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Beltrán Catalán E, Brito García N, Pato Cour E, Muñoz Fernández S, Gómez Gómez A, Díaz Valle D, Hernández Garfella M, Francisco Hernández FM, Trujillo Martín MDM, Silva Fernández L, Villanueva G, Suárez Cuba J, Blanco R. SER recommendations for the treatment of uveitis. REUMATOLOGIA CLINICA 2023; 19:465-477. [PMID: 37839964 DOI: 10.1016/j.reumae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/12/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis. METHODS Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed. RESULTS Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus. CONCLUSIONS Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.
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Affiliation(s)
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - Santiago Muñoz Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía. Universidad Europea de Madrid, Madrid, Spain
| | | | - David Díaz Valle
- Unidad de Inflamación Ocular, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | - Lucía Silva Fernández
- Servicio de Reumatología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Julio Suárez Cuba
- Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Ricardo Blanco
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Cantabria, Spain
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Wong MOM, Yu AHY, Chan CKM. Two Year Outcomes of Trabeculectomy in Cytomegalovirus Anterior Uveitis with Uncontrolled Intraocular Pressure. Ocul Immunol Inflamm 2023; 31:1490-1496. [PMID: 35914307 DOI: 10.1080/09273948.2022.2103828] [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: 12/14/2021] [Revised: 06/10/2022] [Accepted: 07/14/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE To describe the two-year outcome of trabeculectomy in cytomegalovirus(CMV) anterior uveitis(AU). METHODS Records of 29 eyes of 29 consecutive CMV AU patients undergoing MMC-augmented trabeculectomy for uncontrolled IOP despite maximal tolerated topical medications were retrospectively reviewed. Treatment success was defined as IOP≤21 mmHg with same or reduced number of IOP-lowering medications compared to baseline, without systemic acetazolamide or further interventions for uncontrolled IOP. RESULTS Treatment success was 79.3% (23/29) at 24 months. Both median IOP and number of IOP-lowering medications dropped significantly from baseline (p < .01 and p < .001, all time-points, Wilcoxon sign-rank test, respectively), with 63.2% and 19.0% reduction in AU relapse/year and steroid use(p = .001 and 0.03, respectively), without sight-threatening sequelae. At 24 months, AU frequency was not significantly different between successful cases with and without ≥12-month use of topical ganciclovir (p = .51, Mann-Whitney U test). CONCLUSION MMC-augmented trabeculectomy was efficacious for IOP control in nearly 80% of CMV AU cases over two years.
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Affiliation(s)
- Mandy Oi Man Wong
- Hong Kong Eye Hospital, HKSAR, Hong Kong, People's Republic of China
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, HKSAR, Hong Kong, People's Republic of China
| | - Amy Hiu Ying Yu
- Hong Kong Eye Hospital, HKSAR, Hong Kong, People's Republic of China
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, HKSAR, Hong Kong, People's Republic of China
| | - Carmen Kar Mun Chan
- Hong Kong Eye Hospital, HKSAR, Hong Kong, People's Republic of China
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, HKSAR, Hong Kong, People's Republic of China
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3
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Wong MOM, Yu AHY, Chan CKM. Efficacy and safety of oral valganciclovir in cytomegalovirus anterior uveitis with uncontrolled intraocular pressure. Br J Ophthalmol 2020; 105:1666-1671. [PMID: 33011687 DOI: 10.1136/bjophthalmol-2020-317044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/19/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS While cytomegalovirus (CMV) anterior uveitis (AU) patients often require glaucoma surgery, the effectiveness of systemic anti-viral in long-term intraocular pressure (IOP) control is not well established. Our study aims to identify the 2-year efficacy and safety of oral valganciclovir in CMV AU with uncontrolled IOP. METHODS In this retrospective case series, one eye from each of 17 immunocompetent PCR-proven patients with CMV AU who received a single course of oral valganciclovir for 20-148 days for medically uncontrolled IOP during 2008-2018 were identified. They were examined at baseline, week 2, months 1, 2 and 3, then every 3 months up to 2 years after commencement of valganciclovir, or until IOP-lowering procedure. RESULTS Median baseline IOP and IOP-lowering medication were 27.0 mm Hg (IQR: 22.9-31.0 mm Hg), and 4.0, respectively. IOP was significantly lower than baseline from 2 weeks to 12 months and at 21 and 24 months after starting valganciclovir (p=0.001 to 0.041, Wilcoxon sign-rank test), with 16.9-46.0% median IOP reduction. Seven (41.2%) and six (35.3%) patients had IOP≤21 mm Hg with same, or reduced, topical medications by 12 and 24 months, respectively. Median time to IOP-lowering intervention or second course of valganciclovir was 12.4 months. There was no serious medication-related adverse event. Common side effects included reduced monocyte count (9 patients) and deranged renal function/electrolytes (5 patients). IOP spike and wound leak occurred in 35.5% and 29.4% of patients, respectively, after diagnostic aqueous tap. CONCLUSION In CMV AU with uncontrolled IOP, >1/3 of the patients avoided glaucoma surgery over 2 years with a course of oral valganciclovir.
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Affiliation(s)
- Mandy O M Wong
- Hong Kong Eye Hospital, Hong Kong SAR, China .,Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Amy H Y Yu
- Hong Kong Eye Hospital, Hong Kong SAR, China.,Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Carmen K M Chan
- Hong Kong Eye Hospital, Hong Kong SAR, China.,Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong SAR, China
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Chen YH, Gepstein R, Sharief L, Tseng HJ, Wei R, Zhang X, Lightman S, Tomkins-Netzer O. Outcome and risk of ocular complications of managing children with chronic anterior uveitis with topical rimexolone 1. Int Ophthalmol 2020; 40:1061-1068. [PMID: 32318939 DOI: 10.1007/s10792-020-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 11/08/2019] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the efficacy and safety of 1% rimexolone ophthalmic suspension in children with chronic anterior uveitis under real-life conditions in a tertiary center. METHODS This is a retrospective longitudinal study. Medical records were analyzed at baseline, 1, 3, 6 and 12 months before and after switching to rimexolone for best-corrected visual acuity (BCVA), oral steroid use, number of flares, IOP and anti-glaucoma management. RESULTS Twenty-four patients (41 eyes) diagnosed with either anterior uveitis (n = 25, 60.0%) or panuveitis (n = 16, 40%) were enrolled. The mean age was 10.5 years (4-16 years). The number of patients requiring oral prednisolone reduced from 8 patients (32.0%) at baseline to 3 patients (20.0%) at 12 months (P < 0.001). Following baseline, the median number of uveitis flares reduced from 2.0 (inter-quartile range (IQR) 1.0-2.75) to 1.0 (IQR 0.0-1.0) compared to the 12 months before baseline (P < 0.001). The mean IOP reduced from baseline (22.0 ± 7.3 mmHg) to 1 month (18.8 ± 8.7 mmHg, P = 0.01) and remained stable up to 12 months (15.9 ± 5.0 mmHg, P < 0.001). Average BCVA, dose of oral prednisolone and anti-glaucoma treatments did not change compared to the baseline. The development for IOP ≥ 30 mmHg was associated with a known corticosteroid response [odds ratio (OR) 6.8, P = 0.003] and a dose > 7.5 mg/day oral prednisolone (OR 4.4, P = 0.033). CONCLUSIONS Rimexolone 1% ophthalmic suspension is an effective and safe topical steroid for pediatric anterior uveitis.
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Affiliation(s)
- Yi-Hsing Chen
- Institute of Ophthalmology, University College of London, London, UK.,Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Moorfields Eye Hospital, London, UK
| | | | - Lazha Sharief
- Institute of Ophthalmology, University College of London, London, UK.,Moorfields Eye Hospital, London, UK
| | - Hsiao-Jung Tseng
- Biostatistical Center for Clinical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - Xiaozhe Zhang
- Institute of Ophthalmology, University College of London, London, UK
| | - Sue Lightman
- Institute of Ophthalmology, University College of London, London, UK.,Moorfields Eye Hospital, London, UK
| | - Oren Tomkins-Netzer
- Institute of Ophthalmology, University College of London, London, UK. .,Moorfields Eye Hospital, London, UK. .,Ophthalmology Department, Lady Davis Carmel Medical Center, Technion-Israel Institute of Technology, Haifa, Israel.
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Musleh MG, Bokre D, Dahlmann-Noor AH. Risk of intraocular pressure elevation after topical steroids in children and adults: A systematic review. Eur J Ophthalmol 2019; 30:856-866. [PMID: 31668084 DOI: 10.1177/1120672119885050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Topical steroids may induce a rise in intraocular pressure. The risk may increase with prolonged use, high frequency of administration, young age, higher ocular penetrance and higher anti-inflammatory potency. We aimed to study this relationship by comparing published rates of intraocular pressure elevation following administration of topical steroids and compared the risk of higher versus lower dosage regimes, high- versus low-potency/penetration steroids and adults versus children. Data sources used were Ovid Embase, Ovid Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Scopus, CINHAL Plus and LILACS. Eligible studies were randomised controlled trials of topical steroids versus any other topical steroid, nonsteroidal anti-inflammatory drugs, placebo or vehicle, or a different mode of administration administered for 7 days or longer that reported intraocular pressure elevation from baseline as >10, 6-15 or >15 mm Hg in adults or children. Risks of bias were reviewed using the GRADE quality approach. Data were extracted into the software package, RevMan, Version 5 (Cochrane Collaboration). In total, 43 studies were included. Meta-analysis was not possible. Topical steroids of lower anti-inflammatory potency, and with reduced intraocular penetration, are associated with reduced incidence of intraocular pressure elevation. A comparison of data in children and adults is limited by the use of different reporting systems. The principal obstacle to meta-analysis is the different reporting systems used to categorise intraocular pressure elevation. We recommend future studies should report intraocular pressure elevation >10 mm Hg from baseline to allow meta-analysis of data.
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Affiliation(s)
| | - Desta Bokre
- Joint Library of Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Annegret H Dahlmann-Noor
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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Heiligenhaus A, Minden K, Tappeiner C, Baus H, Bertram B, Deuter C, Foeldvari I, Föll D, Frosch M, Ganser G, Gaubitz M, Günther A, Heinz C, Horneff G, Huemer C, Kopp I, Lommatzsch C, Lutz T, Michels H, Neß T, Neudorf U, Pleyer U, Schneider M, Schulze-Koops H, Thurau S, Zierhut M, Lehmann HW. Update of the evidence based, interdisciplinary guideline for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Semin Arthritis Rheum 2018; 49:43-55. [PMID: 30595409 DOI: 10.1016/j.semarthrit.2018.11.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized. METHODS Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure). RESULTS Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of ≥ 2 years of uveitis inactivity. CONCLUSIONS An interdisciplinary, evidence-based treatment guideline for JIAU is presented.
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Affiliation(s)
- A Heiligenhaus
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany.
| | - K Minden
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Tappeiner
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H Baus
- The Participation of the Following Bodies: Parents' Group for Children with Uveitis and their Families, Germany
| | - B Bertram
- Professional Association of Ophthalmologists (BVA), Germany
| | - C Deuter
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - I Foeldvari
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - D Föll
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Frosch
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - G Ganser
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Gaubitz
- German Society of Rheumatology (DGRh), Germany
| | - A Günther
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Heinz
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - G Horneff
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Huemer
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - I Kopp
- Association of the Scientific Medical Societies in Germany (AWMF), Germany
| | - C Lommatzsch
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - T Lutz
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - H Michels
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - T Neß
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - U Neudorf
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - U Pleyer
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Schneider
- German Society of Rheumatology (DGRh), Germany
| | | | - S Thurau
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Zierhut
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H W Lehmann
- The Society for Paediatric Rheumatology (GKJR), Germany
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Squires H, Poku E, Bermejo I, Cooper K, Stevens J, Hamilton J, Wong R, Denniston A, Pearce I, Quhill F. A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults. Health Technol Assess 2018; 21:1-170. [PMID: 29183563 DOI: 10.3310/hta21680] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis. DATA SOURCES Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016. REVIEW METHODS Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken. RESULTS Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness. LIMITATIONS The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base. CONCLUSIONS Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041799. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hazel Squires
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Inigo Bermejo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Fahd Quhill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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8
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Bron A, Denis P, Hoang-Xuan TC, Boureau-Andrieux C, Crozafon P, Hachet E, Medhorn E, Akingbehin A. The Effects of Rimexolone 1% in Postoperative Inflammation after Cataract Extraction. A Double-Masked Placebo-Controlled Study. Eur J Ophthalmol 2018; 8:16-21. [PMID: 9590590 DOI: 10.1177/112067219800800105] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim A multicentre, randomized, placebo-controlled double-masked study was conducted to assess the efficacy and safety of Rimexolone 1% eye drops in reducing inflammation after cataract surgery and intra-ocular lens implantation. Methods Rimexolone 1% (124 patients) or placebo (58 patients) was given, four times a day for 14 days starting 22-34 hours after surgery. All patients also received tobramycin 0.3% four times a day for 7 days. The clinical signs of ocular inflammation were recorded on days 1, 3, 8, 15 and 17 or 18. Results Rimexolone 1% markedly decreased the mean inflammation severity scores, and the sum of clinical assessments of cells and flare in the anterior chamber compared with placebo at each assessment. In addition, the percentage of patients with no anterior chamber inflammation was significantly higher with Rimexolone 1% than with the placebo at each assessment. All these results were statistically significant. Intra-ocular pressure did not rise after treatment with Rimexolone 1%. Conclusions The results suggest that Rimexolone 1% ophthalmic solution is an effective and safe steroidal anti-inflammatory agent for topical use following cataract surgery and intraocular lens implantation.
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Affiliation(s)
- A Bron
- Department of Ophthalmology, Faubourg Raines Hospital, Dijon, France
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Abstract
Background Sarcoidosis constitutes one of the leading causes of ocular inflammation. Chronic ocular sarcoidosis can affect any segment of the eye and its adnexa, producing a wide range of clinical manifestations and severity. If left untreated, permanent visual impairment or even blindness may ensue. Treatment approaches vary from topical therapy to systemic agents that induce immunosuppression to different levels according to disease severity. Objective To review the published literature on the management options for chronic ocular sarcoidosis and provide a comprehensive list of available treatment strategies, including the newer biologics. Summary Ocular disease remains a challenging aspect of sarcoidosis and may even be the presenting sign of the disease. Prompt and effective therapy may reverse visual damage and prevent permanent loss of vision. Because of the complexity of the disease, a multidisciplinary approach is often required, with a view to addressing both the ocular and other systemic manifestations of sarcoidosis. Recent data suggest that achieving overall optimal systemic control is of paramount importance in controlling eye inflammation as well. Cytotoxic immunosuppressive agents for refractory chronic ocular disease, as well as biologic anti-TNFα therapies, have advanced the management of chronic disease and should be considered corticosteroid-sparing strategies before the onset of significant steroid-induced morbidity.
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Affiliation(s)
- Artemis Matsou
- Second Department of Ophthalmology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece
| | - Konstantinos T Tsaousis
- Ophthalmology Department, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
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10
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Ha JY, Lee TH, Sung MS, Park SW. Comparison of the Efficacy of Topical Steroids after Trabeculectomy in Patients with Primary Open-angle Glaucoma. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2018. [DOI: 10.3341/jkos.2018.59.4.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jun Young Ha
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
| | - Tae Hee Lee
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
| | - Mi Sun Sung
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Woo Park
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
- Center for Creative Biomedical Scientists, Chonnam National University, Gwangju, Korea
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Sheppard JD, Foster CS, Toyos MM, Markwardt K, Da Vanzo R, Flynn TE, Kempen JH. Difluprednate 0.05% versus Prednisolone Acetate 1% for Endogenous Anterior Uveitis: Pooled Efficacy Analysis of Two Phase 3 Studies. Ocul Immunol Inflamm 2017; 27:484-496. [PMID: 29260952 DOI: 10.1080/09273948.2017.1407433] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose: To analyse pooled data from 2 similar phase 3 noninferiority studies comparing difluprednate 0.05% versus prednisolone acetate 1% in patients with endogenous anterior uveitis. Methods: Patients received difluprednate alternating with vehicle or prednisolone acetate for 14 days (8 drops/day in both groups), followed by tapering from day 14 to 28. All patients were observed until day 42. Results: More patients on difluprednate than on prednisolone acetate were cleared of anterior chamber cells on day twenty one (71.3% vs 54.7%; p = 0.02); results were similar at the other time points. Treatment withdrawals were higher with prednisolone acetate than difluprednate (19.8% vs 7.4%; log-rank p = 0.02). Study discontinuation due to lack of efficacy was also higher with prednisolone acetate than difluprednate (14.0% vs 0%; p = 0.0002 [pre-specified exploratory analysis]). Conclusions: More difluprednate-treated eyes were quiet following 21 days of treatment, and difluprednate-treated patients were much less likely to be withdrawn from the study because of treatment failure.
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Affiliation(s)
- John D Sheppard
- a Eastern Virginia Medical School , Norfolk , Virginia , USA
| | - C Stephen Foster
- b Massachusetts Eye Research and Surgery Institution , The Ocular Immunology and Uveitis Foundation , Cambridge , Massachusetts , USA
| | | | | | | | - Thomas E Flynn
- f Ellsworth Uveitis and Retina Care , Ellsworth , Maine , USA.,g Edward S. Harkness Eye Institute , New York, New York , USA
| | - John H Kempen
- h Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts , USA.,i The Discovery Eye Center, MyungSung Christian Medical Center and MyungSung Medical School , Addis Ababa , Ethiopia
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Asproudis I, Katsanos A, Kozeis N, Tantou A, Konstas AG. Update on the Treatment of Uveitis in Patients with Juvenile Idiopathic Arthritis: A Review. Adv Ther 2017; 34:2558-2565. [PMID: 29143927 DOI: 10.1007/s12325-017-0635-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 12/11/2022]
Abstract
Chronic uveitis is a common extra-articular manifestation of juvenile idiopathic arthritis. The classic clinical picture is one of chronic anterior uveitis, which usually remains asymptomatic until ocular complications arise. The risk of uveitis is increased in girls with an early onset of oligoarthritis and positive antinuclear antibodies. Even though the inflammation in patients with juvenile idiopathic arthritis is initially limited in the anterior part of the eye, chronic active inflammation may eventually cause significant damage to the posterior pole. Complications may include band keratopathy, cataract, secondary glaucoma, posterior synechiae, cystoid macular edema, and hypotony. The cooperation of ophthalmologists with rheumatologists may help define the best treatment plan. The ophthalmic therapeutic regimen includes topical corticosteroids and mydriatics, while in severe cases immunosuppressive and biological agents are introduced. Surgical management of complications might be needed.
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Clarke SLN, Sen ES, Ramanan AV. Juvenile idiopathic arthritis-associated uveitis. Pediatr Rheumatol Online J 2016; 14:27. [PMID: 27121190 PMCID: PMC4848803 DOI: 10.1186/s12969-016-0088-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/21/2016] [Indexed: 12/14/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with JIA-associated uveitis its most common extra-articular manifestation. JIA-associated uveitis is a potentially sight-threatening condition and thus carries a considerable risk of morbidity. The aetiology of the condition is autoimmune in nature with the predominant involvement of CD4(+) T cells. However, the underlying pathogenic mechanisms remain unclear, particularly regarding interplay between genetic and environmental factors. JIA-associated uveitis comes in several forms, but the most common presentation is of the chronic anterior uveitis type. This condition is usually asymptomatic and thus screening for JIA-associated uveitis in at-risk patients is paramount. Early detection and treatment aims to stop inflammation and prevent the development of complications leading to visual loss, which can occur due to both active disease and burden of disease treatment. Visually disabling complications of JIA-associated uveitis include cataracts, glaucoma, band keratopathy and macular oedema. There is a growing body of evidence for the early introduction of systemic immunosuppressive therapies in order to reduce topical and systemic glucocorticoid use. This includes more traditional treatments, such as methotrexate, as well as newer biological therapies. This review highlights the epidemiology of JIA-associated uveitis, the underlying pathogenesis and how affected patients may present. The current guidelines and criteria for screening, diagnosis and monitoring are discussed along with approaches to management.
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Affiliation(s)
- Sarah L. N. Clarke
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ UK ,School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Ethan S. Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ UK ,School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Athimalaipet V. Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ UK ,School of Clinical Sciences, University of Bristol, Bristol, UK
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Abstract
Uveitis is a potentially sight-threatening complication of juvenile idiopathic arthritis (JIA). JIA-associated uveitis is recognized to have an autoimmune aetiology characterized by activation of CD4(+) T cells, but the underlying mechanisms might overlap with those of autoinflammatory conditions involving activation of innate immunity. As no animal model recapitulates all the features of JIA-associated uveitis, questions remain regarding its pathogenesis. The most common form of JIA-associated uveitis is chronic anterior uveitis, which is usually asymptomatic initially. Effective screening is, therefore, essential to detect early disease and commence treatment before the development of visually disabling complications, such as cataracts, glaucoma, band keratopathy and cystoid macular oedema. Complications can result from uncontrolled intraocular inflammation as well as from its treatment, particularly prolonged use of high-dose topical corticosteroids. Accumulating evidence supports the early introduction of systemic immunosuppressive drugs, such as methotrexate, as steroid-sparing agents. Prospective randomized controlled trials of TNF inhibitors and other biologic therapies are underway or planned. Future research should aim to identify biomarkers to predict which children are at high risk of developing JIA-associated uveitis or have a poor prognosis. Such biomarkers could help to ensure that patients receive earlier interventions and more-potent therapy, with the ultimate aim of reducing loss of vision and ocular morbidity.
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Schaal S, Reddy SV, Kaplan HJ. Current medical and surgical therapeutic approaches to cystoid macular edema in uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2015. [DOI: 10.1586/17469899.2015.1003042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Suresh PK, Sah AK. Nanocarriers for ocular delivery for possible benefits in the treatment of anterior uveitis: focus on current paradigms and future directions. Expert Opin Drug Deliv 2014; 11:1747-68. [DOI: 10.1517/17425247.2014.938045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Preeti K Suresh
- University Institute of Pharmacy, Faculty of Technology, Pt. Ravishankar Shukla University,
Raipur-492010, (C.G.), India
| | - Abhishek K Sah
- Pt. Ravishankar Shukla University, University Institute of Pharmacy, Faculty of Technology,
Raipur-492010, (C.G.), India
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Comparison of Efficacy and Ocular Surface Toxicity of Topical Preservative-free Methylprednisolone and Preserved Prednisolone in the Treatment of Acute Anterior Uveitis. Cornea 2014; 33:366-72. [DOI: 10.1097/ico.0000000000000039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pleyer U, Ursell PG, Rama P. Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same? Ophthalmol Ther 2013; 2:55-72. [PMID: 25135807 PMCID: PMC4108144 DOI: 10.1007/s40123-013-0020-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Indexed: 11/30/2022] Open
Abstract
The efficacy of topical corticosteroids as ocular anti-inflammatory agents following cataract surgery is well-documented. They also help to prevent a number of complications associated with post-operative ocular inflammation, including corneal edema and cystoid macular edema. However, topical corticosteroids are associated with side effects, such as increased intraocular pressure (IOP). Indeed, corticosteroid-induced ocular hypertension and the potential for steroid-induced glaucoma remain the leading drawbacks of topical corticosteroid therapy. Some individuals are known to experience a high degree of IOP elevation with low doses or short durations of treatment with topical corticosteroids. Careful monitoring of IOP in such individuals is essential. Few randomized, controlled studies are available on the comparative safety and efficacy of common topical corticosteroids in the treatment of post-operative ocular inflammation. Furthermore, the lack of consistent reporting criteria for clinically significant IOP increases across clinical studies makes meaningful comparisons among corticosteroids difficult. This review aims to examine data from available published studies, including studies in steroid responders, to determine whether topical corticosteroids are the same in terms of their effect on IOP. Early generation corticosteroids, such as dexamethasone and prednisolone, are more likely to result in clinically significant increases in IOP. Newer corticosteroids, such as rimexolone and the retro-metabolically designed corticosteroid, loteprednol etabonate, offer similar anti-inflammatory efficacy to older corticosteroids with less effect on IOP. However, randomized controlled trials of newer corticosteroids are needed. The proportion of patients exhibiting an increase of ≥10 mmHg IOP in clinical studies has emerged as the most clinically relevant parameter for ophthalmologists to consider when deciding on which topical corticosteroid to use.
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Affiliation(s)
- Uwe Pleyer
- Department of Ophthalmology, University Medicine Charité, Humboldt University, Charitéplatz 1, 10117, Berlin, Germany,
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Heiligenhaus A, Michels H, Schumacher C, Kopp I, Neudorf U, Niehues T, Baus H, Becker M, Bertram B, Dannecker G, Deuter C, Foeldvari I, Frosch M, Ganser G, Gaubitz M, Gerdes G, Horneff G, Illhardt A, Mackensen F, Minden K, Pleyer U, Schneider M, Wagner N, Zierhut M. Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int 2011; 32:1121-33. [DOI: 10.1007/s00296-011-2126-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 08/22/2011] [Indexed: 12/14/2022]
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Foster CS, Davanzo R, Flynn TE, McLeod K, Vogel R, Crockett RS. Durezol (Difluprednate Ophthalmic Emulsion 0.05%) compared with Pred Forte 1% ophthalmic suspension in the treatment of endogenous anterior uveitis. J Ocul Pharmacol Ther 2011; 26:475-83. [PMID: 20809807 DOI: 10.1089/jop.2010.0059] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the efficacy and safety of difluprednate ophthalmic solution 0.05% (Durezol; Alcon Laboratories, Fort Worth, TX) compared with prednisolone acetate ophthalmic suspension 1% (Pred Forte; Allergan, Inc., Irvine, CA) for endogenous anterior uveitis. METHODS In this phase 3, multicenter, randomized, noninferiority trial, 90 patients with endogenous anterior uveitis [>10 anterior chamber (AC) cells and an AC flare score of ≥2 in at least 1 eye] received either difluprednate 4x /day (QID) (n=50) or prednisolone 8x/day (n=40) for 14 days, followed by a 2-week tapering regimen. The main outcome measure was change from baseline in AC cell grade on day 14. RESULTS At day 14, mean AC cell grade improvement for difluprednate-treated patients was similar to prednisolone-treated patients (2.1 vs. 1.9, respectively), proving noninferiority. At day 14, 68.8% of difluprednate patients had AC cell clearing (grade 0:≥ 1cell) compared with 61.5% of prednisolone patients. In the prednisolone-treated group, 12.5% of patients were withdrawn because of investigator-determined lack of efficacy; no difluprednate-treated patients were withdrawn for this reason (P=0.01). Clinically significant intraocular pressure elevation occurred in 3 difluprednate-treated patients (6.0%) and 2 prednisolone-treated patients (5.0%). CONCLUSIONS Difluprednate administered QID is at least as effective as prednisolone administered 8x/day in resolving the inflammation and pain associated with endogenous anterior uveitis. Difluprednate provides effective treatment for anterior uveitis and requires less frequent dosing than prednisolone acetate. CLINICAL TRIAL REGISTRATION Trial NCT00501579 was registered at the National Institutes of Health Registry in July 2007 ( http://clinicaltrials.gov/ct2/show/NCT00501579?term=sirion&rank=4 ).
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Affiliation(s)
- C Stephen Foster
- Ocular Immunology and Uveitis Foundation, Harvard Medical School, Massachusetts Eye Research and Surgery Institution , Cambridge, MA 02142, USA.
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Warrian KJ, Hodge WG. Idiopathic Uveitis. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol 2010; 58:11-9. [PMID: 20029142 PMCID: PMC2841369 DOI: 10.4103/0301-4738.58468] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Accepted: 06/17/2009] [Indexed: 12/20/2022] Open
Abstract
Uveitis is composed of a diverse group of disease entities, which in total has been estimated to cause approximately 10% of blindness. Uveitis is broadly classified into anterior, intermediate, posterior and panuveitis based on the anatomical involvement of the eye. Anterior uveitis is, however, the commonest form of uveitis with varying incidences reported in worldwide literature. Anterior uveitis can be very benign to present with but often can lead to severe morbidity if not treated appropriately. The present article will assist ophthalmologists in accurately diagnosing anterior uveitis, improving the quality of care rendered to patients with anterior uveitis, minimizing the adverse effects of anterior uveitis, developing a decision-making strategy for management of patients at risk of permanent visual loss from anterior uveitis, informing and educating patients and other healthcare practitioners about the visual complications, risk factors, and treatment options associated with anterior uveitis.
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Affiliation(s)
- Rupesh V Agrawal
- L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Somasheila Murthy
- L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Virender Sangwan
- L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
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Kavuncu S, Horoz H, Ardagil A, Erbil HH. Rimexolone 1% versus prednisolone acetate in preventing early postoperative inflammation after cataract surgery. Int Ophthalmol 2007; 28:281-5. [PMID: 17762913 DOI: 10.1007/s10792-007-9131-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 07/11/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare the efficacy and safety of rimexolone 1% and prednisolone acetate 1% ophthalmic suspensions in controlling intraocular inflammation in the early period after cataract surgery. METHODS Eighty patients undergoing cataract extraction with intraocular lens implantation, either planned extra capsular cataract extraction (PECCE) or phacoemulsification surgery, were evaluated in a prospective, randomized, observer-masked, clinical trial in which efficacy in controlling early postoperative inflammation and safety of prednisolone acetate 1% one eye drop every 4 h (n = 36 eyes) was compared with that of rimexolone 1% one eye drop every 4 h (n = 44 eyes) in an eighteen day course. Efficacy was assessed from changes of the anterior chamber cell count, flare, conjunctival hyperemia, and ciliary congestion by means of slit lamp biomicroscopy on days 1, 3, 8, 15, and 18. Intraocular pressure (IOP) and possible side effects were also recorded on each visit. RESULTS Anterior chamber cell count and flare showed no difference in the two groups at any visits. The rimexolone group was associated with significantly higher score for conjunctival hyperemia on days one and three (P < 0.05) and the prednisolone acetate group was associated with a significantly higher score for corneal edema on day 8 (P < 0,05). However, there were no between group differences in IOP. CONCLUSIONS Rimexolone 1% ophthalmic suspension was as effective and safe as prednisolone acetate 1% ophthalmic suspension in controlling inflammation in the early period after cataract surgery.
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Yang J, Yang S, Yang YL, Zheng H, Weng L, Liu L. Microbial hydroxylation of 16α,17α-dimethyl-17β-(l-oxopropyl)androsta-l,4-dien-3-one to rimexolone by Curvularia lunata AS 3.4381. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.molcatb.2007.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
AIM To study the overall level of evidence-based practice in an accident and emergency eye unit in the UK and evaluate the extent of evidence-based practice by ophthalmologists and nurse practitioners (NPs). METHODS The case notes of all new patients attending our accident and emergency department for a period of 1 week were reviewed prospectively. For each case, the diagnosis at presentation and its intervention was ascertained. A literature search using Medline and Cochrane library was performed to assess the level of evidence provided for each diagnosis-intervention pair. Each diagnosis-intervention pair was evaluated and graded to assess the best level of evidence provided. RESULTS A total of 474 new patients attended the eye casualty during the study period. No diagnosis was made in 27 cases and they were excluded from the analysis. Out of 447 patients, 308 (68.9%) cases were managed by NPs and 139 (31.1%) by doctors. A total of 294 (65.8%) patient interventions were based on evidence from systematic reviews, meta-analysis and randomised-controlled trials, of which 223 were managed by NPs and 71 by ophthalmologists. This difference was statistically significant with P<0.001. One hundred and seven (23.9%) interventions were supported by evidence from prospective and retrospective trials. CONCLUSION This study demonstrated that two-thirds of interventions were based on the highest level of evidence and was comparable to studies performed in other specialities. It also highlights the advanced role of trained NPs in acute ophthalmology.
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Affiliation(s)
- R Bhatt
- Wolverhampton and Midland Counties Eye Infirmary, Wolverhampton, UK
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Abstract
The ocular system is crucial to survival. It is subject to many of the same diseases found in other organ systems (e.g., diabetes) as well as diseases of ageing (e.g., macular degeneration) and other diseases (e.g., myopia). This review describes ocular diseases which are treatable, or potentially treatable, by pharmacological intervention (e.g., glaucoma, ocular infection, ocular allergy, ocular inflammation, dry eye and retinal pathology). Presented is a background of these diseases, the medical need for therapy, and current and potential new treatments.
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Affiliation(s)
- Gary D Novack
- PharmaLogic Development, Inc., San Rafael, CA 94903-1093, USA.
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Gaudio PA. A review of evidence guiding the use of corticosteroids in the treatment of intraocular inflammation. Ocul Immunol Inflamm 2004; 12:169-92. [PMID: 15385194 DOI: 10.1080/092739490500192] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To review the published laboratory and clinical studies pertaining to the efficacy of corticosteroids in the treatment of intraocular inflammation. METHODS A Pubmed computer search was conducted of all publications focusing on the efficacy of corticosteroids in treating ocular inflammation, with an additional search of pertinent citations culled from these articles. RESULTS Experimental evidence has established the efficacy of corticosteroid eyedrops in treating intraocular inflammation. The effectiveness of periocular corticosteroid injections as well as of systemic corticosteroids is supported by extensive clinical experience, although placebo-controlled trials are lacking. Few studies have documented differences in efficacy between the common corticosteroid agents or between the different routes of administration. Subconjunctival injection appears to achieve higher intraocular corticosteroid levels than do other routes of periocular injection or systemic therapy. Clinical experience with intravitreous corticosteroid injection is insufficient to firmly attest to its efficacy or safety. CONCLUSION The efficacy of corticosteroids in treating intraocular inflammation is based on limited experimental evidence and considerable clinical experience.
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Affiliation(s)
- Paul A Gaudio
- Department of Ophthalmology, Mettapracharak Hospital, Nakhorn Pathom, Thailand
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Yaylali V, Ozbay D, Tatlipinar S, Yildirim C, Ozden S. Efficacy and safety of rimexolone 1% versus prednisolone acetate 1% in the control of postoperative inflammation following phacoemulsification cataract surgery. Int Ophthalmol 2004; 25:65-8. [PMID: 15085979 DOI: 10.1023/b:inte.0000018551.80409.0a] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy and safety of rimexolone 1% ophthalmic suspension compared to that of 1% prednisolone acetate in the control of inflammation in eyes undergoing cataract extraction with phacoemulsification followed by posterior chamber intraocular lens implantation. METHODS Forty-eight patients who underwent uncomplicated cataract extraction with phacoemulsification followed by posterior chamber IOL implantation constituted the study group of this prospective, randomized, double-masked investigation. Patients were randomly assigned to two treatment groups; rimexolone 1% ophthalmic suspension (27 subjects) or prednisolone acetate 1% (21 subjects). Postoperatively, patients used topical rimexolone or prednisolone drops four times a day for 15 days. Patients were examined at the first postoperative day (day 1), and days 3, 7 and 15. The major efficacy parameters assessed clinically on each visit were anterior chamber cells, anterior chamber flare and conjunctival hyperemia. Safety of the rimexolone was evaluated by IOP values and the presence of adverse effects. RESULTS Regarding all three efficacy parameters, rimexolone was found to be clinically and statistically equivalent to prednisolone acetate. Intraocular pressure values during the postoperative period were also similar in both groups. CONCLUSION Rimexolone 1% ophthalmic suspension is both an effective and safe topical steroid in controlling postoperative inflammation after cataract extraction with phacoemulsification.
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Affiliation(s)
- Volkan Yaylali
- Pamukkale University School of Medicine, Department of Ophthalmology, Denizli, Turkey.
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Biswas J, Ganeshbabu TM, Raghavendran SR, Raizada S, Mondkar SV, Madhavan HN. Efficacy and safety of 1% rimexolone versus 1% prednisolone acetate in the treatment of anterior uveitis ? a randomized triple masked study. Int Ophthalmol 2004; 25:147-53. [PMID: 15847313 DOI: 10.1007/s10792-004-5195-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of 1% rimexolone versus 1% prednisolone acetate ophthalmic suspension in the treatment of anterior uveitis. METHODS A randomised triple masked, parallel comparison of rimexolone and prednisolone acetate ophthalmic suspensions was carried out on 78 patients with acute, chronic and recurrent anterior uveitis. Treatment regimen included instillation of one or two drops of drug one hourly through the waking hours during the first week, two hourly in the second week, four times a day in the third week, two times a day for the first 4 days and once a day for the 3 days in the last week. The patient was clinically evaluated on the 3-4th, 7-10th, 14th, 21st and 28th days. The patient was also reviewed on the 30th day. Anterior chamber cells and flare reactions were compared for evaluating the efficacy of the drugs. RESULT Rimexolone is as effective as prednisolone acetate ophthalmic suspension in the treatment of anterior uveitis. The largest difference found was 0.1 in the flare reaction (statistically insignificant; p = 0.3) and 0.2 score units (statistically significant; p = 0.01) in the cells. Overall, comparison of the drugs shows no clinical significance in the treatment of anterior uveitis by either drug. Difference in intraocular pressure (IOP) was also statistically insignificant (p > 0.05). However, three patients in the prednisolone acetate group and 1 patient from the rimexolone group showed a rise in IOP. CONCLUSION Rimexolone 1% ophthalmic suspension is as effective as and safer than prednisolone acetate 1% ophthalmic suspension in the treatment of anterior uveitis.
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Affiliation(s)
- Jyotirmay Biswas
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai 600 006, India.
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Bhattacherjee P, Mukhopadhyay P, Paterson CA, Graff G, Gamache DA, Yanni JM. AL-2512, a novel corticosteroid: preclinical assessment of anti-inflammatory and ocular hypertensive effects. J Ocul Pharmacol Ther 2003; 19:353-60. [PMID: 12964959 DOI: 10.1089/108076803322279408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The anti-inflammatory efficacy and ocular hypertensive effect of AL-2512 were characterized in rodent and feline models of ocular inflammation. Neutrophil influx into ocular tissue following topical ocular administration of test drugs was evaluated in models of endotoxin-induced uveitis. In rats, the anti-inflammatory efficacy of AL-2512 was compared with that of 0.1% dexamethasone. Test drug or vehicle was administered topically before subplantar injection of endotoxin. Neutrophil influx was assessed at 24 hours. Feline eyes, injected intravitreally with endotoxin, were treated topically with 0.1% AL-2512, 1.0% prednisolone acetate or vehicle at various timepoints before and after endotoxin injection. At 12 hours, protein concentration and leukocyte count in aqueous humor were determined. In the feline intraocular pressure (IOP) model, after baseline IOP values were established, AL-2512, dexamethasone, or vehicle was administered topically to both eyes of cats. IOP was measured daily before and during treatment. Topical ocular administration of AL-2512 inhibited endotoxin-induced leukocyte influx in rodent and feline models of uveitis. In rats, AL-2512 significantly inhibited neutrophil influx by 89%, compared with 93% by dexamethasone. In feline eyes, AL-2512 significantly (p < 0.05) inhibited leukocyte infiltration of aqueous humor by 59%, compared to 37% inhibition by prednisolone acetate. Intraocular pressure in cats treated for 32 days with AL-2512 or dexamethasone increased 6% and 18%, respectively. The ocular anti-inflammatory effect of AL-2512 was equivalent to dexamethasone and superior to prednisolone acetate in rat and feline models of ocular inflammation, respectively. This steroid provides anti-inflammatory efficacy equivalent to dexamethasone with a reduced risk of inducing ocular hypertension.
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Affiliation(s)
- Parimal Bhattacherjee
- Department of Ophthalmology and Visual Sciences, University of Louisville, Louisville, KY, USA
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Abstract
PURPOSE To describe a case of interface fluid after laser in situ keratomileusis (LASIK) and review the literature on this rare complication after LASIK. METHODS We present a case report and literature review. Articles for this review were chosen from electronic database and manual literature searches. MEDLINE searches were made from 1990 to April 2002, using the key words "interface fluid" and "LASIK." RESULTS A 40-year-old man had uneventful LASIK for residual refractive error from previous penetrating keratoplasty in his right eye. Diffuse lamellar keratitis began 1 day postoperatively. Topical corticosteroids were administered. Six weeks after LASIK, a layer of interface fluid developed. Intraocular pressure was 9 mmHg when measured centrally by Goldmann applanation tonometry and 30 mmHg by Tono-pen tonometry. The interface fluid resolved with antiglaucoma agents and corticosteroids combined with cyclosporine. CONCLUSIONS This case, along with other reported cases, demonstrate the clinical features of interface fluid after LASIK.
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Affiliation(s)
- W Andrew Lyle
- The Eye Institute of Utah, Salt Lake City, UT 84107, USA
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37
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Abstract
Millions of people suffer from a wide variety of ocular diseases, many of which lead to irreversible blindness. The leading causes of irreversible blindness in the elderly--age-related macular degeneration and glaucoma--will continue to effect more individuals as the worldwide population continues to age. Although there are therapies for treating glaucoma, as well as ongoing clinical trials of treatments for age-related macular degeneration, there still is a great need for more efficacious treatments that halt or even reverse ocular diseases. The eye has special attributes that allow local drug delivery and non-invasive clinical assessment of disease, but it is also a highly complex and unique organ, which makes understanding disease pathogenesis and ocular drug discovery challenging. As we learn more about the cellular mechanisms involved in age-related macular degeneration and glaucoma, potentially, new drug targets will emerge. This review provides insight into some of the new approaches to therapy.
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38
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Abstract
Corticosteroids, used prudently, are one of the most potent and effective modalities available in the treatment of ocular inflammation. However, they can produce a plethora of adverse ocular and systemic events. In order to optimise and target drug delivery, whilst minimising systemic adverse effects, a diverse range of local ophthalmic preparations and delivery techniques have been developed. Topical drops and ointments remain the primary methods for administration of ocular corticosteroids. However, ocular penetration of topical corticosteroid drops depends upon drug concentration, chemical formulation of corticosteroid, and composition of the vehicle, therefore, apparently small modifications in preparations can produce a more than 20-fold difference in intraocular drug concentration. Periocular injections of corticosteroids continue to have a useful, but limited, therapeutic role and longer acting, intraocular delayed-release devices are in early clinical studies. Although newer corticosteroids with lesser pressure elevating characteristics have been developed, corticosteroid-induced ocular hypertension and glaucoma continue to be significant risks of local and systemic administration. Posterior subcapsular cataract, observed following as little as 4 months topical corticosteroids use, is thought to be due to covalent binding of corticosteroid to lens protein with subsequent oxidation. Inappropriate use of topical corticosteroid in the presence of corneal infections also continues to be a cause of ocular morbidity. Other risks of locally administered ophthalmic corticosteroids include: tear-film instability, epithelial toxicity, crystalline keratopathy, decreased wound strength, orbital fat atrophy, ptosis, limitation of ocular movement, inadvertent intraocular injection, and reduction in endogenous cortisol. This extensive review assesses the therapeutic benefits of locally administered ocular corticosteroids in the context of the risks of adverse effects.
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Affiliation(s)
- Charles N J McGhee
- Discipline of Ophthalmology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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39
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Cazabon S, Morrell AJ. Rimexolone-induced intraocular pressure elevation. Eye (Lond) 2001; 15:663-4. [PMID: 11702986 DOI: 10.1038/eye.2001.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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40
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Carnahan MC, Goldstein DA. Ocular complications of topical, peri-ocular, and systemic corticosteroids. Curr Opin Ophthalmol 2000; 11:478-83. [PMID: 11141645 DOI: 10.1097/00055735-200012000-00016] [Citation(s) in RCA: 253] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Topical ophthalmic, oral, and intravenous corticosteroids have long been associated with ocular side effects. Recent data suggest that inhaled corticosteroids are also associated with the development of cataract and increased intraocular pressure. Thus far, nasally administered steroids have not been associated with the same effects. Local injection of steroids, even at sites far from the eye, have been associated with the development of cataract, glaucoma, and even retinal and choroidal emboli. Any physician prescribing corticosteroids should be aware of these potential ocular side effects and should advise patients accordingly.
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Affiliation(s)
- M C Carnahan
- Eye Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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41
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42
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Tran VT, Mermoud A, Herbort CP. Appraisal and management of ocular hypotony and glaucoma associated with uveitis. Int Ophthalmol Clin 2000; 40:175-203. [PMID: 10791265 DOI: 10.1097/00004397-200004000-00014] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- V T Tran
- Hôpital Jules Gonin, University of Lausanne, Switzerland
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43
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44
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McGill JI, Holgate ST, Church MK, Anderson DF, Bacon A. Allergic eye disease mechanisms. Br J Ophthalmol 1998; 82:1203-14. [PMID: 9924312 PMCID: PMC1722368 DOI: 10.1136/bjo.82.10.1203] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- J I McGill
- Southampton University Hospitals, Southampton General Hospital, USA
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45
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Abstract
Raised intraocular pressure is a common and frequently serious complication of anterior uveitis. The milieu of inflammatory cells, the mediators they release, and the corticosteroid therapy used to treat the uveitis can participate in the pathogenesis of uveitic glaucoma. These factors alter the normal anatomic structure of the anterior chamber and angle, influencing aqueous production and outflow. These changes act to disrupt the homeostatic mechanisms of intraocular pressure control. Structural changes in the angle can be acute, such as in secondary angle closure with pupillary block glaucoma, or chronic, such as combined steroid-induced and secondary open angle glaucoma. Management of uveitic glaucoma may be difficult because of the numerous mechanisms involved in its pathogenesis. Diagnostic and therapeutic decisions are guided by careful delineation of the pathophysiology of each individual case. The goal of treatment is to minimize permanent structural alteration of aqueous outflow and to prevent damage to the optic nerve head. This article reviews the pathogenesis of uveitic glaucoma, with specific attention to etiology. Medical and surgical therapies are also discussed, with emphasis on the more recent developments in each category.
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Affiliation(s)
- R S Moorthy
- Doheny Eye Institute, University of Southern California School of Medicine, Los Angeles, USA
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