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Baquet-Walscheid K, Neß T, Maier PC, Lapp T. Peripheral Ulcerative Keratitis: Clinical Characteristics, Differential Diagnoses and Therapeutic Concepts. Klin Monbl Augenheilkd 2024; 241:633-643. [PMID: 38776930 DOI: 10.1055/a-2290-4420] [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: 05/25/2024]
Abstract
Peripheral ulcerative keratitis (PUK) is an inflammatory disease of the peripheral cornea, which may frequently be associated with several rare, but potentially life-threatening systemic diseases. The inflammatory pathogenesis of PUK results from humoral and cell-mediated inflammation. The diagnosis is usually based on the typical clinical findings and always requires detailed diagnostic testing to identify a potential systemic underlying disease. Treatment includes topical and systemic immunosuppressive and immunomodulatory therapeutic strategies and, in the event of impending or existing perforation, also various surgical interventions. PUK is a potentially blinding disease that initially affects the periphery, but, if left untreated, can lead to destruction of the entire cornea. Interdisciplinary diagnostic testing and therapy are crucial to preserve vision in the affected patients and reduce morbidity and mortality. The following article provides an overview of the pathophysiology, clinical findings, possible underlying systemic diseases, relevant differential diagnoses and therapeutic strategies.
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Affiliation(s)
- Karoline Baquet-Walscheid
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
| | - Thomas Neß
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
| | | | - Thabo Lapp
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
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Baquet-Walscheid K, Rath T, Heiligenhaus A. Ocular Involvement in Selected Rheumatic Diseases - Clinical Manifestation in Adulthood. Klin Monbl Augenheilkd 2024; 241:626-632. [PMID: 38574680 DOI: 10.1055/a-2239-0412] [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: 04/06/2024]
Abstract
Ocular manifestations of rheumatic diseases are common and contribute significantly to the morbidity and reduced quality of life of affected patients. Knowledge of typical clinical manifestations is important for the rheumatologist in order to support the reference of patients with corresponding symptoms for ophthalmological consultation at an early stage of disease, or to initiate regular screening examinations (e.g. in patients with Behçet's syndrome). Conversely, a (possibly urgent) rheumatological assessment is crucial for certain ophthalmological diseases, in order not to overlook a (possibly fatal) systemic associated disease. Patients with rheumatic or inflammatory ocular diseases should always be informed by the treating physician about possible symptoms of other organ manifestations, in order to avoid a delayed diagnosis. "Classic" associations for uveitis are (HLA-B27-associated) spondyloarthritis and acute anterior uveitis, as well as retinal vasculitis with or without panuveitis and Behçet's syndrome. In patients with rheumatoid arthritis or ANCA-associated vasculitis, however, scleritis (with or without peripheral ulcerative keratitis) typically occurs, but a variety of other findings are also possible. Close interdisciplinary collaboration, particularly regarding therapeutic decisions, is crucial to ensuring a good prognosis for the patient.
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Affiliation(s)
- Karoline Baquet-Walscheid
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
| | - Thomas Rath
- Rheumatologie, Fachklinik Bad Bentheim, Deutschland
| | - Arnd Heiligenhaus
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
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Karaca I, Tran EM, Park S, Bromeo A, Khojasteh H, Tran ANT, Yavari N, Akhavanrezayat A, Yasar C, Uludag Kirimli G, Than NTT, Hassan M, Or C, Ghoraba H, Do DV, Nguyen QD. Intravenous cyclophosphamide therapy for patients with severe ocular inflammatory diseases who failed other immunomodulatory therapies. J Ophthalmic Inflamm Infect 2024; 14:12. [PMID: 38466527 DOI: 10.1186/s12348-023-00372-z] [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: 08/23/2023] [Accepted: 11/09/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Ocular inflammatory diseases, including scleritis and uveitis, have been widely treated with immunomodulatory therapies (IMTs) as a steroid-sparing approach. Such strategy includes conventional therapies (antimetabolites, alkylating agents, and calcineurin inhibitors) as well as biologic agents like adalimumab, infliximab, rituximab, and tocilizumab. Cyclophosphamide (CP) is an alkylating agent and mainly inhibits the functioning of both T and B cells. Though known to have potential adverse events, including bone marrow suppression, hemorrhagic cystitis, and sterility, CP has been shown to be efficacious, especially in recalcitrant cases and when used intravenous (IV) for a limited period. MAIN FINDINGS We conducted a retrospective case-series to assess the safety and efficacy of CP therapy for patients with severe ocular inflammatory diseases who failed other IMTs. Medical records of 1295 patients who presented to the Uveitis Clinic at the Byers Eye Institute at Stanford between 2017 and 2022 were reviewed. Seven patients (10 eyes) who received CP therapy for ocular inflammatory diseases with at least one year of follow-up were included. The mean age of the patients (4 males, 3 females) was 61.6 ± 14.9 (43.0-89.0) years. Clinical diagnoses included necrotizing scleritis (5 eyes), peripheral ulcerative keratitis (2 eyes), orbital pseudotumor (1 eye), HLA-B27 associated panuveitis and retinal vasculitis (2 eyes). Ocular disease was idiopathic in 3 patients, and was associated with rheumatoid arthritis, IgG-4 sclerosing disease, dermatomyositis, and ankylosing spondylitis in 1 patient each. All the patients had history of previous IMT use including methotrexate (5), mycophenolate mofetil (3), azathioprine (1), tacrolimus (1), adalimumab (2), infliximab (4), and rituximab (1). The mean follow-up time was 34.4 ± 11.0 (13-45) months, and mean duration of CP therapy was 11.9 ± 8.8 (5-28) months. Remission was achieved in 5 patients (71.4%). Four patients (57.1%) experienced transient leukopenia (white blood cell count < 4000/mL). SHORT CONCLUSION CP therapy can be considered a potentially effective and relatively safe therapeutic option for patients with severe ocular inflammatory diseases who failed other IMTs including biologics (TNFa and CD20 inhibitors).
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Affiliation(s)
- Irmak Karaca
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Elaine M Tran
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - SungWho Park
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Albert Bromeo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Hassan Khojasteh
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Anh Ngọc Tram Tran
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Negin Yavari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Amir Akhavanrezayat
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Cigdem Yasar
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Gunay Uludag Kirimli
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Ngoc Tuong Trong Than
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Christopher Or
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Hashem Ghoraba
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V Do
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA.
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Clarke D, Sartor L, Do V, Manolios N, Swaminathan S, Samarawickrama C. Biologics in peripheral ulcerative keratitis. Semin Arthritis Rheum 2023; 63:152269. [PMID: 37776666 DOI: 10.1016/j.semarthrit.2023.152269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 10/02/2023]
Abstract
Over the past two decades biologic therapies have seen a rapid uptake in the management of ocular inflammation. Peripheral ulcerative keratitis (PUK), once a harbinger of blindness and mortality in refractory rheumatological disease, is now increasingly being treated with these agents. We conducted a review to evaluate the evidence base for this application and to provide a road map for their clinical usage in PUK, including dosage and adverse effects. A literature search across Medline, Embase and Cochrane Database of Systematic Reviews was undertaken to identify all patients with PUK that were treated with a biologic in a peer viewed article. Overall, whilst the evidence base for biologic use in PUK was poor, reported cases demonstrate an increasingly powerful and effective role for biologics in refractory PUK. This was particularly the case for rituximab in PUK secondary to granulomatous with polyangiitis.
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Affiliation(s)
- Daniel Clarke
- Department of Ophthalmology, Royal Hobart Hospital, Tasmania, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lauren Sartor
- Department of Ophthalmology, Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vu Do
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Manolios
- Department of Ophthalmology, Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sanjay Swaminathan
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Rheumatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia; Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, New South Wales, Australia; Centre for Immunology and Allergy Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Chameen Samarawickrama
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Translational Ocular Research and Immunology Consortium, Sydney University, New South Wales, Australia.
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Kamra D, Chappadi K, Dudam R, Murthy SI. Management of simultaneous bilateral immune-mediated peripheral ulcerative keratitis. Eur J Ophthalmol 2023; 33:NP23-NP27. [PMID: 36579799 DOI: 10.1177/11206721221149066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Peripheral ulcerative keratitis (PUK) is a sight threatening disease, often immune mediated and can rapidly progress to corneal perforation. Here we report the successful management of simultaneous bilateral peripheral ulcerative keratitis presenting with corneal perforation with surgical intervention and systemic immunosuppression. CASE DESCRIPTION A 41-year-old female presented with similarly located super-nasal peripheral ulcerative keratitis (PUK) in both eyes and focal area of adjoining scleritis in the left eye. Serological investigations for systemic immune-mediated conditions showed positive rheumatoid factor test. She underwent cyanoacrylate glue application in both eyes, and was started on topical and oral corticosteroids and oral immunomodulators, and the right eye stabilized. The left eye required a second surgical intervention with a corneal patch graft following which the condition stabilized. CONCLUSION AND IMPORTANCE This case highlights the importance of investigating for an underlying systemic etiology in PUK and the role of systemic immunosuppression prior to and after surgical intervention in order to arrest the disease and prevent recurrences.
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Affiliation(s)
- Dhruv Kamra
- Cornea Service, Shantilal Shangvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Kiranmayi Chappadi
- Cornea Service, Shantilal Shangvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Rajkiran Dudam
- Department of Rheumatology, Hyderabad Rheumatology Center, Hyderabad, Telangana India
| | - Somasheila I Murthy
- Cornea Service, Shantilal Shangvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
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Ruiz-Lozano RE, Ramos-Davila EM, Garza-Garza LA, Gutierrez-Juarez K, Hernandez-Camarena JC, Rodriguez-Garcia A. Rheumatoid arthritis-associated peripheral ulcerative keratitis outcomes after early immunosuppressive therapy. Br J Ophthalmol 2023; 107:1246-1252. [PMID: 35418476 DOI: 10.1136/bjophthalmol-2022-321132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS To evaluate the role of early immunosuppressive therapy (IMT) in the management of rheumatoid arthritis (RA)-associated peripheral ulcerative keratitis (PUK). METHODS Single-centre, retrospective, comparative cohort study. Patients with RA-associated PUK were divided into two groups; those exposed to and those not exposed to early IMT, defined as administrating therapy within the first 4 weeks from the PUK onset. Outcomes included PUK recurrence, control of inflammation and development of ocular complications, including corneal scarring and perforation, cataract formation or progression and permanent visual loss. RESULTS A total of 52 eyes from 36 patients were included for analysis; 37 (71.2%) eyes received early IMT and 15 (28.8%) eyes did not. Follow-up time was 41.2+53.3 months (range: 4-236 months). While early IMT was a protective factor (HR 0.345, 95% CI 0.126 to 0.946, p=0.039), late RA diagnosis after PUK onset (HR 4.93, 95% CI 1.75 to 13.85, p=0.002) and retarded (≥2 months) control of inflammation (HR 8.37, 95% CI 1.88 to 37.16, p=0.005) were risk factors for PUK recurrence. Late IMT (OR 7.75, 95% CI 2.00 to 29.99, p=0.003), an unknown diagnosis of RA at first visit (OR 4.14, 95% CI 1.15 to 14.91, p=0.030) and at least one PUK recurrence (OR 6.42, 95% CI 1.71 to 24.07, p=0.006) were risk factors for visual loss. Survival analysis rendered eyes exposed to early IMT a lower risk of PUK recurrence (p=0.039). CONCLUSION Eyes with RA-associated PUK exposed to early IMT were more likely to achieve earlier inflammatory control, fewer recurrences and had better visual outcomes.
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Affiliation(s)
- Raul E Ruiz-Lozano
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
| | - Eugenia M Ramos-Davila
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
| | - Lucas A Garza-Garza
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
| | - Kathia Gutierrez-Juarez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
| | - Julio C Hernandez-Camarena
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
| | - Alejandro Rodriguez-Garcia
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Nuevo Leon, Mexico
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Cunningham ET, Agarwal M, Smit DP, Tugal-Tutkun I, Thorne JE. Mooren's Ulcer. Ocul Immunol Inflamm 2023; 31:673-674. [PMID: 37134277 DOI: 10.1080/09273948.2023.2193129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Emmett T Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA
- The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA
| | - Mamta Agarwal
- The Uveitis & Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Derrick P Smit
- The Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ilknur Tugal-Tutkun
- The Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Jennifer E Thorne
- The Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Chen HC, Hsiao FC, Meir YJ, Hsiao CH, Chen KJ, Ma DK, Wu WC. Peripheral ulcerative keratitis in a patient with granulomatous rosacea. Taiwan J Ophthalmol 2023; 13:80-83. [DOI: 10.4103/tjo.tjo-d-22-00079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/03/2022] [Indexed: 01/06/2023] Open
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Hecquet S, Valnet Rabier MB, Lepelley M, Verhoeven F, Delbosc B, Avouac J, Prati C, Gauthier AS, Wendling D. Ophthalmic adverse events under tofacitinib and baricitinib: Case analysis of the European Pharmacovigilance Database. Joint Bone Spine 2023; 90:105483. [PMID: 36370964 DOI: 10.1016/j.jbspin.2022.105483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Sophie Hecquet
- Department of Rheumatology, Besançon University Medical Center, Besançon, France; EA 4267 "PEPITE", FHU Increase, Bourgogne-Franche Comte University, UFR SMP, Besançon, France
| | | | - Marion Lepelley
- Department of Pharmacovigilance, Grenoble University Medical Center, Besançon, France
| | - Frank Verhoeven
- Department of Rheumatology, Besançon University Medical Center, Besançon, France; EA 4267 "PEPITE", FHU Increase, Bourgogne-Franche Comte University, UFR SMP, Besançon, France
| | - Bernard Delbosc
- Department of Ophthalmology, Besançon University Medical Center, Besançon, France
| | - Jérôme Avouac
- Department of Rheumatology, Cochin University Hospital, Paris, France
| | - Clément Prati
- Department of Rheumatology, Besançon University Medical Center, Besançon, France; EA 4267 "PEPITE", FHU Increase, Bourgogne-Franche Comte University, UFR SMP, Besançon, France
| | - Anne-Sophie Gauthier
- Department of Ophthalmology, Besançon University Medical Center, Besançon, France
| | - Daniel Wendling
- Department of Rheumatology, Besançon University Medical Center, Besançon, France; EA 4266 "EPILAB", Bourgogne-Franche Comte University, UFR SMP, Besançon, France.
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Updates of ocular involvement in granulomatosis with polyangiitis. Graefes Arch Clin Exp Ophthalmol 2022; 261:1515-1523. [DOI: 10.1007/s00417-022-05918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
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Calvo-Río V, Sánchez-Bilbao L, Álvarez-Reguera C, Castañeda S, González-Mazón I, Demetrio-Pablo R, González-Gay MA, Blanco R. Baricitinib in severe and refractory peripheral ulcerative keratitis: a case report and literature review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221137126. [PMID: 36419482 PMCID: PMC9677317 DOI: 10.1177/1759720x221137126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/12/2022] [Indexed: 10/02/2023] Open
Abstract
Ocular disease, such as scleritis and peripheral ulcerative keratitis (PUK), may be a serious ocular complication. We present a patient with severe and refractory PUK treated with baricitinib. A review of the literature on Janus kinase inhibitors (JAKINIB) in refractory ocular surface pathology was also performed. For the literature review, the search in PubMed, Embase, and the Cochrane library was carried out from inception until 31 May 2021, including conference proceedings from four major rheumatology congresses. All original research articles studying JAKINIB treatment in patients with inflammatory eye disease were included. We present an 85-year-old woman with rheumatoid arthritis (RA) and secondary Sjögren's syndrome refractory to methotrexate, leflunomide, certolizumab pegol, adalimumab, and tocilizumab (TCZ). However, 10 months after starting TCZ, the patient suffered a perforation secondary to PUK, requiring urgent surgical intervention. In the absence of infection, she was treated with boluses of intravenous methylprednisolone followed by oral prednisone at high doses in a decreasing pattern together with baricitinib at a dose of 2 mg/day with a very rapid and persistent favorable response to eye and joint symptoms. After 18 months of treatment, the patient had not presented serious side effects or signs of reactivation of her disease. In addition to this report, three other studies including one PUK associated with RA and two non-infectious scleritis treated with tofacitinib were included in this literature review. All three patients had experienced an insufficient response to conventional treatment, including biologic agents, before being switched to JAKINIB, leading to a complete or partial recovery in all of them without significant adverse effects so far. JAKINIBs (baricitinib and tofacitinib) may be an effective and safe therapy in patients with severe autoimmune and refractory ocular surface pathology, such as scleritis and PUK.
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Affiliation(s)
- Vanesa Calvo-Río
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Lara Sánchez-Bilbao
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Carmen Álvarez-Reguera
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Santos Castañeda
- Rheumatology, Hospital Universitario La
Princesa and IIS-IP, Madrid, Spain
| | - Iñigo González-Mazón
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Rosalía Demetrio-Pablo
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Miguel A. González-Gay
- Rheumatology Division, Hospital Universitario
Marqués de Valdecilla, Avda. Valdecilla s/n., Santander 39008, Spain
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario
Marqués de Valdecilla, Avda. Valdecilla s/n., Santander 39008, Spain
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Peripheral Ulcerative Keratitis: Management. CURRENT OPHTHALMOLOGY REPORTS 2022. [DOI: 10.1007/s40135-022-00301-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
PURPOSE OF REVIEW To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases. RECENT FINDINGS Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death. SUMMARY Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.
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Affiliation(s)
| | - Rex M McCallum
- Department of Medicine, Division of Rheumatology, Duke University, Durham, North Carolina, USA
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14
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Li Y, McKelvie J, McLintock C. Visual Outcomes of Patients With Peripheral Ulcerative Keratitis and the Effect of Immunosuppression-A 6-Year Experience in Queensland, Australia. Eye Contact Lens 2022; 48:283-288. [PMID: 35580360 DOI: 10.1097/icl.0000000000000906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Peripheral ulcerative keratitis (PUK) can cause significant ocular morbidity and mortality. This study aimed to review the effects of systemic immunosuppression on visual outcomes. METHODS A state-wide, retrospective case series based in Queensland, Australia, was performed. A review of patients who presented with PUK to the major tertiary ophthalmology referral centers between January 2015 and January 2021 was undertaken. Parameters recorded included clinical features at presentation, investigations undertaken, treatment provided, visual outcomes, and mortality outcomes. The effect of immunomodulatory therapy on the change in vision from presentation to the most recent review was analyzed. RESULTS Twenty-two eyes of 26 patients with PUK (average age 69.81±14.54 years) were included and had a mean follow-up period of 577.73 days. Twelve patients (54.5%) had systemic autoimmune disease, one patient (4.5%) had positive syphilis serology, and nine patients (40.9%) had idiopathic PUK. Eighteen patients (81.8%) were treated with systemic steroids and 10 patients (45.5%) were treated with steroid-sparing immunomodulatory therapy. Average logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) at presentation and final follow-up were 0.63±0.65 and 0.64±0.82, respectively. Those who were treated with immunomodulatory therapy had a nonstatistically significant improvement in BCVA (-0.10±0.29 with vs. +0.10±0.35 without), and a similar trend was seen for doxycycline (-0.08±0.09 with vs. +0.22±0.49 without). Four of five perforations (80%) were surgically managed. Four patients (18.2%) were deceased. CONCLUSIONS Peripheral ulcerative keratitis poses significant clinical challenges and requires intensive medical treatment, frequently involving systemic immunomodulatory therapy. Surgical treatment is required in a significant minority of cases. Ocular management alongside the use of doxycycline and immunomodulatory therapy in consultation with specialist physicians can optimize visual and systemic outcomes.
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Affiliation(s)
- Ye Li
- Department of Ophthalmology (Y.L., C.M.), Princess Alexandra Hospital, Brisbane, Australia ; Department of Ophthalmology (J.M.), University of Auckland, Auckland, New Zealand ; and Faculty of Medicine (Y.L., C.M.), University of Queensland, Brisbane, Australia
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Atienza-Mateo B, Prieto-Peña D, Vicente-Rabaneda EF, Blanco R, González-Gay MA, Castañeda S. Utility of tocilizumab in autoimmune eye diseases. Expert Opin Biol Ther 2022; 22:789-799. [DOI: 10.1080/14712598.2022.2066971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Belén Atienza-Mateo
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Diana Prieto-Peña
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Miguel A. González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
- Department of Medicine, University of Cantabria, Santander, Spain
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Madrid, Spain
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Mehta K, Gujjar AP, Babu K. Peripheral Ulcerative Keratitis in a Young Lady with Systemic Lupus Erythematosus Post Rituximab Infusion-A Case Report. Ocul Immunol Inflamm 2022; 30:1312-1314. [PMID: 35212598 DOI: 10.1080/09273948.2022.2037654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM We report a new ocular finding of episcleritis (OD) and peripheral ulcerative keratitis (OS) in a 40-year-old lady with a 13-year history of systemic lupus erythematosus (SLE), 3 weeks post-rituximab infusion. MATERIALS & METHODS Retrospective case report. RESULTS A 40-year-old lady with a history of SLE and 3 weeks post rituximab infusion developed a new onset episcleritis (OD) and peripheral ulcerative keratitis (OS). As the PUK continued to advance with a leading edge, intravenous methyl prednisolone 1 gm/day was given for 3 days followed by a slow tapering course of oral prednisolone 50 mg/day. Though her ocular inflammation resolved, she developed pneumonia 6 weeks later. At 10 months follow-up, there were no ocular recurrences. She is currently on mycophenolate mofetil 2 gm/day along with oral prednisolone of 10 mg/day. CONCLUSION This case highlights the new occurrence of episcleritis and PUK in SLE post-rituximab infusion.
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Affiliation(s)
- Komal Mehta
- Department of Ophthalmology, Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, India
| | - Aishwarya Pinakin Gujjar
- Department of Ophthalmology, Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, India
| | - Kalpana Babu
- Department of Ophthalmology, Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, India
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Hӧllhumer R. Peripheral ulcerative keratitis: A review of aetiology and management. AFRICAN VISION AND EYE HEALTH 2022. [DOI: 10.4102/aveh.v81i1.697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Peripheral ulcerative keratitis (PUK) is a severe inflammatory disease of the peripheral cornea that can be caused by local factors or systemic inflammatory disease.Aim: The purpose of this review is to give an overview of the pathophysiology, aetiology, clinical features, diagnosis, and management of PUK.Method: A PubMed search was conducted using the keywords, ‘peripheral ulcerative keratitis’ and ‘Mooren’s ulcer’.Results: The peripheral cornea has unique characteristics the predispose to the development of PUK. These include fine capillary arcades that allow for deposition of immune complexes and subsequent activation of an inflammatory cascade with corneal melt. Several conditions have been implicated in the aetiology of PUK. The most commonly cited causes are rheumatoid arthritis (RA), granulomatosis with polyangiitis (GPA) and various dermatoses. In patients with RA, PUK usually presents in established disease, whereas in GPA, PUK may be the presenting feature in up to 60% of cases. In RA it heralds the onset of a systemic vasculitis with significant associated morbidity and mortality. The management of PUK follows an individualised stepwise approach. All patients require supportive measures to encourage healing and halt the process of keratolysis. Systemic autoimmune conditions need a systemic corticosteroid as a fast-acting agent to halt the inflammatory process while cytotoxic therapy maintains long term disease control. Failure to achieve disease control with CTT, necessitates the use of a biologic agent.Conclusion: Peripheral ulcerative keratitis is a severe inflammatory disease of the peripheral cornea that needs a thorough diagnostic workup and stepwise management approach.
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罗 靓, 霍 文, 张 钦, 李 春. [Clinical characteristics and risk factors of rheumatoid arthritis with ulcerative keratitis]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:1032-1036. [PMID: 34916677 PMCID: PMC8695151 DOI: 10.19723/j.issn.1671-167x.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To investigate the clinical characteristics, risk factors and prognosis of ulcerative keratitis (UK) in patients with rheumatoid arthritis (RA). METHODS Sixteen patients with UK (the UK group) were screened among 4 773 RA patients hospitalized at Peking University People's Hospital from January 2003 to May 2021, and 72 patients with RA without UK in the control group were selected by propensity score matching (PSM). The clinical features, laboratory data and medications between the two groups were collected and analyzed. RESULTS The average age of the patients with RA was 60 years at the time of the complication of UK. UK appeared on average in the 16th year of RA, with the majority of UK occurring in the 7th year of RA and beyond (14 cases), however, a minority of UK was the first symptom of RA (1 case). UK associated with RA manifested as simple marginal UK in 8 cases, marginal UK with perforation in 5 cases, marginal UK with uveitis in 2 cases and central UK with perforation in 1 case. The number of swollen joints was significantly higher in the UK group than in the control group [6.0(2.5, 23.0) vs. 3.0(1.0, 9.8), Z=-2.047, P=0.041], and the proportion of secondary Sjögren syndrome (SS, 37.5% vs. 6.9%, χ2=11.175, P=0.004) and interstitial lung disease (ILD, 37.5% vs. 8.3%, χ2=9.456, P=0.008) were significantly higher in the RA patients with UK than the patients without UK. The uses of sulfasalazine (12.5% vs. 48.6%, χ2=7.006, P=0.008), leflunomide (31.3% vs. 63.9%, χ2=5.723, P=0.017) and gold salt(6.3% vs. 33.8%, χ2=4.841, P=0.032)were significantly lower in the UK group than in the control group. However, there was no statistically significant comparison between the two groups for the 28-joint disease activity score-erythrocyte sedimentation rate (5.3±1.8 vs. 5.1±1.6, t=0.309, P=0.761). Logistic analysis showed the number of swollen joints (OR=1.148), secondary SS (OR=79.118), complicated with ILD (OR=6.596) and the use of sulfasalazine (OR=0.037) were independent relevant factors (P < 0.05) for UK in RA patients. CONCLUSION The number of swollen joints, secondary SS, complicated with ILD and the use of sulfasalazine are independent relevant factors for UK in patients with RA.
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Affiliation(s)
- 靓 罗
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
- 重庆市中西医结合康复医院康复科,重庆 400013Department of Rehabilitation, Chongqing Rehabilitation Hospital of Integrated Traditional and Western, Chongqing 400013, China
| | - 文岗 霍
- 河北以岭医院风湿免疫科,石家庄 050091Department of Rheumatology and Immunology, Hebei Yiling Hospital, Shijiazhuang 050091, China
| | - 钦 张
- 北京大学人民医院眼科,北京 100044Department of Ophthalmology, Peking University People's Hospital, Beijing 100044, China
| | - 春 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
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Sota J, Girolamo MM, Frediani B, Tosi GM, Cantarini L, Fabiani C. Biologic Therapies and Small Molecules for the Management of Non-Infectious Scleritis: A Narrative Review. Ophthalmol Ther 2021; 10:777-813. [PMID: 34476773 PMCID: PMC8589879 DOI: 10.1007/s40123-021-00393-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/24/2021] [Indexed: 01/06/2023] Open
Abstract
Scleritis refers to a wide spectrum of ocular conditions ranging from mild to sight-threatening scleral inflammation that may compromise visual function and threaten the anatomical integrity of the ocular globe. Most aggressive forms like necrotizing or posterior scleritis are often difficult-to-treat cases, refractory to conventional treatment. The association with systemic diseases, namely rheumatoid arthritis, Sjögren syndrome, granulomatosis with polyangiitis, and relapsing polychondritis, may have prognostic implications as well. A better understanding of the pathogenesis of ocular inflammatory diseases have paved the way to more effective and targeted treatment approaches. In this regard, a growing body of evidence supports the potential role of biologic agents in the management of non-infectious scleral inflammation, either idiopathic or in a background of immune-mediated systemic disorders. Biologic agents such as anti-tumor necrosis factor agents, interleukin-1 and interleukin-6 inhibitors as well as CD20 blockade have displayed promising results. More specifically, several studies have reported their ability to control scleral inflammation, reduce the overall scleritis relapses, and allow a glucocorticoid-sparing effect while being generally well tolerated. Anecdotal reports have also been described with other biologic agents including abatacept, ustekinumab, daclizumab, and alemtuzumab as well as targeted small molecules such as tofacitinib. Further studies are warranted to fully elucidate the role of biologic agents in non-infectious scleritis and investigate specific areas with the aim to administer treatments in the context of personalized medicine. This review summarizes the available data regarding clinical trials, small pilot studies, and real-life experience of the last two decades reporting the use of biologic agents in the management of non-infectious scleritis.
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Affiliation(s)
- Jurgen Sota
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinics, University of Siena, Policlinico "Le Scotte", viale Bracci 16, 53100, Siena, Italy
| | - Matteo-Maria Girolamo
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinics, University of Siena, Policlinico "Le Scotte", viale Bracci 16, 53100, Siena, Italy
| | - Gian Marco Tosi
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinics, University of Siena, Policlinico "Le Scotte", viale Bracci 16, 53100, Siena, Italy.
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
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20
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Bonnet I, Rousseau A, Duraffour P, Pouchot J, Nguyen CD, Gabison E, Seror R, Marotte H, Mariette X, Nocturne G. Efficacy and safety of rituximab in peripheral ulcerative keratitis associated with rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2020-001472. [PMID: 33510042 PMCID: PMC7845725 DOI: 10.1136/rmdopen-2020-001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/20/2020] [Accepted: 12/28/2020] [Indexed: 12/23/2022] Open
Abstract
Objective Peripheral ulcerative keratitis (PUK) is a rare but severe ocular complication of rheumatoid arthritis (RA). It can be considered as an ocular manifestation of rheumatoid vasculitis (RV). Our case series aimed to evaluate the efficacy of rituximab (RTX) for PUK occurring in patients with RA. Methods Study population were patients with RA-associated PUK treated with RTX 1000 mg on days 1 and 15 at least once after the diagnosis. We identified patients referred to the rheumatology and ophthalmology departments of our hospital between February 2014 and June 2020. We also included patients referred by their specialist after being contacted through the Club Rhumatismes et Inflammation. Demographic data and clinical and biological features were retrospectively collected. Results We included seven patients (three men and four women, median age 58 years). All but one had a long-standing RA with a median disease duration of 13.9 years (IQR 0–30.2). RA was erosive in six out of seven patients. All patients had rheumatoid factors and anticitrullinated peptides antibodies were positive in six of them. PUK was complicated by corneal perforation in three patients and required surgery. After a median follow-up of 29.8 months (IQR 5–75), corneal inflammation was controlled in all patients. PUK recurred in one patient, 8 months after a single infusion of RTX. 71% of the patients presented a good articular response. No patient developed other manifestations of RV. No serious adverse event related to RTX was observed. Conclusion RTX appears to be an efficient and safe therapeutic option in the treatment of RA-associated PUK.
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Affiliation(s)
- Isabelle Bonnet
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Rousseau
- Ophtalmology, Hospital Bicetre, Le Kremlin-Bicetre, Île-de-France, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | | | - Jacques Pouchot
- Internat Medicine, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | - Chi Duc Nguyen
- Rheumatology, Hospital Centre Bethune, Bethune, Nord-Pas de Calais, France
| | - Eric Gabison
- Ophtalmology, Hôpital Bichat Claude-Bernard, Paris, Île-de-France, France.,Centre de Référence pour les Maladies Ren Ophtalmologie (OPHTARA), Fondation Rothschild, Paris, Île-de-France, France
| | - Raphaele Seror
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | - Hubert Marotte
- Rhumatologie, CHU Saint-Etienne, Saint-Etienne, France.,SAINBIOSE, INSERM U1059, University of Lyon, Saint-Etienne, France, University of Lyon, Saint-Etienne, France
| | - Xavier Mariette
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | - Gaetane Nocturne
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
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21
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Kate A, Basu S. Systemic Immunosuppression in Cornea and Ocular Surface Disorders: A Ready Reckoner for Ophthalmologists. Semin Ophthalmol 2021; 37:330-344. [PMID: 34423717 DOI: 10.1080/08820538.2021.1966059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose: Many diseases of the cornea and ocular surface are manifestations of an underlying autoimmune process and require systemic immunosuppression for their management. These cases often present to a general ophthalmologist before being referred to an ocular immunologist or rheumatologist. However, the patients do need to be followed by the ophthalmologist to assess disease progression or for management of ocular co-morbidities and for taking care of ocular complications of the disease. Undeniably, there is a certain hesitance to promptly initiate them on systemic therapy because the literature regarding the indications, dosages, and side effects of this group of drugs is vast and dispersed.The aim of this review is to provide a source of ready reference for the general ophthalmologist as well as trainees and residents, on systemic immunosuppression for corneal and ocular surface disease. Methods: This review included 153 studies which were published as randomized controlled trials, systematic reviews, or as nonrandomized comparative studies (cohort or case-control series) on the topic of systemic immunosuppression in cornea and ocular surface disorders.Results: This review provides a concise summary of both the types of drugs and the common indications where they would be indicated, along with treatment and monitoring algorithms for each specific disease condition. The most used group of drugs are corticosteroids, which have significant side effects, particularly when administered systemically or for longer periods of time. To overcome this, steroid-sparing immunosuppressants are recommended. The four main classes of immunosuppressants used today are antimetabolites, T-cell inhibitors, alkylating agents and biologic agents. This review details the use of these drugs in ocular surface inflammation, including the dosing schedule, side effects and monitoring in allergic conjunctivitis, mucous membrane pemphigoid, peripheral ulcerative keratitis, immunological rejection against corneal allografts, anterior scleritis and aqueous deficiency dry eyes. Conclusions: This review provides an uncluttered and wholesome understanding of systemic immunosuppression in cornea and ocular surface diseases, with the hope that this will serve as a ready reckoner and help bridge the gap between ophthalmology and rheumatology for the betterment of our patients.
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Affiliation(s)
- Anahita Kate
- The Cornea Institute, KVC Campus, LV Prasad Eye Institute, Vijayawada, India
| | - Sayan Basu
- The Cornea Institute, KAR Campus, LV Prasad Eye Institute, Hyderabad, India.,Prof. Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, India
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Cohen F, Gabison EE, Stéphan S, Belkhir R, Nocturne G, Best AL, Haigh O, Barreau E, Labetoulle M, Seror R, Rousseau A. Peripheral ulcerative keratitis in rheumatoid arthritis patients taking tocilizumab: paradoxical manifestation or insufficient efficacy? Rheumatology (Oxford) 2021; 60:5413-5418. [DOI: 10.1093/rheumatology/keab093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/18/2021] [Indexed: 01/26/2023] Open
Abstract
Abstract
Objectives
Peripheral ulcerative keratitis (PUK) is a severe corneal condition associated with uncontrolled RA. Tocilizumab (TCZ) is used to control RA, however, episodes of paradoxical ocular inflammation have been reported in TCZ-treated patients. We report a case series of PUK in TCZ-treated RA patients with ophthalmological and systemic findings and discuss the potential underlying mechanisms.
Methods
Four patients (six eyes), 47–62 years of age, were included. At the onset of PUK, the median duration of RA was 13 years [interquartile range (IQR) 3–13] and the median treatment with TCZ was 9 months (IQR 3–14). Two patients had active disease [28-joint DAS (DAS28) >3.2] and the disease was controlled in two patients (DAS28 ≤3.2).
Results
TCZ was initially replaced by another immunomodulatory treatment in all patients and later reintroduced in two patients without PUK recurrence. Corneal inflammation was controlled in all cases with local and systemic treatments, with severe visual loss in one eye.
Conclusion
PUK may occur in patients with long-standing RA after a switch to TCZ and can be interpreted, depending on the context, as insufficient efficacy or a paradoxical manifestation. These cases highlight the urgent need for reliable biomarkers of the efficacy and paradoxical reactions of biologics.
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Affiliation(s)
- Florian Cohen
- Service d’Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Université Paris-Saclay, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Le Kremlin-Bicêtre
| | - Eric Ernest Gabison
- Service d'Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Hôpital Bichat et Fondation Ophtalmologique Rothschild, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Paris
| | - Sophie Stéphan
- Service d'Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Hôpital Bichat et Fondation Ophtalmologique Rothschild, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Paris
| | - Rakiba Belkhir
- Department of Rheumatology, Assistance Publique – Hôpitaux de Paris, Hôpitaux universitaires Paris-Saclay—Hôpital Bicêtre, Le Kremlin Bicêtre
| | - Gaetane Nocturne
- Department of Rheumatology, Assistance Publique – Hôpitaux de Paris, Hôpitaux universitaires Paris-Saclay—Hôpital Bicêtre, Le Kremlin Bicêtre
- Department of Immunology of Viral and Auto-Immune Disease, UMR1184, CEA, Fontenay-aux-Roses, France
| | - Anne-Laurence Best
- Service d’Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Université Paris-Saclay, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Le Kremlin-Bicêtre
| | - Oscar Haigh
- Department of Immunology of Viral and Auto-Immune Disease, UMR1184, CEA, Fontenay-aux-Roses, France
| | - Emmanuel Barreau
- Service d’Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Université Paris-Saclay, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Le Kremlin-Bicêtre
| | - Marc Labetoulle
- Service d’Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Université Paris-Saclay, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Le Kremlin-Bicêtre
- Department of Immunology of Viral and Auto-Immune Disease, UMR1184, CEA, Fontenay-aux-Roses, France
| | - Raphaele Seror
- Department of Rheumatology, Assistance Publique – Hôpitaux de Paris, Hôpitaux universitaires Paris-Saclay—Hôpital Bicêtre, Le Kremlin Bicêtre
| | - Antoine Rousseau
- Service d’Ophtalmologie, Assistance Publique – Hôpitaux de Paris, Université Paris-Saclay, Centre de Référence Maladies Rares en Ophtalmologie, OPHTARA, Le Kremlin-Bicêtre
- Department of Immunology of Viral and Auto-Immune Disease, UMR1184, CEA, Fontenay-aux-Roses, France
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Gomes BF, Santhiago MR. Biology of peripheral ulcerative keratitis. Exp Eye Res 2021; 204:108458. [PMID: 33493475 DOI: 10.1016/j.exer.2021.108458] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Peripheral ulcerative keratitis (PUK) is a progressive peripheral thinning of the corneal stroma caused by proinflammatory mediators' release from corneal limbal vasculitis. The clinical presentation is an epithelial defect with a crescent-shaped stromal inflammation. Its exact pathophysiologic mechanisms of PUK remain partially understood, but the overall understanding of the fundamental processes that mediate and effect corneal immunity has continued to expand over the past 25 years. The unique anatomical and physiological characteristics of the periphery in relation to collagen bundles and peripheral corneal vascular arch contribute to the occurrence of this type of ulcer in this region, in addition to the concentration of complement and immunoglobulins. There is a relevant participation of the adjacent conjunctiva. Both cell-mediated immunity and humoral immunity are implicated in the pathogenesis of PUK, and the postulated mechanisms are autoimmune reactions to corneal antigens, deposition of circulating immune complexes and hypersensitivity reactions to foreign antigens. These immunocomplexes are deposited in limbic vessels resulting in the activation of the classical pathway of the complement system and, consequently, in the chemotaxis of inflammatory cells and in the release of several pro-inflammatory cytokines, which allow the production and release of matrix metalloproteinases. The release of inflammatory cytokines by infiltrating cells may induce keratocyte activation, which could then generate more release of a variety of cytokines, such as the neutrophil calgranulin C, thus facilitating an autoimmune response to the protein and precipitating an antibody- and cell-mediated hyperimmune reaction in the peripheral cornea.
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Romano C, Esposito S, Ferrara R, Cuomo G. Tailoring biologic therapy for real-world rheumatoid arthritis patients. Expert Opin Biol Ther 2020; 21:661-674. [PMID: 33147106 DOI: 10.1080/14712598.2021.1847268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: The cornerstone of rheumatoid arthritis (RA) therapy relies on the treat-to-target strategy, which aims at dampening inflammation as soon as possible in order to achieve persistent low disease activity or, ideally, remission, according to validated disease activity measures. Traditional disease-modifying antirheumatic drugs (DMARDs) may be chosen in monotherapy or in combination as first-line therapy; in case of an unsatisfactory response after a 3-6-month trial, biologic therapy may be commenced.Areas covered: Real-life RA patients may present with concomitant comorbidities/complications or be in peculiar physiological states which raise more than one question as to which biotherapy may be more well suited considering the whole clinical picture. Therefore, a thorough literature search was performed to identify the most appropriate biologic therapy in each setting considered in this review.Expert opinion: Here we provide suggestions for the use of biologic drugs having a predictable better outcome in specific real-world conditions, so as to ideally profile the patient to the best of the current knowledge.
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Affiliation(s)
- Ciro Romano
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Sergio Esposito
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Roberta Ferrara
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Giovanna Cuomo
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
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