Takeshi Kezuka

Risk and prognostic factors of poor visual outcome in Behcet's disease with ocular involvement

PurposeThe purpose of the study was to determine factors correlated with the progression of irreversible visual disturbance in Behcets disease (BD) with ocular involvement.MethodsForty-seven BD patients with ocular inflammation, who presented with the first ocular episode, and who had been followed continuously for 5–10 years in our hospital, were studied. Charts were reviewed for gender, onset age of uveitis, complete or incomplete type BD, HLA-B51 status, final visual acuity at the last remission period, mean number of ocular attacks per year, and clinical findings of iridocyclitis with profuse hypopyon, strong vitreous opacity blocking the observation of retinal vessels, diffuse retinal vasculitis, and exudates with hemorrhage within the retinal vascular arcade.ResultsPatients with a visual acuity of ≤20/200 and those with >20/200 differed significantly in the mean number of ocular attacks per year and clinical findings of strong vitreous opacity and exudates within the retinal vascular arcade, but not with regard to the other factors. In addition, the frequency of ocular attacks showed a significant negative correlation with the outcome of visual acuity. Logistic regression analysis indicated a significant association of an average of more than three ocular attacks per year, strong vitreous opacity, and exudates within the retinal vascular arcade with poor visual outcome.ConclusionsThis study indicates that more than three ocular attacks per year, strong vitreous opacity, and exudates within the retinal vascular arcade are the risk and prognostic factors for a poor outcome of visual acuity in BD patients.

Correlation of vascular endothelial growth factor with chemokines in the vitreous in diabetic retinopathy.

Purpose: The purpose of this study was to simultaneously measure the concentrations of multiple cytokines, including vascular endothelial growth factor, in the vitreous of patients with diabetic retinopathy and to examine their relation with clinical findings. Methods: Vitreous samples from 46 eyes with diabetic retinopathy and 19 eyes with nondiabetic macular disease (controls) were used. Nine cytokines were simultaneously measured using a FACSCalibur flow cytometer. Results: Vascular endothelial growth factor, interleukin-8, monocyte chemotactic protein-1, interferon-inducible protein-10, and monokine induced by interferon-&ggr; were detected in the vitreous samples, and the concentrations were significantly (P < 0.001) higher in patients with diabetic retinopathy compared with control subjects. Vascular endothelial growth factor, interleukin-8, monocyte chemotactic protein-1, and monokine induced by interferon-&ggr; concentrations were significantly (P < 0.05) higher in active retinopathy than in inactive retinopathy. Furthermore, a significant (P < 0.01) positive correlation was observed between vascular endothelial growth factor concentration and interleukin-8, monocyte chemotactic protein-1, interferon-inducible protein-10, or monokine induced by interferon-&ggr; concentration in the vitreous. Conclusion: Vascular endothelial growth factor, interleukin-8, monocyte chemotactic protein-1, interferon-inducible protein-10, and monokine induced by interferon-&ggr; were expressed at high levels locally in ocular tissues in diabetic retinopathy, and these cytokines may form a network and interact to impact the pathogenesis of the disease.

Relationship between NMO-antibody and anti-MOG antibody in optic neuritis.

Background: Damage to astrocytes by anti-aquaporin-4 antibody (AQP4-Ab), also known as NMO antibody, has been implicated as the cause of neuromyelitis optica. Myelin oligodendrocyte glycoprotein (MOG) is well known as the causative protein of multiple sclerosis (MS). MOG antigen is currently considered as a cause of optic neuritis (ON) associated with MS because immunization with MOG antigen derived from oligodendrocytes induces murine ON with myelitis. We investigated the relationship between NMO antibody (NMO-Ab) and anti-MOG antibody (MOG-Ab) and potential in patients with ON for recovery of vision. Methods: Thirty-three eyes of 23 patients with ON were studied. At presentation, serum NMO-Ab was measured by immunofluorescence using HEK 293 cells transfected with AQP4–GFP, and anti-MOG1–125 antibody was measured by enzyme-linked immunosorbent assay. MOG-Ab seropositivity was defined by comparing with MOG-Ab level obtained from 8 healthy normal subjects. Results: Eleven (47%) of 23 ON patients were NMO-Ab seropositive, while 8 (34%) of the 23 patients were MOG-Ab seropositive. Six (26%) of 23 patients were seropositive for both NMO-Ab and MOG-Ab. Ten (43%) of 23 patients were seronegative for both antibodies. Three (50%) of 6 eyes of patients seropositive for both antibodies did not respond to corticosteroid pulse therapy and plasmapheresis, and visual acuity remained unchanged. In the NMO-Ab(−)/MOG-Ab(−) group, visual acuity improved significantly (P < 0.0001). In the other 3 groups (NMO-Ab(+)/MOG-Ab(+), NMO-Ab(+)/MOG-Ab(−), and NMO-Ab(−)/MOG-Ab(+)), visual acuity did not change significantly (P = 0.53, 0.42, and 0.45, respectively). Conclusion: NMO-Ab and MOG-Ab could be potential biomarkers to determine visual prognosis in patients with ON.

Evaluation of the Long-Term Efficacy and Safety of Infliximab Treatment for Uveitis in Behçet's Disease: A Multicenter Study

PURPOSE To evaluate the long-term efficacy and safety of infliximab for the treatment of uveitis in Behçets disease (BD). DESIGN Retrospective multicenter study using a questionnaire. PARTICIPANTS A total of 164 consecutive patients with BD treated with infliximab for more than 1 year were studied. The mean age at initiation of infliximab treatment was 42.6±11.7 years, and the mean treatment duration was 32.9±14.4 months. METHODS Data before and at the last visit during infliximab treatment were analyzed in 4 groups divided by duration of treatment: group A (n = 43, 12-<24 months), group B (n = 62, 24-<36 months), group C (n = 42, 36-<48 months), and group D (n = 17, ≥48 months). MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA), relapse of ocular inflammation, numbers of ocular inflammatory attacks per year, and adverse effects of infliximab therapy. RESULTS The frequency of ocular attacks decreased in all groups (from 5.3±3.0 to 1.0±0.3 in group A, 4.8±4.6 to 1.4±0.3 in group B, 4.1±2.9 to 0.9±0.3 in group C, and 9.5±5.8 to 1.6±0.5 in group D; all P < 0.05). The BCVA was improved in approximately 55% of the eyes after treatment. Mean BCVA converted to logarithm of the minimum angle of resolution was improved after treatment with infliximab in groups A to C (from 0.79±1.04 to 0.59±0.94 in group A, 0.59±1.07 to 0.41±1.04 in group B, and 1.15±1.77 to 0.92±1.73 in group C; all P < 0.05) but not in group D. Uveitis relapsed in 59.1% of all patients after infliximab treatment, and no difference in duration until relapse was observed between individual groups. Approximately 80% of relapses occurred within 1 year after the initiation of infliximab treatment in all groups, 90% of which were controlled by increasing doses of topical corticosteroids and shortening the interval of infliximab infusion. Adverse effects were observed in 65 cases or 35% of all subjects. Infliximab treatment was continued in 85% of the patients, but 15% of the patients discontinued infliximab treatment because of adverse effects or insufficient efficacy. CONCLUSIONS Infliximab reduced the frequency of ocular attacks and improved visual acuity in patients with BD-related uveitis and was generally well tolerated with few serious adverse events.

Supplementation of CD4+CD25+ regulatory T cells suppresses experimental autoimmune uveoretinitis

Aims: To investigate whether supplementation of natural CD4+CD25+ regulatory T cells ameliorates mouse experimental autoimmune uveoretinitis (EAU) induced by CD4+ T cell-dependent interphotoreceptor retinoid-binding protein (IRBP). Methods: C57BL/6 mice were immunised with human interphotoreceptor retinoid-binding protein peptide 1–20 (IRBP1–20), and IRBP1–20-sensitised T cells were obtained. CD4+CD25+ T cells derived from naive mice were cocultured with IRBP1–20-sensitised T cells, and their proliferation responses and cytokine production were measured. In addition, CD4+CD25+ T cells were transferred intravenously into mice 7 or 15 days after immunisation with IRBP1–20, and the severity of EAU and T cell proliferation responses were evaluated. Results: CD4+CD25+ regulatory T cells effectively inhibited both the proliferation of, and interleukin (IL)2, IL5 and interferon (IFN)γ production by, IRBP1–20-sensitised T cells. Adoptive transfer of CD4+CD25+ regulatory T cells to IRBP1–20-immunised mice conferred considerable protection from EAU development and inhibition of T cell proliferation responses to IRBP1–20. Conclusion: These findings show that natural CD4+CD25+ regulatory T cells possess the ability to inhibit activation of IRBP-reactive T cells that have been already sensitised in vivo, and adoptive transfer of these cells ameliorates EAU even in the effector phase. Supplementation of natural CD4+CD25+ regulatory T cells may have therapeutic potential for effective treatment of uveitis.

A new method for assessing motion-in-depth perception in strabismic patients

Aim: In strabismus clinics, stereoscopic depth perception is usually examined using static stimuli, but these stimuli do not necessarily allow assessment of the ability to perceive motion in depth. We assessed the ability to perceive motion-in-depth perception using a novel stereo motion test that we developed and compared with that to perceive static depth perception using a conventional stereo test in strasbismic patients. Methods: To investigate motion-in-depth perception in patients with strabismus, we developed a stereo motion test using four types of computer-generated dynamic visual stimuli. Three of them are random dot stereograms of two parallel planes moving in depth. The patient is asked to indicate the planes’ direction of rotation in depth (in the first and second types) or the presence/absence of motion-in-depth signal (in the third type). The fourth type of stimulus was a random dot stereogram of a rotating cylinder. The upper and lower parts of the cylinder rotate in opposite directions, and the patient is asked to indicate the position of the border between the two parts. Threshold disparity was defined as the disparity (relative disparity between the nearest and farthest points of the planes or the cylinder) that gives a critical level of performance with the method of limit. The conventional Titmus stereo test using static visual stimuli was used to assess static depth perception. The measurements were performed in 52 strabismic patients, aged between 4 and 38 years old, who visited Tokyo Medical University Hospital between January 2003 and July 2004. Results: The results showed a poor correlation in the threshold of individual patients between the stereo motion test and conventional Titmus stereo test. For example, the ability to perceive motion in depth (disparity threshold <500 sec of arc) was demonstrated in three of seven patients who were not able to perceive depth using static stimuli (0/9 for Titmus circle). These results suggest that the process of the dynamic element of binocular depth perception is preserved in some of the strabismic patients who lack static stereopsis. Conclusion: This study indicates the importance of testing motion-in-depth perception as well as static depth perception in assessing stereopsis in strabismic patients.

Intravitreal injection of Tacrolimus (FK506) suppresses ongoing experimental autoimmune uveoretinitis in Rats

Aim: To determine whether intravitreal injection of tacrolimus suppresses ongoing experimental autoimmune uveoretinitis (EAU) in rats. Methods: Rats were immunised with interphotoreceptor retinoid-binding protein peptide (R14) and given an intravitreal injection of tacrolimus on day 12 after immunisation. Intraocular inflammation was assessed by slit-lamp biomicroscopy and histopathological examination. Interferon γ and tumour necrosis factor α protein levels in the ocular tissues were measured. Gene expression of chemokines was determined in ocular tissues by reverse transcription-polymerase chain reaction. To evaluate the systemic effect of intravitreal injection of tacrolimus, delayed-type hypersensitivity was measured by ear swelling. Results: Clinical and pathological scores showed that ocular inflammation of tacrolimus-treated eyes was markedly less than that of vehicle-treated eyes. The amount of interferon γ and tumour necrosis factor α was considerably inhibited in tacrolimus-treated eyes. The gene expression of monocyte chemattractant protein-1 (MCP-1) and regulated upon activation, normal T cell expressed and secreted (RANTES) was markedly reduced in tacrolimus-treated eyes. Delayed-type hypersensitivity responses were not impaired in tacrolimus-treated rats. Conclusions: Intravitreal injection of tacrolimus was highly effective in suppressing the ongoing process of EAU without any side effects on systemic cellular immunity. This treatment may be useful in the management of patients with severe uveitis.

Relation of Intraocular Concentrations of Inflammatory Factors and Improvement of Macular Edema After Vitrectomy in Branch Retinal Vein Occlusion

PURPOSE To investigate the association of intraocular concentrations of inflammatory factors and improvement of macular edema after vitrectomy for patients with macular edema in branch retinal vein occlusion (BRVO). DESIGN Retrospective case-control study. METHODS Seventeen patients with BRVO who underwent vitreous surgery for macular edema and 15 control patients were enrolled from Hachioji Medical Center of Tokyo Medical University. The concentrations of eight inflammatory factors were measured in vitreous and aqueous fluids obtained at the time of vitrectomy using a flow cytometer. Macular thickness was measured by optical coherence tomography before and one, three, and six months after surgery. Correlations between the concentrations of inflammatory factors and macular thickness were statistically analyzed. RESULTS Higher aqueous and vitreous concentrations of vascular endothelial growth factor (VEGF) and interleukin (IL)-8 were significantly correlated with a greater difference in macular thickness between before and six months after surgery (vitreous VEGF, P=.047; aqueous VEGF, P=.032; vitreous IL-8, P=.016; and aqueous IL-8, P=.032). Higher intraocular concentrations of monokine induced by interferon γ (Mig) were significantly correlated with a smaller degree of macular thickness six months after surgery (vitreous Mig, P=.038; aqueous Mig, P=.009). CONCLUSION High preoperative VEGF, IL-8, and Mig concentrations were associated with improvement of macular edema six months after vitreous surgery in patients with macular edema attributable to BRVO.

Profile of intraocular immune mediators in patients with age-related macular degeneration and the effect of intravitreal bevacizumab injection.

Purpose: To measure intraocular cytokine levels in patients with exudative age-related macular degeneration and analyze changes in the cytokine profile 2 days after intravitreal bevacizumab injection. Methods: This prospective case–control study enrolled 37 patients (37 eyes) with age-related macular degeneration including polypoidal choroidal vasculopathy. Twenty-eight age-matched patients (28 eyes) who underwent cataract surgery were used as controls. Undiluted aqueous humor samples were collected after intravitreal bevacizumab injection. Two days after intravitreal bevacizumab injection, cataract surgery was performed and undiluted aqueous humor samples were collected at the beginning of surgery (10 eyes). Twenty-three cytokines were measured using flow cytometry. P values were corrected in multiple comparisons using the conservative Bonferroni–Holm method. The level of significance was set at 0.0022 (0.05/23). Results: At baseline, aqueous humor levels of vascular endothelial growth factor, angiogenin, interferon gamma-inducible protein (IP)-10, macrophage inflammatory protein (MIP)-1&bgr;, monokine induced by interferon &ggr; (Mig), and monocyte chemotactic protein (MCP)-1 were significantly higher in the age-related macular degeneration group than in the control group (P < 0.0022). The result of exploratory multivariate analysis showed that elevated angiogenin level was an important factor that discriminates the two groups (P = 0.0004). Two days after intravitreal bevacizumab injection, vascular endothelial growth factor levels tended to be reduced (P = 0.049), whereas interleukin (IL)-6 and IL-8 levels increased significantly (P < 0.0022). Conclusion: Vascular endothelial growth factor and also angiogenin, IP-10, MCP-1, MIP-1&bgr;, and Mig may be related to the pathogenesis of age-related macular degeneration. Intravitreal bevacizumab injection increases inflammatory cytokine levels, suggesting the induction of an inflammatory process.

Visual Functional and Histopathological Correlation in Experimental Autoimmune Optic Neuritis

PURPOSE To elucidate the correlation between visual threshold of optokinetic tracking (OKT), visual evoked potential (VEP), and histopathology at different time points after induction of experimental autoimmune optic neuritis (EAON). METHODS EAON was induced in C57BL/6 mice by subcutaneous immunization with an emulsified mixture of myelin oligodendrocyte glycoprotein (MOG)(35-55) peptide. OKT and VEP were measured on days 7, 14, 21, 28, and 42 postimmunization. After VEP measurements, the mice were killed and their eyes were enucleated for histopathological studies. Immunohistochemical staining was performed using cell-specific markers for characterization of cells in the optic nerve: CD3 (T cells), Iba-1 (microglia), MBP (myelin basic protein), and neurofilament (axons). RESULTS Functionally, OKT threshold decreased as early as day 7, and VEP latency was significantly prolonged on day 21. Axon degeneration was observed as early as day 14. Activated microglia infiltration was also observed on day 14, before T cell infiltration, which peaked on day 21. Demyelination, confirmed by MBP staining, was observed on day 21. CONCLUSIONS Microglial infiltration in the optic nerve coincided with decline in OKT threshold and preceded VEP latency prolongation, while VEP latency prolongation coincided with T cell infiltration and demyelination of the optic nerve. These findings may contribute to understanding of the pathophysiology of optic neuritis and future development of more effective therapeutic strategy for refractory optic neuritis.