A case of autoimmune-related retinopathy and optic neuropathy syndrome treated by autologous nonmyeloablative hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation as rescue therapy for refractory autoimmune retinopathy: a case report

Autoimmune retinopathy (AIR) is a rare, potentially blinding retinal disease that remains a challenging condition to manage when resistant to conventional immune-modulatory approaches. We report clinical and electrophysiological improvement in a 49-year-old patient who underwent an autologous hematopoietic stem cell transplant (aHSCT) for thymoma-associated AIR after experiencing progressive disease despite receiving periocular and systemic steroids, mycophenolate mofetil, baricitinib, tacrolimus, bortezomib, rituximab, plasmapheresis, and intravenous immunoglobulin. The aHSCT had two stages: (i) peripheral blood stem cell harvest following mobilization with cyclophosphamide and granulocyte colony-stimulating factor, and (ii) conditioning regimen with plasmapheresis, rituximab, cyclophosphamide, and anti-thymocyte globulin high-dose therapy, followed by autologous hematopoietic cell infusion of 5.74 million cells. Symptoms of photopsia rapidly abated after undergoing aHSCT, and objective investigations of structure and function similarly demonstrated improvement. At 22 months' follow-up, she continued to demonstrate the durability of the clinical response. The present report suggests that in judiciously selected patients, HSCT may provide a rescue option for refractory AIR. Further cases are needed to confirm these results.

Autoimmune retinopathy in a patient with smoldering multiple myeloma: a case report

PURPOSE

Multiple myeloma (MM) is a plasma cell dyscrasia leading to proliferation of monoclonal plasma cells. Ocular involvement in multiple myeloma is uncommon but can occur. The ocular manifestations of MM may include the cornea, uvea, and retinal vasculature. We present a rare case of autoimmune retinopathy associated with smoldering MM.

CASE

A 76-year-old female with no significant past medical or ocular history presented with four months of worsening vision, difficulty with night driving, and loss of peripheral vision. Examination was notable for pallor of the optic nerves and vascular attenuation. Visual field testing demonstrated significant and progressive field loss in both eyes. An electroretinogram was extinguished under all conditions. Serum protein electrophoresis showed a significant elevation of IgG with an M-spike, and a subsequent bone marrow biopsy was performed showing 12.5% plasma cells, consistent with the diagnosis of MM. CAR antibody testing was positive for anti-enolase, anti-GAPDH, and anti-Rab6 antibodies, consistent with autoimmune retinopathy.

DISCUSSION

Autoimmune retinopathy associated with MM is exceedingly rare. Management of this condition is challenging, as treatment of the underlying disease does not often lead to improvement in visual symptoms. Ultimately, visual prognosis is very poor, and both patients and clinicians should be aware of the guarded visual potential.

CONCLUSION

The association of autoimmune retinopathy with multiple myeloma is rare. It is crucial for physicians to be aware of such manifestations to ensure timely and appropriate diagnosis and management for patients.

Autoimmune-Related Retinopathy Presenting As Plaquenil Toxicity in Patients With Systemic Lupus Erythematosus

Purpose: To report 3 cases of autoimmune retinopathy (AIR) in patients with systemic lupus erythematosus (SLE) to explore the association between these conditions and highlight additional clinical consideration of AIR in patients presenting with atypical retinopathy in the context of hydroxychloroquine use. Methods: The medical and clinical follow-up records of 3 clinical cases were reviewed. The eligibility criteria were the absence of other retinopathy or systemic autoimmune diseases. Results: All patients had a long-standing diagnosis of SLE and had been taking hydroxychloroquine at a dose exceeding the American Academy of Ophthalmology recommendations. All 3 patients had extensive retinal degeneration atypical in appearance for drug toxicity alone. Examination, imaging, electroretinograms, and autoantibody assays eventually led to the diagnosis of AIR. Conclusions: Further study of the AIR and SLE may reveal an association between these conditions. In patients with SLE presenting with retinal degeneration, AIR may be underdiagnosed.

Advanced Therapy and Clinical Trials to Treat Patients with Optic Nerve Diseases

Optic nerve diseases include a wide variety of pathogenic conditions triggering injury or dysfunction of the optic nerves that lead to visual impairment or blindness in one or both eyes. Despite their pathogenic variety, most of them proceed through common mechanisms that allow them to investigate together. Nevertheless, roles of the cells, tissues, genes, growth factors, and proteins, and all underlying pathophysiological mechanisms need to be studied fully for better management of each optic nerve disease. This review presents a collection of information regarding ongoing and completed clinical trials (CT) of advanced therapies that deliver stem cell and gene therapy treatments as drugs to patients with optic nerve diseases as well as successes and failures achieved in treating these patients in the last few years. These drugs seem safe from creating neurotoxicity. It describes outcomes of a bibliographic search for stem cell therapy, gene therapy, and neuroprotection-based CT registered in the International ClinicalTrials.gov, the European EudraCT, and the Spanish REEC database, and related papers published in the PUBMED database by applying different search terminologies. This review overall informs the patients of optic neurodiseases that advanced therapies are progressing successfully in search of effective and safe treatments for them.

Paraneoplastic ocular syndrome: a pandora's box of underlying malignancies

Paraneoplastic syndromes affecting the visual system are a group of conditions that arise in the systemic malignancy framework. In this review, we have provided a detailed and comprehensive overview of the published literature on the various ophthalmic paraneoplastic manifestations. A systematic review of many databases has been performed to identify ample literature on the paraneoplastic syndromes related to ophthalmology. We have discussed here the clinical features, pathogenesis, and treatment strategies of various ophthalmic paraneoplastic syndromes. It can be challenging to distinguish these disorders from their non-paraneoplastic counterparts and to determine the appropriate systemic assessment for the tumour responsible, to have a proper approach towards the management of the syndrome. METHOD: We searched PubMed, Science Direct and Journal of Ophthalmology for studies published in English between 1995 and April 2020, incorporating the general search term "paraneoplastic ocular syndrome" with connecting terms relevant to subheadings-e.g. Key search terms were cancer-associated retinopathy, (CAR), melanoma-associated retinopathy, (MAR), paraneoplastic retinopathy, autoimmune retinopathy, autoimmune-related retinopathy, and optic neuropathy, (ARRON), acute zonal occult outer retinopathy, (AZOOR), paraneoplastic vitelliform maculopathy, paraneoplastic vitelliform retinopathy, bilateral diffuse uveal melanocytic proliferation, (BDUMP), paraneoplastic optic neuropathy, (PON), polyneuropathy, organomegaly, endocrinopathy, monoclona gammopathy, and skin changes syndrome (POEMS) and various other terms. References from identified studies have been reviewed and included if deemed appropriate, valid, and scientifically important. If referenced in a selected English paper, we contemplated papers in other languages too. We preferentially selected papers that have been published in the last 10 years, but we have included relevant older references.

Refractory Giant Cell Arteritis Complicated by Vision Loss From Optic Atrophy and Maculopathy Associated With Pachymeningitis

BACKGROUND

We describe a 75-year-old woman who experienced vision loss in her left eye due to biopsy-proven giant cell arteritis (GCA). She subsequently developed pachymeningitis causing refractory headaches and bilateral optic neuropathy and maculopathy.

METHODS

Case report with literature review.

RESULTS

Eighteen months after the initial diagnosis of GCA, imaging studies in our patient demonstrated pachymeningeal enhancement, and meningeal biopsy confirmed lymphoplasmacytic tissue infiltrates with low frequencies of IgG4+ plasma cells. Laboratory investigation revealed the presence of 3 antiretinal antibodies and antimyeloperoxidase antibodies, consistent with autoimmune retinopathy. Treatment with B-cell-depleting anti-CD20 antibodies suppressed meningeal inflammation and prevented further vision loss.

CONCLUSIONS

This case illustrates that bilateral vision loss and chronic headaches in patients with GCA may result from retina-directed autoimmunity and pachymeningitis.

Electroretinographic improvement after rituximab therapy in a patient with autoimmune retinopathy

Purpose

To describe the effect of rituximab on full-field electroretinography (ERG) in a patient with nonparaneoplastic autoimmune retinopathy (npAIR).

Observations

A 58-year-old male patient with visual complaints, positive anti-retinal antibodies and negative work-up for cancer was diagnosed with npAIR. Visual acuity and ancillary tests were normal except abnormal ERG in both eyes. The patient was given one course of rituximab 375 mg/m²/week for 4 weeks and cyclophosphamide 1 gr/m²/month for 6 months. A second course of rituximab was necessary as autoantibody titers showed no change and as new antibodies were noted after treatment with rituximab and cyclophosphamide. Electroretinography was repeated after the first course of rituximab, after cyclophosphamide, and the second course of rituximab therapy.

Conclusions and importance

Rituximab therapy led to marked improvement in full-field ERG readings and regression of symptoms was reported by the patient after rituximab infusions. The effect of rituximab in npAIR was objectively demonstrated with ERG.

[Review of approaches to cell therapy in ophthalmology]

The review covers global trends in cell therapy research and clinical trials aimed at the treatment of ophthalmic diseases. Some definitions are provided and mechanisms of action of cell products studied to date are listed.

Autoimmune-Related Retinopathy and Optic Neuropathy Accompanied by Anti-GAD Antibodies

Autoimmune-related retinopathy and optic neuropathy is characterized by visual loss in the presence of antibodies against retina or optic nerve antigens in the absence of neoplasia. We report a case with progressive central visual loss accompanied by latent autoimmune diabetes in an adult. Visual fields, multimodal imaging and electrophysiological testing showed characteristic changes without evidence of neoplasia on positron emission tomography. Immunologic testing revealed abnormal reactivity against a 20 kDa optic nerve antigen and 40 kDa and 62 kDa retina antigens along with antibodies against anti-glutamic acid decarboxylase, a constellation which we believe to be unique.

Autoimmune retinopathies: a report of 3 cases

PURPOSE

To describe 3 representative cases of autoimmune retinopathy (AIR).

METHODS

Clinical records of patients with a diagnosis of AIR were analyzed for demographic data, clinical findings, ancillary and laboratory tests, and treatment employed.

RESULTS

Three female patients diagnosed with AIR had bilateral reduction of electroretinogram amplitudes and elevation of visual field threshold within the central 30 degrees of the visual field that was disproportionately more severe than the clinical findings of retinal degeneration. The diagnoses were cancer-associated retinopathy, non-neoplastic AIR, and hereditary retinal dystrophy with secondary inflammation. Optic nerve involvement was also present in all cases. The patient with non-neoplastic AIR was successfully treated with systemic corticosteroids and immunomodulatory agents.

CONCLUSION

High index of suspicion is essential for an early diagnosis of AIR. Visual function and electrophysiological tests should be included in the initial workup of patients who present with suggestive clinical signs and symptoms of AIR.

Ophthalmic transplantology: posterior segment of the eye--part II

Background

Transplants of the retina are among the new strategies being used in the treatment of genetic and degenerative macular diseases. Moreover, various cell cultures are being tested to treat retinal disorders.

Material/Methods

Literature dated from 2004 to 2011 was comprehensively examined via Medline and PubMed searches for the following terms: auto-, homo-, heterologous transplantation, retina, stem cells, cultivated cells.

Results

Tissue and cell therapy of retinal diseases are reviewed, including full-thickness retina/retinal pigment epithelium (RPE)/choroid graft; full and partial thickness RPE/choroid complex grafts; RPE/Bruch membrane complex graft; and RPE, iris pigment epithelium and stem cell grafts. Recommendations for transplants, as well as the benefits and weaknesses of specific techniques in retina transplants, are discussed.

Conclusions

Auto- and allogenic transplants of a full or partial thickness retina/RPE/Bruch membrane/choroid complex represent an alternative treatment offered to patients with some macular diseases. Stem cell transplantation to reconstruct and regenerate the macula requires further biomolecular and animal research studies.

Diversity in autoimmunity against retinal, neuronal, and axonal antigens in acquired neuro-retinopathy

PURPOSE

Autoimmune retinopathies and optic neuropathies are complex disorders of the retina and the optic nerve, in which patients develop autoantibodies (AAbs) against retinal and optic nerve proteins. Autoimmunity might significantly influence the outcome of retinal and optic nerve degenerative process but the pathogenic process is not fully elucidated. To better understand the role of AAbs in pathogenicity of these suspected autoimmune visual disorders, we focused on unique AAbs specificities associated with the syndrome to identify their antigenic targets in the optic nerve and retina.

METHODS

Serum samples were obtained from patients, whose visual disorders were potentially autoimmune in nature, including patients with cancer with possible paraneoplastic syndrome. Autoantibodies were tested against human optic nerve and retinal antigens for specificity by Western blotting and immunofluorescence.

RESULTS

Out of 209 tested for anti-optic nerve autoantibodies, 55% showed specific neuronal autoantibodies. The repertoire of anti-optic nerve autoantibodies often differed from anti-retinal antibodies. The major antigenic targets for these antibodies could be divided into four groups. Autoantibodies specific to classical glycolytic enzymes involved in energy production (α and γ enolases, glyceraldehyde 3-phosphate dehydrogenase) also reacted with retinal antigens. Autoantibodies targeted neuronal-specific myelin proteins (MBP, MOG), aquaporin 4, and collapsing response mediator protein 5 reacted with optic nerve antigens. They showed immunostaining of axons and myelin in the optic nerve as determined by double immunofluorescence.

CONCLUSION

We identified novel neuronal autoantigens not previously known to be associated with acquired autoimmune retinopathy and optic neuropathy. Knowledge of the full autoantibody repertoire perpetuating this syndrome is an important first requirement in increasing our understanding of the autoimmune process to facilitate better diagnosis, prognosis, and treatment.

Anti-γ-enolase autoimmune retinopathy manifesting in early childhood

OBJECTIVE

To describe the clinical, molecular, and serologic findings of a case in which autoimmune retinopathy and early-onset heritable retinal degeneration were both considered in the differential diagnosis.

METHODS

A 3-year-old girl had clinical findings suggestive of a childhood-onset retinal degeneration. Samples of DNA and serum were collected. The coding regions of 11 genes associated with Leber congenital amaurosis were sequenced. The patient's serum reactivity to soluble and insoluble fractions of human retinal protein was compared with that of healthy control subjects (n = 32), patients with inflammatory eye disease (n = 80), and patients with molecularly confirmed retinal degenerations (n = 11). Two-dimensional gel electrophoresis and mass spectrometry were used to identify a protein that corresponded to a reactive band on Western blot.

RESULTS

No plausible disease-causing mutations were identified in any of the retinal disease genes tested. However, the patient's serum showed reactivity to a single retinal antigen of approximately 47 kDa. Two-dimensional gel electrophoresis and mass spectrometry revealed the major reactive species to be neuron-specific enolase (NSE). Autoantibodies targeting NSE were not observed in any healthy control subjects or patients with inflammatory eye disease. However, anti-NSE activity was found in 1 child with molecularly confirmed Leber congenital amaurosis.

CONCLUSION

This patient's clinical and laboratory findings coupled with the recently discovered role of anti-NSE antibodies in canine autoimmune retinopathy suggest that autoantibodies targeting NSE are involved in the pathogenesis of her disease.

CLINICAL RELEVANCE

Infection or inflammation within the retina early in life may lead to an autoimmune phenocopy of early-onset inherited retinal degeneration.