Anti-Tumor Necrosis Factor α versus Tocilizumab in the Treatment of Refractory Uveitic Macular Edema: A Multicenter Study from the French Uveitis Network

Comparative effectiveness of intravenous versus subcutaneous tocilizumab for refractory uveitis: a retrospective analysis

PURPOSE

To compare the efficacy and safety of intra-venous tocilizumab (IV TCZ) and sub-cutaneous tocilizumab (SC TCZ) in the treatment of non-infectious intermediate, posterior and, panuveitis.

DESIGN

Multicenter, retrospective, observational study.

PARTICIPANTS

Adult patients with non-infectious uveitis treated with TCZ.

METHODS

Patients received IV TCZ (8 mg/kg/4 weeks; n = 66) or SC TCZ (162 mg/week; n = 70). The decision to introduce TCZ and the administration route were left to the discretion of the clinician.

MAIN OUTCOME MEASURES

Primary outcome: resolution of macular edema at 6 months; secondary outcomes: proportion of patients with treatment success and inactive disease, best-corrected visual acuity (BCVA) change from baseline, median time to relapse or serious adverse events leading to treatment discontinuation, corticosteroid-sparing effect, and adverse events.

RESULTS

One hundred thirty-six patients (46% men, median age 51 years, interquartile range 41-65 years) were included. Patients in the IV TCZ group had more severe disease, i.e. more frequent macular edema, worse initial BCVA, more frequent previous anti-TNF alpha failure. A significantly higher proportion of patients in the IV TCZ achieved resolution of macular edema at 6 months (OR 3.96; 95% CI 1.3-12.92; p=0.01). The difference was not significant after 12 months of treatment (OR 2.46; CI 95% 0.30-30.18; p=0.40). The gain in visual acuity after 12 months of treatment was higher in the IV TCZ group, with a 0.19 logMAR gain of BCVA, compared to SC TCZ. At 12 months, 63% of patients in the IV TCZ group and 58% of patients in the SC TCZ group (p=0.80) had an inactive disease and 71% of patients in both groups had treatment success (p=0.99). Median time to relapse or serious adverse events leading to treatment discontinuation were not statistically different between the two groups. A total of 36 patients (26%) had at least one adverse event: 15 patients (23%) in the IV TCZ group and 21 patients (30%) in the SC TCZ group.

CONCLUSION

Although interpretation of the data are limited by their retrospective nature, these data suggest that intravenous tocilizumab may result in faster resolution of uveitic macular edema than does subcutaneous tocilizumab.

Prognostic Factors of Treatment Failure with First-Line Corticosteroid-Sparing Agents in Patients with Birdshot Chorioretinopathy: A Retrospective Study

PURPOSE

To investigate prognostic factors of treatment failure with first-line corticosteroid-sparing agents in patients with birdshot chorioretinopathy (BCR).

METHODS

This retrospective single center study recruited patients with HLA A29-positive BCR between 2004 and 2023. First-line treatment consisted in oral corticosteroids (prednisone) and mycophenolate mofetil (MMF) or interferon alpha-2a (IFN). Second-line treatment consisted in biologics, i.e. anti-TNFα or tocilizumab (TCZ). At baseline, the characteristics of patients treated with MMF/IFN and patients requiring biologics were compared.

RESULTS

Forty-three patients (86 eyes) were included. Mean follow-up duration was 7.9 +/- 5.6 years. All patients were treated with prednisone. MMF/IFN was successful in 22 patients, while 21 patients required biologics. At baseline, clinical papillitis and angiographic leakage of the optical nerve were statistically more frequent in patients requiring biologics compared to patients treated with MMF/IFN, p = 0.004 and p = 0.003 respectively. At baseline, retinal nerve fiber layer (RNFL) thickness was elevated in patients requiring biologics (153 vs 117 μm; p = 0.02). At baseline, mean deviation evaluated by automatized visual field was significantly worse in patients requiring biologics (-7.85 vs - 4.87 ; p = 0.04). Among 11 patients treated sequentially with MMF, anti-TNFα and TCZ, mean prednisone dose significantly decreased with anti-TNFα compared to MMF (13.2 vs 21.9 mg/day, p = 0.002), TCZ compared to MMF (5.7 vs 21.9, p < 0.001) and TCZ compared to anti-TNFα (5.7 vs 13.2, p = 0.001).

CONCLUSION

At baseline, clinical papillitis, angiographic papillary leakage, RNFL thickness and mean deviation could be prognostic factors of treatment failure with first-line corticosteroid-sparing agents in patients with BCR.

Outcomes in non-infectious uveitis patients treated with adalimumab in a tertiary eye care center

PURPOSE

To evaluate the efficacy of adalimumab (ADA) treatment in non-infectious uveitis and the effect of disease duration, age, and etiology on treatment outcome.

METHODS

This retrospective study included patients with active non-infectious uveitis who were on ADA treatment with at least 3 months follow-up from a single tertiary care center. Uveitis type, any associated systemic disease, uveitis duration before ADA, duration of ADA treatment, best-corrected visual acuity (BCVA), anterior chamber cell (ACC) grade, vitritis grade, intraocular pressure (IOP) values, central macular thickness (CMT), fundus fluorescein angiography (FFA) score, complications and relapse rate were recorded.

RESULTS

A total of 146 eyes of 77 patients (women=41, men=36) were included in the analysis. The mean age was 25.1±15.7 years. BCVA showed no significant improvement overall (+0.08, P=0.059) following ADA treatment. A weak negative correlation was found between the change in BCVA from baseline to final follow-up and disease duration before initiating ADA (r=-0.22, P=0.005). ACC and vitritis grade decreased significantly (-0.50, p<0.001; -0.51, P<0.001; respectively). The decrease in CMT was not significant (-18.6, P=0.390). Twenty patients (25.9%) experienced a relapse during treatment, and the mean relapse time was 24.9 months (95%CI: 21.0-28.9). Eleven (14.1%) of the patients required systemic corticosteroids as bridge therapy before ADA treatment and to suppress relapse while on ADA treatment. The mean dose of methylprednisolone decreased from 55.2±20.3mg to 12.3±18.0mg, and corticosteroids were discontinued in 7 of these patients.

CONCLUSION

ADA effectively controls intraocular inflammation and maintains visual stability in patients with non-infectious uveitis. Although BCVA did not show a statistically significant improvement overall, initiating ADA treatment early was correlated with better visual outcomes in some patients, particularly those who began treatment shortly after their disease onset. The corticosteroid burden was reduced.

Case Report: ROSAH syndrome presents diagnostic and therapeutic challenges

Background

Retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis, and headache (ROSAH) syndrome is an autosomal dominant disorder caused by a heterozygous missense mutation in alpha kinase 1 (ALPK1). This series reports the presentation and treatment outcomes of three first-degree relatives with ROSAH syndrome.

Methods

Retrospective chart review, whole exome sequencing.

Results

A 16-year-old male presented with bilateral optic disc edema, macular edema, retinal degeneration, and vitreous inflammation. His mother and brother had similar clinical features. Whole exome gene sequencing identified a shared heterozygous mutation in the ALPK1 gene c.710C>T, consistent with ROSAH syndrome. Ophthalmic manifestations in this family included optic nerve edema, macular edema, panuveitis, glaucoma, and widespread retinal cone and rod dysfunction. While the proband's macular edema improved with intravitreal dexamethasone and systemic tocilizumab, immune suppression did not prevent retinal degeneration.

Conclusion

A diagnosis of ROSAH syndrome, suggested by the concomitant presentation of optic disc edema, uveitis, and retinal degeneration, can be made by targeted genetic sequencing of the ALKP1 gene. While ROSAH-associated ocular inflammation and macular edema may respond to local steroids and immune suppression, retinal degeneration may progress despite these therapies.

Molecular insights into ulcerative colitis and orbital inflammation

Ulcerative colitis (UC) is an increasingly prevalent inflammatory condition affecting the intestinal mucosa, while nonspecific orbital inflammation (NSOI) is a common non-neoplastic orbital disorder. Exploring the molecular interplay between UC and NSOI may help physicians make earlier diagnoses and enhance treatment approaches. We analyzed gene expression datasets (GSE58331, GSE105149, GSE206285, and GSE179285) for UC and NSOI from the GEO database. Using WGCNA and differential expression analysis, we identified genes commonly altered in both diseases. GO enrichment, PPI networks, and transcription factor prediction were performed using Cytoscape plugins (cytoHubba and iRegulon). Machine learning techniques were employed to assess transcription factor activity and evaluate potential therapeutic targets among the hub genes. We conducted an association analysis using the TwoSampleMR package in R to explore potential causal relationships between NSOI and UC. A total of 85 intersecting genes between NSOI and UC were identified, and enrichment analyses revealed their roles in immune and inflammatory processes. Key biomarkers, including CXCL10, CXCR4, CXCL9, CD27, SELL, MMP9, CD79A, CD3E, GZMK, and CCL19, were highlighted, linking them to processes such as leukocyte migration, viral response, and monocyte differentiation. STAT1 was identified as a shared transcription factor influencing both diseases. Machine learning algorithms identified eight potential genes for diagnostic and therapeutic use, with CXCL10 emerging as a key player in the pathogenesis of NSOI and UC. CXCL10 likely regulates CXCR4, LCK, CCR7, and other genes involved in pathways such as cytokine-cytokine receptor interactions, HIV-1 infection, and Epstein-Barr virus infection. This study offers insights into the co-pathogenic mechanisms of UC and NSOI, providing a foundation for further mechanistic research and therapeutic development.

Uveitic macular oedema in ocular tuberculosis patients in a non-endemic country: characteristics, management, and visual Outcomes

OBJECTIVE

To describe clinical features, treatment strategies and visual acuity changes of eyes with uveitic macular oedema (UMO) in ocular tuberculosis (OTB) patients from a non-TB-endemic country.

METHODS

This retrospective study was conducted using a 10-year period registry of OTB patients diagnosed in Erasmus MC, Rotterdam. Longitudinal analysis of visual acuity trajectory in eyes with and without UMO was performed using linear mixed effect model.

RESULTS

Out of 93 included patients, 23 (24.7%; 26 eye episodes) presented with baseline UMO. Older age (p = 0.024) and diabetes coexistence (p = 0.048) were associated with UMO. Eyes with baseline UMO showed lower presenting best-corrected visual acuity (BCVA) (p = 0.024). Posterior uveitis (p = 0.005), the presence of active vitreous cells (p = 0.016) and retinal vasculitis (p = 0.008) were ocular signs associated with UMO. A step-wise treatment approach primarily initiated with local steroids, followed by a combination with oral acetazolamide and, if necessary, additional systemic immunosuppressants. Overall, this approach resulted in complete UMO resolution in 77% (20/26) of cases. UMO resolution was shorter among eyes co-managed with ATT, although statistically not significant (p = 0.144). Eyes experiencing at least one UMO episode exhibited lower visual acuity at the last-follow-up than those without (p = 0.020).

CONCLUSIONS

Active vitreous cells, retinal vasculitis and posterior uveitis are associated with UMO among OTB patients. The time-to-resolution of UMO for eyes co-managed with ATT was shorter compared to those without, suggesting that patients with UMO in OTB should be treated with ATT.

Integrated analysis of genetic, proteinic, and metabolomic alterations in Behcet's disease

Numerous studies have investigated the alterations of genes, proteins, and metabolites in Behcet's disease (BD). By far, little is known about the depiction of panoramic changes underlying this disease. This study purposed to assess the consistently dysregulated genes, proteins, and metabolites in BD across publications using the vote-counting approach. This study was based on 745 studies that identified a collection of 2354 differential molecules with 3574 molecule entries in blood, peripheral blood mononuclear cells, CD4+T cells, and aqueous humor samples from patients with BD. In this study, the results of binomial analysis showed that the circulating levels of 38 molecules, including interferon-γ and interleukin 17, were consistently upregulated, whereas high density lipoprotein cholesterol, apolipoprotein A, hemoglobin, and glutathione were consistently downregulated. The levels of interferon-γ, tumor necrosis factor-α and toll like receptor 4 in peripheral blood mononuclear cells, and interferon-γ and interleukin-17 in CD4+T cells were consistently upregulated. Additionally, the levels of interferon-γ, tumor necrosis factor-α and C-X-C motif chemokine ligand 8 in aqueous humor were consistently upregulated. Collectively, this study showed that the hyperactivity of Th1 and Th17 responses played an essential role in the pathogenesis of BD, and the progression of this disease was associated with enhanced neutrophil chemotaxis, vascular endothelial injury, activation of haemostatic system, and oxidative stress.

Juvenile idiopathic arthritis and associated uveitis: A review of pathogenesis, diagnosis, and management

Juvenile idiopathic arthritis (JIA) is the most common rheumatologic disorder in children, posing significant physical and emotional challenges due to its chronic nature and the need for prolonged immunosuppressive therapies. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition. Despite advances in biologic treatments, JIA continues to present substantial therapeutic challenges, necessitating multiple treatment attempts and close monitoring for secondary failures. JIA-associated uveitis remains one of the most challenging and aggressive types of uveitis, particularly in children, due to its early onset, chronicity, and limited therapeutic responses despite new treatments. Early recognition and prompt treatment of both arthritis and uveitis are essential for achieving sustained remission and preventing complications. Effective management of JIA-uveitis requires a collaborative approach between pediatric rheumatologists and ophthalmologists to ensure timely assessments, regular screenings, and necessary therapy adjustments. This integrated care approach is crucial for achieving optimal outcomes. Therefore, this review aims to extensively analyze the pathogenesis, diagnosis, and therapy of JIA and its associated uveitis.

The therapeutic potential of targeting Oncostatin M and the interleukin-6 family in retinal diseases: A comprehensive review

Retinal diseases, which can lead to significant vision loss, are complex conditions involving various cellular and molecular mechanisms. The interleukin-6 (IL-6) family, particularly Oncostatin M (OSM), has garnered attention for their roles in retinal inflammation, angiogenesis, and neuroprotection. This comprehensive review explores the dual nature of OSM and other IL-6 family members in retinal pathophysiology, highlighting their contribution to both degenerative and regenerative processes. The review also examines current research on OSM's interaction with key signaling pathways and discusses the potential of OSM and the IL-6 family as potential therapeutic targets. Understanding these mechanisms could lead to innovative treatments that modulate OSM activity, offering new avenues for managing retinal diseases and contributing to the development of more effective interventions.

Interleukin-6 in non-infectious uveitis: Biology, experimentalevidence and treatment strategies

Uveitis is the leading cause of visual impairment worldwide. Interleukin-6 (IL-6), which is upregulated in response to inflammation, is one of the most important inflammatory cytokines associated with uveitis. Two major IL-6 receptors (IL-6R) mediate the pro-inflammatory and anti-inflammatory biological effects of IL-6. This review summarized multiple perspectives on the mechanism of IL-6-mediated uveitis, based on experimental evidence from clinical and animal models. It includes discussions on the roles of the downstream IL-6 signaling pathway, immunocytes, and the blood-retinal barrier. Therapeutic strategies aimed at blocking the action of IL-6 have progressed in clinical practice. However, due to the adverse events associated with existing biologics including infections, drugs that selectively inhibit intraocular IL-6 still require further development. The novel concept of converting the pro-inflammatory effects of IL-6 into protective effects also requires further research. In addition, the relationship between the trans-presentation of IL-6R and T-helper17 cells in uveitis remains unexplored. This review aims to consolidate our current understanding of the biology, signaling pathways, experimental models, and immune pathogenesis related to IL-6 and uveitis. We also discuss clinical strategies focused on blocking IL-6 as a treatment for uveitis. Targeting IL-6 provides unlimited potential for improving the diagnosis, treatment, and prognosis of uveitis.

Long-term effects of tocilizumab on retinal and choroidal inflammation in Birdshot uveitis

BACKGROUND

Tocilizumab (TCZ), an interleukin-6 receptor antagonist, is approved for treating rheumatic diseases and has demonstrated efficacy in managing refractory non-infectious uveitis (NIU). This retrospective study aimed to investigate the long-term effects of TCZ on inflammation in the retinal and choroidal compartments in Birdshot NIU.

METHODS

Eight patients (16 eyes) received TCZ and were included in the analysis. The primary outcomes measured were inflammatory activity in the retina and choroid, assessed by fluorescein angiography (FA) and indocyanine green angiography (ICGA) using the Angiography Scoring for Uveitis Working Group at baseline, 6, 12, 24, and 36 months.

RESULTS

The mean follow-up time with TCZ treatment was 33 months. At baseline, the median FA score was 14 (quartiles: 10.25, 15.25), which significantly decreased over time (at 36 months: 8 (5.5, 11); p = 0.004). In contrast, the ICGA score significantly increased within the first year (median at baseline: 5 (4.75, 7.25); at 6 months: 7 (6, 9.25); at 12 months: 7 (6.5, 9.25); p = 0.002), but returned to baseline levels after two years (at 24 months: 5 (5, 6.5); at 36 months: 5.5 (4, 7.5)). Central retinal thickness (CRT) improved significantly after 6 months (median at baseline: 295 µm (275, 322); at 6 months: 275 µm (251, 308); p = 0.01).

CONCLUSION

TCZ is effective in reducing retinal vasculitis and CRT in refractory Birdshot uveitis over time, but might be less effective in managing choroidal inflammation. Further studies are needed to determine the optimal treatment strategies for TCZ therapy in NIU.

Uveitic Macular Edema: Clinical Outcomes in Real-World Practice

PURPOSE

To examine the real-world management and outcomes of uveitic cystoid macular oedema (CME).

DESIGN

Retrospective study.

METHODS

Patients with uveitic CME were identified from the Inflammatory Eye Disease database. 248 eyes of 218 patients with uveitic CME were identified. Main Outcome Measures: Time to resolution, time to recurrence and vision loss.

RESULTS

Median age at time of CME was 51.7 years [IQR 37.3-63.9]. Overall likelihood of resolution was 209/248 eyes (85.3%). Resolution occurred in 34.1% with topical therapy, 69.2% treated with oral prednisone (72.9% if prednisone dose ≥ 60 mg/day), 73.5% treated with orbital floor steroid, and 86.7% treated with intravitreal steroid. On multivariate analysis, ERM was associated with decreased resolution of CME (HR 0.735 p = 0.045). Additionally, infectious aetiology approached significance (HR 0.635 p = 0.059) for CME resolution. Recurrence occurred in 85 eyes (36.5%). Predictors of increased likelihood of recurrence were current smoking status (HR 1.818 p = 0.042) and subretinal fluid at diagnosis (HR 1.577 p = 0.043). Eyes with infectious aetiology had lower chance of CME resolution, but those that did resolve had lower probability of recurrence (HR 0.891 p = 0.019). Moderate vision loss (20/50-20/200) occurred in 24 eyes (9/7%) and severe vision loss (≤20/200) in 17 eyes (6.9%).

CONCLUSIONS

Management of CME is challenging given the heterogeneous aetiologies, severity of the macular edema as well as response to the therapy. A high rate of resolution was observed, given sufficient time, but recurrence occurs in one-third. Current smoking status plays an important role in the risk of recurrence of CME and patients should be encouraged to stop smoking.

Uveitis in Giant Cell Arteritis: A Retrospective Study of Seven Observational Cases and Literature Review

PURPOSE

To describe the demographic and clinical characteristics of uveitis in patients with giant cell arteritis (GCA), their treatments, and evolution.

METHODS

A national retrospective cohort study was performed. The inclusion criteria were as follows: patients with GCA fulfilling the 2022 ACR/EULAR criteria and a diagnostic of uveitis attested by an ophthalmologist.

RESULTS

Seven women were included. The median age at diagnosis of uveitis was 71 years (64-84). All uveitis were diagnosed during active GCA (five at initial diagnosis, two at relapse). All uveitis were acute (100%), mostly anterior (86%) and bilateral (71%). Granulomatous features were less common (29%). All uveitis were treated with local and systemic corticosteroids. After a median follow-up of 30 (21-55) months, all patients achieved complete ophthalmic remission, with only one relapse at 2 years. GCA was also in complete remission.

CONCLUSIONS

Uveitis could reveal GCA, and its presence correlated with disease activity of GCA. The most frequent clinical presentation of uveitis was acute and anterior; using local and systemic corticosteroids, the prognosis was favorable.

CYSTOID MACULAR EDEMA IN BIRDSHOT RETINOCHOROÏDITIS: Long-Term Treatment Study in 142 Patients

PURPOSE

To assess the long-term efficacy and safety of treatments for cystoid macular edema in birdshot retinochoroïditis.

METHODS

Observational retrospective study of 142 HLA-A29-positive patients with cystoid macular edema; the main outcome was the optical coherence tomography intraretinal cysts resolution.

RESULTS

During the mean follow-up of 75 months (12-178), 61.3% of patients were successfully treated using 1 to 3 treatment steps, while the others needed more steps. At 6 months, there were no significant effects on ME for anti-TNF (tumor necrosis factor) and IVIg (immunoglobulin) in contrast to antimetabolites (OR 1.98), systemic GCS (glucocorticosteroids), CsA (cyclosporine A) and tocilizumab (odds ratio closed to 2.7), intraocular injected GCS (odds ratio of 4.2), and interferon (odds ratio of 4.4). The percentages of therapeutic success trend to decrease from the initial three treatment steps to the subsequent treatment steps, for systemic GCS (84% to 70%), for anti-TNF (42% to 33%), and for CsA (71% to 33%); the success percentages did not decrease for injected GCS (83% to 89%). Macular edema recurrence occurred with the highest percentage for injected GCS (86.8%, P = 0.01) and the lowest for tocilizumab (10.5%, P = 0.001). Interferons-α and tocilizumab were associated with the lowest prednisone daily doses.

CONCLUSION

The classical uveitic cystoid macular edema therapeutic algorithm could be adapted to birdshot retinochoroïditis.

Tocilizumab for cystoid macular edema secondary to retinitis pigmentosa

PURPOSE

To describe the effect of tocilizumab (TCZ) on cystoid macular edema (CME) and retinal vascular leakage (RVL) in retinitis pigmentosa (RP).

METHODS

Retrospective case series.

RESULTS

We present 2 cases of RP with marked inflammatory features in the form of CME and RVL. There was initial diagnostic uncertainty with posterior uveitis. Both patients were treated with corticosteroids, conventional disease-modifying antirheumatic drugs (cDMARDs), and biological DMARDs (bDMARDs) for the inflammatory features with partial and inconsistent treatment response. When treatment was switched to intravenous (IV) TCZ, dramatic reduction in CME and RVL were observed in both patients. Diagnosis of RP was eventually made based on findings of ancillary tests (macular spectral-domain optical coherence tomography, visual fields, full-field electroretinogram). Genetic testing led to a molecular diagnosis of EYS-related autosomal recessive RP in patient 1, while patient 2 had negative gene panel results.

CONCLUSIONS

IV TCZ can be an effective treatment option in RP-related CME and RVL. Whether this treatment strategy has an effect on prognosis remains to be established, but it is possible considering chronic CME-related retinal damage is a major driver of central vision loss in RP.

Corticosteroids for the Management of Uveitic Macular Edema: A Comprehensive Review

Uveitis, which refers to the inflammation of the uveal tract and surrounding structures in the eye, poses a significant risk of vision impairment, with macular edema (UME) being a prevalent complication. The current statement reviews UME's prevalence, pathogenesis, diagnosis, and management strategies, focusing on the utility of systemic and local corticosteroid therapy. Corticosteroids, with their multifaceted effects on inflammatory pathways, serve as the cornerstone of UME treatment. Various administration routes, including topical, periocular, intraocular, and systemic, are employed based on the anatomical type and severity of inflammation. The efficacy of different corticosteroid formulations, such as difluprednate, triamcinolone acetonide, dexamethasone implant, and fluocinolone acetonide implant, is evaluated through clinical trials and retrospective studies. Additionally, the role of corticosteroid-sparing treatments, including antimetabolites like methotrexate and mycophenolate mofetil, is explored. Emerging techniques, such as suprachoroidal space triamcinolone acetonide administration, offer promising alternatives for managing UME. Through a thorough examination of current evidence, this review provides valuable insights into optimizing the management of UME and improving visual outcomes in patients with uveitis.

Characterizing autoimmune uveitis to systemic diseases: a retrospective study from a Syrian tertiary reference center

Background

Uveitis, a notable cause of severe visual impairment, is frequently characterized as infectious or noninfectious autoimmune uveitis (AU), the latter of which is commonly associated with younger individuals and systemic diseases. Despite the condition's widespread impact, there are substantial gaps in the comprehension of its pathogenesis, clinical presentation, and therapeutic response, particularly concerning systemic disease-associated uveitis.

Aim of the study

The current study aims to bridge these gaps through an extensive examination of demographic and clinical features in AU patients, thereby informing future research, and therapeutic strategies, and improving patient outcomes.

Methods

This retrospective observational study analyzed 261 patients with systemic disease-associated uveitis from January 2018 to December 2022 in Damascus, Syria. With diagnoses made using the Standardization of Uveitis Nomenclature Working Group Criteria, the study evaluated tailored treatment efficacy at the 24-month post-treatment mark, alongside comprehensive ophthalmic examinations, laboratory evaluations, and radiographic assessments.

Results

In our study, included 87 patients with Systemic Disease-Associated Autoimmune Uveitis (SDA-AU). Women represented 64.36% of this group, and the mean age at diagnosis was 39.8±17.9 years (range 7-71) for men and 43.8±15.4 years (range 11-69). The most reported symptom was a painful red eye (52.87%). The onset of symptoms was sudden for 32.18% of patients, while 67.81% reported gradual development. Complications occurred in 33.33% of patients, including cataracts (41.37% of those with complications) and glaucoma (17.24%). Laboratory evaluations showed elevated inflammation markers in 66.66% of patients. Upon the 24-month assessment, 48.27% of patients achieved complete remission, 37.93% showed significant improvement, while disease worsened in 13.79% of cases.

Conclusion

Our findings demonstrated that the presentation of AU in this cohort frequently precedes the diagnosis of systemic diseases, affirming the vital role of an early and accurate diagnosis of uveitis for the detection of underlying systemic conditions. In conclusion, our study underlines the significance of a comprehensive and multidisciplinary approach in the management of SD-AU, leading to improved prognosis and quality of life for patients.

Decoding Behcet's Uveitis: an In-depth review of pathogenesis and therapeutic advances

Behcet's disease (BD) is a rare but globally distributed vasculitis that primarily affects populations in the Mediterranean and Asian regions. Behcet's uveitis (BU) is a common manifestation of BD, occurring in over two-thirds of the patients. BU is characterized by bilateral, chronic, recurrent, non-granulomatous uveitis in association with complications such as retinal ischemia and atrophy, optic atrophy, macular ischemia, macular edema, and further neovascular complications (vitreous hemorrhage, neovascular glaucoma). Although the etiology and pathogenesis of BU remain unclear, numerous studies reveal that genetic factors (such as HLA-B51), dysregulated immune responses of both the innate and adaptive immune systems, infections (such as streptococcus), and environmental factors (such as GDP) are all involved in its development. Innate immunity, including hyperactivity of neutrophils and γδT cells and elevated NK1/NK2 ratios, has been shown to play an essential role in this disease. Adaptive immune system disturbance, including homeostatic perturbations, Th1, Th17 overaction, and Treg cell dysfunction, is thought to be involved in BU pathogenesis. Treatment of BU requires a tailored approach based on the location, severity of inflammation, and systemic manifestations. The therapy aims to achieve rapid inflammation suppression, preservation of vision, and prevention of recurrence. Systemic corticosteroids combined with other immunosuppressive agents have been widely used to treat BU, and beneficial effects are observed in most patients. Recently, biologics have been shown to be effective in treating refractory BU cases. Novel therapeutic targets for treating BU include the LCK gene, Th17/Treg balance, JAK pathway inhibition, and cytokines such as IL-17 and RORγt. This article summarizes the recent studies on BU, especially in terms of pathogenesis, diagnostic criteria and classification, auxiliary examination, and treatment options. A better understanding of the significance of microbiome composition, genetic basis, and persistent immune mechanisms, as well as advancements in identifying new biomarkers and implementing objective quantitative detection of BU, may greatly contribute to improving the adequate management of BU patients.

[An update on Behçet's syndrome]

Behçet's syndrome (BS, synonym: Behçet's disease, or Adamantiades-Behçet's disease, ABD) is classified as a vasculitis of variable vessel size and can manifest itself in both arterial and venous vessels. Its extensive and at the same time interindividually very different clinical picture is not uncommon a challenge, both with regard to the diagnosis of this rheumatic systemic disease, which is rather rare in our latitudes, and its therapeutic options. In addition to the four cardinal symptoms of recurrent oral aphthae, genital aphthae, skin and eye lesions, the clinical picture offers numerous other manifestations which often require interdisciplinary cooperation. In addition to the above mentioned ocular involvement, which can still lead to blindness if inadequately treated, this is especially true for intestinal and cerebral manifestations as well as for large vessel vasculitis.A final revision of the European League Against Rheumatism recommendations for the management of Behcet's syndrome (EULAR) was made in 2018, and the recommendations are now established internationally as an important treatment guide. Therapy is based on the leading organ involvement. After adalimumab received approval for the treatment of posterior ocular involvement in 2016, another agent, apremilast, became available in 2020. The drug is recommended for the treatment of recurrent oral aphthae in adult Behçet's patients requiring systemic therapy. Nevertheless, there is a further need for new drugs.This article aims to highlight recent findings in the areas of epidemiology, immunopathogenesis & genetics, clinical findings, and therapy, with an emphasis on clinical relevance.

Insights into the diagnosis and management of sarcoid uveitis: A review

Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.

Tocilizumab attenuates choroidal neovascularization by regulating macrophage polarization through the IL-6R/STAT3/VEGF pathway

Globally, age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment. Up to 80% of severe vision loss is caused by AMD, which is characterized by the development of choroidal neovascularization (CNV). Uncertainty exists regarding the precise pathophysiological mechanisms of CNV. It has been suggested that the interleukin (IL) IL-6/IL-6R signaling pathway is crucial in the progression of CNV. Tocilizumab (TCZ), a monoclonal antibody, binds to soluble and membrane-bound IL-6R and competitively inhibits IL-6 downstream signaling. Previous research has demonstrated that TCZ promotes several roles related to inflammation and neovascularization. However, the effects of TCZ on CNV and the underlying mechanism are still unknown. This study found that TCZ administration decreased the area and leakage of CNV lesions in the mice model of laser-induced CNV. Additionally, results demonstrated that TCZ promotes the expression of iNOS, CCL-3, CCL-5, TNF-α and inhibits the expression of Arg-1, IL-10, YM-1 and CD206. Furthermore, TCZ treatment inhibited the signal transducer and activator of transcription (STAT) STAT3/vascular endothelial growth factor (VEGF) pathway, which was activated after CNV formation. Colivelin, a STAT3 agonist, reversed the inhibitory effects of TCZ on CNV formation and macrophage polarization. In a mouse model of laser-induced CNV, our findings demonstrated that TCZ attenuated CNV formation and inhibited the leakage of CNV lesions by regulating macrophage polarization via inhibiting the STAT3/VEGF axis. TCZ is the potential therapeutic strategy for CNV.

An Observational Study in the Real Clinical Practice of the Treatment of Noninfectious Uveitis

BACKGROUND

The aim of this study was to describe the characteristics of patients with uveitis associated with an immunologic or idiopathic disease that requires immunosuppressive treatment and the response to such treatments in real clinical practice.

METHODS

An observational, descriptive, longitudinal, and retrospective study of a cohort of patients diagnosed with noninfectious uveitis was performed. To assess the response to treatment, we evaluated the change in visual acuity, vitritis, and the presence of macular edema.

RESULTS

We included 356 patients. Overall, 12% required treatment with systemic corticosteroids, and 66 patients (18.5%) required immunosuppressive/biological treatment, with methotrexate being the most used (55%). Immunosuppressive drugs were used in 59 cases (in 56 patients, as the first choice of treatment and for 3 patients as the second choice after treatment with biologics). Treatment with biologics was the first choice in 10 patients out of 66 (15%), and 34 (48%) required them at some time during the disease, with adalimumab being the most commonly used. Thirty-five patients (53%) needed to switch drugs due to a lack of response to the first one. There were no differences between different drugs in the resolution of vitritis and improvement in vision.

CONCLUSIONS

The use of systemic corticosteroids and immunosuppressive/biologics was necessary for a high number of patients with noninfectious uveitis. In our series, tocilizumab was significantly more effective in the resolution of macular edema.

Efficacy and Safety of Adalimumab in Patients with Behçet Uveitis: A Systematic Review and Meta-Analysis

PURPOSE

To examine the long-term efficacy and safety of adalimumab (ADA) in patients with Behçet uveitis (BU).

METHODS

A systematic review and meta-analysis of observational studies was performed. Pooled results are presented as mean difference or standardized mean difference (std diff) and 95% confidence intervals (CI). Visual acuity (VA), intraocular inflammation grade, central macular thickness, corticosteroid (CS) sparing effect and adverse events were evaluated.

RESULTS

Ten studies were included finally for quantitative and qualitative synthesis. ADA therapy resulted in 0.124 (95%CI: 0.084, 0.165) logMAR improvement in VA. In addition, ADA therapy resulted in decreased grade of intraocular inflammation [std diff, -1.187 (95%CI: -1.508, -0.866)] and macular thickness [std diff, -0.564 (95%CI: -0.843, -0.286)] and caused a decrease in CS dosage [std diff, -1.809 (95%CI: -2.420, -1.198)]. The pooled rate of overall adverse events for ADA in 301 patients was 8.5% (95%CI: 0.039, 0.177).

CONCLUSION

ADA is an efficient therapy that improves VA and controls intraocular inflammation, macular edema and retinal vasculitis. As the disease exposure time increased, improvement in VA was less. The safety and CS-sparing effect of ADA were demonstrated with few adverse effects. The results provided evidence that ADA can be used safely and efficiently as the first-line drug in patients with BU.

Inflammatory cytokines as mediators of retinal endothelial barrier dysfunction in non-infectious uveitis

Characterised by intraocular inflammation, non-infectious uveitis includes a large group of autoimmune and autoinflammatory diseases that either involve the eye alone or have both ocular and systemic manifestations. When non-infectious uveitis involves the posterior segment of the eye, specifically the retina, there is substantial risk of vision loss, often linked to breakdown of the inner blood-retinal barrier. This barrier is formed by non-fenestrated retinal vascular endothelial cells, reinforced by supporting cells that include pericytes, Müller cells and astrocytes. Across the published literature, a group of inflammatory cytokines stand out as prominent mediators of intraocular inflammation, with effects on the retinal endothelium that may contribute to breakdown of the inner blood-retinal barrier, namely tumour necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, IL-17 and chemokine C-C motif ligand (CCL)2. This article reviews the function of each cytokine and discusses the evidence for their involvement in retinal endothelial barrier dysfunction in non-infectious uveitis, including basic laboratory investigations, studies of ocular fluids collected from patients with non-infectious uveitis, and results of clinical treatment trials. The review also outlines gaps in knowledge in this area. Understanding the disease processes at a molecular level can suggest treatment alternatives that are directed against appropriate biological targets to protect the posterior segment of eye and preserve vision in non-infectious uveitis.

Risk factors, clinical features and treatment of Behçet's disease uveitis

Behçet's disease is a systemic vasculitis frequently associated with intraocular inflammation. Recent findings identified independent clinical clusters in Behçet's disease, each involving distinct combinations of affected organs. Ocular Behçet's disease, mainly manifested as uveitis, is characterized as an independent cluster with a low likelihood of association with other system involvements, such as intestinal, cardiovascular, or central nervous system. A prevailing theory suggests that the pathogenesis of the disease is multifactorial, where a variety of genetic and infectious agents may interact with each other to cause the disease. Among sporadic cases, the human leukocyte antigen (HLA) genes, including HLA-B51, HLA-A26, HLA-B15, and HLA-B5701, have been found to be a key component conferring genetic susceptibility. Outside the HLA region, a set of susceptibility variants are identified, closely related to interleukin (IL)-23/IL-17 pathway, tumor necrosis factor (TNF) signaling, and pattern recognition receptor systems. Microbial infections, such as Streptococcus sanguinis, Mycobacterium tuberculosis, and Herpes simplex virus (HSV), are linked to play the triggering of disease in immunogenetically predisposed individuals. Clinically, due to the notable relapsing-remitting course of ocular Behçet's disease, the prevention of recurrent attack would be the primary treatment goal. Combination of corticosteroids and immunomodulatory drugs, such as anti-TNF agents, interferon, and conventional immunosuppressants (e.g. cyclosporine, azathioprine), have been the mainstream regimen for the disease. Future research may focus on comparing the effectiveness of immunomodulatory drugs and identifying the most suitable subgroups for a specific drug on the basis of the knowledge of the molecular heterogeneity of the disease.

Behçet's disease uveitis

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior or panuveitis. It is non-granulomatous. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralisation usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, prevention of recurrent attacks, achievement of complete remission, and preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update previous article by our team on pathogenesis, diagnostic approaches, identification of factors associated with relapse and the therapeutic strategy of BD uveitis.

[An update on Behçet's syndrome]

Behçet's syndrome (BS, synonym: Behçet's disease, or Adamantiades-Behçet's disease, ABD) is classified as a vasculitis of variable vessel size and can manifest itself in both arterial and venous vessels. Its extensive and at the same time interindividually very different clinical picture is not uncommon a challenge, both with regard to the diagnosis of this rheumatic systemic disease, which is rather rare in our latitudes, and its therapeutic options. In addition to the four cardinal symptoms of recurrent oral aphthae, genital aphthae, skin and eye lesions, the clinical picture offers numerous other manifestations which often require interdisciplinary cooperation. In addition to the above mentioned ocular involvement, which can still lead to blindness if inadequately treated, this is especially true for intestinal and cerebral manifestations as well as for large vessel vasculitis.A final revision of the European League Against Rheumatism recommendations for the management of Behcet's syndrome (EULAR) was made in 2018, and the recommendations are now established internationally as an important treatment guide. Therapy is based on the leading organ involvement. After adalimumab received approval for the treatment of posterior ocular involvement in 2016, another agent, apremilast, became available in 2020. The drug is recommended for the treatment of recurrent oral aphthae in adult Behçet's patients requiring systemic therapy. Nevertheless, there is a further need for new drugs.This article aims to highlight recent findings in the areas of epidemiology, immunopathogenesis & genetics, clinical findings, and therapy, with an emphasis on clinical relevance.

Interleukin-6 in retinal diseases: From pathogenesis to therapy

Interleukin-6 (IL-6) is a pleiotropic cytokine that participates in immunomodulation, inflammation, increases vascular permeability, hematopoiesis, and stimulates cell proliferation, among other biological processes. It exerts effects primarily through the classic and trans-signaling pathways. Many studies have demonstrated that IL-6 plays a critical role in the development of retinal diseases including diabetic retinopathy, uveitis, age-related macular degeneration, glaucoma, retinal vein occlusion, central serous chorioretinopathy and proliferative vitreoretinopathy. Thus, the progressive development of drugs targeting IL-6 and IL-6 receptor may play a role in the treatment of multiple retinal diseases. In this article, we comprehensively review the IL-6's biological functions of and its mechanisms in the pathogenesis of various retinal diseases. Furthermore, we summarize the drugs targeting IL-6 and its receptor and prospect their potential application in retinal diseases, hoping to provide new ideas for the treatment of retinal diseases.

Comparison of infliximab with adalimumab for the treatment of non-infectious uveitis: a systematic review and meta-analysis

PURPOSE

To compare the efficacy and safety of infliximab with that of adalimumab in the treatment of non-infectious uveitis (NIU).

METHODS

We searched for relevant studies in the PubMed, Embase, ClinicalTrials.gov, Cochrane Library databases, Grey Matters, Grey Literature Report, OpenGrey, China National Knowledge Infrastructure (CNKI), and Wan Fang databases up to September 2022. The incidences of complete remission of inflammation, response to therapy, adverse events and corticosteroid-sparing effect were evaluated.

RESULTS

Eleven clinical trials covering 1459 NIU patients were included. Complete remission of inflammation after therapy was achieved in 161 (37.5%) patients in the infliximab group and 151 (39.6%) patients in the adalimumab group. These two groups were not significantly different (P = 0.37). Four studies reported response to anti-TNF therapy involving 449 patients, of whom 241/272 (88.6%) treated with infliximab and 153/177 (86.4%) treated with adalimumab achieved partial or complete remission of inflammation. No significant difference was observed between the two cohorts in terms of response to therapy (P = 0.86). There was no significant difference between infliximab and adalimumab with regard to corticosteroid-sparing effect (P = 0.58). The pooled effect size (P = 0.001) showed a statistically significant difference, with the incidence of adverse events being 17.91% for infliximab and 12.12% for adalimumab.

CONCLUSION

Our systematic review and meta-analysis of 11 studies suggests that infliximab and adalimumab have similar therapeutic efficacy and corticosteroid-sparing effect in patients with NIU. However, adalimumab has a marginal advantage over infliximab in terms of adverse events. Large-scale RCTs with a longer follow-up are required to further evaluate these two anti-TNF-α agents in patients with NIU.

Behçet's Disease Uveitis

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior, or panuveitis. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralization usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and the preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update to a previous article by our team on pathogenesis, diagnostic approaches, and the therapeutic strategy of BD uveitis.

Sarcoidosis-Related Uveitis: A Review

Sarcoidosis is an inflammatory disease that involves the eyes in 10-55% of cases, sometimes without systemic involvement. All eye structures can be affected, but uveitis is the most common ocular manifestation and causes vision loss. The typical ophthalmological appearance of these uveitis is granulomatous (in cases with anterior involvement), which are usually bilateral and with synechiae. Posterior involvement includes vitritis, vasculitis and choroidal lesions. Tuberculosis is a classic differential diagnosis to be wary of, especially in people who have spent time in endemic areas. The diagnosis is based on histology with the presence of non-caseating epithelioid granulomas. However, due to the technical difficulty and yield of biopsies, the diagnosis of ocular sarcoidosis is often based on clinico-radiological features. The international criteria for the diagnosis of ocular sarcoidosis have recently been revised. Corticosteroids remain the first-line treatment for sarcoidosis, but up to 30% of patients require high doses, justifying the use of corticosteroid-sparing treatments. In these cases, immunosuppressive treatments such as methotrexate may be introduced. More recent biotherapies such as anti-TNF are also very effective (as they are in other non-infectious uveitis etiologies).

Human retinal endothelial cells express functional interleukin-6 receptor

BACKGROUND

Interleukin (IL)-6 is an inflammatory cytokine present in the eye during non-infectious uveitis, where it contributes to the progression of inflammation. There are two major IL-6 signaling pathways: classic signaling and trans-signaling. Classic signaling requires cellular expression of the IL-6 receptor (IL-6R), which exists in membrane-bound (mIL-6R) and soluble (sIL-6R) forms. Prevailing dogma is that vascular endothelial cells do not produce IL-6R, relying on trans-signaling during inflammation. However, the literature is inconsistent, including with respect to human retinal endothelial cells.

FINDINGS

We examined IL-6R transcript and protein expression in multiple primary human retinal endothelial cell isolates, and assessed the effect of IL-6 on the transcellular electrical resistance of monolayers. Using reverse transcription-polymerase chain reaction, IL-6R, mIL-6R and sIL-6R transcripts were amplified in 6  primary human retinal endothelial isolates. Flow cytometry on 5 primary human retinal endothelial cell isolates under non-permeabilizing conditions and following permeabilization demonstrated intracellular stores of IL-6R and the presence of mIL-6R. When measured in real-time, transcellular electrical resistance of an expanded human retinal endothelial cell isolate, also shown to express IL-6R, decreased significantly on treatment with recombinant IL-6 in comparison to non-treated cells across 5 independent experiments.

CONCLUSIONS

Our findings indicate that human retinal endothelial cells produce IL-6R transcript and functional IL-6R protein. The potential for classic signaling in human retinal endothelial cells has implications for the development of therapeutics targeted against IL-6-mediated pathology in non-infectious uveitis.

Interleukin-6 and Macular Edema: A Review of Outcomes with Inhibition

This paper describes the current literature on the molecular pathophysiology of interleukin-6 (IL-6) in the genesis of macular edema and on the outcomes with IL-6 inhibitors in the treatment of non-infectious macular edema. The role of IL-6 in the development of macular edema has been well elucidated. IL-6 is produced by multiple cells of the innate immune system and leads to a higher likelihood of developing autoimmune inflammatory diseases, such as non-infectious uveitis, through a variety of mechanisms. These include increasing the helper T-cell population over the regulatory T-cell population and leading to the increased expression of inflammatory cytokines, such as tumor necrosis factor-alpha. In addition to being key in the generation of uveitis and subsequent macular edema through these inflammatory pathways, IL-6 also can lead to the development of macular edema through other pathways. IL-6 induces the production of vascular endothelial growth factor (VEGF) and facilitates vascular leakage by downregulating tight junction proteins in retinal endothelial cells. Clinically, the use of IL-6 inhibitors has been found to be efficacious primarily in the context of treatment-resistant non-infectious uveitis and secondary macular edema. IL-6 is a key cytokine in retinal inflammation and macular edema. It is thus not surprising that the use of IL-6 inhibitors in treatment-resistant macular edema in the setting of non-infectious uveitis has been well documented as an effective treatment option. The use of IL-6 inhibitors in macular edema secondary to non-uveitic processes has only begun to be explored.

Perspectives of Therapeutic Drug Monitoring of Biological Agents in Non-Infectious Uveitis Treatment: A Review

Biological drugs, especially those targeting anti-tumour necrosis factor α (TNFα) molecule, have revolutionized the treatment of patients with non-infectious uveitis (NIU), a sight-threatening condition characterized by ocular inflammation that can lead to severe vision threatening and blindness. Adalimumab (ADA) and infliximab (IFX), the most widely used anti-TNFα drugs, have led to greater clinical benefits, but a significant fraction of patients with NIU do not respond to these drugs. The therapeutic outcome is closely related to systemic drug levels, which are influenced by several factors such as immunogenicity, concomitant treatment with immunomodulators, and genetic factors. Therapeutic drug monitoring (TDM) of drug and anti-drug antibody (ADAbs) levels is emerging as a resource to optimise biologic therapy by personalising treatment to bring and maintain drug concentration within the therapeutic range, especially in those patients where a clinical response is less than expected. Furthermore, some studies have described different genetic polymorphisms that may act as predictors of response to treatment with anti-TNFα agents in immune-mediated diseases and could be useful in personalising biologic treatment selection. This review is a compilation of the published evidence in NIU and in other immune-mediated diseases that support the usefulness of TDM and pharmacogenetics as a tool to guide clinicians’ treatment decisions leading to better clinical outcomes. In addition, findings from preclinical and clinical studies, assessing the safety and efficacy of intravitreal administration of anti-TNFα agents in NIU are discussed.

Tocilizumab in Juvenile Idiopathic Arthritis Associated Uveitis, a Narrative Review

Juvenile idiopathic arthritis (JIA) associated uveitis (JIA-U) is the most common extra-articular manifestation of JIA, affecting 10–15% of patients, especially in oligoarticular JIA where its course may be faint. Therefore, JIA-U is one of the most challenging pediatric uveitis, associated with major ocular morbidity and possibly leading to irreversible structural ocular damage and to vision-threatening complications. Adequate management is crucial for avoiding visual impairment complications. Since the introduction of biologic disease modifying anti-rheumatic drugs (bDMARDS), the visual prognosis of JIA-U has dramatically improved over the decades. Tumor necrosis factor-α (TNF-α) blockers are the most used bDMARDs in treating JIA-U with large evidence of efficacy. However, inadequate response to these agents, either due to intolerance or inefficacy, may be observed, requiring a swap to other classes of immunosuppressive agents, including anti-IL-6, anti-CD20, and, more recently, JAK inhibitors. Tocilizumab is a humanized monoclonal antibody to the interelukin-6 receptor preventing IL-6 from binding to its soluble and membrane-bound receptors. A growing body of literature provides promising results about the efficacy of intravenous and subcutaneous tocilizumab in the treatment of JIA-U. A narrative review of the literature on this topic will improve our knowledge on the potential use of tocilizumab in JIA-U.

Anti-TNF vs tocilizumab in refractory uveitic cystoid macular edema due to Behcet's disease. Multicenter study of 49 patients

OBJECTIVE

To compare the efficacy of TNF inhibitors (adalimumab (ADA) and infliximab (IFX)) vs tocilizumab (TCZ) in patients with refractory cystoid macular edema (CME) due to Behçet's disease (BD).

METHODS

Multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. We analyzed the evolution of macular thickness (main outcome), best-corrected visual acuity (BCVA) and intraocular inflammation (Tyndall and vitritis) from baseline up to 4 years in the 3 groups mentioned.

RESULTS

49 patients and 72 eyes with CME were included. ADA was used in 25 patients (40 eyes), IFX in 15 (21 eyes) and TCZ in 9 (11 eyes). No statistically significant baseline differences were observed between the 3 groups except for a lower basal BCVA in TCZ group and a higher basal degree of intraocular inflammation in ADA group. Most patients from all groups had received several conventional immunosuppressive drugs. In addition, most patients in the group of TCZ had also received anti-TNF agents. Biological therapy was used in monotherapy (n=8) or combined with conventional immunosuppressive drugs (n=41). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory intraocular remission was achieved in all groups.

CONCLUSION

Refractory CME associated with BD uveitis can be effectively treated either with ADA, IFX or TCZ. Furthermore, TCZ is effective in patients resistant to anti-TNF therapy.

Current pharmacological solutions for Behçet's syndrome

INTRODUCTION

Behçet's syndrome (BS) has a heterogeneous clinical phenotype, and its clinical manifestations may respond differently to drugs commonly used to treat BS. The type, dose, and duration of immunomodulatory, immunosuppressive, and biologic agents should be tailored individually.

AREAS COVERED

We reviewed the literature for articles on BS management that were published until June 2022 and summarized the management options in BS for each type of organ involvement. We aimed to cover all currently available pharmacological agents used in BS, as well as surgical and interventional options, focusing on recent evidence.

EXPERT OPINION

The management aims in BS are to preserve function and quality of life and to avoid damage. The choice of treatment modalities depends on the organs that are actively involved, the severity of that involvement, and prognostic factors. A treat-to-attack strategy would help improve long-term outcomes in BS.

Outcomes of uveitic macular edema in the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial

PURPOSE

To evaluate the outcomes of uveitic macular edema at 6 months and 12 months in patients treated with methotrexate or mycophenolate mofetil.

DESIGN

Subanalysis of a block-randomized, observer-masked, multi-center clinical trial.

SUBJECTS/PARTICIPANTS

Patients were enrolled into the First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial between August 2013 and August 2017.

METHODS/INTERVENTION/TESTING

Patients were randomized to oral methotrexate 25mg weekly or mycophenolate mofetil 1.5g twice daily for 12 months, along with a corticosteroid taper. In addition to standardized clinical examination, all patients underwent spectral domain optical coherence tomography imaging at each visit. At the 6-month primary endpoint, patients who achieved treatment success continued the same treatment for a subsequent 6 months and treatment failures switched to the other treatment group.

MAIN OUTCOME MEASURES

Pre-specified primary outcome at 6 months and 12 months outcomes of central subfield thickness and visual acuity.

RESULTS

Of 216 patients in the FAST Trial, 42 eyes of 30 patients in the methotrexate group and 55 eyes of 41 patients in the mycophenolate group had uveitic macular edema. Baseline median central subfield thickness was 359μm and 342μm in the methotrexate and mycophenolate groups, respectively. At 12 months, for those who stayed on the same treatment, macular thickness decreased from baseline by 23 μm (IQR, -39.0 to 13) and 18 μm (IQR, -68.5 to 9), in the methotrexate and mycophenolate groups, respectively, (P=0.76). In patients who switched treatment at 6 months, macular thickness decreased from baseline by 12.5 μm (IQR, -29.8 to -2.3) and 92 μm (IQR, -240 to -18) in the methotrexate and mycophenolate groups, respectively, (P=0.23). At 12 months, 7/19 (37%) eyes on methotrexate had resolution of macular edema compared to 15/25 (60%) eyes on mycophenolate (P=0.10). For those that switched treatments, 8/17 (47%) eyes on methotrexate and 6/11 (55%) eyes on mycophenolate had improvement of macular edema, (P=0.92) CONCLUSIONS: Treatment with methotrexate or mycophenolate mofetil for uveitic macular edema results in similar improvements in macular thickness at 6 and 12 months. At 12 months, approximately half of eyes in each antimetabolite group still had persistent macular edema.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.