The Ocular Immunology and Uveitis Foundation preferred practice patterns of uveitis management

Ocular Drug Distribution and Safety of a Noninvasive Ocular Drug Delivery System of Dexamethasone Sodium Phosphate in Rabbit

PURPOSE

To determine the ocular toxicity, systemic exposure, and amounts of dexamethasone sodium phosphate (DSP) in ocular tissues after administration of DSP with the Visulex system (DSP-Visulex).

METHODS

DSP-Visulex was applied onto healthy rabbit eyes. DSP concentrations (4%, 8%, 15%, and 25%) and treatment durations (5, 10, and 20 min) were evaluated for the amounts of DSP in the ocular tissues and in plasma after single administrations of DSP-Visulex. The drug in eye tissues and plasma was analyzed by high-performance liquid chromatography-UV/VIS and by liquid chromatography-mass spectrometry, respectively. The safety and tolerability were ascertained based on clinical observations and histopathological examinations from repeat weekly DSP-Visulex treatments (4%, 8%, 15%, and 25% for 20 min) for 12 weeks.

RESULTS

Significant amounts of DSP (ie, higher than 1 μg/g) were found in the anterior chamber, retina-choroid, cornea, vitreous, conjunctiva, and sclera after single applications of DSP-Visulex. The DSP concentrations in the ocular tissues and in plasma increased with increased DSP concentrations in the Visulex applicator and with increased application times. Systemic DSP was rapidly detected. The plasma half-life was 2-3 h. C_max was 148 and 1,844 ng/mL, and the area under the plasma drug concentration versus time curve (AUC) was 418 and 3,779 ng · h/mL for the low dose (4% DSP-Visulex for 5 min) and the high dose (15% DSP-Visulex for 20 min), respectively. Ocular findings over 12 weeks were mostly conjunctival injection and eye discharge. These were transient and mild. Histopathological examinations indicated the eyes to be normal.

CONCLUSIONS

DSP can be administered safely and effectively into the rabbit eye with the Visulex system. Treatment duration and DSP concentration are important factors in achieving therapeutic levels. Repeat applications of DSP-Visulex are safe and well tolerated for weekly administrations over 4-12 weeks. DSP-Visulex has clinical potential for the noninvasive treatment of ocular diseases.

Safety and Efficacy of Adalimumab in Patients with Noninfectious Uveitis in an Ongoing Open-Label Study: VISUAL III

PURPOSE

To evaluate safety and efficacy of adalimumab in patients with noninfectious intermediate, posterior, or panuveitis.

DESIGN

Phase 3, open-label, multicenter clinical trial extension (VISUAL III).

PARTICIPANTS

Adults meeting treatment failure (TF) criteria or who completed VISUAL I or II (phase 3, randomized, double-masked, placebo-controlled) without TF.

METHODS

Patients received adalimumab 40 mg every other week. Interim follow-up data were described from VISUAL III weeks 0 through 78.

MAIN OUTCOME MEASURES

Disease quiescence, steroid-free quiescence, active inflammatory chorioretinal/retinal vascular lesions, anterior chamber cell grade, vitreous haze grade, best-corrected visual acuity (BCVA), and corticosteroid dose. Binary data were reported using nonresponder imputation (NRI), continuous data using last observation carried forward and as-observed analysis, and corticosteroid dose using observed-case analysis. Adverse events (AEs) were reported from first adalimumab dose in VISUAL III through interim cutoff.

RESULTS

Of 424 patients enrolled, 371 were included in intent-to-treat analysis. At study entry, 242 of 371 (65%) patients had active uveitis; 60% (145/242, NRI) achieved quiescence at week 78, and 66% (95/143, as-observed) of those were corticosteroid free. At study entry, 129 of 371 (35%) patients had inactive uveitis; 74% (96/129, NRI) achieved quiescence at week 78, and 93% (89/96, as-observed) of those were corticosteroid free. Inflammatory lesions, anterior chamber grade, and vitreous haze grade showed initial improvement followed by decline in patients with active uveitis and remained stable in patients with inactive uveitis. BCVA improved in patients with active uveitis from weeks 0 to 78 (0.27 to 0.14 logMAR; left and right eyes; as-observed) and remained stable in patients with inactive uveitis. Mean corticosteroid dose decreased from 13.6 mg/day (week 0) to 2.6 mg/day (week 78) in patients with active uveitis and remained stable in those with inactive uveitis (1.5-1.2 mg/day). AEs (424 events/100 patient-years) and serious AEs (16.5 events/100 patient-years) were comparable with previous VISUAL trials.

CONCLUSIONS

Patients with active uveitis at study entry who received adalimumab therapy were likely to achieve quiescence, improve visual acuity, and reduce their daily uveitis-related systemic corticosteroid use. Most patients with inactive uveitis at study entry sustained quiescence without a systemic corticosteroid dose increase. No new safety signals were identified.

Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

TOPIC

An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics.

CLINICAL RELEVANCE

The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents.

METHODS

An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence.

RESULTS

In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed.

CONCLUSIONS

Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

Pembrolizumab-triggered Uveitis: An Additional Surrogate Marker for Responders in Melanoma Immunotherapy?

Immunotherapy leads to significantly prolonged survival of patients with metastatic melanoma. Autoimmune side effects including colitis, dermatitis, and endocrine abnormalities are common in patients treated with ipilimumab [anti-CTLA4 (cytotoxic T-lymphocyte-associated protein 4)]. Antibodies such as pembrolizumab that interfere with the PD-1 (programmed cell death 1)/PD-L1 pathway show greater efficacy and less toxicity than ipilimumab. Here we report 2 cases of pembrolizumab-induced uveitis associated with complete or partial tumor response. We suggest that uveitis may serve as a surrogate marker for a tumor response to therapy with pembrolizumab.

Efficacy and safety of immunomodulatory drugs in patients with anterior uveitis: A systematic literature review

BACKGROUND

To assess the efficacy and safety of immunomodulatory drugs in patients with noninfectious anterior uveitis (AU).

METHODS

Systematic review of studies were retrieved from Medline (1961 to March 2016), Embase (1961 to March 2016), and Cochrane Library (up to March 2016), and a complementary hand search was also performed. The selection criteria were as follows: (population) noninfectious AU patients, adults; (intervention) immunomodulatory drugs (any dose, regimen, route of administration, duration of treatment); (outcome) control of inflammation, steroid-sparing effect, AU flares, adverse events, and so on; (study design) systematic literature reviews, randomized controlled trials, and observational studies. The study quality was assessed using the Jadad scale and according to The Oxford Centre for Evidence-based Medicine (update 2009).

RESULTS

We included 13 studies of moderate-poor quality, with a mean duration from 5 months to 20 years, and number of AU patients ranging from 9 to 274. Patient's demographic and clinical characteristics were very heterogeneous. In most cases, uveitis anatomic classification criteria and outcomes definitions were unclear. Some of the studies only included AU patients with a systemic disease associated, mostly spondyloarthritis, others, mixed populations (idiopathic and systemic disease associated patients), and in some articles this data is not described. We found that methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might prevent AU flares, improve ocular inflammation and visual acuity, and decrease systemic steroids doses.

CONCLUSIONS

Although there is a lack of robust evidence, methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might be effective in AU patients.

Uveitis: a sight-threatening disease which can impact all systems

Uveitis describes a group of conditions characterised by intraocular inflammation. The term uveitis technically describes inflammation of the uvea which comprises the iris, ciliary body and choroid, however now encompasses inflammation of adjacent intraocular structures such as the retina, vitreous and optic nerve. Uveitis is a significant cause of blindness worldwide, but its impact is generally underappreciated due to a lack of awareness and understanding of the condition among the public and most non-ophthalmic healthcare professionals. In this review, we provide an introduction to uveitis for the non-specialist, outlining the clinical presentations that should raise the suspicion of the disease, the signs that should be looked for and a framework in which to understand the condition. We show how a logical approach to classifying uveitis by aetiology and anatomical focus of disease provides the basis for treatment strategies (drug and route of administration) and clinical presentation and prognosis. We also show why understanding uveitis is helpful to clinicians working in almost every speciality due to the wide-ranging associations with systemic disease.

Successful ustekinumab treatment of noninfectious uveitis and concomitant severe psoriatic arthritis and plaque psoriasis

We report the first successful treatment of noninfectious uveitis with ustekinumab in a patient with severe concomitant psoriasis and psoriatic arthritis who failed to respond to conventional immune suppressants and with contraindications to tumor necrosis factor alpha inhibitors.

Comparative efficacy of steroid-sparing therapies for non-infectious uveitis

Introduction

Non-infectious uveitis encompasses a group of inflammatory eye diseases that can cause irreversible vision loss if left untreated or undertreated. In cases requiring stemic treatment, a step-wise treatment approach is often employed starting with corticosteroids for severe active disease, followed by initiation of steroid-sparing therapies to maintain inflammatory control and avoid the abundant complications of long-term corticosteroid use.

Areas covered

We review the current high-quality evidence comparing the efficacy of various systemic steroid-sparing agents in the treatment of non-infectious uveitis. For studies to be included, they had to have a prospective, randomized, comparative design or a retrospective design including at least 100 patients.

Expert commentary

Given the rarity of uveitis and the heterogeneity of uveitic diseases, there are few randomized controlled studies that directly compare the relative efficacy of the various steroid-sparing immunosuppressive agents. Therefore, current treatment strategies are based mainly on data from observational series.

Preoperative Inflammatory Control and Surgical Outcome of Vitrectomy in Intermediate Uveitis

Purpose. To demonstrate the long-term effectiveness of vitrectomy for intermediate uveitis (IU) and to determine whether complete control of inflammation before vitrectomy is necessary. Methods. This retrospective study included 66 eyes of 66 patients with IU who underwent vitrectomy for vitreoretinal complications. Eyes were followed for at least 12 months after vitrectomy. The degree of inflammation control and visual acuity were compared before and after vitrectomy. These parameters were compared according to the presence of complete inflammation control before surgery. Results. The indications of vitrectomy included epiretinal membrane (26 eyes), vitreous opacity (21 eyes), and tractional retinal detachment (12 eyes), among others. Uveitic attacks did not occur in 44 of the 66 patients after vitrectomy. The numbers of uveitis attacks, local steroid injections, and systemic medications significantly decreased, and vision meaningfully improved after vitrectomy. These parameters did not differ significantly, regardless of the presence of preoperative inflammation. Conclusions. This study showed that vitrectomy is a good modality to manage vitreoretinal complications associated with IU, even if complete control of intraocular inflammation is not achieved before vitrectomy.

MC5r and A2Ar Deficiencies During Experimental Autoimmune Uveitis Identifies Distinct T cell Polarization Programs and a Biphasic Regulatory Response

Autoantigen-specific regulatory immunity emerges in the spleen of mice recovering from experimental autoimmune uveitis (EAU), a murine model for human autoimmune uveoretinitis. This regulatory immunity provides induced tolerance to ocular autoantigen, and requires melanocortin 5 receptor (MC5r) expression on antigen presenting cells with adenosine 2 A receptor (A2Ar) expression on T cells. During EAU it is not well understood what roles MC5r and A2Ar have on promoting regulatory immunity. Cytokine profile analysis during EAU revealed MC5r and A2Ar each mediate distinct T cell responses, and are responsible for a functional regulatory immune response in the spleen. A2Ar stimulation at EAU onset did not augment this regulatory response, nor bypass the MC5r requirement to induce regulatory immunity. The importance of this pathway in human autoimmune uveitis was assayed. PBMC from uveitis patients were assayed for MC5r expression on monocytes and A2Ar on T cells, and comparison between uveitis patients and healthy controls had no significant difference. The importance for MC5r and A2Ar expression in EAU to promote the induction of protective regulatory immunity, and the expression of MC5r and A2Ar on human immune cells, suggests that it may be possible to utilize the melanocortin-adenosinergic pathways to induce protective immunity in uveitic patients.

An anti-TNF-α antibody mimetic to treat ocular inflammation

Infliximab is an antibody that neutralizes TNF-α and is used principally by systemic administration to treat many inflammatory disorders. We prepared the antibody mimetic Fab-PEG-Fab (FpF_infliximab) for direct intravitreal injection to assess whether such formulations have biological activity and potential utility for ocular use. FpF_infliximab was designed to address side effects caused by antibody degradation and the presence of the Fc region. Surface plasmon resonance analysis indicated that infliximab and FpF_infliximab maintained binding affinity for both human and murine recombinant TNF-α. No Fc mediated RPE cellular uptake was observed for FpF_infliximab. Both Infliximab and FpF_infliximab suppressed ocular inflammation by reducing the number of CD45+ infiltrate cells in the EAU mice after a single intravitreal injection at the onset of peak disease. These results offer an opportunity to develop and formulate for ocular use, FpF molecules designed for single and potentially multiple targets using bi-specific FpFs.

A Focus on the Epidemiology of Uveitis

PURPOSE

Uveitis is a common, sight-threatening inflammatory ocular disease and includes multiple heterogeneous clinical entities. The prevalence of various types of uveitis depends upon multiple factors, such as age, sex, race, geographic distribution, environmental influence, genetics, and social habits. Epidemiologic research of uveitis is necessary to understand the etiology and immunopathogenesis of this group of diseases. The present study attempts to concentrate on the most recent information on the epidemiology of uveitis and compare it with previous knowledge.

METHODS

An extensive literature search was performed in the Medline database (PubMed) and included surveys completed until 2015. Articles that reported prevalence and incidence were studied. References cited in the articles were also studied.

RESULTS

The incidence and prevalence of uveitis differs based on age, anatomic location of the inflammatory process (anterior, intermediate, posterior uveitis, panuveitis), gender, histopathology (granulomatous, non-granulomatous), type of inflammatory process (acute, chronic, recurrent), and etiology (infectious, non-infectious). Prevalence differs by geographic location. Idiopathic anterior uveitis is the most common form of uveitis in the community. Infectious causes are common (30-60%) in the developing countries. Herpes and toxoplasmosis are the leading infectious causes of uveitis. Non-infectious uveitic conditions are generally more common in the developed world. An increase in the prevalence of infectious etiologies, including tuberculosis and syphilis, has been seen in developed countries. Introduction of new treatment options has also changed patterns of disease.

CONCLUSIONS

Introduction of new uveitis entities, changes in the incidence of already known disease and increased availability of diagnostic testing have all altered the epidemiology of uveitis in recent years. Knowledge of regional patterns of disease is essential. A more detailed classification of uveitis with the establishment of uniform diagnostic criteria and prospective population based studies would certainly benefit epidemiologic research and clinical practice.

Treatment of pediatric uveitis with adalimumab: the MERSI experience

PURPOSE

To evaluate adalimumab therapy in children with uveitis.

METHODS

The electronic health records of pediatric patients diagnosed with uveitis and treated with adalimumab therapy were reviewed retrospectively. Demographic information, site and degree of intraocular inflammation, visual acuity, underlying systemic disorders, duration of therapy, side effects, and ability to obtain steroid-free remission were recorded.

RESULTS

A total of 17 patients were included, 16 patients with anterior uveitis and 1 with panuveitis; 14 patients had bilateral disease. Juvenile idiopathic arthritis had been diagnosed in 14 patients, sarcoidosis in 1 patient, and idiopathic etiology in 2 patients. Of the 17 patients, 13 (about 77%) achieved steroid-free remission, and 4 did not. Six patients flared after discontinuation of adalimumab, with evidence of inflammation noted 3-7 months later. Adalimumab therapy was of 12-64 months' duration (mean, 36 months). At the time of initiation, 14 patients were using other agents concomitantly with adalimumab; 3 patients were on adalimumab monotherapy. At 1 year's follow-up, 12 patients were using combination therapy, and 3 patients were on adalimumab monotherapy: 11 patients had no evidence of inflammation. Side effects included pain at site of injection in 3 patients, anemia in 1 patient, and depression in 1 patient.

CONCLUSIONS

In our study cohort, adalimumab was effective in inducing steroid-free remission. It was well tolerated, especially in combination with other immunomodulatory agents. The dosing and the interval can be adjusted to further improve inflammation control.

Involvement of B cells in non-infectious uveitis

Non-infectious uveitis-or intraocular inflammatory disease-causes substantial visual morbidity and reduced quality of life amongst affected individuals. To date, research of pathogenic mechanisms has largely been focused on processes involving T lymphocyte and/or myeloid leukocyte populations. Involvement of B lymphocytes has received relatively little attention. In contrast, B-cell pathobiology is a major field within general immunological research, and large clinical trials have showed that treatments targeting B cells are highly effective for multiple systemic inflammatory diseases. B cells, including the terminally differentiated plasma cell that produces antibody, are found in the human eye in different forms of non-infectious uveitis; in some cases, these cells outnumber other leukocyte subsets. Recent case reports and small case series suggest that B-cell blockade may be therapeutic for patients with non-infectious uveitis. As well as secretion of antibody, B cells may promote intraocular inflammation by presentation of antigen to T cells, production of multiple inflammatory cytokines and support of T-cell survival. B cells may also perform various immunomodulatory activities within the eye. This translational review summarizes the evidence for B-cell involvement in non-infectious uveitis, and considers the potential contributions of B cells to the development and control of the disease. Manipulations of B cells and/or their products are promising new approaches to the treatment of non-infectious uveitis.

Pharmacologic Treatment of Noninfectious Uveitis

Uveitis encompasses a spectrum of diseases whose common feature is intraocular inflammation, which may be infectious or noninfectious in etiology (Nussenblatt and Whitcup 2010). Infectious causes of uveitis are typically treated with appropriate antimicrobial therapy and will not be discussed in this chapter. Noninfectious uveitides are thought have an autoimmune component to their etiology and are thus treated with anti-inflammatory agents.