Three eyes had glaucoma, 2 of which underwent successful glaucoma surgery and one was managed with topical antiglaucoma medications.

CONCLUSION

In patients with refractory uveitis associated with BD who are treated with infliximab, cataract surgery is safe and has a good prognosis.

Trabeculotomy in a Behçet's Disease Patient One Week after Infliximab Administration

Purpose

To describe a patient with Behçet's disease and anterior uveitis, which was not cured by local and systemic corticosteroid treatments, who underwent trabeculotomy one week after infliximab administration.

Methods

The patient received preoperative antibiotic therapy followed by trabeculotomy one week after infliximab administration. We observed ocular findings before and after surgery.

Results

Anterior uveitis improved after infliximab administration. The elevated intraocular pressure improved after surgery and there were no intraoperative complications. Neither ocular inflammatory attacks nor infectious complications were found in the operated eye of the patient during follow-up.

Conclusion

Trabeculotomy one week after administration of infliximab appears to be safe and effective in treating secondary glaucoma associated with Behçet's disease.