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Kempen JH, Newcomb CW, Washington TL, Foster CS, Sobrin L, Thorne JE, Jabs DA, Suhler EB, Rosenbaum JT, Sen HN, Levy-Clarke GA, Nussenblatt RB, Bhatt NP, Lowder CY, Goldstein DA, Leiderman YI, Acharya NR, Holland GN, Read RW, Dunn JP, Dreger KA, Artornsombudh P, Begum HA, Fitzgerald TD, Kothari S, Payal AR, Daniel E, Gangaputra SS, Kaçmaz RO, Liesegang TL, Pujari SS, Khachatryan N, Maghsoudlou A, Suga HK, Pak CM, Helzlsouer KJ, Buchanich JM. Use of Immunosuppression and the Risk of Subsequent Overall or Cancer Mortality. Ophthalmology 2023; 130:1258-1268. [PMID: 37499954 PMCID: PMC10811288 DOI: 10.1016/j.ophtha.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE To determine the incidence of all-cause and cancer mortality (CM) in association with immunosuppression. DESIGN Retrospective cohort study at ocular inflammatory disease (OID) subspecialty centers. We harvested exposure and covariate data retrospectively from clinic inception (earliest in 1979) through 2010 inclusive. Then we ascertained overall and cancer-specific mortalities by National Death Index linkage. We constructed separate Cox models to evaluate overall and CM for each class of immunosuppressant and for each individual immunosuppressant compared with person-time unexposed to any immunosuppression. PARTICIPANTS Patients with noninfectious OID, excluding those with human immunodeficiency infection or preexisting cancer. METHODS Tumor necrosis factor (TNF) inhibitors (mostly infliximab, adalimumab, and etanercept); antimetabolites (methotrexate, mycophenolate mofetil, azathioprine); calcineurin inhibitors (cyclosporine); and alkylating agents (cyclophosphamide) were given when clinically indicated in this noninterventional cohort study. MAIN OUTCOME MEASURES Overall mortality and CM. RESULTS Over 187 151 person-years (median follow-up 10.0 years), during which 15 938 patients were at risk for mortality, we observed 1970 deaths, 435 due to cancer. Both patients unexposed to immunosuppressants (standardized mortality ratio [SMR] = 0.95, 95% confidence interval [CI], 0.90-1.01) and those exposed to immunosuppressants but free of systemic inflammatory diseases (SIDs) (SMR = 1.04, 95% CI, 0.95-1.14) had similar mortality risk to the US population. Comparing patients exposed to TNF inhibitors, antimetabolites, calcineurin inhibitors, and alkylating agents with patients not exposed to any of these, we found that overall mortality (adjusted hazard ratio [aHR] = 0.88, 0.89, 0.90, 1.11) and CM (aHR = 1.25, 0.89, 0.86, 1.23) were not significantly increased. These results were stable in sensitivity analyses whether excluding or including patients with SID, across 0-, 3-, or 5-year lags and across quartiles of immunosuppressant dose and duration. CONCLUSIONS Our results, in a cohort where the indication for treatment was proven unassociated with mortality risk, found that commonly used immunosuppressants-especially the antimetabolites methotrexate, mycophenolate mofetil, and azathioprine; the TNF inhibitors adalimumab and infliximab, and cyclosporine-were not associated with increased overall and CM over a median cohort follow-up of 10.0 years. These results suggest the safety of these agents with respect to overall and CM for patients treated with immunosuppression for a wide range of inflammatory diseases. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Sight for Souls, Bellevue, Washington; MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.
| | - Craig W Newcomb
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri L Washington
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts
| | - Lucia Sobrin
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer E Thorne
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Portland Veteran's Affairs Medical Center, Portland, Oregon
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon; Legacy Devers Eye Institute, Portland, Oregon
| | - H Nida Sen
- Department of Ophthalmology, George Washington University, Washington, District of Columbia; Janssen Retina Global Clinical Development, Princeton, New Jersey
| | - Grace A Levy-Clarke
- Department of Ophthalmology and Visual Sciences, West Virginia University, Morgantown, West Virginia
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirali P Bhatt
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Careen Y Lowder
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic, Cleveland, Ohio
| | - Debra A Goldstein
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Yannek I Leiderman
- Illinois Eye & Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Nisha R Acharya
- F.I. Proctor Foundation, Department of Ophthalmology, University of California San Francisco School of Medicine, San Francisco, California
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Russell W Read
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - James P Dunn
- Mid-Atlantic Retina, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Kurt A Dreger
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Pichaporn Artornsombudh
- Department of Ophthalmology, Somdech Phra Pinkloa Hospital, Royal Thai Navy, Bangkok, Thailand; Department of Ophthalmology, Chulalongkorn University, Bangkok, Thailand
| | - Hosne A Begum
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tonetta D Fitzgerald
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srishti Kothari
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ebenezer Daniel
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sapna S Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Teresa L Liesegang
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon
| | - Siddharth S Pujari
- Siddharth Netralaya Superspecialty Eye Hospital, Belgaum, Karnataka, India
| | - Naira Khachatryan
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hilkiah K Suga
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Clara M Pak
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Kathy J Helzlsouer
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanine M Buchanich
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Papaliodis GN, Rosner BA, Dreger KA, Fitzgerald TD, Artornsombudh P, Kothari S, Gangaputra SS, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Sen HN, Suhler EB, Thorne JE, Bhatt NP, Foster CS, Jabs DA, Pak CM, Ying GS, Kempen JH. Incidence of and Risk Factors for Cataract in Anterior Uveitis. Am J Ophthalmol 2023; 254:221-232. [PMID: 37414328 PMCID: PMC10528977 DOI: 10.1016/j.ajo.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE To estimate the incidence/risk factors for cataract in noninfectious anterior uveitis. DESIGN Retrospective multicenter cohort study (6 US tertiary uveitis sites, 1978-2010). METHODS Data were harvested by trained expert reviewers, using protocol-driven review of experts' charts. We studied cataract incidence-newly reduced visual acuity worse than 20/40 attributed to cataract; or incident cataract surgery-in 3923 eyes of 2567 patients with anterior uveitis. RESULTS Cataract developed in 507 eyes (54/1000 eye-years, 95% CI 49-59). Time-updated risk factors associated with cataract included older age (≥65 vs <18 years: adjusted hazard ratio [aHR] 5.04, 95% CI 3.04-8.33), higher anterior chamber cell grade (P(trend)=0.001), prior incisional glaucoma surgery (aHR 1.86, 95% CI 1.10-3.14), band keratopathy (aHR 2.23, 95% CI 1.47-3.37), posterior synechiae (aHR 3.71, 95% CI 2.83-4.87), and elevated intraocular pressure ≥30 vs 6-20 mm Hg (aHR 2.57, 95% CI 1.38-4.77). Primary acute (aHR 0.59, 95% CI 0.30-1.15) and recurrent acute (aHR 0.74, 95% CI 0.55-0.98) had lower cataract risk than chronic anterior uveitis. Higher-dose prednisolone acetate 1%-equivalent use (≥2 drops/day) was associated with >2-fold higher cataract risk in eyes with anterior chamber cell grades 0.5+ or lower but was not associated with higher cataract risk in the presence of anterior chamber cells of grade 1+ or higher. CONCLUSIONS Cataract complicates anterior uveitis in ∼5.4/100 eye-years. Several fixed and modifiable risk factors were identified, yielding a point system to guide cataract risk minimization. Topical corticosteroids only were associated with increased cataract risk when anterior chamber cells were absent or minimally present, suggesting their use to treat active inflammation (which itself is cataractogenic) does not cause a net increase in cataract incidence.
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Affiliation(s)
- George N Papaliodis
- From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary (G.N.P., J.H.K.), Boston, Massachusetts, USA; Department of Ophthalmology, Harvard Medical School (G.N.P., C.S.F., J.H.K.), Boston, Massachusetts, USA.
| | - Bernard A Rosner
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School (B.A.R.), Boston, Massachusetts, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health (B.A.R.), Boston, Massachusetts, USA
| | - Kurt A Dreger
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health (K.A.D.), Baltimore, Maryland, USA; Department of Ophthalmology, Johns Hopkins School of Medicine (K.A.D., J.E.T., D.A.J.), Baltimore, Maryland, USA
| | - Tonetta D Fitzgerald
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine (T.D.F., N.P.B., G.-s.Y., s.k.), Philadelphia, Pennsylvania, USA
| | - Pichaporn Artornsombudh
- Massachusetts Eye Research and Surgery Institution (P.A., S.K., C.S.F.), Waltham, Massachusetts, USA; Department of Ophthalmology, Somdech Phra Pinklao Hospital, Royal Thai Navy (P.A.), Bangkok, Thailand;; Department of Ophthalmology, King Chulalongkorn Memorial Hospital (P.A.), Bangkok, Thailand
| | - Srishti Kothari
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine (T.D.F., N.P.B., G.-s.Y., s.k.), Philadelphia, Pennsylvania, USA; Massachusetts Eye Research and Surgery Institution (P.A., S.K., C.S.F.), Waltham, Massachusetts, USA
| | - Sapna S Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center (S.S.G.), Nashville, Tennessee, USA
| | - Grace A Levy-Clarke
- Department of Ophthalmology and Visual Sciences, West Virginia University (G.A.L.-C.), Morgantown, West Virginia, USA
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health (R.B.N., H.N.S.), Bethesda, Maryland, USA
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University (J.T.R., E.B.S.), Portland, Oregon, USA; Department of Medicine, Oregon Health and Science University (J.T.R.), Portland, Oregon, USA; Legacy Devers Eye Institute (J.T.R.), Portland, Oregon, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, National Institutes of Health (R.B.N., H.N.S.), Bethesda, Maryland, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University (J.T.R., E.B.S.), Portland, Oregon, USA; Portland Veteran's Affairs Medical Center (E.B.S.), Portland, Oregon, USA
| | - Jennifer E Thorne
- Department of Ophthalmology, Johns Hopkins School of Medicine (K.A.D., J.E.T., D.A.J.), Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health (J.E.T., D.A.J.), Baltimore, Maryland, USA
| | - Nirali P Bhatt
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine (T.D.F., N.P.B., G.-s.Y., s.k.), Philadelphia, Pennsylvania, USA
| | - C Stephen Foster
- Department of Ophthalmology, Harvard Medical School (G.N.P., C.S.F., J.H.K.), Boston, Massachusetts, USA; Massachusetts Eye Research and Surgery Institution (P.A., S.K., C.S.F.), Waltham, Massachusetts, USA
| | - Douglas A Jabs
- Department of Ophthalmology, Johns Hopkins School of Medicine (K.A.D., J.E.T., D.A.J.), Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health (J.E.T., D.A.J.), Baltimore, Maryland, USA
| | - Clara M Pak
- University of Rochester School of Medicine & Dentistry (C.M.P.), Rochester, New York, USA; MCM Eye Unit, MyungSung Christian Medical Center (MCM) General Hospital and MyungSung Medical School (J.H.K., C.M.P.), Addis Ababa, Ethiopia
| | - Gui-Shuang Ying
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine (T.D.F., N.P.B., G.-s.Y., s.k.), Philadelphia, Pennsylvania, USA
| | - John H Kempen
- From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary (G.N.P., J.H.K.), Boston, Massachusetts, USA; Department of Ophthalmology, Harvard Medical School (G.N.P., C.S.F., J.H.K.), Boston, Massachusetts, USA; MCM Eye Unit, MyungSung Christian Medical Center (MCM) General Hospital and MyungSung Medical School (J.H.K., C.M.P.), Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine (J.H.K.), Addis Ababa, Ethiopia.
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Siktberg J, Hamdan S, Liu Y, Chen Q, Donahue SP, Patel SN, Sternberg P, Robinson J, Kammer JA, Gangaputra SS. Validation of a Standardized Home Visual Acuity Test for Teleophthalmology. Ophthalmology Science 2021; 1:100007. [PMID: 36246005 PMCID: PMC9560535 DOI: 10.1016/j.xops.2021.100007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/25/2022]
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4
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Pistilli M, Gangaputra SS, Pujari SS, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Sen HN, Suhler EB, Thorne JE, Bhatt NP, Foster CS, Begum H, Fitzgerald TD, Dreger KA, Kempen JH. Contemporaneous Risk Factors for Visual Acuity in Non-Infectious Uveitis. Ocul Immunol Inflamm 2021; 29:1056-1063. [PMID: 33621148 DOI: 10.1080/09273948.2020.1828493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We evaluated the associations of clinical and demographic characteristics with visual acuity (VA) with over 5 years in a subspecialty noninfectious uveitis population. METHODS Retrospective data from 5,530 noninfectious uveitis patients were abstracted by expert reviewers, and contemporaneous associations of VA with demographic and clinical factors were modeled. RESULTS Patients were a median of 41 years old, 65% female, and 73% white. Eyes diagnosed ≥5 years prior to cohort entry had worse VA (-1.2 lines) than those diagnosed <6 months prior, and eyes with cataract surgery performed prior to entry had worse VA (-5.9 lines) than those performed during follow-up. Vitreous haze (-4.2 lines for 3+ vs quiet), hypotony (-2.5 lines for ≤5 mm Hg vs 6-23 mm Hg), and CNV (-1.8 lines) all were strongly associated with reduced VA. CONCLUSION Factors associated with reduced VA included well-known structural complications, and lack of subspecialty care during cataract surgery.
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Affiliation(s)
- Maxwell Pistilli
- Department of Ophthalmology, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sapna S Gangaputra
- Department of Ophthalmology and Vision Sciences, Vanderbilt Eye Institute, Nashville, Tennessee, USA
| | | | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Grace A Levy-Clarke
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland, USA.,Tampa Bay Uveitis Center, Tampa, Florida, USA
| | | | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA.,Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA.,Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.,Portland Veteran's Affairs Medical Center, Portland, Oregon, USA
| | - Jennifer E Thorne
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nirali P Bhatt
- Department of Ophthalmology, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hosne Begum
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tonetta D Fitzgerald
- Department of Ophthalmology, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kurt A Dreger
- Department of Ophthalmology, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John H Kempen
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,MCM Eye Unit, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia, USA
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Gangaputra SS, Patel SN. Ocular Symptoms among Nonhospitalized Patients Who Underwent COVID-19 Testing. Ophthalmology 2020; 127:1425-1427. [PMID: 32585259 PMCID: PMC7308009 DOI: 10.1016/j.ophtha.2020.06.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Sapna S Gangaputra
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Shriji N Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
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6
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Pistilli M, Joffe MM, Gangaputra SS, Pujari SS, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Sen HN, Suhler EB, Thorne JE, Bhatt NP, Foster CS, Begum H, Fitzgerald TD, Dreger KA, Altaweel MM, Holbrook JT, Kempen JH. Visual Acuity Outcome over Time in Non-Infectious Uveitis. Ocul Immunol Inflamm 2019; 29:1064-1071. [PMID: 31821051 DOI: 10.1080/09273948.2019.1687733] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: We evaluated visual acuity (VA) over 5 years in a subspecialty noninfectious uveitis population.Methods: Retrospective data from 5,530 noninfectious uveitis patients with anterior, intermediate, posterior or panuveitis were abstracted by expert reviewers. Mean VA was calculated using inverse probability of censoring weighting to account for losses to follow-up.Results: Patients were a median of 41 years old, 65% female, and 73% white. Initial mean VA was worse among panuveitis (20/84) than posterior (20/64), intermediate (20/47), and anterior (20/37) uveitides. On average, mean VA improved by 0.62, 0.51, 0.37, and 0.26 logMAR-equivalent lines over 2 years, respectively (each P < .001), then remained stable, except posterior uveitis mean VA worsened to initial levels.Conclusion: Mean VA of uveitic eyes improved and, typically, improvement was sustained under uveitis subspecialty care. Because VA tends to improve under tertiary care, mean VA change appears a better outcome for clinical studies than time-to-loss of VA.
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Affiliation(s)
- Maxwell Pistilli
- The Scheie Eye Institute, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.,The Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Marshall M Joffe
- The Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sapna S Gangaputra
- Department of Ophthalmology and Vision Sciences, Vanderbilt Eye Institute, Nashville, TN, USA
| | | | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Departments of Ophthalmology and Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Laboratory of Immunology, National Eye Institute, Bethesda, MD, USA
| | - Grace A Levy-Clarke
- Tampa Bay Uveitis Center, Tampa, FL, USA.,Department of Ophthalmology, Oregon Health and Science University, Portland, OR, USA
| | | | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, OR, USA.,Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, Bethesda, MD, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, OR, USA.,Department of Medicine, Oregon Health and Science University, Portland, OR, USA.,Ophthalmology Service, Portland Veteran's Affairs Medical Center, Portland, OR, USA
| | - Jennifer E Thorne
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nirali P Bhatt
- The Scheie Eye Institute, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Cambridge, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Hosne Begum
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tonetta D Fitzgerald
- The Scheie Eye Institute, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kurt A Dreger
- The Scheie Eye Institute, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.,Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael M Altaweel
- The Fundus Photograph Reading Center, University of Wisconsin School of Medicine, Madison, WI, USA.,Department of Ophthalmology and Vision Sciences, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Janet T Holbrook
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Clinical Trials and Synthesis, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - John H Kempen
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,MCM Eye Unit, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
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7
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Gangaputra SS, Newcomb CW, Joffe MM, Dreger K, Begum H, Artornsombudh P, Pujari SS, Daniel E, Sen HN, Suhler EB, Thorne JE, Bhatt NP, Foster CS, Jabs DA, Nussenblatt RB, Rosenbaum JT, Levy-Clarke GA, Kempen JH. Comparison Between Methotrexate and Mycophenolate Mofetil Monotherapy for the Control of Noninfectious Ocular Inflammatory Diseases. Am J Ophthalmol 2019; 208:68-75. [PMID: 31344346 DOI: 10.1016/j.ajo.2019.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/13/2019] [Accepted: 07/13/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare mycophenolate mofetil (MMF) to methotrexate (MTX) as corticosteroid-sparing therapy for ocular inflammatory diseases. DESIGN Retrospective analysis of cohort study data. METHODS Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained via medical record review. The study included 352 patients who were taking single-agent immunosuppression with MTX or MMF at 4 tertiary uveitis clinics. Marginal structural models (MSM)-derived statistical weighting created a virtual population with covariates and censoring patterns balanced across alternative treatments. With this methodological approach, the results estimate what would have happened had none of the patients stopped their treatment. Survival analysis with stabilized MSM-derived weights simulated a clinical trial comparing MMF vs MTX for noninfectious inflammatory eye disorders. The primary outcome was complete control of inflammation on prednisone ≤10 mg/day, sustained for ≥30 days. RESULTS The time to success was shorter (more favorable) for MMF than MTX (hazard ratio = 0.68, 95% confidence interval: 0.46-0.99). Adjusting for covariates, the proportion achieving success was higher at every point in time for MMF than MTX from 2 to 8 months, then converges at 9 months. The onset of corticosteroid-sparing success took more than 3 months for most patients in both groups. Outcomes of treatment (MMF vs MTX) were similar across all anatomic sites of inflammation. The incidence of stopping therapy for toxicity was similar in both groups. CONCLUSIONS Our results suggest that, on average, MMF may be faster than MTX in achieving corticosteroid-sparing success in ocular inflammatory diseases.
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Affiliation(s)
- Sapna S Gangaputra
- Vanderbilt Eye Institute, Nashville, Tennessee, USA; Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Craig W Newcomb
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marshall M Joffe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kurt Dreger
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hosne Begum
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Pichaporn Artornsombudh
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA; Department of Ophthalmology, Somdech Phra Pinkloa Hospital, Royal Thai Navy, Bangkok, Thailand; Department of Ophthalmology, Chulalongkorn University, Bangkok, Thailand
| | - Siddharth S Pujari
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA; Siddharth Netralaya, Belgaum, Karnataka, India
| | - Ebenezer Daniel
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA; Portland Veteran's Affairs Medical Center, Portland, Oregon, USA
| | - Jennifer E Thorne
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nirali P Bhatt
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA; Departments of Ophthalmology and Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA; Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA; Legacy Devers Eye Institute, Portland, Oregon, USA
| | | | - John H Kempen
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA; MCM Eye Unit/Ophthalmology, MyungSung Christian Medical Center and MyungSung Medical School, Addis Ababa, Ethiopia
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Noble CW, Gangaputra SS, Thompson IA, Yuan A, Apolo AB, Lee JM, Papaliodis GN, Kodati S, Bishop R, Magone MT, Sobrin L, Sen HN. Ocular Adverse Events following Use of Immune Checkpoint Inhibitors for Metastatic Malignancies. Ocul Immunol Inflamm 2019; 28:854-859. [PMID: 31013173 DOI: 10.1080/09273948.2019.1583347] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To report the clinical features, severity, and management of ocular immune-related adverse events (irAEs) in the setting of immune checkpoint inhibitor therapy for metastatic malignancies. METHODS Retrospective chart review at three tertiary ophthalmology clinics. Electronic medical records were reviewed between 2000 and 2017 for patients with new ocular symptoms while undergoing checkpoint inhibition therapy. RESULTS Eleven patients were identified. Ocular irAEs ranged from keratoconjunctivitis sicca to Vogt-Koyanagi-Harada-like findings. Average timing of irAEs from starting checkpoint inhibitor therapy was 15.7 weeks. Ocular inflammation was successfully controlled with corticosteroids in most cases, however three patients discontinue treatment as a result of ocular inflammation with decreased visual acuity, two discontinued due to progression of metastatic disease, and one discontinued due to severe systemic irAEs. CONCLUSION We found a wide spectrum of ocular irAEs associated with immune checkpoint inhibitors. In most cases, ocular AEs did not limit ongoing cancer treatment.
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Affiliation(s)
- Carl W Noble
- Department of Ophthalmology, George Washington University , Washington DC, USA
| | | | - Ian A Thompson
- Department of Ophthalmology, National Eye Institute , Bethesda, USA
| | - Amy Yuan
- Department of Ophthalmology, Massachusetts Eye and Ear Institute , Boston, USA
| | - Andrea B Apolo
- Department of Oncology, National Cancer Institute , Bethesda, USA
| | - Jung-Min Lee
- Department of Oncology, National Cancer Institute , Bethesda, USA
| | - George N Papaliodis
- Department of Ophthalmology, Massachusetts Eye and Ear Institute , Boston, USA
| | - Shilpa Kodati
- Department of Ophthalmology, National Eye Institute , Bethesda, USA
| | - Rachel Bishop
- Department of Ophthalmology, National Eye Institute , Bethesda, USA
| | - M Teresa Magone
- Department of Ophthalmology, Washington DC Veterans Hospital , Washington DC, USA
| | - Lucia Sobrin
- Department of Ophthalmology, Massachusetts Eye and Ear Institute , Boston, USA
| | - H Nida Sen
- Department of Ophthalmology, National Eye Institute , Bethesda, USA
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9
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Daniel E, Pistilli M, Kothari S, Khachatryan N, Kaçmaz RO, Gangaputra SS, Sen HN, Suhler EB, Thorne JE, Foster CS, Jabs DA, Nussenblatt RB, Rosenbaum JT, Levy-Clarke GA, Bhatt NP, Kempen JH. Risk of Ocular Hypertension in Adults with Noninfectious Uveitis. Ophthalmology 2017; 124:1196-1208. [PMID: 28433444 DOI: 10.1016/j.ophtha.2017.03.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To describe the risk and risk factors for ocular hypertension (OHT) in adults with noninfectious uveitis. DESIGN Retrospective, multicenter, cohort study. PARTICIPANTS Patients aged ≥18 years with noninfectious uveitis seen between 1979 and 2007 at 5 tertiary uveitis clinics. METHODS Demographic, ocular, and treatment data were extracted from medical records of uveitis cases. MAIN OUTCOME MEASURES Prevalent and incident OHT with intraocular pressures (IOPs) of ≥21 mmHg, ≥30 mmHg, and increase of ≥10 mmHg from documented IOP recordings (or use of treatment for OHT). RESULTS Among 5270 uveitic eyes of 3308 patients followed for OHT, the mean annual incidence rates for OHT ≥21 mmHg and OHT ≥30 mmHg are 14.4% (95% confidence interval [CI], 13.4-15.5) and 5.1% (95% CI, 4.7-5.6) per year, respectively. Statistically significant risk factors for incident OHT ≥30 mmHg included systemic hypertension (adjusted hazard ratio [aHR], 1.29); worse presenting visual acuity (≤20/200 vs. ≥20/40, aHR, 1.47); pars plana vitrectomy (aHR, 1.87); history of OHT in the other eye: IOP ≥21 mmHg (aHR, 2.68), ≥30 mmHg (aHR, 4.86) and prior/current use of IOP-lowering drops or surgery in the other eye (aHR, 4.17); anterior chamber cells: 1+ (aHR, 1.43) and ≥2+ (aHR, 1.59) vs. none; epiretinal membrane (aHR, 1.25); peripheral anterior synechiae (aHR, 1.81); current use of prednisone >7.5 mg/day (aHR, 1.86); periocular corticosteroids in the last 3 months (aHR, 2.23); current topical corticosteroid use [≥8×/day vs. none] (aHR, 2.58); and prior use of fluocinolone acetonide implants (aHR, 9.75). Bilateral uveitis (aHR, 0.69) and previous hypotony (aHR, 0.43) were associated with statistically significantly lower risk of OHT. CONCLUSIONS Ocular hypertension is sufficiently common in eyes treated for uveitis that surveillance for OHT is essential at all visits for all cases. Patients with 1 or more of the several risk factors identified are at particularly high risk and must be carefully managed. Modifiable risk factors, such as use of corticosteroids, suggest opportunities to reduce OHT risk within the constraints of the overriding need to control the primary ocular inflammatory disease.
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Affiliation(s)
- Ebenezer Daniel
- Scheie Eye Institute, Philadelphia, Pennsylvania; Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maxwell Pistilli
- Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srishti Kothari
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Naira Khachatryan
- Scheie Eye Institute, Philadelphia, Pennsylvania; Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts
| | - R Oktay Kaçmaz
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Mallinckrodt Pharmaceuticals, Staines-upon-Thames, England, United Kingdom
| | - Sapna S Gangaputra
- Department of Ophthalmology and Visual Science, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Laboratory of Immunology, National Eye Institute, Bethesda, Maryland
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland
| | - Eric B Suhler
- Department of Ophthalmology, Department of Medicine, Oregon Health and Science University, Portland, Oregon; Portland Veteran's Affairs Medical Center, Portland, Oregon
| | - Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - James T Rosenbaum
- Department of Ophthalmology, Department of Medicine, Oregon Health and Science University, Portland, Oregon; Legacy Devers Eye Institute, Portland, Oregon; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nirali P Bhatt
- Scheie Eye Institute, Philadelphia, Pennsylvania; Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - John H Kempen
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts; Discovery Eye Center, MyungSung Christian Medical Center, Addis Ababa, Ethiopia
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10
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Altaweel MM, Gangaputra SS, Thorne JE, Dunn JP, Elner SG, Jaffe GJ, Kim RY, Rao PK, Reed SB, Kempen JH. Morphological assessment of the retina in uveitis. J Ophthalmic Inflamm Infect 2016; 6:33. [PMID: 27613274 PMCID: PMC5017967 DOI: 10.1186/s12348-016-0103-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background The objective of this study is to describe a system for color photograph evaluation in uveitis and report baseline morphologic findings for the Multicenter Uveitis Steroid Treatment (MUST) Trial. Four-hundred seventy-nine eyes of 255 subjects with intermediate, posterior, and panuveitis had stereoscopic color fundus photographs obtained by certified photographers and evaluated by certified graders using standardized procedures to evaluate morphologic characteristics of uveitis. The posterior pole was evaluated for macular edema, vitreoretinal interface abnormalities, and macular pigment disturbance/atrophy; the optic disk was assessed for edema, pallor, or glaucomatous changes. The presence of neovascularization, vascular occlusion, vascular sheathing, and tractional retinal changes was determined. A random subset of 77 images was re-graded to determine the percentage agreement with the original grading on a categorical scale. Results At baseline, 437/479 eyes had images available to grade. Fifty-three eyes were completely ungradable due to media opacity. Common features of intermediate and posterior/panuveitis were epiretinal membrane (134 eyes, 35 %), and chorioretinal lesions (140 eyes, 36 %). Macular edema was seen in 16 %. Optic nerve head and vascular abnormalities were rare. Reproducibility evaluation found exact agreement for the presence of chorioretinal lesions was 78 %, the presence and location of macular edema was 71 %, and the presence of epiretinal membrane was 71 %. Vertical cup-to-disk ratio measurement had intra-class correlation of 0.75. Conclusions The MUST system for evaluating stereoscopic color fundus photographs describes the morphology of uveitis and its sequelae, in a standardized manner, is highly reproducible, and allows monitoring of treatment effect and safety evaluation regarding these outcomes in clinical trials. Electronic supplementary material The online version of this article (doi:10.1186/s12348-016-0103-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael M Altaweel
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA. .,Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, 2870 University Ave. Suite 206, Madison, WI, 53705, USA.
| | - Sapna S Gangaputra
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA
| | - Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, The Johns Hopkins University, Baltimore, MD, USA
| | - James P Dunn
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, USA
| | | | | | - Rosa Y Kim
- Retina Consultants of Houston, Houston, TX, USA
| | - P Kumar Rao
- Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, MO, USA
| | - Susan B Reed
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA
| | - John H Kempen
- Departments of Ophthalmology and Biostatistics & Epidemiology and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
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Sen HN, Vitale S, Gangaputra SS, Nussenblatt RB, Liesegang TL, Levy-Clarke GA, Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Jabs DA, Kempen JH. Periocular corticosteroid injections in uveitis: effects and complications. Ophthalmology 2014; 121:2275-86. [PMID: 25017415 DOI: 10.1016/j.ophtha.2014.05.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the benefits and complications of periocular depot corticosteroid injections in patients with ocular inflammatory disorders. DESIGN Multicenter, retrospective cohort study. PARTICIPANTS A total of 914 patients (1192 eyes) who had received ≥ 1 periocular corticosteroid injection at 5 tertiary uveitis clinics in the United States. METHODS Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained at every visit via medical record review by trained reviewers. MAIN OUTCOME MEASURES Control of inflammation, improvement of visual acuity (VA) to ≥ 20/40, improvement of VA loss attributed to macular edema (ME), incident cataract affecting VA, cataract surgery, ocular hypertension, and glaucoma surgery. RESULTS Among 914 patients (1192 eyes) who received ≥ 1 periocular injection during follow-up, 286 (31.3%) were classified as having anterior uveitis, 303 (33.3%) as intermediate uveitis, and 324 (35.4%) as posterior or panuveitis. Cumulatively by ≤ 6 months, 72.7% (95% CI, 69.1-76.3) of the eyes achieved complete control of inflammation and 49.7% (95% CI, 45.5-54.1) showed an improvement in VA from <20/40 to ≥ 20/40. Among the subset with VA <20/40 attributed to ME, 33.1% (95% CI, 25.2-42.7) improved to ≥ 20/40. By 12 months, the cumulative incidence of ≥ 1 visits with an intraocular pressure of ≥ 24 mmHg and ≥ 30 mmHg was 34.0% (95% CI, 24.8-45.4) and 15.0% (95% CI, 11.8-19.1) respectively; glaucoma surgery was performed in 2.4% of eyes (95% CI, 1.4-3.9). Within 12 months, among phakic eyes initially ≥ 20/40, the incidence of a reduction in VA to <20/40 attributed to cataract was 20.2% (95% CI, 15.9-25.6); cataract surgery was performed within 12 months in 13.8% of the initially phakic eyes (95% CI, 11.1-17.2). CONCLUSIONS Periocular injections were effective in treating active intraocular inflammation and in improving reduced VA attributed to ME in a majority of patients. The response pattern was similar across anatomic locations of uveitis. Overall, VA improved in one half of the patients at some point within 6 months. However, cataract and ocular hypertension occurred in a substantial minority.
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Affiliation(s)
- H Nida Sen
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland.
| | - Susan Vitale
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland
| | - Sapna S Gangaputra
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Teresa L Liesegang
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Grace A Levy-Clarke
- Laboratory of Immunology, National Eye Institute, Bethesda, Maryland; Tampa Bay Uveitis Center, Tampa, Florida
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; Veterans' Affairs Medical Center, Portland, Oregon
| | - Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institute, Cambridge, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Douglas A Jabs
- Department of Epidemiology, Center for Clinical Trials, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John H Kempen
- Department of Ophthalmology, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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12
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Artornsombudh P, Pistilli M, Foster CS, Pujari SS, Gangaputra SS, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Kempen JH. Factors predictive of remission of new-onset anterior uveitis. Ophthalmology 2013; 121:778-84. [PMID: 24342020 DOI: 10.1016/j.ophtha.2013.09.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 09/20/2013] [Accepted: 09/26/2013] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To identify factors predictive of remission of inflammation in new-onset anterior uveitis cases treated at tertiary uveitis care facilities. DESIGN Retrospective cohort study. PARTICIPANTS Patients seeking treatment at participating academic uveitis clinics within 90 days of initial diagnosis of anterior uveitis. METHODS Retrospective cohort study based on standardized chart review. MAIN OUTCOME MEASURES Factors predictive of remission (no disease activity without corticosteroid or immunosuppressive treatments at all visits during a 90-day period). RESULTS Nine hundred ninety eyes (687 patients) had a first-ever diagnosis of anterior uveitis within 90 days before initial presentation and had follow-up visits thereafter. The median follow-up time was 160 days. Systemic diagnoses with juvenile idiopathic arthritis (JIA; adjusted hazard ratio [aHR], 0.38; 95% confidence interval [CI], 0.19-0.74) and Behçet's disease (aHR, 0.10; 95% CI, 0.01-0.85) were associated with a lower incidence of uveitis remission. Cases of bilateral uveitis (aHR, 0.68; 95% CI, 0.54-0.87) and those with a history of cataract surgery before presentation (aHR, 0.51; 95% CI, 0.29-0.87) also had a lower incidence of remission. Regarding clinical findings at the initial visit, a high degree of vitreous cells at initial presentation was associated with a lower incidence of remission (for 1+ or more vs. none: aHR, 0.72; 95% CI, 0.55-0.95). An initial visual acuity of 20/200 or worse, with respect to 20/40 or better, also was predictive of a lower incidence of remission (aHR, 0.52; 95% CI, 0.32-0.86). CONCLUSIONS Factors associated with a lower incidence of remission among new-onset anterior uveitis cases included diagnosis with JIA, Behçet's disease, bilateral uveitis, history of cataract surgery, findings of 1+ or more vitreous cells at presentation, and an initial visual acuity of 20/200 or worse. Patients with these risk factors seem to be at higher risk of persistent inflammation; reciprocally, patients lacking these factors would be more likely to experience remission. Patients with risk factors for nonremission of uveitis should be managed taking into account the higher probability of a chronic inflammatory course.
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Affiliation(s)
- Pichaporn Artornsombudh
- The Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts; Department of Ophthalmology, The Scheie Eye Institute, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maxwell Pistilli
- Department of Ophthalmology, The Scheie Eye Institute, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - C Stephen Foster
- The Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Siddharth S Pujari
- The Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts; Om Eye Care Hospital, Belgaum, Karnataka, India
| | - Sapna S Gangaputra
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina; Department of Ophthalmology and Visual Sciences, Fundus Photograph Reading Center, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Douglas A Jabs
- Department of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York; Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Grace A Levy-Clarke
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Portland Veteran's Affairs Medical Center, Portland, Oregon
| | - Jennifer E Thorne
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland; Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John H Kempen
- Department of Ophthalmology, The Scheie Eye Institute, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Ophthalmology, Center for Preventive Ophthalmology and Biostatistics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Gangaputra SS, Altaweel MM, Peng Q, Friedman DS, Rao PK, Foster CS, Kim RY, Reed SB, Srivastava SK, Wong IG, Kempen JH. Morphologic assessment for glaucoma in the Multicenter Uveitis Steroid Treatment (MUST) trial. Ocul Immunol Inflamm 2011; 19:267-74. [PMID: 21770805 DOI: 10.3109/09273948.2011.583376] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To compare Reading Center (RC) cup-to-disc ratio (CDR) assessment from stereoscopic photographs with clinician estimation in a uveitis clinical trial. METHODS Clinical estimation of CDR was performed by ophthalmologists via dilated biomicroscopy. Photographic evaluation was performed at an independent RC by masked, certified evaluators. Quality control was performed by repeat grading of 77 randomly selected images. RESULTS Among 479 eyes with uveitis, 353 eyes had clinical and photographic grades for CDR. Agreement between clinical and RC grading was fair, with exact agreement of 29%. Agreement within 0.1 and 0.2 CDR was 70 and 93%, respectively (weighted κ = .34). Intergrader reproducibility at the RC was better (weighted κ = .59, ICC 0.74). CONCLUSION Morphologic assessment of cup to disc ratio is an important outcome and safety measure for determining glaucomatous damage in clinical trials. Masked RC measurements are more likely to be accurate than biomicroscopic grading in identifying meaningful anatomical change associated with glaucoma.
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Affiliation(s)
- Sapna S Gangaputra
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin 53717, USA
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