Visual prognosis in Behçet's disease

Spectral domain optical coherence tomography as an adjunctive tool for screening Behçet uveitis

Background

This study investigated the association of central macular thickness (CMT) and macular volume (MV) with severity of Behçet uveitis in the absence of macular edema (ME).

Methods

This retrospective, interventional study included a total 131 treatment-naïve Behçet patients with varying degree of uveitis in the absence of ME. The mean CMT and MV were obtained by spectral domain optical coherence tomography (SD ODT). The patients were classified according to the anatomical classification of Behçet uveitis. The main outcome measure was comparison of mean CMT and MV with the types of Behçet uveitis.

Results

Sixty patients (45.8%) with no uveitis, 41 patients (31.3%) with anterior uveitis, 18 patients (13.7%) with posterior uveitis, and 12 patients (9.2%) with panuveitis. The mean CMT were 261.6±22.2 μm in no uveitis, 268.1±17.8 μm in anterior uveitis, 306.4±32.9 μm in posterior uveitis, and 300.4±44.0 μm in panuveitis (P < 0.001). The mean MV was 8.7±0.3 mm³ in those without uveitis, 8.8±0.3 mm³ in anterior uveitis, 9.9±1.1 mm³ in those with posterior uveitis, and 9.7±0.4 mm³ in panuveitis (P < 0.001). Types of Behçet uveitis was the only significant factor correlated with the mean CMT (B = 18.170, β = 0.408, P < 0.001) and the mean MV (B = 0.328, β = 0.652, P < 0.001).

Conclusions

The mean CMT and MV were significantly thicker in the Behçet uveitis with posterior involvement. SD OCT can be used for an adjunctive tool for screening Behçet uveitis, especially for the presence of posterior involvement.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Immunosuppression in Behçet's disease Clinical management and long-term visual outcome

The authors review the visual prognosis of 44 patients with Behçet's disease referred to the Ophthalmology and Rheumatology Departments (Hospital S. João-one of the two major referral centers in Northern Portugal), due to ocular complaints or for routine examination, in the last ten years. All fulfilled the clinical criteria for diagnosis of Behçet's disease. Twenty-six were male and 18 female, with mean age 37 years (range 23-66). The mean evolution time since the first clinical manifestations was ten years (range 1-21). Aphthous stomatitis (100%) and genital ulcers (77.3%) were the initial manifestations preceding eye involvement. HLA-B(51)(5) was present in 27 of 36 typed patients (75%). Ocular manifestations were present in 33 patients (75%)-22 patients with panuveitis, eight with hypopyon, four with chronic anterior uveitis and three with episcleritis. Mean age of onset of ocular complications was 32 years (range 20-54). Retinal vaso-occlusive vasculitis was diagnosed in 26 patients (22 with panuveitis and four with posterior uveitis). To prevent ocular relapses, all needed immunosuppression with corticosteroids (drops, depo or systemic), combined with cyclosporine A (CsA) (5 mg/kg/day) in 13 patients and with chlorambucil or cyclophosphamide in six patients, when sight threatening uveitis had previously been refractory to treatment with systemic steroids. The 13 patients under CsA were observed for a period ranging from eight months to five years. Lowdose CsA was found to abrogate the intraocular inflammation, was well tolerated and had no major adverse effects. Regardless of the type of treatment, 21% (14/66) of the eyes lost useful vision five to ten years after initial diagnosis.

Immunopathology of the noninfectious posterior and intermediate uveitides

The posterior and intermediate uveitides share an underlying immune etiology; however, they can be clinically and immunopathologically distinguished. Although the initiating stimuli for posterior and intermediate uveities are not known, it is believed that an exogenous agent (such as a bacterium or a virus) or an endogenous molecule may induce disease. In either case, T-helper lymphocytes in conjunction with human leukocyte antigens are likely to be involved. This review examines the epidemiology, histology, immunopathology, and theories of pathogenesis of several posterior and intermediate uveitides, including sympathetic ophthalmia, Vogt-Koyanagi-Harada syndrome, Behçet's disease, sarcoidosis, intermediate uveitis, white dot syndromes, and birdshot retinochoroidopathy.

Efficacy and safety of systemic recombinant interferon-alpha in Behçet's disease

OBJECTIVES

To evaluate the therapeutic efficacy and safety of systemic recombinant interferon alpha-2a (IFN-alpha) in patients with Behcet's disease (BD) and to determine the incidence of episodes in complete responders during the one-year pretreatment period and follow-up.

DESIGN

An open clinical study.

SETTING

Departments of Dermatology and Ophthalmology, University of Patras, Greece and Department of Dermatology, Heinrich-Heine University of Düsseldorf, Germany.

SUBJECTS

Twelve patients (aged 23-52 years) with active BD who had previously been unsuccessfully treated with systemic steroids and/or immunosuppressives.

INTERVENTIONS

IFN-alpha was administered subcutaneously at a dose of 6 X 10(6) IU per day 3 times per week for 2 months.

MAIN OUTCOME MEASURES

Change of area or number of mucocutaneous lesions, grading score for thrombophlebitis and ocular inflammation, haematological and biochemical parameters and number of episodes during the pretreatment period and the follow-up. Evaluation of IFN-alpha side effects.

RESULTS

Nine patients (75.0%) revealed a complete remission, two (16.6%) a partial remission and one patient (8.3%) showed no response. During the follow-up in five out of the nine complete responders (55.5%) no episodes of BD were seen, whereas, the other four patients (44.5%) had 1-2 episodes, as compared to 5-8 and 5-12 episodes, respectively, during the pretreatment period. An influenza-like syndrome (fever, nausea and myalgias) appeared during the early phase of therapy in all (but one) patients. No patient had to discontinue IFN-alpha because of intolerance.

CONCLUSIONS

Subcutaneous human recombinant interferon alpha-2a appears to be an effective and fairly well tolerated therapy for BD.

Causes and frequency of blindness in patients with intraocular inflammatory disease

AIMS/BACKGROUND

Uveitis, an intraocular inflammatory disease, is a significant cause of visual impairment. It is not known how many patients with uveitis will retain visual acuity and how many develop visual impairment or even blindness. The aim of this study was to assess the frequency of blindness in patients with uveitis and, more specifically, to identify the clinical profile of patients at risk for visual loss.

METHODS

A cross sectional and retrospective study of 582 patients with uveitis who visited the ophthalmology departments of two university hospitals in the Netherlands was performed.

RESULTS

Within the group of 582 patients, 203 (35%) exhibited blindness or visual impairment; bilateral legal blindness developed in 22 (4%) patients, 26 (4.5%) had one blind eye with visual impairment of the other, and nine (1.5%) had bilateral visual impairment. Unilateral blindness developed in 82 (14%) patients, whereas 64 (11%) exhibited unilateral visual impairment. The most important cause of both blindness and visual impairment was cystoid macular oedema (29% and 41%, respectively). Complications of uveitis were encountered in more than half of the patients and 23% underwent one or more surgical procedures. When the patients were subdivided according to anatomical site, those with panuveitis had the worst visual prognosis. The systemic diseases associated with a poor visual prognosis were juvenile chronic arthritis and sarcoidosis. Ocular toxoplasmosis was the most frequent cause of unilateral visual loss.

CONCLUSIONS

Cystoid macular oedema is the most frequent complication of uveitis and its occurrence plays a decisive role in the visual outcome of this disease.