Chlorambucil combination therapy in refractory serpiginous choroiditis: A cure?

Oral cyclophosphamide treatment for clinical periocular inflammation of unknown origin

This study outlines a scenario involving unilateral periocular inflammation exhibited resistance to conventional immunomodulatory therapy (IMT) and biologic response modifying agents, which was successfully managed with oral cyclophosphamide monotherapy. A 39-year-old male visited our clinic, expressing discomfort and swelling in his left upper eyelid for six months. All multidisciplinary consultations and imaging yielded normal results. He remained consistently on a dosage of 50 mg oral prednisone. Blood tests yielded results within the normal range or were negative, with the exception of the antinuclear antibody. He did not respond to conventional IMT and biological response modifier agents. Ultimately, the patient began oral cyclophosphamide. One month after commencing cyclophosphamide treatment, the oral prednisone dosage was gradually reduced without any flare-up. oral cyclophosphamide can serve as a valuable treatment for periocular inflammation that does not respond to standard conventional IMT and biologic response modifier agents.

Intravenous Golimumab in the Treatment of Juvenile Idiopathic Arthritis and Its Associated Uveitis

PURPOSE

To demonstrate the efficacy and safety of intravenous golimumab infusion in treating juvenile idiopathic arthritis-associated anterior uveitis.

METHODS

This study was a retrospective observation case series. Electronic records of patients diagnosed with juvenile idiopathic arthritis-associated anterior uveitis who received intravenous golimumab infusion were examined.

RESULTS

A total of 24 eyes of 13 patients were included in this study. During 12 months before starting intravenous golimumab, the median grade of anterior chamber reaction was 1 (range: 0.5-3), and the median number of flare-ups was 1 (1-3). During 12 months following the start of intravenous golimumab, the median grade of anterior chamber reaction was 0 (range: 0-1), and the median number of flare-ups was 0 (range: 0-1). Before starting intravenous golimumab, the average number of immunomodulatory agents was 2.6 ± 1.0 with a range of 2 to 5. The average age of patients at the time of starting intravenous golimumab was 13.69 ± 5.23 years (range between 5 and 22). A total of 11 (84.6%) patients responded to intravenous golimumab. The medication was discontinued in one patient due to ineffectiveness and in another patient due to the development of psoriasis as an adverse effect. Cystoid macular edema was present in six eyes of three patients which resolved in all six eyes after starting intravenous golimumab.

CONCLUSION

Intravenous golimumab proves to be efficacious and safe for inducing and sustaining remission in JIA and JIA-associated uveitis. Nonetheless, further robust studies with larger sample sizes are needed to substantiate our findings.

Tuberculosis-related serpiginous choroiditis: aggressive therapy with dual concomitant combination of multiple anti-tubercular and multiple immunosuppressive agents is needed to halt the progression of the disease

Background/purpose

Serpiginous-like choroiditis is a rare immune-mediated sub-entity of tubercular uveitis with a usually deleterious outcome. Treatment is still controversial. The purpose in this case series is to indicate that only aggressive treatment comprising multiple anti-tubercular and multiple immunosuppressive agents seems to be able to halt the disease progression.

Methods

This retrospective case series included patients diagnosed with Interferon Gamma Release Assays (IGRA) -positive serpiginous choroiditis, seen at the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland, treated with combined multiple antitubercular and immunosuppressive agents at presentation and having a sufficient follow-up. Disease history before referral, appraisal of disease, treatment modalities and follow-up were analyzed. Inclusion criteria were positive IGRA patients with serpiginous choroiditis with complete Spectral-Domain Optic coherence tomography (SD-OCT) and angiography images.

Results

From 2001 to 2020, 24 of 1525 new patients (0.26%) were diagnosed as serpiginous choroiditis. 10/24 were related to tuberculosis (positive IGRA and/or hyper-positive Mantoux test), 8/24 were IGRA negative and in 6 there was no information available. 4/10 tuberculosis related serpiginous patients fulfilled the inclusion criteria. Mean age was 39 ± 5.3 years. Snellen best corrected vision acuity (BCVA) at presentation in 3/4 where the macula was preserved was 0.96 ± 0.08. In 3/4 patients, treatment with multiple tuberculostatic therapy combined with multiple immunosuppressive agents, started at presentation or in the initial months after the first consultation, was shown to stop the progression of the disease, with a retained visual acuity of 1.0. One patient with macular involvement and a bilateral visual acuity of hand movements after 11 years of insufficient treatment, improved his visual acuity to 0.25 OD and 0.05 OS and presented a substantial visual field improvement that stabilized once multiple anti-tubercular and immunosuppressive therapy was introduced.

Conclusion

IGRA-positive serpiginous choroiditis (serpiginous-like choroiditis) could be halted by combined multiple tuberculostatic and multiple immunosuppressive agents, as seen in our study where 3/4 early treated patients had conserved central function and one late treated patient had recovered a substantial amount of visual field. In all 4 patients this treatment regimen halted the progression of the disease.