William Tucker

Glucocorticoid-resistant Th17 cells are selectively attenuated by cyclosporine A.

Significance Cyclosporine A was one of the first drugs used in clinical practice to successfully rescue glucocorticoid-resistant inflammatory diseases. In this article we extend the characterization of glucocorticoid-resistant human Th17 cells, and demonstrate that this effector memory T-cell subset is reciprocally attenuated by cyclosporine A. This therapeutic paradigm was confirmed in a murine model of autoimmunity, refining our understanding of cyclosporine A’s effect on the adaptive immune response. These data support the rationale for Th17-targeting therapies in the treatment of glucocorticoid-resistant inflammation. Glucocorticoids remain the cornerstone of treatment for inflammatory conditions, but their utility is limited by a plethora of side effects. One of the key goals of immunotherapy across medical disciplines is to minimize patients’ glucocorticoid use. Increasing evidence suggests that variations in the adaptive immune response play a critical role in defining the dose of glucocorticoids required to control an individual’s disease, and Th17 cells are strong candidate drivers for nonresponsiveness [also called steroid resistance (SR)]. Here we use gene-expression profiling to further characterize the SR phenotype in T cells and show that Th17 cells generated from both SR and steroid-sensitive individuals exhibit restricted genome-wide responses to glucocorticoids in vitro, and that this is independent of glucocorticoid receptor translocation or isoform expression. In addition, we demonstrate, both in transgenic murine T cells in vitro and in an in vivo murine model of autoimmunity, that Th17 cells are reciprocally sensitive to suppression with the calcineurin inhibitor, cyclosporine A. This result was replicated in human Th17 cells in vitro, which were found to have a conversely large genome-wide shift in response to cyclosporine A. These observations suggest that the clinical efficacy of cyclosporine A in the treatment of SR diseases may be because of its selective attenuation of Th17 cells, and also that novel therapeutics, which target either Th17 cells themselves or the effector memory T-helper cell population from which they are derived, would be strong candidates for drug development in the context of SR inflammation.

CD14++CD16+ monocytes are enriched by glucocorticoid treatment and are functionally attenuated in driving effector T cell responses

Human peripheral monocytes have been categorized into three subsets based on differential expression levels of CD14 and CD16. However, the factors that influence the distribution of monocyte subsets and the roles that each subset plays in autoimmunity are not well studied. In this study, we show that circulating monocytes from patients with autoimmune uveitis exhibit a skewed phenotype toward intermediate CD14++CD16+ cells, and that this is associated with glucocorticoid therapy. We further demonstrate that CD14++CD16+ monocytes from patients and healthy control donors share a similar cell-surface marker and gene expression profile. Comparison of the effects of intermediate CD14++CD16+ monocytes with classical CD14++CD16− and nonclassical CD14+CD16++ monocytes revealed that the intermediate CD14++CD16+ subset had an attenuated capacity to promote both naive CD4+ T cell proliferation and polarization into a Th1 phenotype, and memory CD4+ T cell proliferation and IL-17 expression. Furthermore, CD14++CD16+ cells inhibit CD4+ T cell proliferation induced by other monocyte subsets and enhance CD4+ T regulatory cell IL-10 expression. These data demonstrate the impact of glucocorticoids on monocyte phenotype in the context of autoimmune disease and the differential effects of monocyte subsets on effector T cell responses.

Idiopathic multifocal choroiditis/punctate inner choroidopathy with acute photoreceptor loss or dysfunction out of proportion to clinically visible lesions.

Purpose: To report acute/subacute vision loss and paracentral scotomata in patients with idiopathic multifocal choroiditis/punctate inner choroidopathy due to large zones of acute photoreceptor attenuation surrounding the chorioretinal lesions. Methods: Multimodal imaging case series. Results: Six women and 2 men were included (mean age, 31.5 ± 5.8 years). Vision ranged from 20/20−1 to hand motion (mean, 20/364). Spectral domain optical coherence tomography demonstrated extensive attenuation of the external limiting membrane, ellipsoid and interdigitation zones, adjacent to the visible multifocal choroiditis/punctate inner choroidopathy lesions. The corresponding areas were hyperautofluorescent on fundus autofluorescence and were associated with corresponding visual field defects. Full-field electroretinogram (available in three cases) showed markedly decreased cone/rod response, and multifocal electroretinogram revealed reduced amplitudes and increased implicit times in two cases. Three patients received no treatment, the remaining were treated with oral corticosteroids (n = 4), oral acyclovir/valacyclovir (n = 2), intravitreal/posterior subtenon triamcinolone acetate (n = 3), and anti-vascular endothelial growth factor (n = 2). Visual recovery occurred in only three cases of whom two were treated. Varying morphological recovery was found in six cases, associated with decrease in hyperautofluorescence on fundus autofluorescence. Conclusion: Multifocal choroiditis/punctate inner choroidopathy can present with transient or permanent central photoreceptor attenuation/loss. This presentation is likely a variant of multifocal choroiditis/punctate inner choroidopathy with chorioretinal atrophy. Associated changes are best evaluated using multimodal imaging.

Levels of blood CD1c+ mDC1 and CD1chi mDC1 subpopulation reflect disease activity in noninfectious uveitis

PURPOSE Myeloid dendritic cells (mDCs) play an important role in autoimmune diseases. However, the role of blood CD1c(+) myeloid dendritic cells 1 (mDC1s), the subset of human blood mDCs, is not well understood in noninfectious uveitis. METHODS Fresh peripheral blood samples from human noninfectious uveitis patients (n = 32) and healthy controls (HCs) (n = 64) were stained with FITC-Lineage 1 (Lin1), PERCP-HLADR, and PE-CD1c antibodies. The levels of mDC1 were quantified by using flow cytometric analysis. Longitudinal data from patients (n = 16) were analyzed to correlate the levels of mDC1 with disease activity. RESULTS Blood CD1c(+) mDC1 and its subpopulation, CD1c(hi) mDC1, were increased in uveitis patients compared with HCs. Longitudinal data demonstrated that both the CD1c(+) mDC1 and CD1c(hi) mDC1 subpopulation reflected a dynamic change in clinical uveitis activity: CD1c expression was increased in active uveitis but decreased when uveitis became inactive. CONCLUSIONS Given these observations, an alteration in blood CD1c(+) mDC1 and the CD1c(hi) mDC1 subpopulation could be a potential biomarker to monitor clinical uveitis activity within patients.

Subconjunctival Sirolimus in the Treatment of Autoimmune Non-necrotizing Anterior Scleritis: Results of a Phase I/II Clinical Trial

PURPOSE To investigate the safety, tolerability and efficacy of subconjunctival sirolimus injections as a treatment for active, autoimmune, non-necrotizing anterior scleritis. DESIGN Phase I/II, single-center, open-label, nonrandomized, prospective pilot study. METHODS Five participants with active, autoimmune, non-necrotizing anterior scleritis with scleral inflammatory grade of ≥1+ in at least 1 quadrant with a history of flares were enrolled. A baseline injection was given, with the primary outcome measure of at least a 2-step reduction or reduction to grade zero in the study eye by 8 weeks. Secondary outcomes included changes in visual acuity and intraocular pressure, ability to taper concomitant immunosuppressive regimen, and number of participants who experienced a disease flare requiring reinjection. Safety outcomes included the number and severity of systemic and ocular toxicities, and vision loss ≥15 ETDRS letters. The study included 6 visits over 4 months with an extension phase to 1 year for participants who met the primary outcome. RESULTS All participants (N = 5, 100%; 95% CI [0.60, 1.00]) met the primary outcome in the study eye by the week 8 visit. There was no significant change in mean visual acuity or intraocular pressure. Three out of 5 patients (60%) experienced flares requiring reinjection. No systemic toxicities were observed. Two participants (40%) experienced a localized sterile inflammatory reaction at the site of the injection, which resolved without complication. CONCLUSIONS Subconjunctival sirolimus leads to a short-term reduction in scleral inflammation, though relapses requiring reinjection do occur. There were no serious adverse events, though a local sterile conjunctival inflammatory reaction was observed.

The Association of Statin Use with Cataract Progression and Cataract Surgery: The AREDS2 Report Number 8

Numerous epidemiologic studies have evaluated the association of statin use and cataracts but the results have been inconsistent. Statins, or 3-hydroxy-3methylglutaryl-coenzyme A reductase inhibitors, are currently the most common lipid-lowering class of drugs. The Age-Related Eye Diseases Study 2 (AREDS2) was a prospective, multicenter, clinical trial that evaluated the progression of age-related macular degeneration (AMD) and cataract in participants aged 50 to 85 with at least intermediate AMD. In this report, we investigated the association of statin use with cataract progression or cataract surgery in AREDS2. The AREDS2, sponsored by the National Eye Institute, evaluated the safety and efficacy of adding lutein and zeaxanthin and/ or omega-3 long-chain polyunsaturated fatty acids to the AREDS supplements in reducing the primary outcome of progression of AMD and the secondary outcome of cataract progression. As reported, the supplementation had no effect on lens opacity progression. The study enrolled 4203 participants aged 50 through 85 between 2006 and 2008 at 82 clinical centers in the United States. The study concluded in October 2012 with a median follow-up of 5 years. Institutional review board approval was obtained at each clinical site, and participants signed informed consent for the study. Participants included in these analyses were bilaterally phakic at baseline and had cortical and posterior subcapsular (PSC) lens opacities involving <5% of the area in the central 5 mm diameter zone of the lens as documented on red reflex lens photographs. Progression to 5% was considered an outcome for both cortical and PSC opacities. Cataract surgery was used as a surrogate of moderate to severe lens opacity of unspecified type. Slit-lamp examination at annual study visits documented the presence of pseudophakia and an interim history of cataract surgery was obtained during study telephone calls that occurred every 6 months between the study visits. Statin use was self-reported at baseline. The propensity score approach can be used to reduce or eliminate the effects of confounding when using observational data (e.g., statin use) to estimate treatment effects. We used logistic regression to estimate propensity scores, which range from 0 to 1 and indicate the probability that a participant is a statin user, based on the risk factors at baseline. Values closer to 1 indicate a greater likelihood of a participant using statins. We then conducted ageand sex-adjusted Cox regression using the propensity score, with and without matching of these scores, to evaluate the association of statin use with progression of lens opacities in either eye. Finally, adjustment was made for the competing risk of death. The unit of analysis is by person. Of the 2771 participants who were bilaterally phakic at baseline with <5% center subfield cortical or PSC opacity, 1184 (42.7%) were statin users. Table 1 (available at www.aaojournal.org) displays the baseline characteristics of these 2 groups. Statin users tended to be older, male, former or current smokers, and to have a history of diabetes and aspirin use. Statin users were also more likely to have a history of hypertension, congestive heart failure, coronary heart disease, angina, myocardial infarction, and stroke. The progression rates at 5 years were 18.0% (499/2771) for cataract surgery, 42.6% (1111/2609) cortical lens opacities, and 30.6% (819/2673) PSC lens opacities. In ageand sex-adjusted analyses that included propensity scores, statin users had an increased risk of cataract surgery (hazard ratio [HR], 1.90; 95% CI, 1.17e3.10), cortical lens opacity progression (HR, 1.52; 95% CI, 1.08e2.12), and PSC lens opacity progression (HR, 1.84; 95% CI, 1.25e2.71; Table 2). Female statin users had an increased risk of cataract progression and cataract surgery. Statin users under the age of 75 years also had an increased risk of PSC lens opacity progression and cataract surgery. Matching statin users and nonusers by propensity scores resulted in 904 matched pairs. Differences in the covariates were then no longer significantly different (Table 1). However, the age difference between each propensity-matched pair could still range between 0 and 30 years, despite the matching. The analyses of the propensity-matched cohort were adjusted for age in the subsequent Cox regression analysis. Results for the matched analyses and the competing risks analysis were similar to those seen for the unmatched analyses (Table 3, available at www.aaojournal.org). The use of statins in AREDS2 participants was associated with cataract surgery and progression of both cortical and PSC lens opacities. Risk of these outcomes seemed to be greater for women and patients <75 years who used statins. The current study has limitations. Although propensity matching is designed to decrease bias by balancing the covariates between those choosing and not choosing to take statins, the propensity technique can adjust only for factors that were measured in AREDS2. Whether unknown or unmeasured factors influenced our findings or the findings of previously conducted observational studies cannot be determined. Of particular concern, given the widespread use of statins in patients with cardiovascular disease, is incomplete adjustment for risk factors associated with both CVD and cataract. Our study was subject to potential recall bias because statin use was self-reported. Both statin dosage and duration of use were not ascertained, but 86% of participants who reported using statins at baseline continued to report statin use at their close-out visit. Our study results are not necessarily generalizable because our study cohort was a select population of patients with intermediate to late AMD. Important strengths of this study include its longitudinal prospective nature, large sample size, standardized examinations, and the centralized grading of the lens photographs. An additional strength of the study was the collection and analyses of data on a large number of potentially important covariates. Our study raises important questions about some of the most commonly used drugs in the population. Additional studies in other populations are needed to determine whether use of statins increases the risk of cataract and whether cataract outcomes with statin use are influenced by sex or age group. Currently, patients

Elevated CD1c+ Myeloid Dendritic Cell Proportions Associate With Clinical Activity and Predict Disease Reactivation in Noninfectious Uveitis.

Purpose To test the association between elevated proportions of CD1c+ myeloid dendritic cells (mDCs) and disease activation/reactivation in noninfectious uveitis. Methods Noninfectious uveitis patients (n = 89) and healthy controls (n = 111) were recruited. The proportion of CD1c+ mDCs in the total dendritic cell (DC) population of peripheral blood was measured by flow cytometry (CD1c+ mDCs gated on Lineage 1+HLADR+ DCs). Disease activity was assessed per Standardization of Uveitis Nomenclature criteria. Uveitis reactivation was ascribed to clinically quiescent patients who developed reactivation of intraocular inflammation within 6 months. Results The proportions of CD1c+ mDCs were increased in noninfectious uveitis patients, especially in active disease, compared to healthy controls. This CD1c+ mDC elevation was not associated with underlying systemic diseases, anatomic locations of uveitis, medications, or demographic factors. Longitudinal data showed that the dynamics of CD1c+ mDC levels were correlated with disease activity. The average proportion of CD1c+ mDCs in active uveitis patients was 60% so we set this as the cutoff between high and low CD1c+ mDC levels. Although 74% of quiescent patients had low proportions of CD1c+ mDCs, 26% still had high proportions. Quiescent patients with high CD1c+ mDC proportions showed increased risk of disease reactivation, compared to quiescent patients with low CD1c+ mDC proportions. Conclusions Increased proportions of CD1c+ mDCs were associated with clinical activity, and quiescent patients with elevated CD1c+ mDCs were more likely to undergo reactivation. This suggests that CD1c+ mDC proportion may be a potential biomarker for assessing clinical activation and reactivation in noninfectious uveitis.

Increased CD1c+ mDC1 with mature phenotype regulated by TNFα–p38 MAPK in autoimmune ocular inflammatory disease

In this study we investigated the role of blood CD1c(+) myeloid dendritic cells 1 (mDC1), a key mDC subtype, in patients with autoimmune uveitis. We observed a significant increase of blood CD1c(+) mDC1 in uveitis patients. The increased CD1c(+) mDC1 exhibited high HLADR expression and less antigen uptake. CD1c(+) mDC1 were divided into two subpopulations. CD1c(hi) mDC1 subpopulation showed less antigen uptake and higher HLADR expression compared to CD1c(lo) mDC1 subpopulation. Importantly, the CD1c(hi) mDC1 subpopulation was increased in uveitis patients. In vitro, mature monocyte-derived dendritic cells (MoDCs), characterized by lower levels of antigen uptake, induced more CD4(+)CD62L(-) T helper cell proliferation. The mature phenotype and function of CD1c(+) mDC1 were regulated by TNFα via a p38 MAPK-dependent pathway. These data show that alterations in the systemic immune response are involved in the pathogenesis of autoimmune uveitis and invite the therapeutic possibility of attenuating uveitis by manipulating blood CD1c(+) mDC1.

Non-invasive method of monitoring retinal vasculitis in patients with birdshot chorioretinopathy using optical coherence tomography

Background/aims To investigate the utility of using montaged optical coherence tomography (OCT) thickness maps to monitor perivascular thickness as a marker of vasculitic activity in patients with large-vessel retinal vasculitis. Methods This is a retrospective cohort study of 22 eyes of 11 patients with a history of retinal vasculitis associated with birdshot chorioretinopathy (BCR). Patients had serial spectral domain 6×6 mm cube OCT scans centred on the fovea, optic nerve and proximal branches of the superior and inferior retinal vessels. OCT thickness change maps for each respective region were analysed. Changes in perivascular thickness were confirmed by assessing vasculitic activity on fluorescein angiography (FA), when clinically indicated. Results In three patients, montaged OCT scans were acquired at diagnosis and serially through initial treatment. In all three patients, montaged OCT demonstrated reduced perivascular thickening with oral prednisone treatment, which was confirmed by FA showing reduced vascular leakage in both eyes. Eight patients had serial montaged OCT scans after diagnosis and initial treatment of BCR. Four of these patients showed fluctuations in perivascular thickness during flares and treatment that were confirmed by either increased or decreased vascular leakage on FA. The other four patients remained quiet on their immunosuppressive treatment regimens, and no changes in perivascular thickness were detected. Conclusions Evaluating large-vessel perivascular thickness on OCT scans may be a useful method for non-invasively monitoring posterior pole large-vessel retinal vasculitis.