Response time and safety profile of pulsed oral methotrexate therapy in idiopathic retinal periphlebitis

Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis

OBJECTIVE

To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience.

METHODS

A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

RESULTS

The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines.

CONCLUSIONS

In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.

Retinal vasculitis: A framework and proposal for a classification system

Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.

Vitreopapillary and vitreomacular traction in proliferative Eales' disease

Vitreoretinal interface alterations leading to vitreopapillary and vitreomacular traction in a 29-year case of proliferative Eales' disease is described for the first time. On fundus examination, an ellipsoid area of vitreomacular traction was noted temporal to the optic disc. A triangular-shaped infolding of the retina was observed superior to the fovea. Epiretinal membrane was seen temporal to the disc involving the macula. Imaging by spectral domain optical coherence tomography in the papillomacular bundle region revealed retinoschisis at the level of the outer nuclear layer and confirmed the presence of retinal infolding and epiretinal membrane in the macular area. Three-dimensional imaging documented vitreoretinal interface alterations exquisitely.

Elevated tumor necrosis factor in serum is associated with increased retinal ischemia in proliferative eales' disease

OBJECTIVE

Tumor necrosis factor (TNF) was evaluated in the serum of patients with proliferative stage of Eales' disease to study its relation with the area of retinal capillary non-perfusion (ischemic retina).

METHODS

Quantification of the levels of TNF was done using sandwich ELISA in 52 cases with proliferative Eales' disease and in 32 healthy controls. Seven 50° photographs of different fields of the fundus were taken on fluorescein angiography. The area of retinal capillary non-perfusion denoting retinal cell death was assessed in terms of optic disc areas.

RESULTS

TNF levels were found to be significantly increased in the proliferative stage of the disease (mean 23.64 ± 3.7 pg/ml) as compared to controls (mean 12.49 ± 2.9 pg/ml; p < 0.001). Higher levels of TNF were found to be associated with an increased area of retinal capillary non-perfusion on fluorescein angiography. TNF levels of 20-31 pg/ml were observed in cases with neovascularization at the disc (n = 33) as compared to 17-21 pg/ml in cases with neovascularization elsewhere (n = 19).

CONCLUSIONS

An increased level of TNF is associated with an increased area of the ischemic retina. It is hypothesized that retinal cell death signaling in proliferative Eales' disease is related to an increased TNF level.

Tumor necrosis factor-α-mediated severity of idiopathic retinal periphlebitis in young adults (Eales' disease): implication for anti-TNF-α therapy

Tumor necrosis factor-alpha (TNF-α) is a pleiotropic inflammatory cytokine. Tumor necrosis factor-alpha was evaluated in the serum samples of patients with idiopathic retinal periphlebitis in young adults (Eales' disease). Retinal periphlebitis was graded according to a new grading system based on severity of inflammation (grade 1-4). Quantification of the TNF-α levels was carried out using ELISA kit in the serum samples of young adults with idiopathic retinal periphlebitis (n = 17) and healthy controls (n = 17) of similar age. Tumor necrosis factor-α level was found to be significantly raised in cases with retinal periphlebitis as compared with controls (p < 0.001). Higher levels of TNF-α were found to be associated with increased severity of retinal periphlebitis. Tumor necrosis factor-α represents a novel target for controlling inflammatory activity in idiopathic retinal periphlebitis. Higher levels of TNF-α, in association with the increased severity of retinal periphlebitis, have implications for early anti-TNF-α therapy.

Interleukin-1 and tumor necrosis factor-alpha: novel targets for immunotherapy in Eales disease

BACKGROUND

Eales disease is an idiopathic obliterative vasculopathy that primarily affects the peripheral retina of young adults. The authors evaluated interleukin 1 beta (IL-1beta), interleukin-6 (IL-6), Interleukin-10 (IL-10), and tumor necrosis factor-alpha (TNF-alpha) in the serum of patients with Eales disease stages for the first time.

METHODS

The study group consisted of 45 consecutive patients of Eales disease [inflammatory stage (n = 15) and proliferative stage (n = 30)] and 28 healthy controls. Immunoassays for the quantification of the levels of four cytokines including IL-1beta, IL-6, IL-10, and TNF-alpha in the serum samples were performed using ELISA kits.

RESULTS

IL-1beta, IL-6, IL-10, and TNF-alpha levels were found to be increased significantly in the inflammatory stage of Eales disease as compared to controls (p < .001). IL-1beta levels decreased significantly during the proliferative stage of the disease as compared to the inflammatory stage (p = .03). TNF-alpha levels increased significantly during the proliferative stage as compared to the inflammatory stage (p = .02).

CONCLUSIONS

Raised levels of IL-1beta and TNF-alpha were observed in the inflammatory stage and persisted in the proliferative stage of the disease. The IL-1 system and TNF-alpha represent novel target for immunotherapy for controlling inflammatory activity and/or the associated long-term sequelae related to angiogenesis in Eales disease.