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Papaliodis GN, Yu Y, Brill DA, Sobrin L, VanderBeek B. Malignancy Risk Associated with the Use of Systemic Immunomodulatory Therapy in the Management of Non-infectious Uveitis. Am J Ophthalmol 2024:S0002-9394(24)00166-1. [PMID: 38679356 DOI: 10.1016/j.ajo.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Patients with non-infectious uveitis (NIU) can require treatment with systemic immunomodulatory therapy (IMT), but it is unclear whether IMT drug categories increase the risk of malignancy in NIU patients. The purpose of this study is to determine if the use of systemic IMT in patients with NIU is associated with an increased risk of malignancy. DESIGN Clinical cohort study METHODS: Patients were identified from a U.S. administrative medical claims database including some Medicare Advantage and commercial plans, from 2000 to 2022. 318,499 NIU patients were identified. Enrollees were included in the analysis if they met the following criteria: continuous enrollment in the plan for at least 1 year, and at least two consecutive visit diagnoses of any type of NIU, after initiation of systemic IMT. We compared the rates of incident malignancy in NIU patients treated with IMT versus the rates among NIU patients not treated with IMT. Multivariable Cox regression models were used to predict the hazard of developing incident cancer. RESULTS Of the 318,498 patients with NIU identified over a 15-year period, 318,996 did not develop malignancy, and 492 did develop malignancy. Of the patients that developed a malignancy, 280 (57%) were treated with systemic corticosteroids; 204 (41%) were treated with antimetabolites; 44 (9%) were treated with T cell inhibitors; 108 (22%) were treated with TNF alpha inhibitors; 2 (0.004%) were treated with interleukin -6 (IL-6) inhibitors; and 1 was treated with CD-20 antibodies. There were no malignancies reported in the group treated with alkylating agents. There was no association between any of the drug classes and incidence of malignancy. CONCLUSION This study suggests that there is no increased risk of malignancy associated with the use of systemic IMT for patients with NIU.
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Affiliation(s)
- George N Papaliodis
- Massachusetts Eye and Ear Infirmary/Harvard Medical School, Ocular Immunology and Uveitis Service, Boston, Massachusetts.
| | - Yinxi Yu
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Lucia Sobrin
- Massachusetts Eye and Ear Infirmary/Harvard Medical School, Ocular Immunology and Uveitis Service, Boston, Massachusetts
| | - Brian VanderBeek
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania
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Azzopardi M, Chong YJ, Sreekantam S, Barry RJ, Poonit N, Rauz S, Murray PI. Real-World Experience in the Use of Immunosuppression for the Management of Inflammatory Eye Disease. Ocul Immunol Inflamm 2024:1-10. [PMID: 38349962 DOI: 10.1080/09273948.2024.2311743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
PURPOSE Patients with sight-threatening inflammatory eye disease (IED) are maintained on systemic immunosuppression whilst in long-term clinical remission. There are no clear guidelines on the duration of remission before implementing treatment withdrawal. We present a real-world analysis on the use of immunosuppression in IED in long-term remission and consider strategies for withdrawal. METHODS Adult IED patients on systemic immunosuppression were categorised into four disease groups: Corneal Transplant Survival Strategies (CTSS), Ocular Surface Disease (OSD), Non-infectious Uveitis (NIU) and Scleritis. Patients with Behçet's disease were excluded. Data on systemic immunosuppressants and biologics used; duration of treatment; reasons for drug discontinuation; disease activity/remission status; duration of clinical remission with an emphasis on patients who had been in remission for a minimum of 24 months were captured. RESULTS Out of a total of 303 IED patients, 128 were on systemic immunosuppression with a clinical remission of their ocular disease for ≥24 months. The median duration of remission was 4-5 years with the longest duration of remission 22 years, and some patients on immunosuppression for up to 23 years. Sixty patients stopped at least one immunosuppressive agent without prior discussion with a health-care practitioner. CONCLUSION Progressive conditions, such as cicatrising conjunctivitis may require lifelong immunosuppression, but patients with NIU and Scleritis and those on CTSS, immunosuppression withdrawal should be considered if they remain in remission for 2 years. Any patient stopping a medication should be contacted immediately for counselling. These data will better inform patients, encourage adherence and aide formal guideline development.
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Affiliation(s)
- Matthew Azzopardi
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yu Jeat Chong
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Sreekanth Sreekantam
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Robert J Barry
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Natraj Poonit
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Saaeha Rauz
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Philip I Murray
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Zhang H, Houadj L, Wu KY, Tran SD. Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review. Diagnostics (Basel) 2024; 14:336. [PMID: 38337852 PMCID: PMC10855398 DOI: 10.3390/diagnostics14030336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.
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Affiliation(s)
- Huixin Zhang
- Faculty of Medicine, Laval University, Quebec, QC G1V 0A6, Canada;
| | - Lysa Houadj
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada;
| | - Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Kempen JH, Newcomb CW, Washington TL, Foster CS, Sobrin L, Thorne JE, Jabs DA, Suhler EB, Rosenbaum JT, Sen HN, Levy-Clarke GA, Nussenblatt RB, Bhatt NP, Lowder CY, Goldstein DA, Leiderman YI, Acharya NR, Holland GN, Read RW, Dunn JP, Dreger KA, Artornsombudh P, Begum HA, Fitzgerald TD, Kothari S, Payal AR, Daniel E, Gangaputra SS, Kaçmaz RO, Liesegang TL, Pujari SS, Khachatryan N, Maghsoudlou A, Suga HK, Pak CM, Helzlsouer KJ, Buchanich JM. Use of Immunosuppression and the Risk of Subsequent Overall or Cancer Mortality. Ophthalmology 2023; 130:1258-1268. [PMID: 37499954 PMCID: PMC10811288 DOI: 10.1016/j.ophtha.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE To determine the incidence of all-cause and cancer mortality (CM) in association with immunosuppression. DESIGN Retrospective cohort study at ocular inflammatory disease (OID) subspecialty centers. We harvested exposure and covariate data retrospectively from clinic inception (earliest in 1979) through 2010 inclusive. Then we ascertained overall and cancer-specific mortalities by National Death Index linkage. We constructed separate Cox models to evaluate overall and CM for each class of immunosuppressant and for each individual immunosuppressant compared with person-time unexposed to any immunosuppression. PARTICIPANTS Patients with noninfectious OID, excluding those with human immunodeficiency infection or preexisting cancer. METHODS Tumor necrosis factor (TNF) inhibitors (mostly infliximab, adalimumab, and etanercept); antimetabolites (methotrexate, mycophenolate mofetil, azathioprine); calcineurin inhibitors (cyclosporine); and alkylating agents (cyclophosphamide) were given when clinically indicated in this noninterventional cohort study. MAIN OUTCOME MEASURES Overall mortality and CM. RESULTS Over 187 151 person-years (median follow-up 10.0 years), during which 15 938 patients were at risk for mortality, we observed 1970 deaths, 435 due to cancer. Both patients unexposed to immunosuppressants (standardized mortality ratio [SMR] = 0.95, 95% confidence interval [CI], 0.90-1.01) and those exposed to immunosuppressants but free of systemic inflammatory diseases (SIDs) (SMR = 1.04, 95% CI, 0.95-1.14) had similar mortality risk to the US population. Comparing patients exposed to TNF inhibitors, antimetabolites, calcineurin inhibitors, and alkylating agents with patients not exposed to any of these, we found that overall mortality (adjusted hazard ratio [aHR] = 0.88, 0.89, 0.90, 1.11) and CM (aHR = 1.25, 0.89, 0.86, 1.23) were not significantly increased. These results were stable in sensitivity analyses whether excluding or including patients with SID, across 0-, 3-, or 5-year lags and across quartiles of immunosuppressant dose and duration. CONCLUSIONS Our results, in a cohort where the indication for treatment was proven unassociated with mortality risk, found that commonly used immunosuppressants-especially the antimetabolites methotrexate, mycophenolate mofetil, and azathioprine; the TNF inhibitors adalimumab and infliximab, and cyclosporine-were not associated with increased overall and CM over a median cohort follow-up of 10.0 years. These results suggest the safety of these agents with respect to overall and CM for patients treated with immunosuppression for a wide range of inflammatory diseases. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Sight for Souls, Bellevue, Washington; MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.
| | - Craig W Newcomb
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri L Washington
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts
| | - Lucia Sobrin
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer E Thorne
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Portland Veteran's Affairs Medical Center, Portland, Oregon
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon; Legacy Devers Eye Institute, Portland, Oregon
| | - H Nida Sen
- Department of Ophthalmology, George Washington University, Washington, District of Columbia; Janssen Retina Global Clinical Development, Princeton, New Jersey
| | - Grace A Levy-Clarke
- Department of Ophthalmology and Visual Sciences, West Virginia University, Morgantown, West Virginia
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirali P Bhatt
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Careen Y Lowder
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic, Cleveland, Ohio
| | - Debra A Goldstein
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Yannek I Leiderman
- Illinois Eye & Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Nisha R Acharya
- F.I. Proctor Foundation, Department of Ophthalmology, University of California San Francisco School of Medicine, San Francisco, California
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Russell W Read
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - James P Dunn
- Mid-Atlantic Retina, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Kurt A Dreger
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Pichaporn Artornsombudh
- Department of Ophthalmology, Somdech Phra Pinkloa Hospital, Royal Thai Navy, Bangkok, Thailand; Department of Ophthalmology, Chulalongkorn University, Bangkok, Thailand
| | - Hosne A Begum
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tonetta D Fitzgerald
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srishti Kothari
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ebenezer Daniel
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sapna S Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Teresa L Liesegang
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon
| | - Siddharth S Pujari
- Siddharth Netralaya Superspecialty Eye Hospital, Belgaum, Karnataka, India
| | - Naira Khachatryan
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hilkiah K Suga
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Clara M Pak
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Kathy J Helzlsouer
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanine M Buchanich
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Jia Y, Yao P, Li J, Wei X, Liu X, Wu H, Wang W, Feng C, Li C, Zhang Y, Cai Y, Zhang S, Ma X. Causal associations of Sjögren's syndrome with cancers: a two-sample Mendelian randomization study. Arthritis Res Ther 2023; 25:171. [PMID: 37715206 PMCID: PMC10503000 DOI: 10.1186/s13075-023-03157-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Several observational studies have explored the associations between Sjögren's syndrome (SS) and certain cancers. Nevertheless, the causal relationships remain unclear. Mendelian randomization (MR) method was used to investigate the causality between SS and different types of cancers. METHODS We conducted the two-sample Mendelian randomization with the public genome-wide association studies (GWASs) summary statistics in European population to evaluate the causality between SS and nine types of cancers. The sample size varies from 1080 to 372,373. The inverse variance weighted (IVW) method was used to estimate the causal effects. A Bonferroni-corrected threshold of P < 0.0031 was considered significant, and P value between 0.0031 and 0.05 was considered to be suggestive of an association. Sensitivity analysis was performed to validate the causality. Moreover, additional analysis was used to assess the associations between SS and well-accepted risk factors of cancers. RESULTS After correcting the heterogeneity and horizontal pleiotropy, the results indicated that patients with SS were significantly associated with an increased risk of lymphomas (odds ratio [OR] = 1.0010, 95% confidence interval [CI]: 1.0005-1.0015, P = 0.0002) and reduced risks of prostate cancer (OR = 0.9972, 95% CI: 0.9960-0.9985, P = 2.45 × 10-5) and endometrial cancer (OR = 0.9414, 95% CI: 0.9158-0.9676, P = 1.65 × 10-5). Suggestive associations were found in liver and bile duct cancer (OR = 0.9999, 95% CI: 0.9997-1.0000, P = 0.0291) and cancer of urinary tract (OR = 0.9996, 95% CI: 0.9992-1.0000, P = 0.0281). No causal effect of SS on other cancer types was detected. Additional MR analysis indicated that causal effects between SS and cancers were not mediated by the well-accepted risk factors of cancers. No evidence of the causal relationship was observed for cancers on SS. CONCLUSIONS SS had significant causal relationships with lymphomas, prostate cancer, and endometrial cancer, and suggestive evidence of association was found in liver and bile duct cancer and cancer of urinary tract, indicating that SS may play a vital role in the incidence of these malignancies.
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Affiliation(s)
- Yiwei Jia
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Peizhuo Yao
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Jia Li
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Xinyu Wei
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Xuanyu Liu
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Huizi Wu
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Weiwei Wang
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Cong Feng
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Chaofan Li
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Yu Zhang
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Yifan Cai
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China
| | - Shuqun Zhang
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China.
| | - Xingcong Ma
- Department of Oncology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710004, People's Republic of China.
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Dutta Majumder P, Agarwal S, Shah M, Srinivasan B, K P, Iyer G, Sharma N, Biswas J, McCluskey P. Necrotizing Scleritis: A Review. Ocul Immunol Inflamm 2023:1-15. [PMID: 37279404 DOI: 10.1080/09273948.2023.2206898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 06/08/2023]
Abstract
Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.
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Affiliation(s)
| | - Shweta Agarwal
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Mauli Shah
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Priyadarshini K
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Geetha Iyer
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Namrata Sharma
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotirmay Biswas
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Peter McCluskey
- Save Sight Institute, The University of Sydney, Sydney, Australia
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Deng J, Liu M, Xiao R, Wang J, Liao X, Ye Z, Sun Z. Risk, Incidence, and Mortality of Breast Cancer in Primary Sjögren’s Syndrome: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:904682. [PMID: 35844507 PMCID: PMC9283727 DOI: 10.3389/fimmu.2022.904682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Primary Sjögren’s syndrome (pSS) and breast cancer are a highly prevalent autoimmune disease and malignancy, respectively, both occurring predominantly in females. Whether there is a link between these two diseases is uncertain. We conducted a systematic review and meta-analysis to investigate the risk, incidence, and mortality of breast cancer in patients with pSS. Methods We systematically searched Embase, PubMed, and Web of Science on January 31, 2022 to identify the study that assessed risk, incidence, or mortality of breast cancer in pSS. The fixed or random-effects models were applied to pool the effect estimates based on heterogeneity measured by Cochran’s Q-test and Higgins’ I2. Results Ten studies involving 725,805 participants and 64,836 pSS patients were included in our analysis. The pooled result showed that, overall, pSS was not associated with the risk (SIR=0.92, 95%CI: 0.66-1.29, P=0.646) and mortality (HR = 0.78, 95%CI: 0.26-2.34, P = 0.664) of breast cancer; however, when stratified by geographic region, we found that patients with pSS in Asian countries (SIR=1.32, 95%CI: 1.10-1.58, P=0.003) and Argentina (SIR=3.76, 95%CI: 1.04-9.45, P=0.019) had an elevated risk of breast cancer, while pSS in Europe was associated with a reduced risk (SIR=0.61, 95%CI: 0.51-0.73, P<0.001). The pooled result from 28,635 female pSS patients indicated that the incidence of breast cancer was 2.15 (95% CI: 1.33-3.50) per 1000 person/years. Conclusion This study suggests that there may be geographical differences in the association between pSS and breast cancer risk; patients with pSS in European countries are associated with a lower risk of breast cancer, while Asia and Argentina are the opposite. Future research is needed to further characterize the effect of pSS on breast cancer risk and the pathophysiological mechanisms underlying this association to unravel the complex relationship between the two.
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Affiliation(s)
- Jian Deng
- Department of Thyroid Breast Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Center for Breast Cancer Prevention and Treatment, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Mengsi Liu
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
- *Correspondence: Zhen Sun, ; Mengsi Liu,
| | - Ruoyi Xiao
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Jin Wang
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Xibei Liao
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhen Ye
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhen Sun
- Department of Clinical Medicine, Hengyang Medical School, University of South China, Hengyang, China
- *Correspondence: Zhen Sun, ; Mengsi Liu,
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Tang Lee Say TL, Yang V, Fingret JM, Zagora S, Symes R, Younan C, Cornish EE, Verma N, Sammel A, Wakefield D, Speden D, McCluskey PJ. Adalimumab in patients with vision-threatening uveitis: real-world clinical experience. BMJ Open Ophthalmol 2021; 6:e000819. [PMID: 34632076 PMCID: PMC8477319 DOI: 10.1136/bmjophth-2021-000819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives Biologics are rapidly emerging as an effective vision saving addition to systemic uveitis therapy. The aim of this multicentre retrospective study is to review the outcomes of a large group of patients treated with adalimumab. Methods A retrospective chart review of patients with refractory non-infectious, active uveitis treated with adalimumab was conducted. The main outcome measures were ability to reduce prednisolone dose, ability to control uveitis, final visual acuity and time to treatment failure. Results Forty-six patients with uveitis, treated with adalimumab were included in the study. The most common anatomical uveitis phenotype was panuveitis (n=17, 37.0%). The most common diagnosis was idiopathic uveitis (n=19, 41.3%). At their latest review (mean: 4.46 years; median 4.40 years), 35 (76.1%) patients were able to discontinue corticosteroids, 11 (23.9%) patients were able to taper to <7.5 mg/day and only 1 (2.2%) patient required 10 mg of prednisone. The mean visual acuity at the latest follow-up of the worse eye was logarithm of the minimum angle of resolution (logMAR) 0.42 (SD 0.72), while the mean visual acuity of the better eye was logMAR 0.19 (SD 0.34). Of the 89 eyes, 21 (23.6%) eyes improved by at least 2 lines, 5 eyes (5.6%) deteriorated by ≥2 lines while vision was unchanged in the remaining 63 (70.8%) eyes. The time to recurrence was 1 in 12.47 person-years for adalimumab, with a 17.4% (8 patient) relapse rate. There were no serious adverse events. Conclusions This study highlights the efficacy of adalimumab in patients with vision-threatening non-infectious uveitis, preserving vision and allowing reduction of corticosteroid dose.
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Affiliation(s)
- Timothy Lee Tang Lee Say
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Cardinal Santos Medical Center, San Juan, Manila, Philippines
| | - Verlyn Yang
- Royal Hobart Hospital, Hobart, Tasmania, Australia.,Gold Coast Hospital and Health Service, Southport, Queensland, Australia.,University of Tasmania, Hobart, Tasmania, Australia
| | - Jacob M Fingret
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Sophia Zagora
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Richard Symes
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Christine Younan
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Elisa Eleanor Cornish
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Nitin Verma
- Royal Hobart Hospital, Hobart, Tasmania, Australia.,University of Tasmania, Hobart, Tasmania, Australia.,East Timor Eye Program, Hobart, Tasmania, Australia
| | - Anthony Sammel
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Denis Wakefield
- Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | | | - Peter J McCluskey
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia.,Royal Hobart Hospital, Hobart, Tasmania, Australia.,Saint Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
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9
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Kempen JH, Pistilli M, Begum H, Fitzgerald TD, Liesegang TL, Payal A, Zebardast N, Bhatt NP, Foster CS, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Sen HN, Suhler EB, Thorne JE. Remission of Non-Infectious Anterior Scleritis: Incidence and Predictive Factors. Am J Ophthalmol 2021; 223:377-395. [PMID: 30951689 DOI: 10.1016/j.ajo.2019.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 02/18/2019] [Accepted: 03/20/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess how often non-infectious anterior scleritis remits and identify predictive factors. METHODS Our retrospective cohort study at four ocular inflammation subspecialty centers collected data for each affected eye/patient at every visit from center inception (1978, 1978, 1984, 2005) until 2010. Remission was defined as inactivity of disease off all suppressive medications at all visits spanning at least three consecutive months or at all visits up to the last visit (to avoid censoring patients stopping follow-up after remission). Factors potentially predictive of remission were assessed using Cox regression models. RESULTS During 1,906 years' aggregate follow-up of 832 affected eyes, remission occurred in 214 (170 of 584 patients). Median time-to-remission of scleritis = 7.8 years (95% confidence interval [CI]: 5.7, 9.5). More remissions occurred earlier than later during follow-up. Factors predictive of less scleritis remission included scleritis bilaterality (adjusted hazard ratio [aHR] = 0.46, 95% CI: 0.32-0.65); and diagnosis with any systemic inflammatory disease (aHR = 0.36, 95% CI: 0.23-0.58), or specifically with Rheumatoid Arthritis (aHR = 0.22), or Granulomatosis with Polyangiitis (aHR = 0.08). Statin treatment (aHR = 1.53, 95% CI: 1.03-2.26) within ≤90 days was associated with more remission incidence. CONCLUSIONS Our results suggest scleritis remission occurs more slowly in anterior scleritis than in newly diagnosed anterior uveitis or chronic anterior uveitis, suggesting that attempts at tapering suppressive medications is warranted after long intervals of suppression. Remission is less frequently achieved when systemic inflammatory diseases are present. Confirmatory studies of whether adjunctive statin treatment truly can enhance scleritis remission (as suggested here) are needed.
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10
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Abstract
The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.
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Affiliation(s)
- Bryn M Burkholder
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Clinical Trials and Evidence Synthesis, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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11
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Ferreira LB, Smith AJ, Smith JR. Biologic Drugs for the Treatment of Noninfectious Uveitis. Asia Pac J Ophthalmol (Phila) 2021; 10:63-73. [PMID: 33481396 DOI: 10.1097/apo.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The management of noninfectious uveitis is constantly evolving. A new "biologic era" in treatment began after the effectiveness of tumor necrosis factor-alpha blocking drugs was demonstrated in rheumatologic inflammatory diseases. The goal of specific immunomodulation with a biologic drug is to target inflammation at the molecular level with a low rate of serious adverse events. The purpose of this review is to summarize current knowledge of biologic drugs in the treatment of noninfectious uveitis by describing clinical studies and recent pharmacological developments.
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Affiliation(s)
| | - Anthony J Smith
- College of Medicine & Public Health, Flinders University, Adelaide, Australia
- Clinical Immunology and Allergy Unit, Flinders Medical Centre, Adelaide, Australia
| | - Justine R Smith
- College of Medicine & Public Health, Flinders University, Adelaide, Australia
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12
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Ogra S, Sims JL, McGhee CNJ, Niederer RL. Ocular complications and mortality in peripheral ulcerative keratitis and necrotising scleritis: The role of systemic immunosuppression. Clin Exp Ophthalmol 2020; 48:434-441. [DOI: 10.1111/ceo.13709] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 11/28/2019] [Accepted: 12/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Siddharth Ogra
- Department of OphthalmologyAuckland District Health Board Auckland New Zealand
| | - Joanne L. Sims
- Department of OphthalmologyAuckland District Health Board Auckland New Zealand
| | - Charles N. J. McGhee
- Department of OphthalmologyAuckland District Health Board Auckland New Zealand
- Department of OphthalmologyUniversity of Auckland Auckland New Zealand
| | - Rachael L. Niederer
- Department of OphthalmologyAuckland District Health Board Auckland New Zealand
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13
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Zagora S, McCluskey P. Biologic therapy for uveitis: a new beginning. Intern Med J 2019; 49:1349-1351. [PMID: 31713337 DOI: 10.1111/imj.14635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Sophia Zagora
- Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter McCluskey
- Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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14
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Jabs DA. Immunosuppression for the Uveitides. Ophthalmology 2018; 125:193-202. [PMID: 28942074 PMCID: PMC5794515 DOI: 10.1016/j.ophtha.2017.08.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/21/2017] [Accepted: 08/07/2017] [Indexed: 12/19/2022] Open
Abstract
The uveitides are a collection of more than 30 diseases characterized by intraocular inflammation. Many cases of juvenile idiopathic arthritis-associated uveitis, many cases of intermediate uveitis, and most cases of posterior and panuveitides requiring treatment are treated with corticosteroids and immunosuppression. Disease-specific, time-updated modeling of clinical data for several uveitides suggests superior prevention of ocular complications and visual outcomes with immunosuppression. These studies also suggest that oral corticosteroids at doses low enough for safe long-term therapy (i.e., <7.5 mg/day) are ineffective, implying that immunosuppression should be part of the initial regimen. The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study was a randomized comparative effectiveness trial comparing systemic therapy with oral corticosteroids and immunosuppression with regional corticosteroid treatment. It demonstrated that, when used properly, oral corticosteroids and immunosuppression can be given safely for up to 7 years with no evident increased risk of systemic side effects compared with regional corticosteroid therapy, except for greater antibiotic use for infections. The Systemic Treatment for Eye Diseases (SITE) Cohort Study suggested long-term safety for this approach, when the immunosuppressive agents were antimetabolites or calcineurin inhibitors. Thus, oral corticosteroids and immunosuppression may be a preferred initial therapy for many noninfectious, intermediate, posterior, and panuveitides. Nonalkylating-agent immunosuppression has a low rate of sustained, drug-free remissions, <10%/year. Nonalkylating-agent immunosuppression for >3 years with control of the inflammation for >2 years is associated with a decreased risk of relapse after discontinuing immunosuppression. Alkylating agents can induce sustained drug-free remissions but likely increase the lifetime risk of cancer. Biologics, which target specific cytokines and pathways, hold promise for the future. Monoclonal antibodies directed against tumor necrosis factor (TNF)-α have been studied most often, and one, adalimumab, is U.S. Food and Drug Administration approved for the treatment of noninfectious, intermediate, posterior, and panuveitides.
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Affiliation(s)
- Douglas A Jabs
- Departments of Ophthalmology and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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15
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Dick AD, Rosenbaum JT, Al-Dhibi HA, Belfort R, Brézin AP, Chee SP, Davis JL, Ramanan AV, Sonoda KH, Carreño E, Nascimento H, Salah S, Salek S, Siak J, Steeples L. Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative. Ophthalmology 2018; 125:757-773. [PMID: 29310963 DOI: 10.1016/j.ophtha.2017.11.017] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/06/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew D Dick
- Ophthalmology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; Institute of Ophthalmology, University College London, London, United Kingdom; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and Institute of Ophthalmology, University College London, London, United Kingdom.
| | - James T Rosenbaum
- Legacy Devers Eye Institute, Portland, Oregon; Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; Departments of Medicine and Cell Biology, Oregon Health & Science University, Portland, Oregon
| | - Hassan A Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Rubens Belfort
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, Federal University of São Paulo and Vision Institute, São Paulo, Brazil
| | - Antoine P Brézin
- Service d'ophtalmologie, Université Paris Descartes, Hôpital Cochin, Paris, France
| | - Soon Phaik Chee
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore; Duke-National University of Singapore Medical School, Ophthalmology & Visual Sciences Academic Clinical Program, Singapore, Republic of Singapore
| | - Janet L Davis
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Athimalaipet V Ramanan
- Ophthalmology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Koh-Hei Sonoda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ester Carreño
- Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Sawsen Salah
- Service d'ophtalmologie, Université Paris Descartes, Hôpital Cochin, Paris, France
| | - Sherveen Salek
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jay Siak
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore; Duke-National University of Singapore Medical School, Ophthalmology & Visual Sciences Academic Clinical Program, Singapore, Republic of Singapore
| | - Laura Steeples
- Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; Manchester Royal Eye Hospital, Central Manchester University Hospitals, and University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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16
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Leitlinie Nr. 24b der DOG und BVA. Ophthalmologe 2017; 114:1122-1134. [DOI: 10.1007/s00347-017-0582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Yates W, McCluskey P, Wakefield D. Long-term immunosuppressive therapy for inflammatory eye disease – the link between systemic treatment, cardiovascular risk and disease? EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1349610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- William Yates
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia
- School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - Peter McCluskey
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia
- Save Sight Institute, University of Sydney, Sydney, Australia
| | - Denis Wakefield
- School of Medical Sciences, University of New South Wales, Kensington, Australia
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18
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Fardeau C, Simon A, Rodde B, Viscogliosi F, Labalette P, Looten V, Tézenas du Montcel S, LeHoang P. Interferon-alpha2a and Systemic Corticosteroid in Monotherapy in Chronic Uveitis: Results of the Randomized Controlled BIRDFERON Study. Am J Ophthalmol 2017; 177:182-194. [PMID: 28315319 DOI: 10.1016/j.ajo.2017.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Macular edema is the leading cause of vision loss in bilateral chronic noninfectious posterior uveitis, and is currently being treated using corticosteroids, immunosuppressive agents, and biotherapies. The aim of this trial was to assess and compare the efficacy and safety of corticosteroids and interferon-α (IFN-α) in adults with such conditions. DESIGN Randomized controlled trial. METHODS Subjects: Adult patients with bilateral posterior autoimmune noninfectious and nontumoral uveitis complicated by macular edema in at least 1 eye. INTERVENTION Patients received either subcutaneous IFN-α2a, systemic corticosteroids, or no treatment for 4 months. The efficacy and safety were assessed for up to 4 months. MAIN OUTCOME MEASURES The main endpoint was the change of the central foveal thickness (CFT) obtained by optical coherence tomography. RESULTS Forty-eight patients were included. In intention-to-treat analysis, the median CFT change showed no significant difference. However, the per-protocol analysis showed a significant difference between groups for both eyes (OD and OS), and for the worse and better eyes. Statistically significant difference was found between the control and corticosteroid groups for the OD (P = .0285), and between the control and IFN-α groups for the OD (P = .0424) and worse eye (P = .0354). Serious adverse events occurred in 2 patients in the IFN group, in 1 patient in the corticosteroid group, and in 2 patients in the control group and were completely resolved after switch. CONCLUSIONS IFN-α and systemic corticosteroids, compared with no treatment, were associated with significant anatomic and visual improvement shown in the per-protocol study.
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19
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Wakefield D, McCluskey P, Wildner G, Thurau S, Carr G, Chee SP, Forrester J, Dick A, Hudson B, Lightman S, Smith J, Tugal-Tutkun I. Inflammatory eye disease: Pre-treatment assessment of patients prior to commencing immunosuppressive and biologic therapy: Recommendations from an expert committee. Autoimmun Rev 2017; 16:213-222. [PMID: 28137477 DOI: 10.1016/j.autrev.2017.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022]
Abstract
AIM To outline recommendations from an expert committee on the assessment and investigation of patients with severe inflammatory eye disease commencing immunosuppressive and/or biologic therapy. METHOD The approach to assessment is based on the clinical experience of an expert committee and a review of the literature with regard to corticosteroids, immunosuppressive drug and biologic therapy and other adjunct therapy in the management of patients with severe sight-threatening inflammatory eye disease. CONCLUSION We recommend a careful assessment and consultative approach by ophthalmologists or physicians experienced in the use of immunosuppressive agents for all patients commencing immunosuppressive and/or biologic therapy for sight threatening inflammatory eye disease with the aim of preventing infection, cardiovascular, metabolic and bone disease and reducing iatrogenic side effects.
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Affiliation(s)
- Denis Wakefield
- University of New South Wales, Faculty of Medicine, Kensington, Australia.
| | - Peter McCluskey
- Save Sight Institute, Sydney Eye Hospital, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Gerhild Wildner
- Section of Immunobiology, Department of Ophthalmology, Clinic of the University of Munich, Munich, Germany
| | - Stephan Thurau
- Section of Immunobiology, Department of Ophthalmology, Clinic of the University of Munich, Munich, Germany
| | - Gregory Carr
- Manly Hospital, North Shore Private Hospital, St Leonards, NSW, Australia
| | - Soon-Phaik Chee
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore; Singapore Eye Research Institute, Department of Ophthalmology, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Duke-NUS Graduate Medical School, Singapore National Eye Centre, Ocular Inflammation and Immunology Department, Singapore
| | - John Forrester
- The Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Andrew Dick
- UCL-Institute of Ophthalmology, London, UK; School of Clinical Science, University of Bristol, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital, London, UK
| | - Bernard Hudson
- Department of Microbiology & Infectious Diseases, Royal North Shore Hospital, St Leonards, Sydney 2065, Australia
| | - Susan Lightman
- UCL/Institute of Ophthalmology, Moorfields Eye Hospital, London EC1V 2PD, UK
| | - Justine Smith
- Eye & Vision Health, Flinders University School of Medicine, Adelaide, Australia
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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Abstract
INTRODUCTION Noninfectious posterior uveitis (NIPU) remains a significant burden of legal blindness. Because of its immune mediated and chronic recurrent nature, common therapy includes (systemic) corticosteroids and immune modulatory agents. Most treatments bear the risk of significant adverse effects. Therefore efforts are made to administer therapeutic agents directly into the vitreous cavity. The purpose of this article is to identify the role of intravitreally applied sirolimus as a recently approved therapeutic option in NIPU. AREAS COVERED A MEDLINE database search was conducted through August 2015 using the terms: intravitreal injection, pharmacology, sirolimus, treatment and uveitis. To provide ongoing and future perspectives in treatment options, also clinical trials as registered at ClinicalTrials.gov were included. Sirolimus (Opsiria) was in licensed from SANTEN in 2015 and approved in Phase III registration trials in the US, Europe and other countries for NIPU. Current information results mainly from registration and Phase III trials. EXPERT OPINION Intravitreal sirolimus appears to be an interesting option in the treatment algorithms of NIPU because of its highly targeted molecular effects, nonsteroidal nature and good safety profile. It has the advantage to avoid systemic side effects, but this has to be balanced against the fact that treatment covers one eye only and bears the risks of any intraocular procedure. Nevertheless a careful evaluation of this agent has to be made, as current experience is almost exclusively based on registration trials and long-term effects still have to be explored.
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Affiliation(s)
- Uwe Pleyer
- a Department of Ophthalmology, Charité , Universitäts-Medizin Berlin, Campus Virchow-Klinikum, University Medicine Berlin , Augustenburger Platz 1, D-13353 Berlin , Germany
| | - Stephan R Thurau
- b Ophthalmology Department , Ludwig Maximilian University of Munich , 80336 Munich , Germany
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21
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Wakefield D, Yates W, Amjadi S, McCluskey P. HLA-B27 Anterior Uveitis: Immunology and Immunopathology. Ocul Immunol Inflamm 2016; 24:450-9. [PMID: 27245590 DOI: 10.3109/09273948.2016.1158283] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute anterior uveitis (AAU) is the commonest type of uveitis and HLA-B27 AAU is the most frequently recognized type of acute anterior uveitis and anterior uveitis overall. Recent evidence indicates that acute anterior uveitis is a heterogenous disease, is polygenic and is frequently associated with the spondyloarthropathies (SpA). Studies of patients with AAU and animal models of disease indicate a role for innate immunity, the IL-23 cytokine pathway and exogenous factors, in the pathogenesis of both SpA and acute anterior uveitis. Recently described genetic associations cluster around immunologic pathways, including the IL-17 and IL-23 pathways, antigen processing and presentation, and lymphocyte development and activation. Patients with ankylosing spondylitis (AS) and AAU share other genetic markers, such as ERAP-1, which show strong evidence of gene-gene interaction and point to new mechanisms of disease pathogenesis. These observations have major implications for understanding the pathogenesis of HLA-B27 diseases, such as AAU, and may lead to the development of more specific therapy for AAU. Received 6 January 2016; revised 6 February 2016; accepted 18 February 2016; published online 31 May 2016.
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Affiliation(s)
- Denis Wakefield
- a Laboratory of Ocular Immunology , University of New South Wales , Kensington , Sydney , Australia
| | - William Yates
- a Laboratory of Ocular Immunology , University of New South Wales , Kensington , Sydney , Australia
| | - Shahriar Amjadi
- a Laboratory of Ocular Immunology , University of New South Wales , Kensington , Sydney , Australia
| | - Peter McCluskey
- b Save Sight Institute, Discipline of Ophthalmology , Sydney Medical School, The University of Sydney , Sydney , Australia
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Wakefield D, McCluskey P, Wildner G, Thurau S. Unmet Needs and Future Directions in Inflammatory Eye Disease. Ocul Immunol Inflamm 2016; 25:122-133. [PMID: 27070178 DOI: 10.3109/09273948.2016.1151897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To explore the unmet needs in the management of patients with severe inflammatory eye disease (IED), future directions for research and therapy, and to develop and facilitate access and delivery of better medical care to patients with severe IED. METHODS The unmet needs and future directions in inflammatory eye disease were identified and discussed by experts in relevant disciplines at a recent international conference. RESULTS A total of 14 major unmet needs were identified and discussed by experts in the areas of ophthalmology, rheumatology, infectious disease, and internal medicine, at an international conference. The major areas discussed are summarized in this review. CONCLUSIONS Identification of unmet needs in IED is seen as a first step in implementing changes in the way we diagnose and treat patients with these sight-threatening IEDs.
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Affiliation(s)
- Denis Wakefield
- a Department of Medicine , University of New South Wales , Kensington , Sydney , Australia
| | - Peter McCluskey
- b University of Sydney, Ophthalmology, Save Sight Institute , Sydney , Australia
| | - Gerhild Wildner
- c Department of Ophthalmology , University of Munich , Munich , Germany
| | - Stephan Thurau
- c Department of Ophthalmology , University of Munich , Munich , Germany
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Kempen JH, Altaweel MM, Drye LT, Holbrook JT, Jabs DA, Sugar EA, Thorne JE. Quality of Life and Risks Associated with Systemic Anti-inflammatory Therapy versus Fluocinolone Acetonide Intraocular Implant for Intermediate Uveitis, Posterior Uveitis, or Panuveitis: Fifty-four-Month Results of the Multicenter Uveitis Steroid Treatment Trial and Follow-up Study. Ophthalmology 2015; 122:1976-86. [PMID: 26298718 PMCID: PMC4581951 DOI: 10.1016/j.ophtha.2015.06.043] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/08/2015] [Accepted: 06/20/2015] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the risks and quality-of-life (QoL) outcomes of fluocinolone acetonide implant versus systemic therapy with corticosteroid and immunosuppression when indicated for intermediate uveitis, posterior uveitis, and panuveitis. DESIGN Additional follow-up of a randomized trial cohort. PARTICIPANTS Two hundred fifty-five patients with intermediate uveitis, posterior uveitis, or panuveitis, randomized to implant or systemic therapy. METHODS Randomized subjects with intermediate uveitis, posterior uveitis, or panuveitis (479 eyes) were followed up over 54 months, with 79.2% completing the 54-month visit. MAIN OUTCOME MEASURES Local and systemic potential complications of the therapies and self-reported health utility and vision-related and generic health-related QoL were studied prospectively. RESULTS Among initially phakic eyes, cataract and cataract surgery occurred significantly more often in the implant group (hazard ratio [HR], 3.0; P = 0.0001; and HR, 3.8; P < 0.0001, respectively). In the implant group, most cataract surgery occurred within the first 2 years. Intraocular pressure elevation measures occurred more frequently in the implant group (HR range, 3.7-5.6; all P < 0.0001), and glaucoma (assessed annually) also occurred more frequently (26.3% vs. 10.2% by 48 months; HR, 3.0; P = 0.0002). In contrast, potential complications of systemic therapy, including measures of hypertension, hyperlipidemia, diabetes, bone disease, and hematologic and serum chemistry indicators of immunosuppression toxicity, did not differ between groups through 54 months. Indices of QoL initially favored implant therapy by a modest margin. However, all summary measures of health utility and vision-related or generic health-related QoL were minimally and nonsignificantly different by 54 months, with the exception of the 36-item Short-Form Health Survey physical component summary score, which favored implant by a small margin at 54 months (3.17 on a scale of 100; P = 0.01, not adjusted for multiple comparisons). Mean QoL results were favorable in both groups. CONCLUSIONS These results suggest that fluocinolone acetonide implant therapy is associated with a clinically important increased risk of glaucoma and cataract with respect to systemic therapy, suggesting that careful monitoring and early intervention to prevent glaucoma is warranted with implant therapy. Systemic therapy subjects avoided a significant excess of toxicities of systemic corticosteroid and immunosuppressive therapies in the trial. Self-reported QoL measures initially favored implant therapy, but over time the measures converged, with generally favorable QoL in both groups.
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Affiliation(s)
- John H. Kempen
- Ocular Inflammation Service, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Preventive Ophthalmology and Biostatistics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Ophthalmology/Scheie Eye Institute, and the Center for Clinical Epidemiology and Biostatistics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael M. Altaweel
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania; the Fundus Photograph Reading Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lea T. Drye
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin; the Center for Clinical Trials, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janet T. Holbrook
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin; the Center for Clinical Trials, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas A. Jabs
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin; the Center for Clinical Trials, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; the Departments of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A. Sugar
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin; the Center for Clinical Trials, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Biostatistics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer E. Thorne
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin; the Center for Clinical Trials, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Mount Sinai School of Medicine, New York, New York; and the Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Immunosuppressive Therapy and Cancer Risk in Ocular Inflammation Patients: Fresh Evidence and More Questions. Ophthalmology 2015; 122:219-21. [DOI: 10.1016/j.ophtha.2014.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 11/19/2014] [Indexed: 11/19/2022] Open
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