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Putera I, Schrijver B, Ten Berge JCEM, Gupta V, La Distia Nora R, Agrawal R, van Hagen PM, Rombach SM, Dik WA. The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies. Prog Retin Eye Res 2023:101189. [PMID: 37236420 DOI: 10.1016/j.preteyeres.2023.101189] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023]
Abstract
Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Benjamin Schrijver
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Vishali Gupta
- Retina and Uvea Services, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rina La Distia Nora
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke NUS University, Singapore; Singapore Eye Research Institute, Singapore; Moorfields Eye Hospital, London, United Kingdom
| | - P Martin van Hagen
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S M Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Betzler BK, Putera I, Testi I, La Distia Nora R, Kempen J, Kon OM, Pavesio C, Gupta V, Agrawal R. Anti-tubercular therapy in the treatment of tubercular uveitis: A systematic review and meta-analysis. Surv Ophthalmol 2023; 68:241-256. [PMID: 36272559 DOI: 10.1016/j.survophthal.2022.10.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
We quantitatively evaluated the efficacy of antitubercular therapy (ATT) in tubercular uveitis (TBU) patients. Main outcome measures include inflammation recurrence, inflammation reduction, complete resolution of inflammation, improved visual acuity (VA), ability to taper corticosteroids to < 10 mg/day without inflammatory progression, and use of adjunctive immunosuppressants while on ATT. This review is prospectively registered in PROSPERO (CRD42020206845). Forty-nine studies reporting data for 4,017 TBU patients were included. In comparative studies, the odds ratio (OR) of inflammatory recurrence was 0.33 (95%CI:0.19-0.60) for TBU patients treated with ATT±corticosteroid versus no ATT. For TBU patients treated with ATT±corticosteroid, the pooled absolute incidences of inflammatory recurrence, inflammatory reduction, complete resolution of inflammation, and visual acuity improvement were 13% (n=310/2,216; 95%CI:9-18), 81% (n=217/276; 95%CI: 62-95), 83% (n=1,167/1,812; 95%CI: 77-89), and 65% (n=347/542; 95%CI:51-78), respectively. Corticosteroids were tapered to <10 mg/day without inflammatory progression in 91% (n=326/395; 95%CI:78-99) of patients, 9% (n=121/1,376; 95%CI:6-13) of whom were administered concomitant immunosuppressive agents alongside ATT. We conclude that treatment of TBU with ATT±corticosteroid is associated with a high level of control or improvement of inflammation. More prospective studies with detailed reporting of ATT regimens, patient subgroups, and outcomes are required to better evaluate ATT effectiveness.
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Affiliation(s)
| | - Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia, Indonesia; Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Rina La Distia Nora
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia, Indonesia; Erasmus Medical Center, Rotterdam, The Netherlands
| | - John Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, United States; Myungsung Christian Medical Center (MCM) Eye Unit, MCM General Hospital and Myungsung Medical School, Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Onn Min Kon
- Chest and Allergy Clinic, St Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, England
| | | | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Singapore Eye Research Institute, Singapore; Duke-NUS Medical School, Singapore.
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Alli HD, Ally N, Mayet I, Dangor Z, Madhi SA. Global prevalence and clinical outcomes of tubercular uveitis: a systematic review and meta-analysis. Surv Ophthalmol 2021; 67:770-792. [PMID: 34626620 DOI: 10.1016/j.survophthal.2021.10.001] [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] [Received: 02/07/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022]
Abstract
Tubercular uveitis (TBU) is an inflammation/infection of the eye secondary to Mycobacterium tuberculosis infection. The difficulty in making the diagnosis has resulted in variable prevalence and clinical response rates. We aimed to determine the global prevalence of TBU in uveitis patients stratified by TB high-burden countries (HBCs) and non-HBCs and by geographic regions and the clinical response of TBU to antitubercular treatment We performed a systematic review and meta-analysis of TBU studies published in PubMed, Scopus and EMBASE, up to June 30, 2020. A random effects model was used for all meta-analyses. Of 5,018 articles identified, 70 prevalence studies (65,607 uveitis and 3,166 TBU cases) and 18 clinical outcome studies (1,570 TBU cases; 1,304 responded to anti-tubercular therapy [ATT]) were analyzed. The overall weighted prevalence of TBU was 4.0% (95% CI, 3-5); in TB HBCs it was 7.0% (95% CI, 5-11), non-HBCs 3.0% (95% CI, 2-4), and sub-Saharan Africa 11.0% (95% CI, 8-15). The overall weighted clinical response was 82.0% (95% CI, 75-89). Despite the difficulty in diagnosing TBU, the prevalence is expectantly higher in HBCs, and sub-Saharan Africa and the clinical outcome is poor. Standardization of diagnostic criteria and ATT is warranted in future cohort studies.
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Affiliation(s)
- Hassan D Alli
- Division of Ophthalmology, St John Eye Hospital/Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
| | - Naseer Ally
- Division of Ophthalmology, St John Eye Hospital/Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Ismail Mayet
- Division of Ophthalmology, St John Eye Hospital/Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Ziyaad Dangor
- Department of Pediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Shabir A Madhi
- Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit (VIDA), Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Bansal R, Khan MM, Dasari S, Verma I, Goodlett DR, Manes NP, Nita-Lazar A, Sharma SP, Kumar A, Singh N, Chakraborti A, Gupta V, Dogra MR, Ram J, Gupta A. Proteomic profile of vitreous in patients with tubercular uveitis. Tuberculosis (Edinb) 2021; 126:102036. [PMID: 33359883 PMCID: PMC11005023 DOI: 10.1016/j.tube.2020.102036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/05/2020] [Revised: 10/31/2020] [Accepted: 11/29/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To elucidate disease-specific host protein profile in vitreous fluid of patients with intraocular inflammation due to tubercular uveitis (TBU). METHODS Vitreous samples from 13 patients with TBU (group A), 7 with non-TBU (group B) and 9 with no uveitis (group C) were analysed by shotgun proteomics using Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS). Differentially expressed proteins (DEPs) were subjected to pathway analysis using WEB-based Gene SeT Analysis Toolkit software. RESULTS Compared to control groups (B + C combined), group A (TBU) displayed 32 (11 upregulated, 21 downregulated) DEPs, which revealed an upregulation of coagulation cascades, complement and classic pathways, and downregulation of metabolism of carbohydrates, gluconeogenesis, glucose metabolism and glycolysis/gluconeogenesis pathways. When compared to group B (non-TBU) alone, TBU displayed 58 DEPs (21 upregulated, 37 downregulated), with an upregulation of apoptosis, KRAS signaling, diabetes pathways, classic pathways, and downregulation of MTORC1 signaling, glycolysis/gluconeogenesis, and glucose metabolism. CONCLUSION This differential protein profile provides novel insights into the molecular mechanisms of TBU and a baseline to explore vitreous biomarkers to differentiate TBU from non-TBU, warranting future studies to identify and validate them as a diagnostic tool in TBU. The enriched pathways generate interesting hypotheses and drive further research.
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Affiliation(s)
- Reema Bansal
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Mohd M Khan
- University of Maryland, School of Medicine, Baltimore, MD, USA; Laboratory of Immune System Biology (LISB), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
| | - Indu Verma
- Department of Biochemistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | | | - Nathan P Manes
- Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Aleksandra Nita-Lazar
- Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Surya P Sharma
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Aman Kumar
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Nirbhai Singh
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Anuradha Chakraborti
- Department of Experimental Medicine & Biotechnology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Vishali Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - M R Dogra
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Jagat Ram
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Amod Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Sharma M, Singh R, Sharma A, Gupta V, Sharma K. IS1081-based Multi-targeted LAMP: An Opportunity to Detect Tubercular Uveitis. Ocul Immunol Inflamm 2020; 30:168-173. [PMID: 32812821 DOI: 10.1080/09273948.2020.1787462] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND - Timely and accurate diagnosis of tubercular uveitis (TBU) is imperative, hence multitargeted loop-mediated isothermal amplification (MLAMP) using three gene targets (IS1081, IS6110 and MPB64) was evaluated for it. METHODS - About 120 vitreous fluid samples [70 clinically suspected TBU (3 culture-positive, 67 culture-negative) and 50 controls] were subjected to MLAMP to evaluate its performance in diagnosing TBU. RESULTS - Overall, the sensitivity, specificity, PPV and NPV of MLAMP in the diagnosis of TBU was 77.14%, 100%, 100% and 75.75%, respectively, with an additional detection of 9 (12.85%) cases (5 by IS1081LAMP and 2 each by MPB64LAMP and IS6110LAMP). Maximum TBU cases were detected by IS1081LAMP (50/70) followed by MPB64LAMP (47/70) and IS6110LAMP (45/70). CONCLUSION - MLAMP, with the incorporation of IS1081, served as a sensitive, rapid, simple and cost-effective technique for TBU diagnosis.
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Affiliation(s)
- Megha Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Sharma RK, Gupta V, Bansal R, Sharma K, Gupta A, Sachdeva N. Immune Profiling of T Cells Infiltrating Vitreous Humor in Tubercular Uveitis. Immunol Invest 2018; 47:615-631. [PMID: 29733740 DOI: 10.1080/08820139.2018.1470640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess cellular composition and local cytokine response in vitreous humor of tubercular uveitis. METHODS Cells were collected from vitreous cassettes and peripheral blood of 8 tubercular uveitis and 5 control subjects, undergoing vitrectomy and analyzed by flow cytometry for cellular composition, activation status, proinflammatory cytokine expression, and uptake of TLR9 ligand, CpG ODN 2216. RESULTS CD3 + T cells with equal proportion of CD4+ and CD8 + T cells formed major fraction of infiltrating cells. The vitreous humor showed higher expression of recent activation marker, CD69, and proinflammatory cytokines, IFN-γ and IL-17A, in CD4 + T cells as compared to peripheral blood. Lastly, intraocular CD4 + T cells showed reduced uptake of ODN 2216 than peripheral blood. CONCLUSIONS Our results indicate that local antigenic stimuli trigger T cell infiltration and activation of CD4 + T cells that are hyporesponsive to TLR9 stimulation. These infiltrating T cells might be responsible in further aggravating ocular inflammation.
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Affiliation(s)
- Ravi Kumar Sharma
- a Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Vishali Gupta
- a Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Reema Bansal
- a Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Kusum Sharma
- b Department of Medical Microbiology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Amod Gupta
- a Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Naresh Sachdeva
- c Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
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Sharma P, Bansal R, Gupta V, Gupta A. Diagnosis of tubercular uveitis by quantitative polymerase chain reaction. J Ophthalmic Inflamm Infect 2010; 1:23-7. [PMID: 21475653 PMCID: PMC3062759 DOI: 10.1007/s12348-010-0004-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 08/23/2010] [Indexed: 11/26/2022] Open
Abstract
Purpose To report the use of real-time or quantitative polymerase chain reaction (qPCR) in confirming the diagnosis of tubercular uveitis. Methods A qPCR assay using primers targeting the MPB64 gene of Mycobacterium tuberculosis (MTB) was developed. A standard curve for quantification of mycobacterial load was generated. Vitreous fluid samples from patients presumed to have tubercular uveitis were assayed to identify and quantify the mycobacterial load. The amount of the test sample product was interpolated from the standard curve of cycle threshold values generated from known starting copy number of standard MTB DNA. Results The copies of MTB genomes in the three test samples studied were found to be 7.61 × 104, 4.53 × 104, and 1.43 × 105, respectively. Conclusion qPCR detected and quantified MTB genome from the vitreous fluid of eyes clinically suspected with tubercular uveitis.
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Affiliation(s)
- Pooja Sharma
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Reema Bansal
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Amod Gupta
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
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