Treatment Of Chronic Noninfectious Uveitis Research Articles

Management of Uveitis Patients on Anti-TNF Agents Who Develop Demyelinating Disease – A Case Series

Background/AimsAnti-tumor necrosis factor (Anti-TNF) agents have proven beneficial for the treatment of chronic non-infectious uveitis, yet rare neurological complications and demyelinating disease can occur with their use. Management of uveitis and neurological disease after developing these rare complications is not well understood. We sought to identify these specific cases and their outcomes through a retrospective observational case series.MethodsElectronic Medical Record (EMR) chart review of 394 non-infectious uveitis patients on anti-TNF therapy focused on identifying patients seen by uveitis specialists at a single institution who were on anti-TNF therapy and had developed neurological symptoms. Cases were reviewed for subsequent management and outcomes of both their neurologic and ocular inflammatory disease.ResultsFive (5) patients were included following complaints of neurological symptoms while on anti-TNF therapy. Subsequent demyelinating diagnosis, acute treatment, and long-term course were described. All five patients continue to be inactive at around three years of anti-TNF discontinuation.ConclusionUnidentified rare neurological symptoms and demyelinating disease associated with the use of anti-TNF agents can be detrimental to patient treatment outcomes. Emphasis is given on possible avoidance and early identification of exacerbating underlying disease through a detailed neurologic history and use of imaging when suspicion is high. Patients may have no evidence of higher neurological risk prior to starting an anti-TNF treatment. Discontinuation of an anti-TNF agent and subsequent control of disease is possible with alternative immunosuppressive treatments.

Intravitreal fluocinolone acetonide 0.19 mg (Iluvien®) for the treatment of uveitic macular edema: 2-year follow-up of 20 patients

To evaluate intravitreal 0.19mg fluocinolone acetonide implant (FAi) (Iluvien®) for the treatment of chronic non-infectious uveitis with associated cystoid macular edema (CME). A retrospective review of medical reports from a single Danish tertiary centre including 20 patients (20 eyes), treated with 0.19mg FAi for non-infectious uveitic CME. The primary endpoints were change in best corrected visual acuity (BCVA) and central retinal thickness (CRT). The secondary endpoints were recurrence rate, change in systemic treatment, and intraocular pressure (IOP). Mean follow-up of the 20 eyes was 2.3 ± 1.1years. BCVA improved at 6 (p = 0.13), 12 (p = 0.05), 18 (p = 0.03), and 24months and CRT decreased at 6 (p = 0.004), 12 (p = 0.006), 18, and 24months after 0.19mg FAi. Within 18months after implantation, four of 14 patients (28.6%) relapsed. Three of five patients discontinued systemic corticosteroids within 4months and one patient continued with reduced dose. Five of 10 patients receiving disease-modifying antirheumatic drugs (DMARDs) at time of implantation discontinued within 1year. No patients started new systemic treatment. Eight eyes were treated with topical IOP-lowering medication at the time of implantation, of these two later underwent trabeculectomy. There were no complications associated with previous glaucoma surgery. This long-term follow-up study showed that intravitreal treatment with 0.19mg FAi should be considered in the treatment of chronic non-infectious uveitic CME in selected patients. This treatment is safe even in selected glaucoma patients and may offer reduction or cessation of local or systemic anti-inflammatory treatment.

A Systematic Switch From Originator Infliximab to Biosimilar Infliximab in Patients With Non-Infectious Uveitis

To investigate the efficacy of biosimilar infliximab compared to that of the originator infliximab for the treatment of chronic non-infectious uveitis. Before-and-after study. All patients in the Central Norway Health Region between 2007 and 2018 were included. They were switched from originator to biosimilar infliximab therapy from 2014 to 2017. The primary outcome was quiescence of uveitis before and after the switch. All patients were seen every 1-3months. Visits were binned into 3-month long periods for each patient takingboth medications. Poisson regression analysis was used to estimate the incidence rate ratio (IRR) of quiescence between the 2 treatments. Twenty-nine patients were treated with infliximab. Twenty-three of those patients were switched from originator to biosimilar infliximab. The majority were white (87%), female (92%), and had chronic anterior uveitis (65%). For patients taking the originator and biosimilar drugs, the median treatment duration was38months (range: 8-131months) and 15months (range: 5-55months), respectively. Concomitant immunosuppressive medications and topical and oral steroids were used similarly during treatment with both originator and biosimilar infliximab. The IRR for quiescence was 0.91 (95% confidence intervals [CI]: 0.7-1.1; P= 0.38), which indicated no statistically significant differences in achieving quiescence after the switch. Also, there were no differences in the incidence rate of flare events with the switch (IRR: 1.04; 95% CI: 0.36-2.98; P= 0.95). IRR adjusted for intraocular surgery was 0.90 (95% CI: 0.7-1.1; P= 0.37). No evidence of differences in effectiveness were found in comparing biosimilar to originator infliximab in patients with chronic non-infectious uveitis.

Treatment of chronic non-infectious uveitis and scleritis.

Ocular inflammations such as uveitis and scleritis can lead to significant visual impairment if not treated properly. To limit potentially sight-threatening complications, good control of the inflammation in the acute phase is necessary. Corticosteroids have been the mainstay of ocular therapies for many years, but high doses of corticosteroids, which are required to maintain quiescence in severe uveitis, can be associated with many systemic and ocular complications. In order to limit steroid side-effects, classic immunosuppressant and immunobiologic agents have been widely used as steroid-sparing agents. In this review, we summarise the immunosuppressive drug therapy utilised in the treatment of ocular inflammatory diseases.

Mycophenolate sodium for the treatment of chronic non-infectious uveitis of childhood

AimTo assess the efficacy and tolerability of mycophenolate sodium (MPS) in the therapy of children with chronic non-infectious uveitis.MethodsRetrospective analysis of 23 children with chronic uveitis, treated with MPS, with...

Comment on: "Use of the Fluocinolone Acetonide Intravitreal Implant for the Treatment of Noninfectious Posterior Uveitis: 3-Year Results of a Randomized Clinical Trial in a Predominantly Asian Population".

I read “Use of the fluocinolone acetonide intravitreal implant for the treatment of noninfectious posterior uveitis (NIPU): 3-year results of a randomized clinical trial in a predominantly Asian population” (December 2014) [1]. This article is certainly of interest, especially regarding the effectiveness of 0.59 and 2.1 mg doses of fluocinolone acetonide (FAc) intravitreal implant for the treatment of NIPU in a predominantly Asian patient population. However, I would like to make sure that your readership does not confuse the FAc intravitreal implant reported by Sangwanet al. (i.e., Retisert; contains 0.59 mg of FAc) with the FAc implant (ILUVIEN®; contains 190 μg of FAc) licenced in Europe for the indication ‘… for the treatment of vision impairment associated with chronic diabetic macular edema (DMO), considered insufficiently responsive to available therapies [2]’. This letter highlights the key differences between Retisert and ILUVIEN. These products are licenced by different manufacturers. Retisert is manufactured by Bausch & Lomb (Rochester, NY, USA) and ILUVIEN is manufactured by Alimera Sciences (based in Atlanta, Georgia, USA and Aldershot, UK). These products contain and deliver different amounts of FAc. Retisert delivers 0.59 mg of FAc with an initial rate of 0.6 mg of FAc per day, which decreases over the 1st month to a steady rate of 0.3–0.4 μg FAc per day [3]. ILUVIEN contains a total of 190 μg of FAc with an average daily release of 0.2 μg of FAc per day [2, 4]. These products release FAc for different amounts of time. Retisert releases 0.3–0.4 μg FAc per day for between 30 [3, 4] and 36 months [1]. In contrast, ILUVIEN releases 0.2 μg FAc per day for up to 36 months [4]. These products are administered differently. Retisert is surgically implanted into the posterior segment of the affected eye through a pars plana incision. ILUVIEN is an intravitreal implant that is inserted using a 25-gage needle into the vitreous cavity in the posterior eye with the optimal placement being inferior to the optic disc and posterior to the equator [2]. These products have different indications. In Europe, Retisert is not licensed whereas ILUVIEN is licensed and indicated for “… the treatment of vision impairment associated with chronic diabetic macular oedema, considered insufficiently responsive to available therapies.” [2]. In the USA, Retisert is indicated for “…the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye” [3] and not for DMO. The indication for ILUVIEN in the USA is for “…or the treatment of diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure” [5]. I would like to highlight that ILUVIEN was designed to improve on the performance of Retisert to deliver the lowest dose of corticosteroid, currently under investigation, to the retina [6]. Furthermore, I would like to point the reader in the direction of Kane et al. [6] which explains the development history and characteristics of Retisert and ILUVIEN. The paper by Campochiaro et al. [4] is also very helpful as it compares the aqueous levels of FAc after the administration of Retisert or ILUVIEN. John Hall, MD Senior Vice President, Medical Director Europe

Long-term results of therapy with mycophenolate mofetil in chronic non-infectious uveitis

Short-term studies have shown mycophenolate mofetil (MMF) to be a useful immunosuppressive agent for the treatment of intraocular inflammation. The aim of our study was to assess the long-term efficacy and tolerability of MMF in patients with chronic non-infectious uveitis, as well as to analyze disease course following discontinuation of therapy. This is a retrospective case series on 60 uveitis patients treated with MMF with a follow-up period of at least 5 years. The main outcome measures were: control of inflammation, corticosteroid-sparing potential, side-effects, ability to stop/taper MMF treatment because of effective control of inflammation and relapse rate after therapy discontinuation. Control of intraocular inflammation (efficacy of MMF), defined as inactive disease under prednisolone dose of ≤ 10 mg daily, was achieved in 43 of 60 patients (72%) after 1 year of MMF treatment at a rate of 0.72 per patient-year (PY), and in 45 of 55 patients (82%) after 2 years therapy (rate: 0.41/PY). An improvement (3 lines) or stabilization of visual acuity was observed in 49 patients (82%), and a worsening in 11 patients (18%, 95% CI: 10-30%). The probability of discontinuing prednisolone, estimated by the Kaplan-Meier method, was 40% after 5 years therapy. The probability of discontinuing mycophenolate mofetil due to efficacy was 33% after 5 years treatment. Recurrences of uveitis occurred in six of 21 patients (29%, rate: 0.11/PY) after MMF discontinuation due to efficacy. The treatment was stopped because of inefficacy in 12 patients (rate: 0.05/PY) and because of side-effects in four patients (rate: 0.02/PY). The rate of adverse effects during MMF therapy was 0.17/PY. Our data show that mycophenolate mofetil is generally effective and well tolerated in the treatment of chronic non-infectious uveitis.