POS0666 TREATMENT EFFECTIVENESS OF UPADACITINIB AT 3 MONTHS IN US PATIENTS WITH RHEUMATOID ARTHRITIS FROM THE UNITED RHEUMATOLOGY NORMALIZED INTEGRATED COMMUNITY EVIDENCE (NICE[TM]) REAL-WORLD DATA

Background:

Upadacitinib (UPA), an oral Janus kinase inhibitor (JAKi), has demonstrated efficacy in the phase 3 SELECT clinical program, conducted across a range of patients (pts) with rheumatoid arthritis (RA).1–6 Real-world data for UPA, including in pts previously treated with a JAKi, have not yet been reported since global approvals beginning in 2019.

Objectives:

To assess the characteristics of US-based pts receiving UPA and its effectiveness in clinical practice at 3 months.

Methods:

This observational study included US-based pts from the United Rheumatology Normalized Integrated Community Evidence (UR-NICE) database who initiated UPA 15 mg once daily from FDA approval (August 2019) to July 31, 2020 and had ≥6-month pre-baseline data available. Effectiveness was assessed in pts with a reported Clinical Disease Activity Index (CDAI) score at 3 months after UPA initiation and included proportions of pts achieving CDAI remission (≤2.8), CDAI low disease activity (≤10), other disease activity measures, and pt-reported outcomes. A subgroup analysis assessed UPA effectiveness in pts with or without prior tofacitinib (TOFA) treatment.

Results:

This analysis included 252 pts treated with UPA 15 mg, of whom 98 (38.9%) received UPA monotherapy and 154 (61.1%) received UPA combined with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs). 64.3% of pts were from the Southern region of the USA. 86.1%, 72.2%, and 47.6% of pts had been previously treated with csDMARDs, biologic DMARDs, and JAKis, respectively. Baseline characteristics were largely similar between UPA monotherapy and combination therapy groups and those with or without prior TOFA treatment (Table 1). Pts with prior TOFA treatment had a longer duration of RA since diagnosis and higher steroid use versus those without. UPA 15 mg improved disease activity scores (including CDAI) and pt-reported outcomes (including physical function and pain) after 3 months of treatment (Figure 1). Similar effectiveness was observed with UPA 15 mg in pts with or without prior TOFA treatment.

Conclusion:

In the UR-NICE real-world database of US-based pts, improvements in clinical and pt-reported outcomes were observed at 3 months in UPA-treated pts with RA, including those with or without prior TOFA treatment, despite the treatment-refractory population included in this dataset.

References:

[1]Burmester GR, et al. Lancet 2018;391:2503–12.

[2]Smolen JS, et al. Lancet 2019;393:2303–11.

[3]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800.

[4]Genovese MC, et al. Lancet 2018;391:2513–24.

[5]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20.

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Table 1.

Baseline characteristics

n (%), unless otherwise statedFull analysis set(n=252)Pts with prior TOFA treatment(n=113)Pts without prior TOFA treatment (n=139)Mean (SD) exposure, days219.7 (112.1)215.7 (116.7)222.9 (108.5)Female199 (79.0)85 (75.2)114 (82.0)Age ≥65 years75 (29.8)34 (30.1)41 (29.5)Oral steroid use140 (55.6)70 (61.9)70 (50.4)Prior csDMARDs217 (86.1)102 (90.3)115 (82.7)Prior TOFA113 (44.8)113 (100.0)0Prior biologic DMARDs182 (72.2)86 (76.1)96 (69.1)Tumor necrosis factor inhibitor147 (58.3)66 (58.4)81 (58.3)Interleukin-6 receptor inhibitor87 (34.5)47 (41.6)40 (28.8)nMean (SD)nMean (SD)nMean (SD)Duration of RA diagnosis, years1884.0 (3.0)895.1 (2.9)993.1 (2.8)Methotrexate dose, mg/week8817.0 (5.1)2817.8 (5.0)6016.6 (5.2)SJC282394.8 (5.7)1084.5 (5.0)1315.0 (6.2)TJC282376.5 (6.7)1076.5 (6.8)1306.5 (6.6)CDAI22520.4 (13.4)10520.2 (13.5)12020.6 (13.3)Routine assessment of patient index data 31654.2 (2.3)724.2 (2.4)934.3 (2.2)Disease Activity Score in 28 joints based on C-reactive protein1673.9 (1.5)833.9 (1.5)843.9 (1.5)Health Assessment Questionnaire-Disability Index1702.5 (2.1)742.4 (2.2)962.5 (2.1)Pain(0–10)22956.5 (28.5)10456.9 (29.3)12556.1 (28.0)SD, standard deviation; S/TJC, swollen/tender joint count

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Hilary Wong, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Allan Gibofsky Shareholder of: AbbVie, Amgen, Johnson & Johnson, and Pfizer, Consultant of: AbbVie, Celgene, Eli Lilly, Flexion, Pfizer, Relburn Pharma, and Samumed. Paid consultant with investment analysts on behalf of the Gerson Lehrman Group, Bhavna Dhillon Shareholder of: May own stock or options in United Rheumatology, Employee of: United Rheumatology, Mark E. Pearson Shareholder of: May own AbbVie stock or options, Namita Tundia Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Kendall Dunlap Shareholder of: May own stocks or shares in AbbVie, Employee of: AbbVie, Grace Wright Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Myriad Autoimmune, Novartis, Sanofi/Regeneron, UCB, and Vindico, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Gilead, Janssen, Myriad Autoimmune, Novartis, Pfizer, Sanofi/Regeneron, and UCB, Employee of: President and Founder of the Association of Women in Rheumatology

Real-time quantitative monitoring of hiPSC-based model of macular degeneration on Electric Cell-substrate Impedance Sensing microelectrodes

Age-related macular degeneration (AMD) is the leading cause of blindness in the developed world. Humanized disease models are required to develop new therapies for currently incurable forms of AMD.

In this work, a tissue-on-a-chip approach was developed through combining human induced pluripotent stem cells, Electric Cell–substrate Impedance Sensing (ECIS) and reproducible electrical wounding assays to model and quantitatively study AMD. Retinal Pigment Epithelium (RPE) cells generated from a patient with an inherited macular degeneration and from an unaffected sibling were used to test the model platform on which a reproducible electrical wounding assay was conducted to model RPE damage. First, a robust and reproducible real-time quantitative monitoring over a 25-day period demonstrated the establishment and maturation of RPE layers on the microelectrode arrays. A spatially controlled RPE layer damage that mimicked cell loss in AMD disease was then initiated. Post recovery, significant differences (P<0.01) in migration rates were found between case (8.6±0.46 μm/h) and control cell lines (10.69±0.21 μm/h). Quantitative data analysis suggested this was achieved due to lower cell–substrate adhesion in the control cell line. The ECIS cell–substrate adhesion parameter (α) was found to be 7.8±0.28 Ω^1/2 cm for the case cell line and 6.5±0.15 Ω^1/2 cm for the control. These findings were confirmed using cell adhesion biochemical assays. The developed disease model-on-a-chip is a powerful platform for translational studies with considerable potential to investigate novel therapies by enabling real-time, quantitative and reproducible patient-specific RPE cell repair studies.

•

hiPSC-RPE model was established and characterised on ECIS microelectrode arrays.

•

A reproducible electrical wound healing assay was used to mimic RPE cell damage.

•

Significant differences in migration rates were found between case and control.

•

Cells recovered through mesenchymal migration mirrored by impedance fluctuations.

•

Case cell line showed significantly higher adhesion than the control cell line.

Retinal imaging as a source of biomarkers for diagnosis, characterization and prognosis of chronic illness or long-term conditions

The black void behind the pupil was optically impenetrable before the invention of the ophthalmoscope by von Helmholtz over 150 years ago. Advances in retinal imaging and image processing, especially over the past decade, have opened a route to another unexplored landscape, the retinal neurovascular architecture and the retinal ganglion pathways linking to the central nervous system beyond. Exploiting these research opportunities requires multidisciplinary teams to explore the interface sitting at the border between ophthalmology, neurology and computing science. It is from the detail and depth of retinal phenotyping that novel metrics and candidate biomarkers are likely to emerge. Confirmation that in vivo retinal neurovascular measures are predictive of microvascular change in the brain and other organs is likely to be a major area of research activity over the next decade. Unlocking this hidden potential within the retina requires integration of structural and functional data sets, that is, multimodal mapping and longitudinal studies spanning the natural history of the disease process. And with further advances in imaging, it is likely that this area of retinal research will remain active and clinically relevant for many years to come. Accordingly, this review looks at state-of-the-art retinal imaging and its application to diagnosis, characterization and prognosis of chronic illness or long-term conditions.

Differentiation and molecular profiling of human embryonic stem cell-derived corneal epithelial cells

It has been suggested that the isolation of scalable populations of limbal stem cells may lead to radical changes in ocular therapy. In particular, the derivation and transplantation of corneal stem cells from these populations may result in therapies providing clinical normality of the diseased or damaged cornea. Although feasible in theory, the lack of donor material in sufficient quantity and quality currently limits such a strategy. A potential scalable source of corneal cells could be derived from pluripotent stem cells (PSCs). We developed an in vitro and serum-free corneal differentiation model which displays significant promise. Our stepwise differentiation model was designed with reference to development and gave rise to cells which displayed similarities to epithelial progenitor cells which can be specified to cells displaying a corneal epithelial phenotype. We believe our approach is novel, provides a robust model of human development and in the future, may facilitate the generation of corneal epithelial cells that are suitable for clinical use. Additionally, we demonstrate that following continued cell culture, stem cell-derived corneal epithelial cells undergo transdifferentiation and exhibit squamous metaplasia and therefore, also offer an in vitro model of disease.

Using human induced pluripotent stem cells to treat retinal disease

The eye is an ideal target for exploiting the potential of human induced pluripotent stem cell (hiPSC) technology in order to understand disease pathways and explore novel therapeutic strategies for inherited retinal disease. The aim of this article is to map the pathway from state-of-the art laboratory-based discoveries to realising the translational potential of this emerging technique. We describe the relevance and routes to establishing hiPSCs in selected models of human retinal disease. Additionally, we define pathways for applying hiPSC technology in treating currently incurable, progressive and blinding retinal disease.

Getting serious with retinopathy: approaching an integrated hypothesis for central serous chorioretinopathy

Development of the prefrontal cortex is believed to play an important role in the maturation of higher cognitive functions such as decision making, cognition and control of part of the neural element of the stress response. The prefrontal cortex undergoes considerable maturation during childhood, including a reduction of synaptic and neural density, a growth of dendrites, and an increase in white matter volume, thereby forming distributed neural networks appropriate for complex cognitive processing, but maturation is not complete until approximately 25 years of age. Serotonin and its receptors (HTRs) play critical roles in brain development and in the regulation of cognition, mood, and anxiety. HTRs are highly expressed in the human prefrontal cortex and exert control over prefrontal excitability. Studies of post-mortem prefrontal brain tissue found distinct developmental patterns of expression of these receptors occurring in early postnatal development and also into adulthood. The general pattern of improved cognitive control and emotion regulation with maturation of the prefrontal cortex, suggests a linear increase in development from childhood to adulthood. Animal studies have shown that dopamine is crucial for communication between the accumbens, amygdala, and prefrontal cortex. Dopamine projections to the prefrontal cortex continue to develop into early adulthood. Central Serous Chorioretinopathy (CSC) is an eye disease affecting people of working age, commonly resulting in repeated unpredictable visually disabling serous retinal detachments and occasionally leading to irreversible reduction in central vision. The disease has been closely linked to the stress response. Despite a concerted effort to understand aetiopathogenesis, disease mechanisms are still largely unclear. This paper, supported by evidence in the literature, proposes a systemic approach to CSC and explains how interactions of the eye with the cerebral cortex could lead to disease. We propose that the lack of development of the neural element of the stress response and in particular the prefrontal cortex is the reason for the absence of CSC in childhood and adolescence. Additionally, we attempt to explain why excess stress hormones do not always result in CSC and why acute attacks occur only once in over half of cases. Finally, we summarise the implications that an integrated systemic hypothesis has for future CSC research and the requirement of a holistic management practice for the identification and treatment of patients with CSC.

Effects of N-acetylcysteine on matrix metalloproteinase-9 secretion and cell migration of human corneal epithelial cells

BACKGROUND

Matrix metalloproteinase-9 (MMP-9) secreted by corneal epithelial cells has a role in the remodelling of extracellular matrix and migration of epithelial cells. Elevated levels of MMP-9 activity in the ocular surface may be involved in the pathogenesis of corneal diseases. N-acetylcysteine (NAC) has been used to treat corneal diseases, including recurrent epithelial erosions. In this study, its effects on the MMP-9 secretion and human corneal epithelial (HCE) cell migration were evaluated in vitro.

METHODS

Confluent HCE cell cultures were treated with 0-20 mM NAC, and tested for MMP-9 secretion and epithelial cell migration by gelatin zymography and scratch wound assay, respectively. Comparisons between different treatment groups were made using analysis of variance, followed by multiple pairwise comparisons.

RESULTS

Twenty mM NAC inhibited the secretion of MMP-9 significantly. Cell migration, assessed after 24 h of wounding, showed a highly significant dose-dependent inhibitory effect.

CONCLUSIONS

This study shows that NAC reduces MMP-9 production by HCE cells and inhibits cell migration in vitro. This information helps to elucidate the mechanisms by which NAC may be beneficial therapeutically and suggests that NAC may be useful for managing corneal erosions and related conditions.

VAMPIRE: Vessel assessment and measurement platform for images of the REtina

We present VAMPIRE, a software application for efficient, semi-automatic quantification of retinal vessel properties with large collections of fundus camera images. VAMPIRE is also an international collaborative project of four image processing groups and five clinical centres. The system provides automatic detection of retinal landmarks (optic disc, vasculature), and quantifies key parameters used frequently in investigative studies: vessel width, vessel branching coefficients, and tortuosity. The ultimate vision is to make VAMPIRE available as a public tool, to support quantification and analysis of large collections of fundus camera images.

Fractal analysis of retinal vessels suggests that a distinct vasculopathy causes lacunar stroke

OBJECTIVES

Lacunar strokes account for 25% of all ischemic strokes and may represent the cerebral manifestation of a systemic small vessel vasculopathy of unknown etiology. Altered retinal vessel fractal dimensions may act as a surrogate marker for diseased cerebral vessels. We used a cross-sectional study to investigate fractal properties of retinal vessels in lacunar stroke.

METHODS

We recruited patients presenting with lacunar stroke and patients with minor cortical stroke as controls. All patients were examined by a stroke expert and had MRI at presentation. Digital retinal photographs were taken of both eyes. Monofractal and multifractal analyses were performed with custom-written semiautomated software.

RESULTS

We recruited 183 patients. Seventeen were excluded owing to poor photographic quality, leaving 166 patients (86 with lacunar and 80 with cortical stroke). The mean age was 67.3 years (SD 11.5 years). The patients with lacunar stroke were younger but the prevalence of diabetes, hypertension, and white matter hyperintensities did not differ between the groups. The mean Dbox (monofractal dimension) was 1.42 (SD 0.02), the mean D0 (multifractal dimension) 1.67 (SD 0.03). With multivariate analysis, decreased Dbox and D0 (both representing decreased branching complexity) were associated with increasing age and lacunar stroke subtype after correcting for hypertension, diabetes, stroke severity, and white matter hyperintensity scores.

CONCLUSIONS

Lacunar stroke subtype and increasing age are associated with decreased fractal dimensions, suggesting a loss of branching complexity. Further studies should concentrate on longitudinal associations with other manifestations of cerebral small vessel disease.

Multi-system neurological disease is common in patients with OPA1 mutations

Additional neurological features have recently been described in seven families transmitting pathogenic mutations in OPA1, the most common cause of autosomal dominant optic atrophy. However, the frequency of these syndromal 'dominant optic atrophy plus' variants and the extent of neurological involvement have not been established. In this large multi-centre study of 104 patients from 45 independent families, including 60 new cases, we show that extra-ocular neurological complications are common in OPA1 disease, and affect up to 20% of all mutational carriers. Bilateral sensorineural deafness beginning in late childhood and early adulthood was a prominent manifestation, followed by a combination of ataxia, myopathy, peripheral neuropathy and progressive external ophthalmoplegia from the third decade of life onwards. We also identified novel clinical presentations with spastic paraparesis mimicking hereditary spastic paraplegia, and a multiple sclerosis-like illness. In contrast to initial reports, multi-system neurological disease was associated with all mutational subtypes, although there was an increased risk with missense mutations [odds ratio = 3.06, 95% confidence interval = 1.44-6.49; P = 0.0027], and mutations located within the guanosine triphosphate-ase region (odds ratio = 2.29, 95% confidence interval = 1.08-4.82; P = 0.0271). Histochemical and molecular characterization of skeletal muscle biopsies revealed the presence of cytochrome c oxidase-deficient fibres and multiple mitochondrial DNA deletions in the majority of patients harbouring OPA1 mutations, even in those with isolated optic nerve involvement. However, the cytochrome c oxidase-deficient load was over four times higher in the dominant optic atrophy + group compared to the pure optic neuropathy group, implicating a causal role for these secondary mitochondrial DNA defects in disease pathophysiology. Individuals with dominant optic atrophy plus phenotypes also had significantly worse visual outcomes, and careful surveillance is therefore mandatory to optimize the detection and management of neurological disability in a group of patients who already have significant visual impairment.

Development and evaluation of an ozonated water system for antimicrobial treatment of durum wheat

Ozonated water is reported to be effective in reducing the microbial load in foods such as fruits, vegetables, and grains. Ozonated water may be an effective alternative to chlorinated water in treating durum wheat before milling. Therefore, durum wheat was washed with ozonated water and analyzed for yeast and mold count (YMC) and aerobic plate count (APC). A system for producing and monitoring ozonated water was developed. The effect of water quality (tap, distilled, and ultra-pure), temperature (7, 15, and 25 degrees C), and pH (2, 4, and 6.5) was evaluated on the following: steady-state dissolved ozone concentration, ozone decay constant, half-life, mass transfer coefficient, equilibrium ozone concentration, and solubility ratio. The study of these parameters was important to attain a stable, high dissolved ozone concentration at the outset of washing and to have information for system improvement and scale-up. A 1% acetic acid solution (pH 2) at 15 degrees C resulted in high dissolved ozone concentration (21.8 mg/L) and long half-life (9.2 min). Subsequently, wheat was washed with 5 wash water types: distilled water, ozonated water (16.5 mg/L), chlorinated water (700 mg/L), acetic acid solution (1%), and acetic acid + ozonated water (1%, 20.5 mg/L). The treated samples were analyzed for YMC and APC. The acetic acid + ozonated water treatment was the most effective, with a reduction of 4.1 and 3.2 log(10) colony forming units/g in YMC and APC, respectively. Though ozonated water was not very effective alone, it was useful in combination with acetic acid.

Republished review. [corrected] Late-onset retinal macular degeneration: clinical insights into an inherited retinal degeneration

AIM

This study describes, in detail, the phenotype of late-onset retinal macular degeneration (L-ORMD) an inherited condition affecting both the retina and anterior segment. A staging based on clinical characteristics is proposed, and the relevance of this condition to current understanding of age-related macular degeneration is discussed.

METHODS

A systematic review of the literature regarding this condition supports a detailed description of the natural history. Clinical experiences in identifying, monitoring and managing patients are also presented.

RESULTS

L-ORMD is a rare fully penetrant autosomal dominant condition resulting from a mutation in the C1QTNF5 gene on chromosome 11. Affected individuals develop bilateral loss of vision, dark-adaptation abnormalities, fundus drusen-like yellow spots, midperipheral pigmentation, choroidal neovascularisation, chorioretinal atrophy and long anteriorly inserted lens zonules. Patients may benefit from treatment with high-dose vitamin A.

CONCLUSIONS

Raised awareness of L-ORMD should lead to earlier diagnosis and improved care for patients. New antivascular endothelial growth factor treatment may provide a new possibility for management. A deeper insight into molecular and genetic mechanisms of L-ORMD may suggest avenues to explore new treatments of this disorder.

Differences in retinal vessels support a distinct vasculopathy causing lacunar stroke

BACKGROUND

Lacunar stroke is common, but the etiology of the small vessel abnormality is unknown. Retinal vessels share ontogeny, size, and physiologic characteristics with cerebral small vessels, and retinopathy is associated with stroke. We compared retinal microvessel appearance as a surrogate for cerebral small vessels in patients with lacunar and large artery cortical ischemic stroke.

METHODS

We prospectively recruited patients with lacunar ischemic stroke and cortical stroke controls. We took digital retinal photographs of each eye. We assessed central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) diameters and arteriovenous ratios (AVRs) using semiautomated computer software methods and quantified arteriovenous nicking and focal arteriolar narrowing.

RESULTS

Among 212 patients (105 lacunar, 107 cortical strokes) of mean age 68 years (SD 12 years), AVR was decreased (0.76 vs 0.78, p = 0.03) and CRVE was increased (44.9 pixels/218 microm vs 42.8 pixels/208 microm, p = 0.01) in lacunar patients compared with cortical patients, but CRAE did not differ (33.2 pixels/161 microm vs 33.7 pixels/163 microm, p = 0.4). On multivariable analysis, increased CRVE was associated with lacunar stroke subtype (p = 0.03) and younger age (p < 0.001) after correcting for other vascular risk factors. Arteriovenous nicking and focal arteriolar narrowing did not differ between ischemic stroke subtypes.

CONCLUSIONS

Retinal venules are wider and arteriovenous ratios are smaller in patients with lacunar strokes compared with those in patients with cortical strokes.

Contextual detection of ischemic regions in ultra-wide-field-of-view retinal fluorescein angiograms

We report a novel prototype algorithm using contextual knowledge to locate ischemic regions in ultra-wide-field-of-view retinal fluorescein angiograms. We use high-resolution images acquired by an Optos ultra-wide-field-of-view (more than 200 degrees) scanning laser ophthalmoscope. We leverage the simultaneous occurrence of ischemia with a number of other signs, detected automatically, typical for the state of progress of the condition in a diabetic patient. The specific nature of ischemic and non-ischemic regions is determined with an AdaBoost learning algorithm. Preliminary results demonstrate above 80% pixel classification accuracy against manual annotations.

Quality of life and relative importance: a comparison of time trade-off and conjoint analysis methods in patients with age-related macular degeneration

AIM

To investigate the relative priorities in quality of life (QoL) in patients with age-related macular degeneration (AMD).

METHODS

Measures of visual function, QoL and utility associated with visual loss were obtained from 122 patients with AMD classified according to macular morphology. The two methods of utility assessment were time trade-off (TTO) and conjoint analysis (CA), which have been recommended by the UK's National Institute of Clinical Excellence as techniques for the assessment of healthcare priorities.

RESULTS

Results show that the two methods for assessing utility are poorly related: TTO relates moderately to visual function and disease severity but CA does not. CA identified two different subgroups of patients: one with outdoor mobility and the other with reading as their main priority.

CONCLUSION

Further work is needed and caution required in interpreting data obtained using these methodologies for determining their relative importance in vision-related QoL studies.

Congenital Corneal Anesthesia

Congenital corneal anesthesia is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group. The sensory deficit may be confined to the cornea, or extend to other divisions of the trigeminal nerve. The sensory deficit may occur as an isolated abnormality, as part of a complex neurological syndrome, or it may occur in association with multiple somatic abnormalities and congenital insensitivity to pain. This condition usually presents between the ages of 8 to 12 months. Poor vision, photophobia, conjunctival injection, and corneal ulceration in the absence of pain and distress in a child should alert the clinician to the possibility of anesthetic cornea. In the early stages of presentation, punctuate keratopathy is the main feature, which may progress to non-healing persistent corneal epithelial defects. This stage may progress to acute corneal lysis and perforation. In most patients, conservative approaches such as copious lubrication, prevention of self-harm and cautious use of bandage contact lenses are effective in preventing progressive corneal damage. Tarsorrhapy is effective in promoting epithelial healing and permanent lateral tarsorraphy may prevent further development of epithelial defects. Amniotic membrane graft may be considered in order to improve epithelial healing. Corneal grafts carry a poor prognosis. Accurate initial diagnosis, evaluation, and proper management are paramount to prevent visual loss due to long-term complications of corneal anesthesia. This review of the literature outlines the problems and approaches in diagnosis, evaluation, and management of this rare condition.

Development of a miniaturised drug delivery system with wireless power transfer and communication

The development of an implantable system designed to deliver drug doses in a controlled manner over an extended time period is reported. Key performance parameters are the physical size, the power consumption and also the ability to perform wireless communications to enable the system to be externally controlled and interrogated. The system has been designed to facilitate wireless power transfer, which is very important for miniaturisation as it removes the need for a battery.

"Worm in the eye": the rationale for treatment of DUSN in south India

AIM

To discuss the rationale for different techniques of treatment for DUSN (diffuse unilateral subacute neuroretinitis) and their effectiveness in two patients from south India.

METHODS

Two rare cases of live worms in DUSN from India are reported, where filarial Brugia malayi is endemic. Both cases presented with progressive unilateral loss of vision with no history of animal contact. They were 40 year old, apparently healthy men. In case 1, the worm (1500-2000 microm) was easy to identify with wriggling movements among crisscrossing diffuse subretinal tracks. The worm was destroyed by a single shot of laser to its advancing end, which was followed by oral steroid to control the inflammation caused by the dead worm. In case 2, the worm was small and difficult to identify. Initially diffuse neuroretinitis was diagnosed and treated with intravenous methylprednisolone and oral corticosteroid. A week later, a small live worm (400-600 microm) was found and subsequently destroyed by laser photocoagulation followed by a combination of anthelminthics.

RESULTS

The patients' vision had improved to 6/60-6/36 from counting fingers after a few weeks.

CONCLUSION

The role of a combination of laser treatment, systemic steroid, and anthelminthics is discussed.

Cellular retention on diagnostic contact lenses: an evaluation of current cleaning protocol

AIMS

To compare cellular contamination of diagnostic contact lenses after two different cleaning methods.

METHODS

Twenty-five used diagnostic contact lenses were cleaned by two different methods and the material retained on their contact surface examined for cells. Two diagnostic contact lenses were examined using electron microscopy and surface debris was subjected to x-ray photoelectron spectroscopy.

RESULTS

Significantly more cells were present on used lenses compared with controls (P<0.001). There was no significant difference in total cell count between the lenses subjected to the two cleaning strategies but the lenses simply wiped clean retained marginally more nucleated cells than controls (P=0.039). Electron microscopy showed the majority of the debris on or close to the rim of the lens. X-ray photoelectron spectroscopy confirmed the presence of proteinaceous material.

CONCLUSIONS

Regardless of cleaning method, significant cellular debris is retained on the surface of diagnostic contact lenses after use.

The aetiology and associations of conjunctival intraepithelial neoplasia

AIM

To summarise the main causes and associations of conjunctival intraepithelial neoplasia (CIN) found in the literature to date.

METHOD

Literature search using Ovid databases on the NHS Scotland E-library, Medline, and the Cochrane Library. The internet search engine Google Scholar was also used to identify relevant articles.

RESULTS

The main causes and associations of CIN in the literature are sun exposure and distance from the equator; human papillomavirus infection, increased p53 expression, and HIV seropositivity. It has been found that in HIV positive individuals CIN is on the increase with people being affected with more aggressive tumours at younger ages.

CONCLUSION

Given that CIN is becoming more common in HIV infected populations and that it has the potential to cause severe disability, it is important to improve our understanding of the condition. Early identification of CIN by an understanding of its aetiology and associations may enable the implementation of preventative measures to reduce its incidence and potentially lead to the diagnosis and further management of conditions such as HIV. Young people presenting with CIN in particular may benefit from HIV testing.

Evolving concepts on the pathogenic mechanisms of aniridia related keratopathy

Heterozygosity for PAX6 deficiency (PAX6+/-) results in aniridia. Corneal changes in aniridia-related keratopathy (ARK) include corneal vascular pannus formation, conjunctival invasion of the corneal surface, corneal epithelial erosions and epithelial abnormalities, which eventually result in corneal opacity and contribute to visual loss. Corneal changes in aniridia have been attributed to congenital deficiency of corneal limbal stem cells. The aim of this paper is to review the potential mechanisms that may underlie the pathogenesis of aniridia related keratopathy. Current evidence, based on clinical observations and an animal model of aniridia suggest that the proliferative potential of the corneal limbal stem cells may not primarily be impaired. The corneal changes in aniridia may be related to an abnormality within the limbal stem cell niche. The mechanisms underlying progressive corneal pathology in aniridia appear multi-factorial and include: (1) abnormal corneal healing responses secondary to anomalous extracellular matrix metabolism; (2) abnormal corneal epithelial differentiation leading to fragility of epithelial cells; (3) reduction in cell adhesion molecules in the PAX6 heterozygous state, rendering the cells susceptible to natural shearing forces; and (4) conjunctival and corneal changes leading to the presence of cells derived from conjunctiva on the corneal surface.

Superior forniceal conjunctival advancement pedicles (SFCAP) in the management of acute and impending corneal perforations

OBJECTIVE/AIM

Corneal perforations can result from a wide variety of disorders and can lead to devastating visual sequelae. Various surgical procedures have been described to manage nontraumatic corneal perforation. Conjunctival flaps offer an important technique in dealing with such corneal emergencies. We report a modified conjunctival flap procedure referred to as superior forniceal conjunctival advancement pedicle (SFCAP) in the successful management of corneal perforation and impending corneal perforation.

PATIENTS AND METHODS

Out of 20 patients who underwent SFCAP for non-traumatic corneal perforation and impending perforation, 16 had corneal perforations. Perforations were secondary to acne rosacea (2), advanced bacterial keratitis (6), corneal anaesthesia(2), multiple retinal procedures (2), previous corneal grafts with a compromised ocular surface (3), and advanced Mooren's ulcer (1).

RESULTS

The globe was preserved in all patients. In 14 of the 16 eyes with perforated corneas the pedicle stabilised. One patient, who was a chronic alcoholic, rubbed the eye during sleep detaching the pedicle a week after surgery. However, the ulcer healed and the integrity of the globe was restored. None of these patients developed secondary glaucoma or ptosis.

CONCLUSION

SFCAP is an appropriate procedure to manage corneal perforations and impending corneal perforations where donor material is not available and transplantation of such tissue is not suitable.

Immunolocalisation of leukaemia inhibitory factor in the cornea

AIM

Leukaemia inhibitory factor (LIF) is a pleotrophic cytokine expressed in a variety of cell types, and have shown to regulate stem cell proliferation, vascular genesis, inflammation, and immunity in various locations. Expression of LIF and its role in the cornea have not been studied previously. In this study, we examined the expression of LIF in the cornea.

MATERIALS AND METHOD

Immunohistochemistry was performed using polyclonal LIF antibodies, and Avidin-Biotin ABC complex on cultured human corneal epithelium corneal fibroblasts and wild-type murine corneal epithelium.

RESULTS

LIF was detected in the cytoplasm of murine corneal epithelium, cultured human corneal epithelium, and fibroblasts. The expression of LIF was mainly cytoplasmic.

CONCLUSION

LIF is expressed in the corneal epithelium and fibroblasts. It may have an important role in the maintenance of homeostasis of the corneal epithelium and cornea stroma. Further studies are necessary to elucidate the role of LIF in the cornea.

Development of a Forced Choice Photographic Questionnaire for Photic Phenomena and Its Testing – Repeatability, Reliability and Validity

AIM

To design, develop and test a system for analysis of photic phenomena.

METHOD

Extensive background research, patient interviews and theoretical studies led to development of a set of photographic images resembling photic phenomena experienced by patients. These photographic images were processed and digitally altered to create scales of severity for each photic phenomenon in which patients indicated their severity of symptoms by choice of image. The system was tested for stability and validity.

RESULTS

The system showed excellent repeatability and reliability. Face, content, criterion and construct validity were all found to be acceptable.

CONCLUSION

The photographic images of photic phenomena analyser is an acceptable, validated measure for the assessment of photic phenomena, in both pseudophakic patients and those with cataract.

A prospective study of visual function and quality of life following PDT in patients with wet age related macular degeneration

AIMS

(1) A prospective study to assess visual function measures and quality of life (QoL) in patients with wet age related macular degeneration (AMD) treated with photodynamic therapy (PDT). (2) To assess if PDT prevents severe visual loss (loss of six or more lines of distance visual acuity) in the treated eye.

METHODS

48 of 51 recruited patients with predominantly classic subfoveal choroidal neovascularisation (CNV) secondary AMD who were treated with PDT were followed up for 1 year. Assessment included distance and near visual acuity, contrast sensitivity, vision related quality of life and fluorescein angiography. Photodynamic therapy using Visudyne was carried out according to standard protocol. Patients were followed up every 3 months and treatment repeated if there was significant leakage from CNV.

RESULTS

At the 12 month follow up, 71% (n = 34) of the patients lost less than three lines of best corrected distance visual acuity. Although there were significant decreases in some of the QoL items tested, patients were significantly less anxious and more independent outdoors at the 12 month follow up.

CONCLUSION

This study is in keeping with published literature with PDT preventing severe visual loss in two thirds of treated patients with predominantly classic CNV.

Delayed diagnosis of HIV infection in ophthalmic practice

The introduction of potent antiretroviral drug combinations has transformed human immunodeficiency virus/acquired immunodeficiency disease syndrome (HIV/AIDS) from an intractable and rapidly fatal disease to a chronic manageable illness with prolonged life survival for many patients. This paper discusses the ophthalmic and medical histories of two young female patients who presented with 'atypical' optic neuropathy and toxoplasma gondii retinochoroiditis and were later found to be HIV infected. We discuss the need for increased vigilance in the ophthalmic community for suspecting HIV infection to allow optimal management of the ophthalmic and systemic manifestations of the disease spectrum associated with HIV/AIDS.

Ex vivo expansion of corneal limbal epithelial/stem cells for corneal surface reconstruction

PURPOSE

The management of severe ocular surface disease due to limbal stem cell deficiency has changed dramatically. The concept of limbal stem cells, as the source of corneal epithelium revolutionised the therapeutic approach of ocular surface reconstruction. Deficiency of limbal stem cells results in blinding ocular surface diseases. Grafting viable limbal tissue, from either fellow healthy eye or a donor eye, with the resident stem cell population may replenish limbal stem cells and can restore the corneal surface to normality. Transplanting the limbal tissue can be achieved through a variety of procedures that include cadaveric keratolimbal allograft (KLAL), live or living related conjunctival limbal allograft (Ir-CLAL) and limbal autograft. Advances in tissue engineering techniques have offered a viable alternative to overcome the limitation of limbal tissue available for transplantation. Epithelial stem cells harvested from a small limbal biopsy can be expanded in vitro on a suitable carrier and then transplanted to the diseased cornea to successfully restore the corneal surface. This article is a chronological review of the important steps that brought ex vivo expanded stem cell transplantation in ocular, particularly corneal surface reconstruction.

METHODS

The MEDLINE data base was searched for the years 1966-2002, using key words cornea, cell culture, ex-vivo expansion, limbus, stem cell, ocular surface and transplantation. Several articles that were not found by MEDLINE search were taken from references from other articles. Inclusion or exclusion of article was based on the relevance to the subject.

CONCLUSIONS

Corneal epithelial reconstruction with ex vivo expanded limbal cells is a potential tool in ocular surface reconstruction, although the technique is currently investigational. Strategies to achieve conjunctival epithelial restoration and tear film replenishment will allow ophthalmic surgeons to truly reconstruct the ocular surface.