Maria Pia Paroli

Infliximab Treatment for Ocular and Extraocular Manifestations of Behçet's Disease

PurposeTo assess the efficacy and safety of infliximab in the treatment of sight-threatening uveitis and extraocular manifestations in patients with Behçets disease.MethodsTwelve patients with Behçets disease and uveitis were treated with infliximab after unsuccessful therapy with other immunosuppressive drugs. The main outcome measures were as follows: the number of uveitis relapses, the number of Behçets disease-related extraocular lesions, and the amount of corticosteroids administered during the treatment as well as during an equal prior period of time while the patients were on other immunosuppressive agents. Visual acuity was recorded at the beginning of infliximab therapy and at the end of follow-up, and was defined as stable if it did not change from baseline, increased if it showed at least one line of improvement from baseline, and decreased if it showed at least a one line decrease from baseline.ResultsDuring an average follow-up of 16.67 ± 7.63 months (median, 15 months), 11 patients (91.6%) showed a reduction in the number of ocular relapses (relapse/month, from 0.35 ± 0.17 to 0.12 ± 0.17, P < 0.001). All of the patients (n = 11) who were taking corticosteroids before infliximab were able to reduce the amount of corticosteroids taken daily during infliximab treatment (from 24.33 ± 10.84 mg/prednisone per day to 8.97 ± 6.81 mg/prednisone per day, P < 0.001), and all presented with a reduced onset of extraocular manifestations of Behçets disease (mean total number, from 2.83 ± 3.61 to 1.51 ± 2.35, P = 0.039). One patient, who had to stop treatment 2 months after starting because of the onset of pulmonary tuberculosis, showed the same number of relapses during infliximab treatment but was able to reduce the mean daily corticosteroid dose. Visual acuity increased by one or more lines in three eyes (12.5%) and remained unchanged in 87.5% of the eyes. Infliximab-related side effects appeared in four patients (33.3%).ConclusionsInfliximab was effective in the treatment of uveitis in these Behçets disease patients, significantly reducing the number of ocular relapses and making possible a significant reduction in the daily dose of corticosteroids administered. Extraocular manifestations of Behçets disease were also controlled by infliximab. Nevertheless, side effects were not uncommon, and an extensive study of systemic conditions before infliximab administration had to be carried out to exclude systemic infection, particularly prior tuberculosis. Jpn J Ophthalmol 2007;51:191–196

Safety and efficacy of infliximab and adalimumab for refractory uveitis in juvenile idiopathic arthritis: 1-year followup data from the Italian Registry.

Objective. To evaluate safety and efficacy of adalimumab (ADA) and infliximab (IFX) for the treatment of juvenile idiopathic arthritis-related anterior uveitis (JIA-AU). Methods. Starting January 2007, patients with JIA-AU treated with IFX and ADA were managed by a standard protocol and data were entered into the National Italian Registry (NIR). At baseline, all patients were refractory to standard immunosuppressive treatment and/or were corticosteroid-dependent. Data recorded every 3 months included uveitis course, number/type of ocular complications, drug-related adverse events (AE), treatment change or withdrawal, and laboratory measures. Data of patients treated for at least 1 year were retrieved from the NIR and analyzed using descriptive statistics. Treatment efficacy was based on change in uveitis course and in number of ocular complications. Results. Up to December 2009, data for 108 patients with JIA-AU treated with anti-tumor necrosis factor-α agents were recorded in the NIR and data from 91, with at least 12 months’ followup, were included in the study. Forty-eight patients were treated with IFX, 43 with ADA. Forty-seven patients (55.3%) achieved remission of AU, 28 (32.9%) had recurrent AU, and 10 (11.8%) maintained a chronic course. A higher remission rate was observed with ADA (67.4% vs 42.8% with IFX; p = 0.025). Ocular complications decreased from 0.47 to 0.32 per subject. Five patients experienced resolution of structural complications. No patient reported serious AE; 8 (8.8%) experienced 11 minor AE (9 with IFX, 2 with ADA). Conclusion. IFX and ADA appear to be effective and safe for treatment of refractory JIA-related uveitis, with a better performance of ADA in the medium-term period.

Uveitis in childhood: an Italian clinical and epidemiological study.

Purpose: To investigate demographics, causes, features, and visual outcomes of pediatric uveitis. Methods: Retrospective cohort study including 257 patients younger than 16 years. Results: Mean age at onset of uveitis was 8.54 ± 3.98 years; 54.5% of the patients were girls. Anterior uveitis occurred in 47.8%, intermediate in 19.4%, posterior in 24.9%, panuveitis in 7.8%. Ocular involvement was bilateral in 67.8%. Infectious uveitis represented 31% of all cases. Causes of severe visual loss were cataract, macular scars, macular edema/maculopathy, and secondary glaucoma. At follow-up 79.3% of eyes maintained a visual acuity between 20/32 and 20/20. Conclusions: Uveitis is rarer in children than in adults. Patients with anterior uveitis comprised the largest group. Posterior uveitis in the pediatric population has a lower incidence than some decades ago. Visual prognosis of pediatric uveitis is improving, owing to an earlier diagnosis and a correct treatment.

Intermediate Uveitis in a Pediatric Italian Population

Purpose: To investigate clinical data, outcome, and treatment of intermediate uveitis in children. Methods: Retrospective cohort study, including 116 children affected by intermediate uveitis. Results: Sixty-two percent of patients were males. Ocular involvement was bilateral in 84%. Mean age at uveitis onset was 10.3 ± 3.6 years and 12.2 ± 7 years at first visit. Ninety-seven percent were classified as having idiopathic uveitis. The incidence of ocular complications during follow-up was 0.131/eye-year. Macular edema or a marked vitreous haze at presentation may be risks factors for incident visual loss. The most frequent causes of visual loss were macular edema (64%) and cataract (21%). Conclusions: Most cases are idiopathic (pars planitis); only few children presented associated systemic disease. Macular edema and severe vitritis at presentation are associated with increased risk of visual impairment. Cystoid macular edema is the main cause of visual impairment.

Retinal complications of juvenile idiopathic arthritis-related uveitis: a microperimetry and optical coherence tomography study.

Purpose: To evaluate ocular complications of juvenile idiopathic arthritis (JIA)-related uveitis; to study macular morphology and sensitivity. Methods: Retrospective chart review of 67 patients. Fourteen consecutive patients (24 eyes) observed from January to December 2008 were submitted to optical coherence tomography study (OCT) and microperimetry MP-1 examination. Results: Most frequent complications were posterior synechiae (63.0%), band keratopathy (53.9%), and cataract (31.8%). Posterior complications were documented in 37.0% of eyes: 13.8% macular edema, 12.0% papillitis, 6.8% epiretinal membranes, 2.5% retinal vasculitis, 1.7% retinal detachment. At OCT examination 25.0% of eyes presented macular edema; macular sensitivity by MP-1 was ≤16.5 dB in 25.0% of eyes. Conclusions: Visual prognosis is good despite ocular complications. Incidence of macular edema seems to be higher when using OCT. Microperimetry may represent a useful tool in detecting alteration in retinal sensitivity that may supplement visual acuity in the follow-up of macular edema.

Intermediate uveitis: comparison between childhood-onset and adult-onset disease.

Purpose To compare demographic and clinical data, systemic disease association, visual prognosis, and complications found in childhood and adult onset of intermediate uveitis (IU). Methods Retrospective cohort study of 287 patients with IU: 122 (42.5%) children at onset (<16 years), 165 (57.5%) adults. The data were entered on a computer-based standardized data entry form for statistical analysis. Student t test was used regarding differences in means. To assess significance of differences in proportions, we used the χ 2 test, but when the population in the subgroup was ≤5 patients, we used the Fisher exact test (p<0.05 were deemed to be statistically significant and as reported were not corrected for multiple testing and so should be viewed as nominal). Results A total of 61% of childhood-onset cases occurred in boys (44% in the adult group), while adult onset was more common in women (56% vs 39%) (p = 0.004, odds ratio [OR] 2.06). Regardless of the onset age, IU was frequently bilateral and idiopathic. The most frequent complication was cystoid macular edema (27.5%, p = 0.469, OR 0.85), which was also the most frequent cause of visual loss. Optic disc edema was more prevalent in children (15.5% vs 9.2%; p = 0.027, OR 1.81), ocular hypertension in adults (15.6% vs 7.5%, p = 0.007, OR 0.44). A total of 25 patients had non-idiopathic IU. A total of 14 patients had multiple sclerosis. Conclusions Intermediate uveitis was mostly idiopathic and bilateral in both groups. Visual prognosis was good and it was not age-related. Childhood onset was more frequent in boys, adult onset in women. Endocrinal factors could be involved.

Paracentral corneal melting in a patient with Vogt-Koyanagi-Harada's syndrome, psoriasis, and Hashimoto's thyroiditis.

The paper describes the occurrence of unilateral paracentral corneal melting in a 65-year-old woman with ocular and systemic signs of Vogt-Koyanagi-Harada’s syndrome (VKH), psoriasis, and Hashimoto’s thyroiditis. Corneal melting, often occurring in association with systemic vasculitis and connective tissue diseases, has rarely been reported in relation to diffuse psoriasis and never in association with VKH.A possible relationship between corneal melting and VKH is suggested.

Recovery of corneal sensitivity after collagen crosslinking with and without epithelial debridement in eyes with keratoconus.

Purpose To evaluate the changes in corneal sensitivity after corneal collagen crosslinking (CXL) with the epithelium off (epi‐off) and with the epithelium on (epi‐on) in eyes with keratoconus. Design Prospective interventional case series. Setting Eye Clinic, A. Fiorini Hospital, Terracina (Latina), Rome, Italy. Methods On the basis of the corneal pachymetry at the area of topographic steepening, eyes treated with CXL were divided in 2 groups: those with a corneal thickness of 400 &mgr;m or more (epi‐off) and those with a corneal thickness of less than 400 &mgr;m (epi‐on). Corneal sensitivity was measured using a contact esthesiometer (Cochet‐Bonnet) before treatment and 1 and 7 days and 1, 3, 6, 9, and 12 months after treatment. Results The study evaluated 50 CXL‐treated eyes in 50 patients (25 epi‐on and 25 epi‐off) from January 7, 2012, to December 15, 2012. In the epi‐off group, corneal sensitivity was statistically significantly reduced for up to 3 months after CXL and gradually returned to normal levels. In the epi‐on group, corneal sensitivity was statistically significantly reduced for up to 7 days but was not statistically significantly different from preoperative values at other measurement times. At 7 days, the corneal sensitivity was statistically significantly lower in the epi‐off eyes than in the epi‐on eyes. Conclusions Epi‐off and epi‐on CXL both caused hypoesthesia, but corneal sensitivity subsequently recovered completely. The corneal hypoesthesia was more pronounced in eyes in which the epi‐off technique was used, and the recovery time was shorter for eyes treated using epi‐on CXL. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Psoriasis and Psoriatic Arthritis-Related Uveitis: Different Ophthalmological Manifestations and Ocular Inflammation Features.

ABSTRACT Purpose: To compare clinical features of uveitis in patients affected by psoriasis and psoriatic arthritis (PsA). Methods: A retrospective case-control study. Results: 117 patients were affected by uveitis and psoriasis or PsA (92 and 25 patients, respectively) from 2003 to 2013. Axial PsA was associated with unilateral uveitis onset compared to the peripheral pattern (p < 0.03). The prevalence of eyes with at least one complication involving anterior segment was significantly more represented in the PsA group than the psoriasis one (p = 0.024). Anterior segment complications were more frequently associated with posterior ones in PsA patients than in psoriasis patients (p = 0.005). Most common complications in total sample at baseline examination were cataract (29.7%), ocular hypertension (17%), macular edema (7%), and pupillary seclusion (4.4%). Conclusion: Uveitis in patients with psoriasis and PsA may have distinguishing clinical features. PsA patients have more ocular complications than those with psoriasis. Both groups need an ophthalmological examination to promptly detect ocular co-morbidity.

Effects of intravitreal bevacizumab on inflammatory choroidal neovascular membrane

Purpose. To test the efficacy of intravitreal bevacizumab (IB) in the treatment of inflammatory choroidal neovascularization (CNV). Methods. A prospective interventional study on patients with subfoveal CNV secondary to posterior/ diffuse uveitis treated with 1.5 mg/0.05 mL of IB. Eight eyes of 8 patients, with mean follow-up of 19.25±6 months, were included. The measurements adopted were 1) changes in best-corrected visual acuity (BCVA), 2) reduction in CNV size, and 3) changes in central foveolar thickness (CFT) measured by optical coherence tomography. Results. The mean number of intravitreal injections was 3.75±1.38. After IB treatment, the mean BCVA improved significantly, from 0.27±0.10 before treatment to 0.5±0.29 after treatment (p<0.05). The CFT also responded well to IB, with 402.75±114.11 μm preoperatively, and after treatment 300.5±90.98 μm (p<0.01). Notably, all patients showed a reduction in the size of the CNV and BCVA remained stable or improved in 7 eyes (87.5%). No episode of active intraocular inflammation was observed and patients continued to receive their systemic steroid or immunosuppressive therapy. Conclusions. Intravitreal bevacizumab may be an additional strategy in inflammatory CNV of eyes with controlled uveitis.