A masked, randomized, dose-response study between cyclosporine A and G in the treatment of sight-threatening uveitis of noninfectious origin

Thirty-two patients with sight-threatening uveitis and a decrease in visual acuity requiring systemic therapy were randomly assigned to either cyclosporine A or G in a dose-escalation study. Groups received from 2.5 mg/kg of body weight/day to 10 mg/kg of body weight/day of either drug along with low-dose prednisone. More patients taking cyclosporine G had improved visual acuity and a decrease in macular edema, which occurred more rapidly than in the other group, even at the lower doses tested. No difference in renal function was noted between groups at any doses tested. Four patients receiving cyclosporine G had hepatic alterations, but only one required cessation of the drug. The study indicates the potential usefulness of cyclosporine G, particularly at lower doses (4 mg/kg of body weight/day), which could lower the potential for serious renal complications.

The role of chorioretinal biopsy in the management of posterior uveitis

BACKGROUND

The ideal management of intraocular inflammation may require a tissue diagnosis. Diagnostic vitrectomy is a well-established method for acquiring such tissue. However, in some patients, the diagnostic pathology is limited to the choroid and retina and vitrectomy may yield no useful information. In such cases, a more aggressive surgical approach to obtain tissue may be useful.

METHODS

The authors performed chorioretinal biopsies on seven patients with progressive chorioretinal lesions of unknown etiology. Indications for biopsy included: (1) macular-threatening lesions unresponsive to therapy, (2) suspicion of malignancy, or (3) suspicion of an infectious etiology. In all cases, it was expected that the results would alter therapy or other aspects of clinical care. Preoperative visual acuity was 20/200 or worse in each eye biopsied with one or more peripheral chorioretinal lesions present. Biopsy specimens were divided into three parts and submitted for light and electron microscopy, immunohistochemistry, and tissue culture.

RESULTS

On the basis of the biopsy findings, a diagnosis of multifocal choroiditis and subretinal fibrosis was rendered in three eyes, sarcoidosis in two eyes, and viral retinitis in two eyes. Therapy was changed in five patients. Final visual acuity was unchanged or improved in five eyes. Complications included the progression of lens opacity in all eyes and the development of phthisis in one eye that was extensively diseased preoperatively.

CONCLUSION

Chorioretinal biopsy may provide useful information for determining the diagnosis and guiding the subsequent management of patients with progressive chorioretinal lesions of unknown etiology.

Monoclonal antibodies against ICAM-1 (CD54) and LFA-1 (CD11a/CD18) inhibit experimental autoimmune uveitis

Cell adhesion molecules are surface proteins important for cell migration and adhesion and are strongly expressed in eyes with inflammation. We studied the expression of two cell adhesion molecules: intercellular adhesion molecule-1 (ICAM-1, CD54) and lymphocyte function-associated antigen-1 (LFA-1, CD11a/CD18) in mice with experimental autoimmune uveitis. B10.A mice were immunized with interphotoreceptor retinoid-binding protein and eyes were serially examined for expression of cell adhesion molecules using immunohistochemical staining. ICAM-1 was expressed on the vascular endothelium of the ciliary body and retina by 7 days after immunization, and LFA-1 was first expressed on some infiltrating inflammatory cells 9 days after immunization. Clear histologic evidence of ocular inflammation did not occur until 11 days after immunization. We then studied the effect of monoclonal antibodies against ICAM-1 and LFA-1 on the development of experimental autoimmune uveitis. Three groups of mice were immunized and treated for 21 days with daily intraperitoneal injections of rat monoclonal antibody against murine ICAM-1 or LFA-1 or with rat IgG as control. Ocular inflammation, graded clinically by examination of the fundus 14 and 21 days after immunization, was significantly decreased in animals treated with anti-ICAM-1 (P < 0.01 at Days 14 and 21) and with anti-LFA-1 antibody (P < 0.01 at Days 14 and 21). The intraocular inflammation graded histologically was also decreased in mice treated with anti-ICAM-1 and anti-LFA-1 antibody. This difference in the histologic grade of inflammation was statistically significant (P < 0.02) between mice treated with anti-ICAM-1 antibody and control mice and approached statistical significance (P < 0.10) in mice treated with anti-LFA-1 antibody compared to the control mice. Proliferative responses to lipopolysaccharide, PPD, and interphotoreceptor binding protein of lymphocytes obtained from the draining lymph nodes of mice treated with the antibodies were lower than those from the control mice, suggesting that cell-cell binding was impaired in treated mice. These data show that ICAM-1 is expressed in the eye before histologic evidence of inflammation, and that monoclonal antibodies against ICAM-1 and LFA-1 are effective in inhibiting experimental autoimmune uveitis in mice.

Monoclonal antibody against CD11b/CD18 inhibits endotoxin-induced uveitis

PURPOSE

To examine the serial expression of cell adhesion molecules in C3H/HeN mice with endotoxin-induced uveitis, and to study the effect of treatment with a monoclonal antibody against Mac-1 on the development of endotoxin-induced uveitis.

METHODS

Immunohistochemical staining was used to document the serial expression of Mac-1, intercellular adhesion molecule-1 (ICAM-1), and lymphocyte function-associated antigen-1 (LFA-1) in eyes of C3H/HeN mice with endotoxin-induced uveitis. Then, in two separate experiments, endotoxin-induced uveitis was produced in a total of 48 mice by injecting Salmonella typhimurium endotoxin into one hind footpad. At the time of endotoxin injection, 24 mice received an intraperitoneal injection of anti-Mac-1 antibody and 24 control mice received an intraperitoneal injection of rat IgG. Histopathologic sections of eyes taken 24 hours after endotoxin injection were graded by two masked observers on a scale of 0 to 4.

RESULTS

Intercellular adhesion molecule-1 was first expressed on the ciliary body epithelium 6 hr after endotoxin injection and Mac-1 and LFA-1 were expressed on infiltrating inflammatory cells 12 hr after endotoxin injection. Treatment with anti-MAC-1 antibody significantly inhibited the development of ocular inflammation when compared with treatment with control IgG (P < 0.001).

CONCLUSION

Intercellular adhesion molecule-1 is expressed in the eye before clinical or histologic signs of inflammation. Furthermore, treatment with antibody against Mac-1 significantly inhibits the development of endotoxin-induced uveitis in mice and suggests that anti-Mac-1 antibody may be useful for treating acute ocular inflammation.

The role of mast cells in endotoxin-induced uveitis

PURPOSE

To investigate the role of mast cells in the induction of endotoxin-induced uveitis (EIU).

METHODS

We previously showed that the mean mast cell number in the anterior uvea was greatest for Lewis rats, lowest for Brown Norway (BN) rats, and intermediate for LBNF1 rats. In the current experiment, we assessed the time of onset and severity of EIU in these three rat strains. We then studied changes in mast cell numbers in the anterior uvea during the induction period of EIU.

RESULTS

Time of onset and severity of EIU were related to the number of mast cells in the anterior uvea. EIU occurred earliest in the Lewis rats, and the maximum mean grade of ocular inflammation on a scale of 0 (no inflammation) to 4 (severe inflammation) +/- standard error of the mean was 3.87 +/- 0.13 for Lewis rats, 1.06 +/- 0.06 for BN rats, and 1.19 +/- 0.12 for LBNF1 rats. The difference between the mean grade of inflammation in the Lewis rats and the other two strains was highly statistically significant (P < .001). In the Lewis rats, mast cell numbers +/- SEM decreased from 68.9 +/- 10.8 at baseline to 49.6 +/- 5.9 4 hr after lipopolysaccharide (LPS) injection and to 27.6 +/- 8.4 8 hr after LPS injection, suggesting that mast cell degranulation occurs before the development of EIU.

CONCLUSION

Mast cells in the anterior uvea appear to potentiate endotoxin-induced ocular inflammation.

Endothelial leukocyte adhesion molecule-1 in endotoxin-induced uveitis

Expression of endothelial leukocyte adhesion molecule-1 (ELAM-1) on endothelial cells leads to the attachment of polymorphonuclear leukocytes. The sequential expression of ELAM-1 and major histocompatibility complex (MHC) class II antigen was examined in the eyes of 59 Lewis rats with endotoxin-induced uveitis (EIU) after the injection of Salmonella typhimurium endotoxin. The eyes were enucleated at 2-hr intervals. Hematoxylin and eosin-stained paraffin-embedded sections and immunohistochemically stained cryostat sections were graded by two masked observers. The MHC class II antigen was expressed on cells in the iris and ciliary body 4 hr after injection of endotoxin and on the corneal endothelium, 8 hr postinjection. It was found that ELAM-1 was expressed first on cells of the ciliary body and iris 10 hr after the injection of endotoxin and on the corneal endothelium, 22 hr postinjection. Clinical and histopathologic disease developed 16 hr postinjection. Adherence of polymorphonuclear cells to the corneal endothelium was observed at the time of ELAM-1 expression. In conclusion, expression of ELAM-1 on ocular tissue occurred in EIU and appeared to promote polymorphonuclear cell accumulation in the anterior segment of the eye.

Combined use of cyclosporine and ketoconazole in the treatment of endogenous uveitis

Ten patients with endogenous uveitis were in clinical remission attributable to treatment with cyclosporine and prednisone. After the cyclosporine dose was reduced by two thirds, these patients were randomly assigned to treatment with or without ketoconazole, a potent inhibitor of cytochrome P-450, in a double-masked placebo-controlled study. The dose was reduced over three days. During a three-month follow-up, no patients treated with ketoconazole had a relapse of uveitis, while four of six (66%) control subjects had a flare-up. Toxicity in the ketoconazole-treated group was limited to a transient decrease in glomerular filtration rate (20% from baseline) at one month in two of six (33%) patients. Renal function was stabilized by further reduction of the cyclosporine dose.

Expression of cell adhesion molecules in posterior uveitis

Cells in the eye express surface molecules that direct leukocyte migration during ocular inflammation. We studied the expression of intercellular adhesion molecule-1, lymphocyte function-associated antigen-1, and endothelial leukocyte adhesion molecule-1 in six enucleated eyes from patients with uveitis and in seven normal control eyes. Lymphocyte function-associated antigen-1 was expressed on infiltrating lymphocytes and intercellular adhesion molecule-1 was expressed on endothelial cells of retinal and choroidal blood vessels and the retinal pigment epithelium in all uveitic eyes, but in none of the normal control eyes. Ocular inflammatory cells stained strongly positive for tumor necrosis factor alpha in all eyes with uveitis, but four of six uveitic eyes showed mild staining for tumor necrosis factor beta and interferon gamma. Cell adhesion molecules are expressed in eyes with posterior uveitis and may be regulated by cytokines such as tumor necrosis factor alpha.

Retinal toxicity in human immunodeficiency virus-infected children treated with 2',3'-dideoxyinosine

To assess the safety and antiretroviral activity of 2',3'-dideoxyinosine, we enrolled 43 children with symptomatic (Centers for Disease Control class P-2) human immunodeficiency virus infection in a Phase I-II study and monitored them prospectively for the development of ocular complications secondary to HIV infection or drug toxicity. Follow-up ranged from 12 to 103 weeks with a median follow-up of 71 weeks. Three of 43 children (7.0%) developed peripheral atrophy of the retinal pigment epithelium during treatment with 2',3'-dideoxyinosine. The two children with the most severe retinal atrophy were enrolled in the study at the highest dosage studied (540 mg/m2/day). In contrast to findings in children, no retinal atrophy in HIV-infected adults treated with 2',3'-dideoxyinosine has been evident to date.

Pneumocystis carinii and Mycobacterium avium-intracellulare infection of the choroid

It has been hypothesized that coinfection with mycobacteria occurs in patients with Pneumocystis carinii choroiditis, but cases demonstrating ocular infection by both organisms have not been reported. This study reports the case of a patient with P. carinii choroiditis who was treated with intravenous trimethoprim and sulfamethoxazole, followed by intravenous trimethoprim and dapsone. The choroidal lesions failed to resolve despite 6 weeks of treatment, and the patient died from massive pulmonary infection caused by P. carinii, Mycobacterium avium-intracellulare, and cytomegalovirus infections. Ocular histologic and electron microscopic examinations revealed choroidal infection by both P. carinii and M. avium-intracellulare. Serum levels of sulfamethoxazole were below the recommended therapeutic range for treating P. carinii infection during the first week of therapy, but adequate drug levels were subsequently obtained. Failure of choroidal lesions of P. carinii to resolve in some cases may suggest insufficient antimicrobial levels in the blood or raise the possibility of coexistent M. avium-intracellulare or other opportunistic infection.

Ocular complications of Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with AIDS

Recent reports suggest that acquired immunodeficiency syndrome (AIDS) patients are at higher risk of developing mucocutaneous reactions such as toxic epidermal necrolysis and Stevens-Johnson syndrome (SJS). Resultant dry eye may be further exacerbated by human immunodeficiency virus (HIV) related lacrimal gland dysfunction and lead to a chronic keratoconjunctivitis. We report one patient with AIDS and toxic epidermal necrolysis and two patients with AIDS and SJS who developed severe dry eye misdiagnosed as infectious keratoconjunctivitis. Cicatrizing mucocutaneous reactions should be suspected in AIDS patients and the dry eye treated to control symptoms and prevent complications.

Immunohistochemistry of Terrien's and Mooren's corneal degeneration

Lamellar keratoplasty specimens from a patient with Terrien's marginal degeneration and a patient with Mooren's ulcer were compared using routine histopathologic and immunohistochemical staining with an avidin-biotin-peroxidase complex. Less than 25% of the resident cells in the Terrien's marginal degeneration specimen expressed major histocompatibility class II antigens compared with 75% to 100% of the resident cells in the Mooren's ulcer specimen. The ratio of CD4 cells (T-helper/inducer) to CD8 cells (T-suppressor/cytotoxic cells) in the Terrien's marginal degeneration specimen was almost 1:1 compared with 24:1 in the Mooren's ulcer specimen. In addition, less than 5% of the infiltrating cells from the Terrien's marginal degeneration specimen stained positive for CD22 (B cells), compared with 25% to 50% from the Mooren's ulcer specimen. These data may help explain why Terrien's marginal degeneration runs a more benign course than does Mooren's ulcer and provides a rationale for the use of immunosuppressive drugs to treat Mooren's ulcer.

Immunohistochemistry of the inflammatory response in Propionibacterium acnes endophthalmitis

Specimens were obtained from two patients with culture-proven Propionibacterium acnes endophthalmitis who had undergone vitrectomy. Wright's and Giemsa stains were performed using cytospin preparations of the dilute vitreous and revealed a predominance of polymorphonuclear leukocytes (80% to 90%). The remaining inflammatory cells in the vitreous were mostly macrophages (10% to 15%); very few lymphocytes were present (less than 5%). Immunohistochemical studies using monoclonal antibodies confirmed the paucity of lymphocytes. Most lymphocytes were CD4+ helper/inducer T cells. Almost no CD8+ suppressor/cytotoxic T lymphocytes or B lymphocytes were found. The inflammatory response in these two patients is most characteristic of acute inflammation and consistent with an underlying bacterial infection, despite a clinical picture of persistent, low-grade inflammation. Infection with P acnes has been shown to inhibit CD8+ T cells and may play a role in the persistent inflammation in cases of P acnes endophthalmitis.

Unrecognized drug dependence in psychiatrically hospitalized elderly patients

The psychiatric in-patient records of 90 patients greater than or equal to 65 years of age were reviewed retrospectively to determine the prevalence of chemical dependence and if lack of recognition and treatment of chemical dependence resulted in serious complications. Nineteen of the 90 patients were characterized as drug dependent and ten of these patients were neither recognized nor detoxified. Seven of the ten nondetoxified patients, but only one of the nine detoxified patients, experienced serious medical complications typically requiring transfer to a medical floor or medical intensive care unit. Unrecognized chemically-dependent patients were significantly more likely to be female benzodiazepine abusers, while recognized chemically dependent patients were significantly more likely to be male alcohol abusers.

Saccadic eye movements in myasthenia gravis

The peak velocities of horizontal saccades were measured in patients with myasthenia gravis (MG) to determine whether they can differentiate MG from other causes of ophthalmoplegia. Eye movements were recorded with electrooculography (EOG) or infrared scleral reflection (IR) in 42 patients with MG, 26 patients with sixth cranial nerve palsy (CNP), 19 patients with chronic progressive external ophthalmoplegia (PEO) and 28 normal subjects. Despite limitation of ductions in MG, the group means of velocities of 10 deg saccades recorded with IR were similar in MG and normal subjects. With EOG, small but statistically significant decreases in mean velocities of 10, 20 and 30 deg saccades were found in MG, compared to those in normal subjects. Twenty-one to 28% of MG patients had velocities outside of the normal range (outliers). In contrast, the group means in CNP and PEO were markedly lower than those in MG and normal subjects. The frequencies of outliers were 89 to 100% in CNP and 88 to 100% in PEO. Measurement of saccadic velocities can be helpful in differentiating MG from other causes of ophthalmoplegia.

Lithium-neuroleptic neurotoxicity in the elderly bipolar patient

The frequency and clinical characteristics of lithium- and neuroleptic-mediated neurotoxicity were determined in 10 elderly bipolar patients. When lithium was used alone and therapeutic serum lithium levels were achieved, neurotoxicity did not develop. However, when a neuroleptic was added, neurotoxicity developed in 60% (three of five) of patients and was characterized by delirium, extrapyramidal signs, and cerebellar dysfunction. Neurotoxicity occurred despite the use of neuroleptic dosages that are considered safe and useful when administered in the absence of other psychoactive drugs.