Human recombinant interferon alfa-2a for the treatment of Behçet's disease with sight threatening posterior or panuveitis

BACKGROUND

Behçet's disease is a multisystem vasculitis of unknown origin. Standard treatment mainly comprises systemic immunosuppressive agents. Ocular involvement, mostly posterior uveitis with retinal vasculitis, leads to blindness in 20-50% of the involved eyes within 5 years. The efficacy of interferon alfa-2a was studied in patients with sight threatening posterior uveitis or retinal vasculitis.

METHODS

50 patients were included in this open, non-randomised, uncontrolled prospective study. Recombinant human interferon alfa-2a (rhIFNalpha-2a) was applied at a dose of 6 million units subcutaneously daily. Dose reduction was performed according to a decision tree until discontinuation. Disease activity was evaluated every 2 weeks by the Behçet's disease activity scoring system and the uveitis scoring system.

RESULTS

Response rate of the ocular manifestations was 92% (three non-responder, one incomplete response). Mean visual acuity rose significantly from 0.56 to 0.84 at week 24 (p<0.0001). Posterior uveitis score of the affected eyes fell by 46% every week (p<0.001). Remission of retinal inflammation was achieved by week 24. Mean Behçet's disease activity score fell from 5.8 to 3.3 at week 24 and further to 2.8 at week 52. After a mean observation period of 36.4 months (range 12-72), 20 patients (40%) are off treatment and disease free for 7-58 months (mean 29.5). In the other patients maintenance IFN dosage is three million units three times weekly.

CONCLUSIONS

rhIFNalpha-2a is effective in ocular Behçet's disease, leading to significant improvement of vision and complete remission of ocular vasculitis in the majority of the patients.

Interleukin-1β-regulating antibody XOMA 052 (gevokizumab) in the treatment of acute exacerbations of resistant uveitis of Behcet's disease: an open-label pilot study

OBJECTIVE

Uveitis and retinal vasculitis are sight-threatening manifestations of Behçet's disease with limited treatment options. This pilot study aimed to evaluate the safety, pharmacokinetics and clinical activity of XOMA 052 (gevokizumab), a recombinant humanised anti-interleukin 1β antibody, in Behçet's disease patients with uveitis.

METHODS

Patients with acute posterior or panuveitis, and/or retinal vasculitis, resistant to azathioprine and/or ciclosporin, and receiving 10 mg/day or less of prednisolone, were enrolled into the 98-day study. Immunosuppressive agents were discontinued at baseline. Patients received a single infusion of XOMA 052 (0.3 mg/kg). The safety and uveitis status and pharmacokinetics of XOMA 052 were evaluated.

RESULTS

Seven patients enrolled and completed the study. No treatment-related adverse event was observed. XOMA 052 treatment was associated with rapid and durable clinical response in all patients. Complete resolution of intraocular inflammation was achieved in 4-21 days (median 14 days), with a median duration of response of 49 days (range 21-97 days); one patient remained exacerbation free throughout the study.

CONCLUSIONS

Well tolerated, XOMA 052 resulted in a rapid onset and sustained reduction in intraocular inflammation in patients with resistant uveitis and retinal vasculitis. Moreover, the effect was observed despite discontinuation of immunosuppressive agents and without the need to increase corticosteroid dosages.

Infliximab Therapy for the Treatment of Refractory Ocular Inflammatory Disease

OBJECTIVE

To report the outcomes of infliximab therapy in the treatment of ocular inflammatory disease refractory to traditional immunomodulatory therapy (IMT).

METHODS

We retrospectively reviewed the medical records of 27 patients. All patients had noninfectious ocular inflammatory disease refractory to traditional IMT and received 5 mg/kg of infliximab at 2-week to 8-week intervals. Main outcome measures were clinical response, reduction in concomitant IMT, and adverse effects. Cumulative incidences of inflammation control and vision change were calculated using life-table methods.

RESULTS

Twenty-one patients experienced sustained improvement in inflammation with their initial course of infliximab therapy. Cumulative incidence of inflammation resolution at 12 months was greater than 90%. Sixteen patients were able to decrease the dose of their concomitant IMT medication or stop all other IMT. Four patients were able to discontinue all other IMT while receiving infliximab therapy. Three patients with scleritis were eventually able to remain inflammation-free while not taking any medication. At 12 months, 56% and 65% of left and right eyes, respectively, showed visual acuity improvement by 2 or more Snellen lines. Only 1 patient developed an adverse event requiring therapy discontinuation.

CONCLUSIONS

We found a high rate of ocular inflammation control with infliximab therapy. The incidence of adverse effects in this study was low.

Expert Opinion on Management of Intraocular Inflammation, Retinal Vasculitis, and Vascular Occlusion after Brolucizumab Treatment

PURPOSE

Recent reports have described a spectrum of uncommon findings of intraocular inflammation (IOI), retinal vasculitis, or retinal vascular occlusion in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal injection (IVI) of brolucizumab. We present guidance on the clinical presentation of this spectrum and propose recommendations for management of these events.

DESIGN

PubMed literature review and expert opinion panel.

PARTICIPANTS

A working group of international medical experts and Novartis medical personnel.

METHODS

The working group deliberated on the clinical presentations and used a 3-pronged approach to develop management recommendations based on (1) critical appraisal of scientific literature; (2) clinical insights from the HAWK and HARRIER trials, postmarketing reports, and assessments from an independent Safety Review Committee (SRC); and (3) their clinical experience.

MAIN OUTCOME MEASURES

Management recommendations for a spectrum of ocular inflammatory events after treatment with brolucizumab or other anti-vascular endothelial growth factors (VEGFs).

RESULTS

Based on insights gained from the available information and the expertise of the contributors, recommendations were proposed for ocular examinations, imaging modalities, and treatment strategies for management of this spectrum of events. Patients should be educated to promptly report any relevant or persistent symptoms after IVI to facilitate timely intervention. Patients diagnosed with IOI should be evaluated for concomitant retinal vasculitis or retinal vascular occlusive events. Clinical examination can be augmented with multimodal imaging techniques, including widefield imaging, fluorescein angiography (with peripheral sweeps), and OCT. Once confirmed, the ongoing brolucizumab treatment should be suspended and intensive treatment with potent corticosteroids (topical, subtenon, intravitreal, or systemic) is recommended, which may be supplemented with other treatment strategies depending on the severity. Based on the clinical outcome of these events, individualized treatment with locally available standard of care should be considered for the underlying nAMD.

CONCLUSIONS

These recommendations emphasize the need for early diagnosis, prompt and timely intervention, intensive treatment, and frequent monitoring to minimize the risk of progression of these events. The proposed recommendations may facilitate a consistent management approach of this spectrum of ocular inflammatory events should they arise in nAMD after treatment with brolucizumab or other anti-VEGFs.

Infliximab effects compared to conventional therapy in the management of retinal vasculitis in Behçet disease

PURPOSE

To assess the outcome of retinal vasculitis in patients with Behçet disease treated with infliximab compared to treatment with conventional therapy.

DESIGN

Nonrandomized, retrospective comparative clinical study.

METHODS

Patients with Behçet disease with all four major criteria were included in this study. Patients had recurrent episodes of uveitis and retinal vasculitis. Thirty-three patients (Group 1) were treated with oral prednisone, cyclosporine, and azathioprine or methotrexate for a minimum period of three months. Ten patients (Group 2) who failed to respond to conventional therapy were given infliximab at a dose of 5 mg/kg in a single intravenous infusion on day 1 and every two weeks for a total of six doses. Patients were given the same treatment during each subsequent relapse. The main outcome measures were the number of relapses, visual outcome, and ocular complications.

RESULTS

The mean follow-up period was 36 months in Group 1 and 30 months in Group 2. The mean number of relapses was significantly reduced and the duration of remission was longer in the infliximab therapy group compared to conventional therapy group (P < .0001). The visual acuity at 24 months follow-up was significantly better in patients treated with infliximab (Group 2) when compared to conventional therapy (Group 1) (P = .0059).

CONCLUSIONS

Patients with Behçet disease had significant decrease in inflammation, improvement of visual acuity, and reduced ocular complications following infliximab when compared to conventional therapy. The number of relapses was less in the infliximab treatment group than the conventional therapy group.

Frosted branch angiitis: a review

The purpose of this study is to present the first report of a case of primary frosted branch angiitis from the UK and to review the characteristics of this rare disease. Primary frosted branch angiitis causes characteristic florid translucent retinal perivascular sheathing of both arterioles and venules in association with variable uveitis, retinal oedema and visual loss, normally with good recovery. A total of 57 cases have been reported in the world literature. Atypical, typically focal frosted branch angiitis may also occur secondary to other causes of intraocular inflammation, especially cytomegalovirus retinitis. Primary frosted branch angiitis has a characteristic presentation but a variable course, typically affecting children or young adults. The disease is likely to represent a common immune pathway in response to multiple infective agents. The optimal treatment is unclear.

Full panretinal photocoagulation and early vitrectomy improve prognosis of retinal vasculitis associated with tuberculoprotein hypersensitivity (Eales' disease)

BACKGROUND/AIMS

Eales' disease is an uncommon vasoproliferative retinal disease affecting otherwise healthy young men that is characterised by obliterative retinal periphlebitis, with sequelae such as recurrent vitreous haemorrhage and traction retinal detachment. This study was undertaken to determine whether visual prognosis of Eales' disease could be improved by appropriate medical and surgical treatment.

METHODS

The authors retrospectively studied 30 patients (46 eyes) who were treated from 1992 to 2001. Recorded data included patient age, sex, race, medical history, medications, results of the ophthalmological examination, results of diagnostic laboratory evaluation, and details of systemic and surgical treatments. The mean follow up was 10.6 months.

RESULTS

19 patients (23 eyes) who presented with active periphlebitis received systemic steroids and antituberculous therapy. Extensive full panretinal photocoagulation was performed in 21 eyes that presented with new vessel formation and peripheral capillary closure with or without vitreous haemorrhage. Vitrectomy and endolaser panretinal photocoagulation was necessary in 15 eyes, for severe non-clearing vitreous haemorrhage in 11 eyes and vitreous haemorrhage with traction retinal detachment in four eyes. Complete regression of the disease was achieved in all eyes. Vitrectomy resulted in a significant visual improvement with 14 of the 15 eyes (93.3%) achieving > or =20/200 visual acuity. Overall, the distribution of visual acuities among eyes improved from presentation to final follow up, with 36.4% of eyes having 20/40 or better acuity at presentation compared with 63.6% of eyes by final follow up.

CONCLUSIONS

These results suggest that aggressive treatment of Eales' disease with systemic steroids and antituberculous therapy, full panretinal photocoagulation and early vitrectomy, when necessary, may result in improving the anatomic and visual outcome.

Acute posterior multifocal placoid pigment epitheliopathy associated with a systemic necrotizing vasculitis

PURPOSE

The authors present a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) associated with a systemic necrotizing vasculitis with mixed features of Wegener granulomatosis and polyarteritis nodosa (PAN).

METHODS

Case report.

RESULTS

A 29-year-old woman developed a severe nosebleed, followed by a low-grade fever, night sweats, and a productive cough. One month later, she began experiencing high fevers, headache, myalgia, neck stiffness, and abdominal pain as well as bilateral blurred vision from APMPPE. Systemic evaluation revealed nasal ulcerations, bilateral pleural effusions, and a bilateral maxillary and ethmoid sinusitis, consistent with Wegener granulomatosis. However, ANCA testing was negative, and a renal and mesenteric angiogram showed aneurysmal dilatations suggestive of PAN. Her ocular and systemic symptoms markedly improved with systemic corticosteroids.

CONCLUSIONS

The cause of APMPPE is unknown. This case of APMPPE associated with systemic necrotizing vasculitis provides support for the choroid as being primarily involved by a diffuse vasculitic process that interrupts choroidal perfusion and causes the characteristic fundus findings in APMPPE.

Retinal vascular disease and the pathogenesis of facioscapulohumeral muscular dystrophy. A signalling message from Wnt?

The peripheral retinal vascular abnormality which accompanies FSHD belongs morphologically and clinically to a class of developmental 'retinal hypovasculopathies' caused by abnormalities of 'Wnt' signalling, which controls retinal angiogenesis. Wnt signalling is also fundamental to myogenesis. This paper integrates modern concepts of myogenic cell signalling and of transcription factor expression and control with data from the classic early ophthalmic and myology embryology literature. Together, they support an hypothesis that abnormalities of Wnt signalling, which activates myogenic programs and transcription factors in myoblasts and satellite cells, leads to defective muscle regeneration in FSHD. The selective vulnerability of different FSHD muscles (notably facial muscle, from the second branchial arch) might reflect patterns of transcription factor redundancies. This hypothesis has implications for FSHD research through study of transcription factors patterning in normal human muscles, and for autologous cell transplantation.

Retinal Vasculitis Due to Secondary Syphilis

BACKGROUND

Retinal vasculitis is one of the manifestations of ocular syphilis.

CASE

A 29-year-old man was referred to our hospital with the complaint of sudden visual loss in the left eye lasting more than three weeks.

OBSERVATIONS

Ophthalmoscopic examination showed retinal hemorrhages, edema, and sheathing of large retinal arteries and veins. Fluorescein angiography revealed extensive occlusion of the affected retinal arteries, veins, and capillaries. Little evidence of uveitis or vitritis was observed. The fluorescent treponemal antibody-absorption test was positive, and the Treponema pallidum hemagglutination titer was 1:10,240. The treatment with penicillin was effective, leading to resolution of the retinal hemorrhages and edema, although occlusion of the retinal vessels persisted.

CONCLUSIONS

Vascular occlusion occurred simultaneously in large retinal arteries, arterioles, and capillaries as well as in segments of retinal veins, resulting in irreversible changes in the vascular walls.

Efficacy of adalimumab and infliximab in recalcitrant retinal vasculitis inadequately responsive to other immunomodulatory therapies

The primary aim of the study was to evaluate the efficacy of tumor necrosis factor (TNF)-α blockers adalimumab (ADA) and infliximab (IFX) in refractory sight-threatening retinal vasculitis (RV) during a 12-month follow-up period. Secondary aims were to evaluate (i) any impact of concomitant conventional disease-modifying anti-rheumatic drugs (cDMARDs) and different lines of biologic therapy; (ii) any difference in terms of efficacy between ADA and IFX; (iii) consequences of biotherapies on the best-corrected visual acuity (BCVA); (iv) corticosteroid-sparing effect; and (vi) ocular complications during anti-TNF-α treatment. Demographic, clinical, and therapeutic data were retrospectively collected from the medical records and statistically analyzed. Forty-eight patients (82 eyes) were recruited, 22 (45.8%) of which received IFX and 26 (54.2%) ADA. The percentages of patients achieving RV remission within 3 and 12 months were 54 and 86%, respectively. A significant decrease in RV detection was identified from baseline to 3-month (p < 0.0001) and 12-month (p < 0.0001) assessments and between 3-month and 12-month visits (p = 0.004). No differences were identified in terms of RV resolution between (i) patients undergoing monotherapy and those co-administered with cDMARDs at 3-month (p = 0.560) and 12-month (p = 0.611) follow-up; (ii) biologic-naïve patients and those already exposed to other biologics at 3-month (p = 0.497) and 12-month (p > 0.99) visits; and (iii) patients treated with ADA and those treated with IFX (p = 0.357). During the study period, a statistically significant corticosteroid-sparing effect was observed (p = 0.0002), while BCVA values did not significantly change (p = 0.950). Anti-TNF-α monoclonal antibodies have proved excellent results in patients with recalcitrant sight-threatening RV.

Intravitreal steroids may facilitate treatment of Eales' disease (idiopathic retinal vasculitis): an interventional case series

PURPOSE

Eales' disease is an idiopathic peripheral perivasculitis leading to proliferative vascular retinopathy, recurrent vitreous haemorrhages, and tractional retinal detachment. It is an elusive cause of blindness in young, otherwise healthy individuals. We studied the effects of intravitreal triamcinolone acetonide (IVTA) in patients of Eales' disease, which may eventually reduce the side effects and cost of management, with results equivalent to or better than oral steroids.

METHODS

Ethics approval and prior patient consent were obtained. Fluorescein fundus angiograms (FFAs) of 12 eyes of 12 Eales' disease patients were taken before enrolment. These patients received 0.1 ml of 40 mg/ml (4 mg) intravitreal triamcinolone through pars plana under topical anaesthesia. Regular weekly follow-ups were initiated to ascertain Snellen visual acuity, intraocular pressure (IOP) with Goldman tonometer, and triple mirror examination. Fluorescein fundus angiography was again performed in the 8th week to monitor response to treatment. Decrease in areas of late perivascular dye extravasation on fluorescein angiography was used as marker for improvement.

RESULTS

Ten out of a total of 12 (83.33%) eyes treated with IVTA showed significant reduction of late leakage from retinal vessels on fluorescein fundus angiography. Two out of 12 eyes (16.67%) did not show considerable decrease in late perivascular fluorescein dye leakage after 8 weeks of intravitreal triamcinolone injection. Two patients (16.67%) had a significant rise in IOP after IVTA.

CONCLUSION

Intravitreal steroids may be advocated for management of idiopathic retinal vasculitis without complications of systemic steroids, and minimize need for more invasive procedures.

[Ocular involvement in Behçet's disease: first 5-year-results for visual development after treatment with interferon alfa-2a]

BACKGROUND

Behçet's disease (BD) is a systemic vasculitis of unknown origin. Up to now ocular involvement has a poor visual prognosis irrespective of immunosuppressive treatment. Now recent open studies have shown that interferon alfa-2a (IFN alfa-2a) is very effective in the treatment of ocular BD. The purpose of this study was to evaluate the long-term development of visual acuity (VA) in patients with severe ocular BD who were treated with IFN alfa-2a.

METHODS

We included 15 eyes of 9 patients with an active panuveitis and/or retinal vasculitis due to BD refractory to immunosuppressive treatment. VA before initiation of IFN-therapy was compared to VA at the end of the follow-up time.

RESULTS

Mean follow-up time was 68.8+/-10.6 months. Mean duration of IFN-treatment was 40.6+/-17.0 months. With the exception of one patient IFN alfa-2a could be discontinued in complete remission of ocular symptoms. During the follow-up time 10 eyes showed an increase of VA of two lines or more. In 5 eyes VA remained stable. There was no decrease of VA in any eye. If a macular edema was present, a quick response to IFN alfa-2a was seen. No eye developed a pale optic disk during follow-up.

CONCLUSION

Compared to conventional immunosuppressants, interferon alfa-2a seems to be much more effective to prevent a loss or decrease of VA over a long period of time in patients with severe ocular BD.

Response time and safety profile of pulsed oral methotrexate therapy in idiopathic retinal periphlebitis

PURPOSE

To evaluate the response time and safety profile of low-dose oral methotrexate pulsed therapy in idiopathic retinal periphlebitis (Eales' disease).

METHODS

A tertiary care center-based prospective interventional study, based on visual acuity grading, was undertaken. Twenty-one consecutive patients with idiopathic retinal periphlebitis were administered 12.5 mg methotrexate as a single oral dose, once per week for 12 weeks (cumulative dose = 150 mg). Each patient was assessed for change in visual acuity grades. Time of first therapeutic response was also noted. Drug safety was monitored by laboratory tests that included twice-weekly white blood cells and differential counts, twice-weekly platelet counts, and monthly liver function tests.

RESULTS

Twenty-one eyes were assessed. Mean follow-up period was 6 months. All showed improvement in visual acuity grades. An excellent visual outcome (6/6 or better) was achieved in 18 (69%) eyes. Time of first therapeutic response varied from 2 to 6 weeks with a majority of eyes (80%) showing response by 4 weeks (median = 3 weeks). All the side effects of methotrexate were mild or moderate in severity and rapidly reversible on dose reduction or discontinuation. No patient had any constitutional symptoms severe enough to necessitate cessation of therapy.

CONCLUSIONS

Low dose oral methotrexate pulse therapy (at a dose of 12.5 mg/week) is clinically effective within 4 weeks, and is associated with an acceptable safety profile.

Refractory retinal vasculitis due to sarcoidosis successfully treated with infliximab

Sarcoidosis is a chronic disease of unknown etiology characterized by granulomatous infiltration of several organs. Up to two- thirds of patients develop ocular inflammation eventually leading to significant visual loss. Treatment includes corticosteroids and immunosuppressive agents, but refractory cases do occur. In this report, the authors describe two patients with multi-systemic sarcoidosis and refractory retinal vasculitis who experienced an excellent response to infliximab. This report emphasizes the importance of TNF-alpha in the pathophysiology of this disease and warrants further studies with anti-TNF therapy in patients with refractory ocular sarcoidosis.

Rifabutin-Associated Panuveitis with Retinal Vasculitis in Pulmonary Tuberculosis

INTRODUCTION

Rifabutin-associated uveitis has been reported frequently in AIDS patients and more rarely in immunocompetent patients. It is characterized clinically by anterior acute uveitis. Only a few poorly documented cases of rifabutin-induced panuveitis with retinal vasculitis have been reported. Here, we report four cases of rifabutin-associated panuveitis with retinal vasculitis.

CASE REPORTS

We describe four patients with active tuberculosis, treated with a multidrug regimen including rifabutin for at least 1.5 months before presentation. The first patient was immunocompetent, the three others had AIDS and were undergoing triple anti-HIV therapy. Three patients were women with a low body weight. All four patients presented with panuveitis and retinal vasculitis. Interruption of the drug rapidly reduced the ocular inflammation in all cases.

CONCLUSION

Four cases of rifabutin-associated panuveitis with retinal vasculitis are reported in patients with active pulmonary tuberculosis. Immunogenicity of Mycobacterium tuberculosis as well as the very low weight of the patients might be implicated in the development of this unusual form of rifabutin-associated uveitis.

Retinal Vasculitis and Cystoid Macular Edema after Body Tattooing: a Case Report

BACKGROUND

To report a case of retinal vasculitis occurring after the placement of permanent tattoos.

HISTORY AND SIGNS

A 21-year-old male was referred to our department with impairment of visual acuity. Permanent tattoos covered the head, body, arms and legs. The patient was examined with ophthalmoscopy, fluorescein angiography, indocyanine green angiography and optical coherence tomography. Systemic medical and laboratory work-up were performed in order to exclude an infectious agent or an inflammatory disease. He had no history of intravenous drug abuse.

THERAPY AND OUTCOME

Our patient presented severe posterior uveitis associated with retinal vasculitis and cystoid macular edema. Laboratory tests ruled out all diseases causing vasculitis. HIV and B, C hepatitis tests were negative. Cystoid macular edema and vasculitis were resolved after immunosuppressive therapy.

CONCLUSIONS

This is the first description of a retinal vasculitis associated with cystoid macular edema in a completely healthy individual after the placement of permanent tattoos. A phagocytosis of tattoo pigments leading to their lysis is described in the literature as a mechanism causing vasculitis.