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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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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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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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Abdel-Aty A, Gupta A, Del Priore L, Kombo N. Management of noninfectious scleritis. Ther Adv Ophthalmol 2022; 14:25158414211070879. [PMID: 35083421 PMCID: PMC8785299 DOI: 10.1177/25158414211070879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/13/2021] [Indexed: 11/15/2022] Open
Abstract
Scleritis is a manifestation of inflammatory eye disease that involves the sclera. It can be divided into multiple subtypes, including diffuse anterior, nodular anterior, necrotizing, and posterior scleritis. In many cases, scleritis is restricted to the eye; however, it can occur in the context of systemic illness, particularly autoimmune and infectious conditions. Patients with autoimmune conditions, such as rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, and polyangiitis with granulomatosis, may develop scleritis flares that may require topical and systemic therapy. Initial therapy typically involves oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, it is important to address the underlying condition, particularly if systemic. Other treatment regimens typically involve either local or systemic steroids or the use of immunomodulatory agents, which have a wide range of efficacy and documented use in the literature. There is a myriad of immunomodulatory agents used in the treatment of scleritis including antimetabolites, calcineurin inhibitors, biologics, and alkylating agents. In this review, we highlight the various subtypes of noninfectious scleritis and explore each of the mainstay agents used in the management of this entity. We explore the use of steroids and NSAIDs in detail and discuss evidence for various immunomodulatory agents.
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Affiliation(s)
- Ahmad Abdel-Aty
- Department of Ophthalmology and Visual Science, School of Medicine, Yale University, New Haven, CT, USA
| | - Akash Gupta
- Department of Medicine, School of Medicine, Yale University, 20 York Street, New Haven, CT 06510, USA
| | - Lucian Del Priore
- Department of Ophthalmology and Visual Science, School of Medicine, Yale University, New Haven, CT, USA
| | - Ninani Kombo
- Department of Ophthalmology and Visual Science, School of Medicine, Yale University, New Haven, CT, USA
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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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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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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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Gupta Y, Kishore A, Kumari P, Balakrishnan N, Lomi N, Gupta N, Vanathi M, Tandon R. Peripheral ulcerative keratitis. Surv Ophthalmol 2021; 66:977-998. [PMID: 33657431 DOI: 10.1016/j.survophthal.2021.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/12/2022]
Abstract
Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.
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Affiliation(s)
- Yogita Gupta
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Alisha Kishore
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Kumari
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Neelima Balakrishnan
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Neiwete Lomi
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Noopur Gupta
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - M Vanathi
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India;.
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Sánchez-Bilbao L, Martínez-López D, Revenga M, López-Vázquez Á, Valls-Pascual E, Atienza-Mateo B, Valls-Espinosa B, Maiz-Alonso O, Blanco A, Torre-Salaberri I, Rodríguez-Méndez V, García-Aparicio Á, Veroz-González R, Jovaní V, Peiteado D, Sánchez-Orgaz M, Tomero E, Toyos-Sáenz de Miera FJ, Pinillos V, Aurrecoechea E, Mora Á, Conesa A, Fernández-Prada M, Troyano JA, Calvo-Río V, Demetrio-Pablo R, González-Mazón Í, Hernández JL, Castañeda S, González-Gay MÁ, Blanco R. Anti-IL-6 Receptor Tocilizumab in Refractory Graves' Orbitopathy: National Multicenter Observational Study of 48 Patients. J Clin Med 2020; 9:jcm9092816. [PMID: 32878150 PMCID: PMC7563792 DOI: 10.3390/jcm9092816] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/18/2020] [Accepted: 08/29/2020] [Indexed: 12/14/2022] Open
Abstract
Graves' orbitopathy (GO) is the most common extrathyroidal manifestation of Graves' disease (GD). Our aim was to assess the efficacy and safety of Tocilizumab (TCZ) in GO refractory to conventional therapy. This was an open-label multicenter study of glucocorticoid-resistant GO treated with TCZ. The main outcomes were the best-corrected visual acuity (BVCA), Clinical Activity Score (CAS) and intraocular pressure (IOP). These outcome variables were assessed at baseline, 1st, 3rd, 6th and 12th month after TCZ therapy onset. The severity of GO was assessed according to the European Group on Graves' Orbitopathy (EUGOGO). We studied 48 (38 women and 10 men) patients (95 eyes); mean age ± standard deviation 51 ± 11.8 years. Before TCZ and besides oral glucocorticoids, they had received IV methylprednisolone (n = 43), or selenium (n = 11). GO disease was moderate (n =29) or severe (n = 19) and dysthyroid optic neuropathy (DON) (n = 7). TCZ was used in monotherapy (n = 45) or combined (n = 3) at a dose of 8 mg/kg IV every four weeks (n = 43) or 162 mg/s.c. every week (n = 5). TCZ yielded a significant improvement in all of the main outcomes at the 1st month that was maintained at one year. Comparing the baseline with data at 1 year all of the variables improved; BCVA (0.78 ± 0.25 vs. 0.9 ± 0.16; p = 0.0001), CAS (4.64 ± 1.5 vs. 1.05 ± 1.27; p = 0.0001) and intraocular pressure (IOP) (19.05 ± 4.1 vs. 16.73 ± 3.4 mmHg; p = 0.007). After a mean follow-up of 16.1 ± 2.1 months, low disease activity (CAS ≤ 3), was achieved in 88 eyes (92.6%) and TCZ was withdrawn in 29 cases due to low disease activity (n = 25) or inefficacy (n = 4). No serious adverse events were observed. In conclusion, TCZ is a useful and safe therapeutic option in refractory GO treatment.
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Affiliation(s)
- Lara Sánchez-Bilbao
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - David Martínez-López
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Marcelino Revenga
- Rheumatology and Ophthalmology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (M.R.); (Á.L.-V.)
| | - Ángel López-Vázquez
- Rheumatology and Ophthalmology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (M.R.); (Á.L.-V.)
| | - Elia Valls-Pascual
- Rheumatology and Ophthalmology, Hospital Universitari Doctor Peset, 46017 Valencia, Spain; (E.V.-P.); (B.V.-E.)
| | - Belén Atienza-Mateo
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Beatriz Valls-Espinosa
- Rheumatology and Ophthalmology, Hospital Universitari Doctor Peset, 46017 Valencia, Spain; (E.V.-P.); (B.V.-E.)
| | - Olga Maiz-Alonso
- Rheumatology and Ophthalmology, Hospital Universitario de Donosti, 20014 San Sebastián, Spain; (O.M.-A.); (A.B.)
| | - Ana Blanco
- Rheumatology and Ophthalmology, Hospital Universitario de Donosti, 20014 San Sebastián, Spain; (O.M.-A.); (A.B.)
| | - Ignacio Torre-Salaberri
- Rheumatology and Ophthalmology, Hospital Universitario de Basurto, 48013 Bilbao, Spain; (I.T.-S.); (V.R.-M.)
| | - Verónica Rodríguez-Méndez
- Rheumatology and Ophthalmology, Hospital Universitario de Basurto, 48013 Bilbao, Spain; (I.T.-S.); (V.R.-M.)
| | | | | | - Vega Jovaní
- Rheumatology, Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Diana Peiteado
- Rheumatology and Ophthalmology, Hospital Universitario La Paz, 28046 Madrid, Spain; (D.P.); (M.S.-O.)
| | - Margarita Sánchez-Orgaz
- Rheumatology and Ophthalmology, Hospital Universitario La Paz, 28046 Madrid, Spain; (D.P.); (M.S.-O.)
| | - Eva Tomero
- Rheumatology, Hospital de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.T.); (S.C.)
| | | | | | - Elena Aurrecoechea
- Rheumatology and Ophthalmology, Hospital Sierrallana, 39300 Torrelavega, Spain; (E.A.); (Á.M.)
| | - Ángel Mora
- Rheumatology and Ophthalmology, Hospital Sierrallana, 39300 Torrelavega, Spain; (E.A.); (Á.M.)
| | - Arantxa Conesa
- Rheumatology, Hospital Clínico Universitario de Valencia, 46018 Valencia, Spain;
| | | | - Juan A. Troyano
- Ophthalmology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Vanesa Calvo-Río
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Rosalía Demetrio-Pablo
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Íñigo González-Mazón
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - José L. Hernández
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Santos Castañeda
- Rheumatology, Hospital de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.T.); (S.C.)
- Cátedra UAM-Roche, EPID-Future, Universidad Autónoma de Madrid (UAM), 28049 Madrid, Spain
| | - Miguel Á. González-Gay
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
- Correspondence: (M.Á.G.-G.); (R.B.)
| | - Ricardo Blanco
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
- Correspondence: (M.Á.G.-G.); (R.B.)
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Dominguez-Casas LC, Sánchez-Bilbao L, Calvo-Río V, Maíz O, Blanco A, Beltrán E, Martínez-Costa L, Demetrío-Pablo R, del Buergo MÁ, Rubio-Romero E, Díaz-Valle D, Lopez-Gonzalez R, García-Aparicio ÁM, Mas AJ, Vegas-Revenga N, Castañeda S, Hernández JL, González-Gay MA, Blanco R. Biologic therapy in severe and refractory peripheral ulcerative keratitis (PUK). Multicenter study of 34 patients. Semin Arthritis Rheum 2020; 50:608-615. [DOI: 10.1016/j.semarthrit.2020.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
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Gurlevik U, Karakoyun A, Yasar E. When rheumatoid arthritis is mentioned, should only dryness come to mind? Clin Rheumatol 2020; 39:3317-3321. [PMID: 32388745 DOI: 10.1007/s10067-020-05124-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/09/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate corneal parameters of rheumatoid arthritis (RA) patients by corneal topography. METHODS One hundred two RA patients and 60 control subjects were enrolled. Corneal topography measurements and ophthalmologic findings were examined from all participants' files. RESULTS Corneal thickness measurements were significantly lower in the RA group (p = 0.025). All values of corneal curvatures (K1, K2, Kmean) in 3 mm, 5 mm, and 7 mm zones were found statistically significantly higher in the RA group compared with the control group. Forty-five RA patients had a dry eye. Disease duration was correlated with dry eye in the RA group. There was a significant correlation between the duration of disease in RA patients and mean corneal curvatures (p 0.012/0.010/0.007, 3/5/7 mm respectively) and central corneal thickness (p 0.025). There is no statistical difference between other topographic measurements. CONCLUSIONS The results suggest that RA patients have thinner and steeper corneas compared with control subjects. These parameters change in negative correlation as the duration of the disease increases. Key Points • Rheumatoid arthritis is an autoimmune disease with systemic involvement. • In rheumatoid arthritis, systemic involvement is affected in the eyes. • When it comes to eye involvement, it comes to mind that it makes the eyes more dryness. • In addition to dryness in the eyes, rheumatoid arthritis makes morphological changes in the cornea.
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Affiliation(s)
- Ugur Gurlevik
- Ophthalmology Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey. .,Physical Therapy and Rehabilitation Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey.
| | - Ahmet Karakoyun
- Ophthalmology Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey.,Physical Therapy and Rehabilitation Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey
| | - Erdogan Yasar
- Ophthalmology Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey.,Physical Therapy and Rehabilitation Department, Faculte of Medicine, Aksaray Education and Research Hospital, Aksaray University, Aksaray, Turkey
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Benchérifa S, Amine B, El Binoune I, Rostom S, Bahiri R. Two cases of perforated corneal ulcers complicating rheumatoid arthritis treated successfully by biological therapy. BMC Rheumatol 2020; 4:6. [PMID: 32055765 PMCID: PMC7006420 DOI: 10.1186/s41927-019-0108-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/01/2019] [Indexed: 11/21/2022] Open
Abstract
Background Peripheral ulcerative keratitis (PUK) is a severe inflammatory ocular disease that can affect patients with a long history of rheumatoid arthritis (RA). The use of biotherapy has revolutionized the treatment of the RA and has provided encouraging outcomes especially in the treatment of PUK reported in few cases. In this article, we describe the case of two patients with the history of perforated corneal ulcer complicating RA treated successfully by biologic agents. Case presentation Case 1: A 45-year-old woman was diagnosed for over 17 years with sero-positive RA refractory to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). She had received one cycle of Rituximab with clinical and biological failure. In July 2017, she presented an active RA flare with a painful left eye and a decreased visual acuity. Ocular examination revealed a corneal perforation in the left eye and a pre-perforation in the right eye. She received an emergency bolus of methylprednisolone 1 g/day during three consecutive days and was followed by Infliximab. After thirteen months, Infliximab was effective on the rheumatic disease and on the corneal involvement as it stopped its gradual perforation in the right eye, and stabilized corneal ulcer in the left eye. Case 2: A 68-year-old man had been diagnosed since 2010 with sero-positive RA refractory to csDMARDs complicated in July 2017 by corneal perforation in the right eye. He was hospitalized for his ocular involvement and his active RA. He received an emergency bolus of methylprednisolone 500 mg/day during three consecutive days and was followed by Rituximab. After six months, we observed the stabilization of the right eye corneal damage and the resolution of articular symptoms. Conclusions Our cases suggest the efficacy of Infliximab (case 1) and Rituximab (case 2) as a treatment of this severe and destructive keratolysis of the cornea complicating an active RA allowing to plan corneal graft. This positive therapeutic response will contribute to increase literature reports of this therapy success.
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Affiliation(s)
- Sara Benchérifa
- Department of Rheumatology A, El Ayachi Hospital-Salé, CHU Ibn Sina, University Mohammed V-, Rabat, Morocco
| | - Bouchra Amine
- Department of Rheumatology A, El Ayachi Hospital-Salé, CHU Ibn Sina, University Mohammed V-, Rabat, Morocco
| | - Imane El Binoune
- Department of Rheumatology A, El Ayachi Hospital-Salé, CHU Ibn Sina, University Mohammed V-, Rabat, Morocco
| | - Samira Rostom
- Department of Rheumatology A, El Ayachi Hospital-Salé, CHU Ibn Sina, University Mohammed V-, Rabat, Morocco
| | - Rachid Bahiri
- Department of Rheumatology A, El Ayachi Hospital-Salé, CHU Ibn Sina, University Mohammed V-, Rabat, Morocco
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Jayashree S, Nirekshana K, Guha G, Bhakta-Guha D. Cancer chemotherapeutics in rheumatoid arthritis: A convoluted connection. Biomed Pharmacother 2018; 102:894-911. [PMID: 29710545 DOI: 10.1016/j.biopha.2018.03.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 12/11/2022] Open
Abstract
Chemotherapy is one of the most popular therapeutic strategies to treat cancer. However, cancer chemotherapeutics have often been associated with impairment of the immune system, which might consequently lead to an augmented risk of autoimmune disorders, such as rheumatoid arthritis. Though the accurate mechanistic facets of rheumatoid arthritis induction have not been interpreted yet, a conglomeration of genetic and environmental factors might promote its etiology. What makes the scenario more challenging is that patients with rheumatoid arthritis are at a significantly elevated risk of developing various types of cancer. It is intriguing to note that diverse cancer chemotherapy drugs are also commonly used to treat symptoms of rheumatoid arthritis. However, a colossal multitude of such cancer therapeutics has demonstrated highly varied results in rheumatoid arthritis patients, including both beneficial and adverse effects. Herein, we attempt to present a holistic account of the variegated modalities of this complex tripartite cross-talk between cancer, rheumatoid arthritis and chemotherapy drugs in order to decode the sinuous correlation between these two appalling pathological conditions.
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Affiliation(s)
- S Jayashree
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - K Nirekshana
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - Gunjan Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
| | - Dipita Bhakta-Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
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García de Oteyza G, Gómez A, de la Paz M. Corneal melting after cataract surgery in a patient with autoimmune disease. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2017; 92:535-538. [PMID: 28743413 DOI: 10.1016/j.oftal.2017.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 06/07/2023]
Abstract
CASE REPORT A 78-year-old woman with rheumatoid arthritis and secondary Sjögren's syndrome presented with corneal melting three days after cataract extraction that required penetrating keratoplasty. By the fourth month, a second corneal transplant was needed due to a new descemetocele associated with her systemic disease. DISCUSSION The underlying disease, together with the surgical history, was responsible for the complication presented. The correct anamnesis prior to cataract surgery, a refined technique, and a close post-operative follow-up can avoid such a serious complication. Immunomodulatory treatments are essential in this type of patient.
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Affiliation(s)
- G García de Oteyza
- Servicio de Superficie Ocular y Córnea, Centro de Oftalmología Barraquer, Barcelona, España.
| | - A Gómez
- Servicio de Superficie Ocular y Córnea, Centro de Oftalmología Barraquer, Barcelona, España
| | - M de la Paz
- Servicio de Superficie Ocular y Córnea, Centro de Oftalmología Barraquer, Barcelona, España
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