A Major Review: Current Aspects of Ocular Behçet's Disease in Japan

Decoding Behcet's Uveitis: an In-depth review of pathogenesis and therapeutic advances

Behcet's disease (BD) is a rare but globally distributed vasculitis that primarily affects populations in the Mediterranean and Asian regions. Behcet's uveitis (BU) is a common manifestation of BD, occurring in over two-thirds of the patients. BU is characterized by bilateral, chronic, recurrent, non-granulomatous uveitis in association with complications such as retinal ischemia and atrophy, optic atrophy, macular ischemia, macular edema, and further neovascular complications (vitreous hemorrhage, neovascular glaucoma). Although the etiology and pathogenesis of BU remain unclear, numerous studies reveal that genetic factors (such as HLA-B51), dysregulated immune responses of both the innate and adaptive immune systems, infections (such as streptococcus), and environmental factors (such as GDP) are all involved in its development. Innate immunity, including hyperactivity of neutrophils and γδT cells and elevated NK1/NK2 ratios, has been shown to play an essential role in this disease. Adaptive immune system disturbance, including homeostatic perturbations, Th1, Th17 overaction, and Treg cell dysfunction, is thought to be involved in BU pathogenesis. Treatment of BU requires a tailored approach based on the location, severity of inflammation, and systemic manifestations. The therapy aims to achieve rapid inflammation suppression, preservation of vision, and prevention of recurrence. Systemic corticosteroids combined with other immunosuppressive agents have been widely used to treat BU, and beneficial effects are observed in most patients. Recently, biologics have been shown to be effective in treating refractory BU cases. Novel therapeutic targets for treating BU include the LCK gene, Th17/Treg balance, JAK pathway inhibition, and cytokines such as IL-17 and RORγt. This article summarizes the recent studies on BU, especially in terms of pathogenesis, diagnostic criteria and classification, auxiliary examination, and treatment options. A better understanding of the significance of microbiome composition, genetic basis, and persistent immune mechanisms, as well as advancements in identifying new biomarkers and implementing objective quantitative detection of BU, may greatly contribute to improving the adequate management of BU patients.

Correlation between Widefield Fundus Fluorescein Angiography Leakage Score and Anterior Chamber Flare in Behçet Uveitis

AIMS

To investigate the correlation between widefield fundus fluorescein angiography (WF-FA) and anterior chamber laser flare photometry (LFP-flare) in Behçet uveitis (BU).

METHODS

Patients with BU who underwent Heidelberg WF-FA between March 2016 and March 2018 were included. Demographics, ocular findings, LFP-flare, central macular thickness were retrospectively analyzed.

RESULTS

Eighty-six patients (162 eyes) were included. There was a high correlation between WF-FA leakage score and LFP-flare (rho: 0.691, p < .001). For a flare value of 5.75 ph/ms or higher, the sensitivity for predicting angiographic leakage was 70% and the specificity was 94% (AUC: 0.897, p < .001). Flare values that were equal or above 7.6 ph/ms were found to be 100% specific for leakage in the WF-FA.

CONCLUSION

A strong correlation was found between WF-FA leakage and LFP-flare in patients with BU. High LFP-flare levels indicate subclinical posterior segment inflammation in clinically inactive BU.

Automated Quantitative Analysis of Anterior Segment Inflammation Using Swept-Source Anterior Segment Optical Coherence Tomography: A Pilot Study

Background: The aim of this study is to develop an automated evaluation of anterior chamber (AC) cells in uveitis using anterior segment (AS) optical coherence tomography (OCT) images. Methods: We analyzed AS swept-source (SS)-OCT (CASIA 2) images of 31 patients (51 eyes) with uveitis using image analysis software (Python). An automated algorithm was developed to detect cellular spots corresponding to hyper-reflective spots in the AC, and the correlation with Standardization of Uveitis Nomenclature (SUN) grading AC cells score was evaluated. The approximated AC grading value was calculated based on the logarithmic approximation curve between the number of cellular spots and the SUN grading score. Results: Among 51 eyes, cellular spots were automatically segmented in 48 eyes, whereas three eyes (all SUN grading AC cells score: 4+) with severe fibrin formation in the AC were removed by the automated algorithm. The AC cellular spots increased with an increasing SUN grading score (p < 0.001). The 48 eyes were split into training data (26 eyes) and test data (22 eyes). There was a significant correlation between the SUN grading score and the number of cellular spots in 26 eyes (rho: 0.843, p < 0.001). There was a significant correlation between the SUN grading score and the approximated grading value of 22 eyes based on the logarithmic approximation curve (rho: 0.774, p < 0.001). Leave-one-out cross-validation analysis demonstrated a significant correlation between the SUN grading score and the approximated grading value of 48 eyes (rho: 0.748, p < 0.001). Conclusions: This automated anterior AC cell analysis using AS SS-OCT showed a significant correlation with clinical SUN grading scores and provided SUN AC grading values as a continuous variable. Our findings suggest that automated grading of AC cells could improve the accuracy of a quantitative assessment of AC inflammation using AS-OCT images and allow the objective and rapid evaluation of anterior segment inflammation in uveitis. Further investigations on a large scale are required to validate this quantitative measurement of anterior segment inflammation in uveitic eyes.

Investigation of anterior segment structures of the eye in Behçet's disease using in vivo confocal microscopy

PURPOSE

We sought to investigate alterations in the corneal subbasal nerve plexus and endothelium in patients with Behçet's disease (BD).

METHODS

This cross-sectional study included 64 patients with BD and 30 age- and gender-matched healthy control subjects. Those with BD were classified as having ocular or non-ocular disease. All subjects underwent a corneal endothelial and subbasal nerve density evaluation using in vivo confocal microscopy (IVCM). The differences among groups were analyzed using the Kruskal-Wallis test followed by Dunn's multiple comparison procedure.

RESULTS

The mean age of study participants was 35.7 ± 10.2 years (16-58) in the ocular BD group, 39.6 ± 14.9 years (11-66) in the non-ocular BD group, and 34.1 ± 11.2 years (21-55) in the control group. No statistical significance was found in terms of age (p = 0.259) or sex (p = 0.560) between groups. The mean endothelial cell density determined with IVCM was 2124.9 [Formula: see text] 417.4 cells/mm² (1811-3275) in the ocular group and 2546 [Formula: see text] 335 cells/mm² (1798-3280) in the control group (p = 0.000). In the ocular group, the mean density of the subbasal nerve plexus was significantly lower (p = 0.004), and nerve tortuosity was significantly higher (p = 0.002).

CONCLUSIONS

Ocular BD could be responsible for changes in the corneal layers, especially endothelial and corneal nerve structures. Nerve density and tortuosity differences could be inflammatory indicators for BD.

Evaluation of retinal and choroidal microcirculation in Behçet's disease

PURPOSE

To investigate retinal perfusion by optical coherence tomography (OCT)-angiography and choroidal vascular features using an OCT-based image binarization method in patients with Behçet's disease (BD) without clinical ocular involvement.

METHODS

This study included 38 patients with non-ocular BD and 35 healthy participants. Macular region was evaluated with OCT-angiography (Optovue, Inc., Fremont, CA). A 6.0 × 6.0 mm rectanglescan centred on the fovea was used to record the scans. The enhanced depth imaging OCT scans (Heidelberg Eye Explorer version 1.8.6.0; Heidelberg Engineering) of the macula and peripapillary scans of the optic nerve head were binarized using ImageJ software (National Institutes of Health, Bethesda, MD, USA). The luminal area (LA), stromal area (SA), total choroidal area (TCA), and choroidal thickness (CT) were analysed. The choroidal vascularity index (CVI) was calculated as the ratio of the LA to the TCA.

RESULTS

Vessel density values of the superficial and deep macular capillary plexus were similar between the two groups (all p > 0.05). There was no significant difference between the groups in terms of the CT and TCA values in the macula and in all peripapillary sectors (all p > 0.05). However, the macula and temporal, nasal, and inferior sectors of the peripapillary area had significantly lower CVI values in the BD group compared with controls (p = 0.009, p = 0.002, p = 0.010, and p = 0.008, respectively).

CONCLUSIONS

Retinal microperfusion deficit was not observed in non-ocular Behçet patients. CVI may be a more robust marker than CT to indicate choroidal perfusion. A reduced CVI may suggest subclinical ocular involvement and choroidal ischemia in these patients.

Incidence and changing patterns of uveitis in Central Tokyo

PURPOSE

The patterns of uveitis in Tokyo have recently changed due to advances in examination tools. We aimed to investigate the changes in the patterns of uveitis between 2004-2015 and 2016-2018.

METHODS

We retrospectively reviewed the data of 732 patients who visited the Uveitis Clinic at the University of Tokyo Hospital between January 2016 and December 2018. Background characteristics, laboratory results, and imaging findings were analysed. We compared the incidences of uveitis in 2016-2018 and 2004-2015 to identify changes in the patterns.

RESULTS

The most frequent diagnoses were sarcoidosis (8.9%), herpetic iridocyclitis (6.7%), intraocular lymphoma (5.5%), Vogt-Koyanagi-Harada disease (4.8%), unclassified acute anterior uveitis (4.6%), Behçet's disease (4.5%), bacterial endophthalmitis (2.9%), and Posner-Schlossman syndrome (2.6%). Suspected sarcoidosis (20.9%) was the most common cause of unclassified uveitis. The incidence of intraocular lymphoma was significantly higher in 2016-2018 than in 2004-2015. Between 2004 and 2018, herpetic iridocyclitis, bacterial endophthalmitis, and juvenile chronic iridocyclitis exhibited an increasing trend, and the incidences of Posner-Schlossman syndrome, unclassified acute anterior uveitis, Behçet's disease, and Vogt-Koyanagi-Harada disease exhibited a decreasing trend.

CONCLUSION

The changing patterns of uveitis were characterised by increases in the incidence of intraocular lymphoma. This may be attributed to recent advances in examination tools, the changes in the referred patient population, and the aging Japanese population.

Immunological tests and their interpretation in uveitis

Uveitis is a complex disorder including both infectious and non-infectious etiologies. Clinical diagnosis is a challenge because many diseases share common clinical signs. Laboratory support is crucial for confirming the clinical diagnosis. Laboratory diagnosis includes direct tests and indirect tests. For example smear, culture, and molecular diagnostics demonstrate the pathogens, hence they are direct tests. Immunologic tests employ an antigen to detect presence of antibodies to a pathogen, or an antibody to detect the presence of an antigen, of the pathogen in the specimens. The immunological tests used in laboratories are made by producing artificial antibodies that exactly “match” the pathogen in question. When these antibodies come into contact with a sample they bind to the matching pathogen if found in the sample. Hence they are grouped under indirect evidence. There are several investigations in uveitis to reach the confirmed diagnosis including microbiological, immunological, imaging and molecular diagnostic testing. In this section we will discuss immunological investigations of infectious and non-infectious uveitis.

Treatment of Behçet's Disease: An Algorithmic Multidisciplinary Approach

Behçet's disease (BD) is a chronic, relapsing inflammatory, multisystem disease of unknown etiology. The disease has a wide clinical spectrum of mucocutaneous lesions and ocular, vascular, articular, neurologic, gastrointestinal and cardiac involvement. Although the number of effective drugs used in the disease's treatment has increased in recent years, BD is still associated with severe morbidity because of mainly mucocutaneous, articular and ocular symptoms and an increased mortality because of large vessel, neurological, gastrointestinal and cardiac involvement. Many factors are associated with a more serious course, such as male gender and a younger age of onset. While the severity of the disease is more pronounced in the first years of the disease, it decreases in most patients after the age of forties. The primary goal of treatment should be the prevention of irreversible organ damage. Therefore, early diagnosis and appropriate treatment and close follow-up are mandatory to reduce the morbidity and mortality of the disease. Treatment varies depending on the organ involved and the severity of the involvement. For all these reasons, the treatment should be personalized and arranged with a multidisciplinary approach according to the organs involved. Treatment is mainly based on suppression of the inflammatory attacks of the disease using local and systemic immunomodulatory and immunosuppressive drugs. In this review, based on the mainly controlled studies and personal experience in clinical practice and basic research in this field, we propose a stepwise, symptom-based, algorithmic approach for the management of BD with a holistic perspective.

Ultra-Widefield Fluorescein Angiography to Monitor Therapeutic Response to Adalimumab in Behcet's Uveitis

Purpose: To investigate the role of ultra-widefield fluorescein angiography (UWFA) for monitoring therapeutic response to adalimumab in patients with Behcet's uveitis.Methods: Patients with Behcet's uveitis treated with adalimumab for ≥30 weeks were included. Intraocular inflammation, best-corrected visual acuity, systemic medications, and UWFA scores were evaluated.Results: Thirty-eight eyes of 20 patients were included. Significant decreases in grading of anterior chamber cells and vitreous haze were observed at 6, 14, and 30 weeks after adalimumab administration (p < .001 for all). UWFA scores on vascular and capillary leakage were decreased at week 6 and further improved at weeks 14 and 30. Moreover, UWFA score further decreased at 14 and 30 weeks, even after manifest inflammation became quiescent at 6 weeks. (p = .004 and 0.001, respectively).Conclusion: UWFA scores significantly improved in Behcet's uveitis patients treated with adalimumab, and further improvement of UWFA scores was found in patients with a clinically quiescent inflammatory state.

Role of Ocular Imaging in Diagnosis and Determining Response to Therapeutic Interventions in Posterior and Panuveitis

ABSTRACT

This review provides a comprehensive description and careful interpretation of various ocular imaging techniques to visualize the different ocular structures in posterior and panuveitis. This can help in the diagnosis, follow-up, and monitoring the response to treatment in patients with different posterior and panuveitic entities.

Long-term efficacy of early infliximab-induced remission for refractory uveoretinitis associated with Behçet's disease

BACKGROUND

To evaluate long-term efficacy of infliximab (IFX) in refractory uveoretinitis associated with Behçet's disease (BD) depending on uveoretinitis duration.

METHODS

Records of 16 patients with BD (32 eyes) followed for >5 years after starting IFX, were retrospectively reviewed. Long-term efficacy was compared between patients with short duration (≤18 months, n=7) versus long duration (>18 months, n=9) of their uveoretinitis prior to starting IFX.

RESULTS

The median follow-up after starting IFX was 132 months (76-146 months). Mean frequency of attacks and the 1-year Behçet's Disease Ocular Attack Score 24 decreased significantly over 10 years. Overall, the percentage of eyes with a best-corrected visual acuity (BCVA) ≥1.0 increased from 47% at baseline to 59% at 5 years; the percentage of eyes with a BCVA ≤0.1 was 19% at both baseline and 5 years. The frequency of ocular attacks decreased similarly in both short duration and long duration groups; however, the percentage of eyes with a BCVA ≥1.0 at 5 years was 100% in the short duration group versus 28% in the long duration group. IFX was discontinued in four patients with an excellent response to IFX therapy; all were young male patients in the short duration group with good BCVA bilaterally, and none had inflammatory recurrences over a median follow-up of 56 months off IFX.

CONCLUSION

Initiation of IFX therapy in patients with BD within 18 months of their uveoretinitis onset was more effective in maintaining good BCVA than after 18 months.

Evaluation of disease activity in uveoretinitis associated with Behçet's disease

Behçet's disease is a multi-organ inflammatory disorder with systemic vasculitis of unknown etiology. Ocular lesions occur in about 70% of patients with Behçet's disease, and it is more frequent and severe in men. The frequency of ocular inflammatory attacks has been used as a main outcome measure to assess the efficacy of therapy on uveoretinitis in patients with Behçet's disease. The ocular Behçet's disease research group of Japan have recently proposed a new scoring system, Behçet's disease ocular attack score 24 (BOS24), to assess the disease activity of ocular Behçet's disease. This review highlights the efficacy and application of the BOS24 scoring system in clinical practice for patients with ocular Behçet's disease. In addition, a new semi-quantitative scoring system to evaluate the degree of retinal vascular leakage on fluorescein angiography reported by our group is described.

Long-Term Outcomes of Behçet's Syndrome-Related Uveitis: A Monocentric Italian Experience

Objectives

To examine demographic and clinical characteristics and long-term visual outcome in a cohort of Italian patients affected by Behçet's uveitis (BU).

Materials and Methods

Retrospective chart review of 47 patients with BU attending our unit between January 2018 and December 2019. Ophthalmologic manifestations, best-corrected visual acuity (BCVA), fluoroangiography and optical coherence tomography findings, and ocular complications were recorded. Predictive factors of a poor visual outcome and long-term complications were also investigated.

Results

Forty-seven patients (23 males and 24 females) for a total of 84 eyes were enrolled. Uveitis was bilateral in 37 (78.7%) patients with panuveitis being the most frequent anatomical pattern (40 out of 84 eyes), whereas 27 eyes presented a posterior uveitis. Isolated anterior uveitis was detected in 16 eyes. A significant improvement of median BCVA between baseline and last follow-up values was detected (p = 0.042). A higher risk of poor visual prognosis was observed in patients with uveitis duration greater than 15 years (p = 0.019). A significant resolution of retinal vasculitis was detected between baseline and last follow-up evaluation (p < 0.0001) whereas the mean ± SD macular thickness did not decrease significantly between baseline (376.00 ± 97.45 μm) and last follow-up evaluation (338.08 ± 55.81 μm). Forty-two eyes developed 57 complications during the disease course. Cataract was the most frequent (n = 12), followed by epiretinal membranes (n = 11) and cystoid macular edema (n = 6). The following variables were identified as predictors of long-term complications: human leukocyte antigen- (HLA-) B51 (p = 0.006), panuveitis (p = 0.037), and a uveitis duration of more than 15 years (p = 0.049).

Conclusions

In Italian patients, BU typically arises in the third decade and predominantly manifests as a bilateral posterior uveitis or panuveitis. Its duration is associated with a poor visual prognosis. Uveitis duration, the presence of HLA-B51, and panuveitis are predictors of long-term structural complications, thus representing main drivers in the treatment decision-making.

Retinal vascular inflammatory and occlusive changes in infectious and non-infectious uveitis

PURPOSE

Retinal vasculitis and occlusive changes are important signs of posterior uveitis and are possible diagnostic markers for uveitis. However, the frequency of arteritis and phlebitis in various uveitis entities, including infectious uveitis (IU) and non-infectious uveitis (NIU), have not been systematically investigated.

STUDY DESIGN

Retrospective.

METHODS

We investigated the frequency of retinal vascular inflammatory and occlusive changes in patients with IU and NIU. The study included 283 patients with intermediate, posterior, or pan-uveitis who were diagnosed with IU (presumed tuberculous uveitis, acute retinal necrosis, cytomegalovirus retinitis, human T-cell lymphotropic virus type 1-associated uveitis, toxoplasmic retinitis, syphilitic uveitis, rubella virus-associated uveitis, fungal endophthalmitis, and bacterial endophthalmitis) or NIU (sarcoidosis, Behçet's disease, Vogt-Koyanagi-Harada disease, human leukocyte antigen-B27-associated uveitis, systemic lupus erythematosus retinopathy, psoriatic uveitis, rheumatoid arthritis/collagen disease-associated uveitis, multiple sclerosis-associated uveitis, and sympathetic ophthalmia). All patients underwent fluorescein angiography (FA) and color photography examinations of the fundus. Presence of inflammatory and occlusive changes was determined by FA images.

RESULTS

Significantly higher positive ratios of phlebitis, vein sheathing, vein occlusion, arteritis, artery sheathing, artery occlusion, and avascular areas were observed in the IU group than in the NIU group (p < 0.05). Notably, the discrepancy between IU and NIU was prominent with regard to retinal arterial changes (arteritis [57.9% vs 11.2%], inflammatory artery sheathing [33.7% vs 0%], and artery occlusion [22.1% vs 3.7%], respectively; p < 0.0001).

CONCLUSION

Findings of vasculitis and occlusion, especially in retinal arteries, in FA strongly suggest an infectious origin of active uveitis.

Predictive factors for work-day loss in Behçet's syndrome: A multi-center study

OBJECTIVE

The aim of this multi-center study was to assess predictive factors for work-day loss as an indirect cost element in Behçet's syndrome (BS).

METHODS

In this cross-sectional, multi-center study, 834 BS patients (F/M: 441/393, age mean: 38.4 ± 10.9 years) were included. Data were collected by a questionnaire regarding treatment protocols, disease duration, smoking pattern, frequency of medical visits during the previous year and self-reported work-day loss during the previous year.

RESULTS

Work-day loss was observed in 16.2% of patients (M/F: 103/32). The percentages of being a smoker (81.8%), using immunosuppressive (IS) medications (82%), and having disease duration <5 years (74%) were higher in male patients with work-day loss (P < .05). The majority of males (90.9%) had more than four clinic visits during the previous year. Moreover, the mean work-day loss (30.8 ± 57.7 days) was higher in patients with vascular involvement (56.1 ± 85.9) than those without (26.4 ± 50.6 days) (P = .046). In addition, increased frequency of ocular involvement (25.9%) was also observed in patients with work-day loss compared to others (8.6%) (P = .059).

CONCLUSION

Work-day loss was associated with both vascular and ocular involvement. Close associations were observed among male gender, early period of the disease, frequent medical visits, being a smoker and treatment with IS medications in patients with work-day loss.

Therapeutic challenges in the treatment of systemic inflammatory disease in pregnancy

Background

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

Methods

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

Results

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

Conclusions

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

Current standardized therapeutic approach for uveitis in Japan

Uveitis is an ocular disease associated with systemic immune-mediated diseases such as rheumatoid arthritis, inflammatory bowel disease and ankylosing spondylitis; and infectious diseases. Infectious uveitis occasionally shows symptoms similar to those of non-infectious uveitis. Therefore, distinguishing between non-infectious and infectious uveitis is critical for definitive diagnosis and appropriate choice of treatment. Once the cause of infection is known, treatment can be promptly initiated. However, in contrast to infectious uveitis, non-infectious uveitis is more difficult to diagnose clinically. Eliminating the possibility of infectious uveitis is important because unlike the infectious type, non-infectious uveitis is treated with immunosuppressive drugs such as corticosteroids and biological agents. Compared to other countries, the drugs available in Japan are limited. Cyclosporin A is the only immunosuppressive drug available for treating uveitis in Japan, and infliximab and adalimumab are the only biological drugs that have been approved for use in the treatment of uveitis in Japan. In this review, I describe the characteristics of typical non-infectious uveitis in Japan and its treatment methods.

Innate immune response in retinal homeostasis and inflammatory disorders

Innate immune cells such as neutrophils, monocyte-macrophages and microglial cells are pivotal for the health and disease of the retina. For the maintenance of retinal homeostasis, these cells and immunosuppressive molecules in the eye actively regulate the induction and the expression of inflammation in order to prevent excessive activation and subsequent tissue damage. In the disease context, these regulatory mechanisms are modulated genetically and/or by environmental stimuli such as damage-associated molecular patterns (DAMPs), and a chronic innate immune response regulates or contributes to the formation of diverse retinal disorders such as uveitis, retinitis pigmentosa, retinal vascular diseases and retinal fibrosis. Here we summarize the recent knowledge regarding the innate immune response in both ocular immune regulation and inflammatory retinal diseases, and we describe the potential of the innate immune response as a biomarker and therapeutic target.

Comparisons of Clinical Features in Japanese Patients with Behçet's Uveitis Treated in the 1990s and the 2000s

Purpose: We investigated clinical characteristics of ocular Behçet's disease (BD) patients treated in the 1990s and the 2000s.Methods: We retrospectively examined records of 68 newly arrived patients with ocular BD followed for more than 4 months during the 2000s and compared to those of 107 patients during the 1990s. Patient profiles, ocular and systemic symptoms, frequency of ocular attacks, BD ocular attack score 24-6 months (BOS24-6M), best-corrected visual acuity (BCVA), and immunomodulatory treatment were noted.Results: Clinical characteristics in the 2000s showed increases in iridocyclitis type, intestinal-, vasculo-, and neuro-BD cases, oral corticosteroid, methotrexate, and infliximab therapy usage, cataract and glaucoma surgery, and pseudophakia, and decreases in BOS24-6M and cyclophosphamide usage. BCVA of 20/30 or better at the final visit was slightly increased in the 2000s.Conclusions: Milder ocular BD tendency was seen in cases in the 2000s, whereas the incidence of special type of BD might be increasing.

Safety and efficacy of infliximab in the treatment of refractory uveoretinitis in Behçet's disease: a large-scale, long-term postmarketing surveillance in Japan

Background

Infliximab, an anti-tumor necrosis factor-alpha antibody, has been reported to have excellent efficacy for refractory uveoretinitis in Behçet’s disease (RUBD), and was approved for this indication in Japan. However, the long-term safety profile and efficacy in real-world clinical settings in patients with RUBD have not been fully clarified. The BRIGHT study, a prospective, large-scale, long-term postmarketing surveillance (PMS) study, was conducted to investigate the long-term safety and efficacy of infliximab in Japanese patients with RUBD.

Methods

All patients with RUBD who started infliximab treatment between January 2007 and January 2010 were enrolled. Safety was evaluated every 6 months for up to 24 months after initiation of therapy in 656 patients, and efficacy was evaluated in 650 patients. Patient characteristics were compared using the chi-square or Fisher’s exact test. The frequency of ocular attacks before and after infliximab treatment was compared using the Wilcoxon signed-rank test. Independent associated factors for safety or efficacy were identified using multiple logistic regression analysis. A two-sided p value <0.05 was considered significant.

Results

Among the 656 patients evaluated for safety, 555 (84.6%) completed the 24-month study period. The incidence of adverse drug reactions (ADRs) and serious ADRs were 32.32% and 6.10%, respectively, and the safety profile was comparable to that of Japanese PMS of infliximab for other diseases. The most common ADRs and serious ADRs were infections (11.89% and 3.66%). Tuberculosis was reported in two patients, and Pneumocystis jirovecii in one. Identified independent associated factors for infections were comorbid respiratory disease, history of allergic disease, and concomitant use of glucocorticoids. Although infusion reactions were observed in 11.13% of patients, most were non-serious. The response rate at 24 months by physician global assessment was 80.7%. Median frequency of ocular attacks per 6 months significantly decreased compared with that before infliximab treatment (2.0 to 0.0), and corrected visual acuity was maintained during the study.

Conclusions

Infliximab treatment had good tolerability and efficacy in Japanese patients with RUBD in this large-scale, long-term PMS. Infliximab treatment seemed to be a good treatment option for RUBD in real-world clinical settings.

Trial registration

UMIN Clinical Trials Registry, UMIN000027733. Retrospectively registered on 6 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1793-7) contains supplementary material, which is available to authorized users.

Noninfectious uveitis in the Asia-Pacific region

Uveitis is a sight-threatening disease. Up to 35% of patients may have impaired vision. Inflammation of the uvea tissue has more than 60 etiologies. Previous reports have shown that 20-40% of uveitis cases were noninfectious. Some of them may be associated with systemic rheumatological and autoimmune diseases but some may affect the eyes only. The epidemiology and clinical situations of some specific uveitis entities vary worldwide because they are influenced by genetic, ethnic, environmental, and socioeconomic factors. The Asia-Pacific region comprises more than 30 countries. Epidemiology and patterns of uveitis vary greatly in this region. However, some uveitis entities, such as Behcet's disease, sarcoidosis, and Vogt-Koyanagi-Harada disease, are more common in this region. Many studies on the epidemiology, risk factors, and immune pathogenesis of this disease have been conducted. In this article, we review the epidemiology of noninfectious uveitis and special situations of these three uveitis entities in the Asia-Pacific region.

Epidemiology of uveitis (2013-2015) and changes in the patterns of uveitis (2004-2015) in the central Tokyo area: a retrospective study

Background

The distribution of uveitis varies with genetic, ethnic, geographic, environmental, and lifestyle factors. Epidemiological information about the patterns of uveitis is useful when an ophthalmologist considers the diagnosis of uveitis. Therefore, it is important to identify the causes of uveitis over the years in different regions. The purposes of this study were to characterize the uveitis patients who first arrived at the University of Tokyo Hospital in 2013–2015, and to analyze the changes in the patterns of uveitis from 2004 to 2012 to 2013–2015.

Methods

We retrospectively identified 750 newly arrived patients with uveitis who visited the Uveitis Clinic in the University of Tokyo Hospital between January 2013 and December 2015, using clinical records. We extracted data on patient age, sex, diagnosis, anatomic location of inflammation, laboratory test results of blood and urine, and chest X-ray and fluorescein fundus angiography findings for each patient. In addition, we compared these data with those from 2004 to 2012 to analyze the changes in the patterns of uveitis.

Results

A definite diagnosis was established in 445 patients (59.3%). The most common diagnoses were herpetic iridocyclitis (7.5%), sarcoidosis (6.1%), Behçet’s disease (4.4%), Vogt–Koyanagi–Harada disease (4.1%), and intraocular lymphoma (4.1%). The most frequent unclassified type of uveitis was suspected sarcoidosis (22.3%). Analysis of the changes in the patterns of uveitis in the central Tokyo area from 2004 to 2012 to 2013–2015 revealed notable increasing trends of herpetic iridocyclitis and intraocular lymphoma, and increasing trends of bacterial endophthalmitis, fungal endophthalmitis, and juvenile chronic iridocyclitis. In contrast, the frequency of sarcoidosis, Behçet’s disease, and Vogt–Koyanagi–Harada disease decreased.

Conclusions

The patterns of uveitis changed considerably from 2004 to 2012 to 2013–2015. Continuous investigations about the epidemiology of uveitis are needed to diagnose uveitis more accurately.

Corneal Endothelial Changes in Behçet's Patients with Inactive Ocular Involvement

PURPOSE

The purpose of this article is to evaluate alterations in the corneal endothelial layer in Behçet's disease (BD) with inactive ocular involvement using specular microscopy.

MATERIALS AND METHODS

Thirty-three eyes of 33 BD patients who had at least one anterior segment involvement and no active inflammation in the last 3 months were included in the study (group 1). Twenty-seven of the 33 BD patients had an anterior uveitis attack and six of them had a panuveitis (both anterior and posterior involvement) attack. Thirty-three eyes of 33 age- and sex-matched healthy subjects were enrolled in the control group (group 2). Corneal endothelial cell density (CD), coefficient of variation (CV), hexagonal cell ratio (HEX), and central corneal thickness (CCT) were measured using specular microscopy (Konan Medical, Nishinomiya, Japan), and the results were compared between groups.

RESULTS

The mean CD was 2739 ± 164.18 cells/mm² in group 1 and 2922 ± 107.60 cells/mm² in group 2 (p = 0.001). The mean CV was 32.9 ± 4.76 in group 1 and 28.5 ± 3.06 in group 2 (p = 0.001). The mean HEX was 44.7 ± 6.51 in group 1 and 49.7 ± 6.10 in group 2 (p = 0.019). The mean CCT was 545.75 ± 40.89 μ in group 1 and 545.66 ± 30.09 μ in group 2 (p > 0.05).

CONCLUSIONS

Ocular attacks in our BD patients may have caused permanent changes in the corneal endothelial layer. However, these changes did not lead to corneal decompensation, but further studies are necessary to confirm these results.

Clinical and imaging features of spinal cord type of neuro Behçet disease: A case report and systematic review

RATIONAL

To investigate the clinical and MRI characteristics of spinal cord nerve Behçet's disease.

PATIENT CONCERNS

One patient with spinal cord nerve Behçet's disease was admitted to our hospital at October 20, 2015.

DIAGNOSE

Spinal cord nerve Behçet's disease.

INTERVENTIONS

Retrospective analysis was performed on such case as well as 16 cases of spinal cord nerve Behçet's disease reported in China or abroad.

OUTCOMES

Seventeen cases of spinal cord type of neuro Behçet's disease include 13 men and 4 women, with an average age of onset of 34.8 years old. The mean time from Behçet's disease symptoms to spinal cord involvement were 10.8 years. The initial symptom in one case was spinal cord injury, and another 4 cases had a recurrence course. The most common performance of spinal cord injury was sensory disturbance (82.4%), following by weakness (76.5%), sphincter or sexual dysfunction (58.8%), and pain in back, backside of neck or lower chest (29.4%). The number of cells was slightly increased or the protein level was increased in cerebrospinal fluid test. And the water channel protein antibody and oligoclonal band of serum levels were all negative. The spinal cord injury involved more than 3 vertebral bodies in 10 cases, and involved more than half of spinal cord in sagittal plane in 8 cases. In acute stage, shock therapy with large dose of glucocorticoid was generally applied both in China and abroad.

LESSONS

The clinical features of spinal cord nerve Behçet's disease were various, making it easily misdiagnosed. Longitudinal extensive transverse myelitis performs as a characteristic manifestation.

Knitting the Threads of Silk through Time: Behçet's Disease-Past, Present, and Future

Behçet's disease (BD) is a chronic relapsing vasculitis that affects vessels of all types and sizes with a broad spectrum of phenotypic heterogeneity and complex immunopathogenesis. Efforts by the scientific community to resolve the unmet needs of BD and gaps in our knowledge have been hampered by considerable challenges that primarily relate to the rare nature of the disease in many parts of the world and its heterogeneity. Controversies remain in many aspects of the disease including the diagnostic criteria, immunopathogenesis and biomarker discovery, geographical variation, and therapeutic considerations. In this review, we highlight recent advances in our scientific understanding of BD, shed new insights into diagnostic and treatment strategies, and discuss residual gaps in our knowledge that will serve as the basis for current and future research.

Ocular Manifestations, Conventional Fundus Fluorescein Angiographic Findings, and Relationship Between Angiographic Findings and Visual Acuity in Behçet's Disease

PURPOSE

Evaluating the ocular manifestation and fundus fluorescein angiography (FA) findings of patients with Behçet's disease as well as the relationship between visual acuity and angiographic findings.

METHODS

Retrospective chart review of patients with Behçet's disease seen at the Farabi Eye Hospital.

RESULTS

Forty-six patients (92 eyes) with mean age of 33.41 ± 10.67 were included. The most frequent presenting symptom and sign were reduced vision (76%) and uveitis (87%), respectively. Panuveitis was the most frequent type of uveitis (76%). Among patients with FA, vasculitis was the most common finding (87%) and it was significantly more severe among patients with visual acuity less than 20/200. Macular leakage (P = 0.001), arterial narrowing (P = 0.000), and posterior retinal vasculitis (P = 0.002) on FA were all associated with worsening final visual acuity.

CONCLUSION

The most common ocular findings in Behçet's disease were panuveitis and vasculitis. Location of vasculitis, arterial narrowing, and macular leakage on initial FA may predict visual prognosis.