Lorenzo Vannozzi

A Pilot Study on Ocular Safety of Intravitreal Infliximab in a Rabbit Model

PURPOSE To determine whether infliximab may be used safely as an intraocular drug, the ocular safety of intravitreal infliximab in rabbits was studied by clinical examination, electroretinography (ERG), and histology in rabbits. METHODS Twelve New Zealand albino rabbits were selected for this study. Different infliximab doses, namely 1.0 mg, 1.7 mg, and 3.3 mg in 0.1 mL, were injected intravitreally into one eye each of three rabbits. As a control, the vehicle solution was injected into the fellow eye of each animal. Eye clinical examination and ERG recordings were made before and 2, 6, and 12 weeks after injection. Eventually, the rabbits were humanely killed, and the retinas were examined by light microscopy. In addition, the elimination half-life of the drug in the vitreous was assessed. RESULTS Slit lamp biomicroscopy, indirect funduscopy, and ERG evidenced no significant differences between control and infliximab-injected eyes in this rabbit model, at any of the tested doses. Histologic examination revealed no retinal abnormality in the rabbits injected with 1 mg and 1.7 mg intravitreal infliximab. In two of three eyes injected with 3.3 mg infliximab, significant edema of the nerve fibers was detected compared with the control group. The half-life of the drug was estimated to be 8.5 days. CONCLUSIONS These results indicate that infliximab may be a safe intravitreal drug in the rabbit model at a dose of up to 1.7 mg. If proven safe and efficacious in further studies, intravitreal injection of infliximab could be considered an alternative to systemic administration in selected patients.

Intravitreal Infliximab Clearance in a Rabbit Model: Different Sampling Methods and Assay Techniques

PURPOSE To investigate the clearance of intravitreal infliximab with the use of different sampling techniques and immunoassay methods in rabbits. METHODS Infliximab (1.6 mg) was intravitreally injected into both eyes of 47 rabbits. Two approaches were used to collect the vitreous: the classic method and a microsampling technique. Whereas the classic method consists of collection of the whole vitreous after enucleation, the microsampling technique consisted of the aspiration of small (10-15 microL) samples with a 200-microL syringe. Samples were taken from 30 minutes to 40 days using both methods and were then compared. Infliximab concentration was estimated with competitive ELISA, dot blot analysis, and Western blot analysis. RESULTS The vitreous half-life of infliximab was estimated to be 6.5 +/- 0.6 days. The data indicated monoexponential decay reaching its conclusion after approximately 40 days. This decay was preceded by 4-day-long diffusion in the vitreous. Microsampling proved to be effective in the vitreous collection, giving statistically comparable signals (+/- 4%, P = 0.68) with respect to the classic procedure. ELISA proved to be the best analytical technique--especially if coupled with microsamplings--because of its lower detection limit, precision, and reduced amount of sample needed. No differences were observed between half-life values obtained by ELISA and dot blot analysis (P = 0.081) and Western blot analysis (P = 0.614). CONCLUSIONS The findings of this study added to the knowledge of infliximab clearance in the vitreous and confirmed the validity of a microsampling technique that was compared with the classic one. ELISA was found to be the best analytical technique when using microsampling.

Successful Treatment of Ocular Sarcoidosis with Rituximab

Sarcoidosis is a multisystem inflammatory disease of undetermined origin. Thoracic involvement is the most common, with lymphoadenopathy and a various degree of lung lesions, such as granulomatous nodules and diffuse interstitial thickening, potentially leading to lung fibrosis. Skin, joints, heart, brain, and eye, however, can also be involved with a wide spectrum of clinical manifestations. Ocular sarcoidosis occurs approximately in one-third of patients, also in apparent absence of disease manifestations in other locations and can potentially involve any element of the eye. Among ocular lesions, however, some are more suggestive of sarcoidosis, such as bilateral granulomatous uveitis. Despite the recent advances in the development of new therapeutic agents, sarcoidosis remains a great therapeutic challenge, because of the current lack of data on the efficacy of the immunosuppressive and biological treatments. A 50-year-old woman was referred to our Center for relapsing uveitis. She had been facing recurrent severe uveitis involving both the eyes for 3 years, with poor and transitory responses to topical treatments and oral steroid therapy. Uveitis recurred regularly shortly after steroid withdrawal. A complete ophthalmic evaluation revealed a bilateral granulomatous panuveitis characterized by anterior chamber Tyndall, keratic precipitates, synechiae, vitreous opacity 3þ in RE and 1þ in LE, and cystoid macular edema OU. Best-corrected visual acuity (BCVA) was 0.70 logMAR RE and 0.20 logMAR LE (Figure 1). A systemic disease was suspected because of the concomitant presence of multiple, raised, erythematous lesions on the anterior surface of the lower legs, identifiable as erythema nodosum, and neurological symptoms, consisting of left arm paresthesias. A brain nuclear magnetic resonance (NMR) was performed, revealing the presence of multiple, nonenhancing lesions of the white matter, compatible with neurosarcoidosis. Full blood count, metabolic panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and the other laboratory tests gave results within normal limits. Antinuclear antibodies (ANA), anti-dsDNA, anti-extractable nuclear antigens (ENA), anti-neutrophil cytoplasm antibodies (ANCA), anti-phospholipid antibodies (aPL), and lupus anticoagulant (LAC) tests were also negative. Angiotensin converting enzyme (ACE), however, was significantly increased (106 U/L). A high-resolution CT of the lung with contrast revealed multiple nodular bilateral lung lesions with mild hilar and mediastinal lymphoadenopathies. To confirm the diagnostic hypothesis we also performed a scintigraphy that revealed abnormal gallium uptake by both parotid glands and lungs. The patient did not consent to a bronchoscopy, but the lung involvement was clinically mild, so the predictive value of such a procedure was low. We started topical therapy (dexamethasone 2% and tropicamide 1%) and oral prednisone

Long‐term efficacy and safety of anakinra in a patient with Behçet's disease and concomitant tuberculosis infection

Behc et’s disease (BD) is a systemic vasculitis with mucocutaneous, gastrointestinal, ocular, vascular, and neurological involvement. Ocular manifestations represent one of major organ involvement, with a high rate of recurrences potentially resulting in partial or total blindness. Treatments may range from the topical approach to disease-modifying antirheumatic drugs and biological agents. Tumor necrosis factor (TNF)-a inhibitors and interferon-a are usually effective in the majority of patients with severe ocular disease. Recent clinical observations with the interleukin (IL)-1 inhibiting agents anakinra, canakinumab, and gevokizumab have suggested their potential role in the treatment of refractory Behc et’s uveitis. Accordingly, in a multicenter retrospective study, we found that treatment with anakinra and canakinumab was effective and safe in 30 patients with BD, with an overall acceptable retention on treatment. Unlike anti-TNFa treatment, IL-1 inhibition has shown a good safety profile regarding the risk of severe infections, particularly in relation to tuberculosis (TB) reactivation. Indeed, interfering with the IL-1 pathway seems safer in comparison with blocking TNFa. This consideration is relevant for patients with BD because of the high prevalence of this disease in geographical areas where TB is a social concern. In this regard, we report herein a patient with BD with concomitant latent TB infection successfully treated with anakinra as first-line biological therapy. A 41-year-old man was diagnosed with BD in 2008 based on recurrent oral aphthosis, genital ulcerations, and pseudofolliculitis. His medical history was also relevant for monthly fever attacks, spontaneously resolved 1 year after the onset of symptoms, hip arthralgia, and

The protean ocular involvement in monogenic autoinflammatory diseases: state of the art

Ocular involvement is frequent in the monogenic autoinflammatory disorders and generally occurs as spontaneously recurring inflammatory events at different ocular sites caused by the aberrant release of proinflammatory cytokines, mainly IL-1β. Over the past decade, we witnessed a significant growth of eye abnormalities associated with idiopathic granulomatous disorders, familial Mediterranean fever, tumor necrosis factor receptor-associated periodic syndrome, mevalonate kinase deficiency, and cryopyrin-associated periodic syndrome. The pathogenetic mechanisms of these disorders have shown the evidence of disrupted cytokine signaling, but the explanation for the heterogeneous ocular involvement remains to be elucidated. We herein review the monogenic autoinflammatory disorders affecting the eye, describing their main clinical features with specific regard to the ocular involvement, which can lead to decreased visual acuity and even blindness, if the primary disorder is undetected or left untreated.

Ocular Safety of Infliximab in Rabbit and Cell Culture Models

PURPOSE To undertake the safety testing of infliximab in animal and cell culture models. METHODS Sixteen New Zealand albino rabbits were divided into 4 groups of 4 animals. Each group received 2 mg of infliximab in the right eye and saline solution in the left eye. Clinical examination and retinal histology were performed at months 1, 2, and 3 for groups A, B, and C, respectively. Electroretinography (ERG) recordings were made before the injection, and at months 1 and 2 for group D. The assessment of the safety of infliximab in retinal pigment epithelial (RPE) and retinal ganglion (RGC-5) cells was performed by Western blot analysis of caspase-3 involved in apoptosis pathway, the analysis of cytotoxicity of infliximab by WST-1 proliferation assay, and time-lapse video-microscopy to register the morphology of treated cells in time-lapse. RESULTS Clinical examination of the eyes, histological study of the retina, and ERG recordings showed no sign of ocular toxicity after a single intravitreal injection of 2 mg of infliximab in the rabbit model. RPE and RGC viability was not reduced either in the range of concentration (up to 3 mg) or during the follow-up interval. CONCLUSION This study suggests that infliximab has no direct retinal toxicity using rabbit (2 mg) and cell culture (2 and 3 mg) models.

Cytomegalovirus retinitis following intravitreal dexamethasone implant in a patient with central retinal vein occlusion.

ciations between subfoveal choroidal thickness (SFCT) and age, refractive error (RE) and axial length (AL) have been demonstrated, although findings are inconsistent and variability in SFCT cannot be fully explained by these factors alone. The high vascular structure of the choroid suggests that some variation in SFCT may be the result of changes in the choroidal blood flow. This study investigated the effects of ocular perfusion pressure (OPP), blood pressure [systolic (SBP) and diastolic (DBP)] and intra-ocular pressure (IOP) on SFCT in normal individuals and also the effect of age, gender, RE and AL. Participants were healthy volunteers, recruited from staff and students from the Ophthalmology Department at St James’s University Hospital, Leeds. Inclusion criteria were as follows: age from 18 to 60 years, no history of ocular disease including ocular surgery and laser, myopia less than 6D and written, informed consent. Ethical approval was obtained from the Leeds Institute of Health Sciences and Leeds Institute of Genetics, Health and Therapeutics and Leeds Institute of Molecule Medicine Joint Ethics Committee (HSLTLM/11/043). OPP formula: OPP = 2/3[DBP + 1/3(SBP DBP)] IOP. All data were collected from participants on the same day, as close in time to OCT imaging as possible. Mean age of the 46 participants was 35.83 (range: 22–60) years, and 21 were male. Mean SFCT was 313.1 lm (SD = 77.0 lm) in the right eyes. Data for right eyes were used for analysis. There was a significant negative correlation between SFCT and the following variables on univariate analysis: AL (p = 0.001, r = 0.47, r = 0.22), SBP (p = 0.041, r = 0.30, r = 0.09), OPP (p = 0.045, r = 0.29, r = 0.08) and a non-significant trend suggesting association between SFCT and DBP (p = 0.053, r = 0.28, r = 0.08), RE (p = 0.055, r = 0.28, r = 0.08) (Fig. 1). Using multiple regression analysis, only AL was found to be a significant independent variable (p = 0.024, r = 0.265). No association seen with other variables. This study identified a modest, negative correlation between SFCT and SBP. SBP has been shown to influence CT, although limited consensus exists. Previous reports state acute rises in blood pressure do not cause significant changes in CT, and therefore, blood pressure-associated variation in CT may occur over a relatively greater time scale (Alwassia et al. 2013). A modest, negative association between SFCT and OPP was found. This finding has been reported previously (Kim et al. 2012). Kim et al. (2012) proposed that relatively thicker choroids may require a lower OPP to maintain ocular blood flow, and in relatively thinner choroids, a higher OPP may be required to compensate for potential reductions in choroidal blood flow. Poor ocular blood flow, secondary to reduced OPP, has been shown to increase the risk of ocular ischaemia, with the fovea at particular risk (Levin et al. 2011; Schmidl et al. 2011). Given the association between SFCT and a range of physiological variables, care needs to be taken in attributing variation in CT as the basis for ocular disease. Rishi et al. (2013) report a study of polypoidal choroidal vasculopathy (PCV) compared to agematched controls and eyes with other forms of neovascular AMD. Eyes with PCV had higher mean OPP than controls and eyes with AMD. This suggests differences in SFCT between diseased and healthy eyes may more likely be the result of physiological variation in ocular and systemic factors. The studied variables here and others need further study to explain fully the variation in SFCT seen in normal individuals and in others with systemic vascular disease.

Ten-Year Retention Rate of Infliximab in Patients with Behçet’s Disease-Related Uveitis

ABSTRACT Purpose: To evaluate the 10-year drug retention rate of infliximab (IFX) in Behçet’s disease (BD)-related uveitis, the effect of a concomitant use of disease modifying anti-rheumatic drugs (DMARDs) on drug survival and differences according to the lines of biologic treatment. Methods: Cumulative survival rates were studied using the Kaplan-Meier plot, while the Log-rank (Mantel-Cox) test was used to compare survival curves. Results: Forty patients (70 eyes) were eligible for analysis. The drug retention rates at 12-, 24-, 60- and 120-month follow-up were 89.03%, 86.16%, 75.66% and 47.11% respectively. No differences were identified according to the use of concomitant DMARDs (p = 0.20), while a statistically significant difference was observed in relation to the different lines of IFX treatment (p = 0.014). Visual acuity improved from baseline to the last follow-up visit (p = 0.047) and a corticosteroid-sparing effect was observed (p < 0.0001). Conclusions: IFX retention rate in BD-uveitis is excellent and is not affected by concomitant DMARDs.

Cumulative retention rate of adalimumab in patients with Behçet’s disease-related uveitis: a four-year follow-up study

Background/aims Adalimumab (ADA) has been shown to be an effective treatment for Behçet’s disease (BD)-related uveitis. We aimed at evaluating the cumulative retention rate of ADA during a 48-month follow-up period in patients with BD-related uveitis, the impact of a concomitant use of disease modifying anti-rheumatic drugs (DMARDs) on ADA retention rate, and differences according to the various lines of biologic therapy (ie, first- vs second-line or more). Predictive factors of response to ADA were also investigated. Methods We enrolled patients diagnosed with BD-related uveitis and treated with ADA between January 2009 and December 2016. Cumulative survival rates were studied using the Kaplan-Meier plot, while the log-rank (Mantel-Cox) test was used to compare survival curves. Statistical analysis was performed to identify differences according to the response to ADA. Results 54 consecutive patients (82 eyes) were eligible for analysis. The drug retention rate at 12- and 48-month follow-up was 76.9% and 63.5%, respectively. No statistically significant differences were identified according to the use of concomitant DMARDs (p=0.27) and to the different lines of ADA treatment (p=0.37). No significant differences were found between patients continuing and discontinuing ADA in terms of age (p=0.24), age at BD onset (p=0.81), age at uveitis onset (p=0.56), overall BD duration (p=0.055), uveitis duration (p=0.46), human leucocyte antigen-B51 positivity (p=0.51), and gender (p=0.47). Conclusions ADA retention rate in BD-related uveitis is excellent and is not affected by the concomitant use of DMARDs or by the different lines of biological therapy. Negative prognostic factors for BD uveitis do not impact ADA efficacy.

Retinal capillaritis in a CRB1-associated retinal dystrophy

ABSTRACT Purpose: To report a case of CRB1-associated retinal dystrophy characterized by vitritis, retinal capillaritis, and cystoid macular edema (CME). Methods: A case report. Results: An 8-year-old boy was diagnosed with intermediate uveitis and treated with corticosteroids. He was subsequently diagnosed with retinal dystrophy and found to have two CRB1 mutations. Conclusions: Retinal capillaritis, vitritis, and CME could be inflammatory features of CRB1 retinal dystrophy in our young patient.