The diagnosis and management of uveitis

Magnetically Assisted Drug Delivery of Topical Eye Drops Maintains Retinal Function In Vivo in Mice

Barded-Biedl syndrome (BBS) is a rare genetic disorder with an unmet medical need for retinal degeneration. Small-molecule drugs were previously identified to slow down the apoptosis of photoreceptors in BBS mouse models. Clinical translation was not practical due to the necessity of repetitive invasive intravitreal injections for pediatric populations. Non-invasive methods of retinal drug targeting are a prerequisite for acceptable adaptation to the targeted pediatric patient population. Here, we present the development and functional testing of a non-invasive, topical, magnetically assisted delivery system, harnessing the ability of magnetic nanoparticles (MNPs) to cargo two drugs (guanabenz and valproic acid) with anti-unfolded protein response (UPR) properties towards the retina. Using magnetic resonance imaging (MRI), we showed the MNPs' presence in the retina of Bbs wild-type mice, and their photoreceptor localization was validated using transmission electron microscopy (TEM). Subsequent electroretinogram recordings (ERGs) demonstrated that we achieved beneficial biological effects with the magnetically assisted treatment translating the maintained light detection in Bbs^-/- mice (KO). To our knowledge, this is the first demonstration of efficient magnetic drug targeting in the photoreceptors in vivo after topical administration. This non-invasive, needle-free technology expands the application of SMDs for the treatment of a vast spectrum of retinal degenerations and other ocular diseases.

Use of the Fluocinolone Acetonide Intravitreal Implant for the Treatment of Noninfectious Posterior Uveitis: 3-Year Results of a Randomized Clinical Trial in a Predominantly Asian Population

Introduction

The fluocinolone acetonide (FA) intravitreal implant 0.59 mg (Retisert^®, Bausch + Lomb, Rochester, NY, USA) provides sustained release of FA directly to the vitreous cavity over a prolonged period of time. The purpose of this study was to evaluate the safety and efficacy of a 0.59- and 2.1-mg FA intravitreal implant in patients with noninfectious posterior uveitis.

Methods

A prospective, multicenter, randomized, double-masked, dose-controlled study was performed. Patients were randomized to the 0.59- or 2.1-mg FA implant surgically placed in the vitreous cavity through a pars plana incision and were evaluated at visits through 3 years. Patients with bilateral disease had the more severely affected eye implanted. Outcomes included uveitis recurrence rate, best-corrected visual acuity (BCVA), use of adjunctive therapy, and safety.

Results

A total of 239 patients, predominantly Asian, were implanted (n = 117, 0.59-mg implant; n = 122, 2.1-mg implant). Approximately 80% of patients had bilateral disease. Recurrence rates for implanted eyes decreased from 42.3% during the 1-year pre-implantation period to 25.9% during the 3-year post-implantation period (P = 0.0003) and increased for nonimplanted fellow eyes from 19.8 to 59.7% (P < 0.0001). More implanted eyes gained ≥3 lines of BCVA compared to nonimplanted fellow eyes (P ≤ 0.0046); and implanted eyes required less adjunctive systemic therapy and fewer periocular injections (P < 0.0001). Elevations of intraocular pressure (≥10 mm Hg) were frequent in implanted eyes (67.8%, 0.59-mg implant; 71.3%, 2.1-mg implant); nearly all (94.9%) phakic implanted eyes required cataract surgery.

Conclusion

The FA intravitreal implant significantly reduced uveitis recurrence rates and led to improvements in visual acuity and reductions in adjunctive therapy. Lens clarity and intraocular pressure require monitoring.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-014-0027-6) contains supplementary material, which is available to authorized users.

A comprehensive review and update on the non-biologic treatment of adult noninfectious uveitis: part I

INTRODUCTION

Treatment of adult, noninfectious uveitis remains a challenge for ophthalmologists around the world. The disease accounts for almost 10% of preventable blindness in the US and can be idiopathic or associated with infectious and systemic disorders. Strong evidence is still emerging to indicate that pharmacologic strategies presently used in rheumatologic or autoimmune disease may be translated to the treatment of intraocular inflammation. Corticosteroid monotherapy is widely regarded as wholly inappropriate, due to the unfavorable risk/benefit profile and poor long-term outcomes. Treatment plans have shifted away from low-dose, chronic corticosteroid therapy for maintenance, towards medium- to high-dose therapy for acute inflammation, followed immediately by initiation of immunomodulatory therapy. These therapies follow the 'stepladder approach', whereby least to more aggressive therapies are trialed to induce remission of inflammation, eventually without corticosteroids of any form (topical, local and systemic).

AREAS COVERED

This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment of ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy.

EXPERT OPINION

The hazard of chronic corticosteroid use for the treatment of adult, noninfectious uveitis is well-documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted.

Recent developments in the treatment of posterior uveitis

Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.

Fluocinolone acetonide implant (Retisert) for chronic cystoid macular edema in two patients with AIDS and a history of cytomegalovirus retinitis

PURPOSE

To report the authors' experience using fluocinolone acetonide (Retisert) to treat cystoid macular edema (CME) resulting from immune recovery uveitis (IRU) in 2 acquired immunodeficiency syndrome (AIDS) patients with a history of cytomegalovirus (CMV) retinitis.

DESIGN

Interventional case series.

METHODS

Medical records were reviewed of 2 patients who received Retisert implantation in 3 eyes for IRU-associated inflammation and CME. Suppression of CMV disease was achieved with oral medication in one patient and with simultaneous implantation of a ganciclovir implant in the other patient.

RESULTS

After Retisert implantation in 3 eyes in AIDS patients on HAART, improvement in CME was seen in 2 eyes. No CMV reactivation was detected during the several-month follow-up period.

CONCLUSIONS

Retisert may be an effective treatment for CME in AIDS patients with IRU reactivation and a history of CMV retinitis.

Downregulation of endotoxin-induced uveitis by intravitreal injection of polylactic-glycolic acid (PLGA) microspheres loaded with dexamethasone

We tested the short- and long-term ability of polylactic-glycolic acid (PLGA) microspheres loaded with dexamethasone to reduce ocular inflammation in rabbits elicited by intravitreal lipopolysaccharide (LPS) injection. PLGA microspheres loaded with dexamethasone were prepared by the solvent evaporation technique from an oil/water emulsion and sterilized by gamma irradiation (25 kGy). The microsphere fraction selected was 2:10 (dexamethasone:PLGA) and contained 141 +/- 0.38 microg dexamethasone/mg PLGA. Microsphere diameters were 20-53 microm, and the mean encapsulation efficiency was 92.97 +/- 0.75%. Seven days prior to the induction of panuveitis, 10 mg of dexamethasone-free or dexamethasone-loaded microspheres were injected into the vitreous. Control animals received no injection. Panuveitis was induced in male New Zealand rabbits (2.5-3.0 kg) by intravitreal injection of Escherichia coli LPS. Clinical evaluation, electroretinography and histopathologic studies were performed in short-term studies of 15 days and in long-term studies of 33 days. Efficacy in reducing inflammation was also studied in vitrectomized eyes. In short-term studies eyes injected with dexamethasone-loaded microspheres had less inflammation than control eyes and eyes injected with blank microspheres. Inflammation reverted in all groups by 15 days after LPS injection. A second LPS dose given on Day 30 provoked a high peak of inflammation in control eyes and in those injected with blank microspheres. In contrast, only slight inflammation occurred in eyes injected with dexamethasone-loaded microspheres. Histopathology and electroretinography supported these results. Dexamethasone-loaded microspheres effectively reduced intraocular inflammation caused by LPS in both short- and long-term studies.

Unilateral granulomatous post-streptococcal uveitis with elevated tension

PURPOSE

We document a presumptive case of unilateral post-streptococcal uveitis. The affected eye manifested a granulomatous anterior uveitis with elevated intra-ocular pressure (IOP) compared with the contra-lateral eye. This presentation was preceded by a recent streptococcal pharyngitis.

CASE REPORT

An asymptomatic, otherwise healthy 13-year-old black female presented with anterior chamber cells, mutton fat resembling keratic precipitates, and elevated IOP in the left eye relative to the right eye. The patient had been diagnosed with streptococcal pharyngitis approximately 1 week before her eye examination. A blood chemistry analysis, rheumatoid profile panel and antistreptolysin antibody titer were requested. The patient was prescribed predinisolone acetate 1% ophthalmic suspension in the left eye.

RESULTS

Anti-streptolysin antibody titers were significantly elevated (291 IU/ml). The patient responded favorably to topical ophthalmic steroid treatment with a reduction of IOP and inflammation.

CONCLUSIONS

Unilateral, granulomatous anterior uveitis may be a variant manifestation of post-streptococcal uveitis. The IOP elevation in these cases may result secondary to concurrent trabeculitis.

Drug delivery methods for posterior segment disease

PURPOSE OF REVIEW

New pharmacotherapies for posterior segment diseases of the eye have been recently introduced which use novel drug delivery methods. The various current and potential future methods will be discussed.

RECENT FINDINGS

Drug delivery systems have been developed which can provide controlled release of drug for potentially long periods of time. Ideal candidates for these devices are chronic conditions that require repeated local administration of drug, such as noninfectious intermediate or posterior uveitis, neovascular age-related macular degeneration, and persistent macular edema due to diabetic retinopathy or venous occlusive disease. Recently, Retisert (Bausch & Lomb, Rochester, New York, USA), a nonbiodegradable fluocinolone acetonide implant, was approved for use in noninfectious uveitis affecting the posterior segment and is currently in clinical trials for the treatment of macular edema. A biodegradable dexamethasone implant is currently in clinical trials for the treatment of uveitis and diabetic macular edema.

SUMMARY

With the development of therapeutic agents that require repeated administration comes a need for new strategies to improve safety and maximize efficacy. Novel drug delivery systems involving nonbiodegradable or biodegradable implants, microparticulates or nanoparticulates, liposomes, or transscleral iontophoresis may provide the solution.

Retisert: is the new advance in treatment of uveitis a good one?

OBJECTIVE

To review the use of corticosteroids for the treatment of uveitis, with a focus on the pharmacology, efficacy, and safety of a newer delivery device, Retisert.

DATA SOURCES

A PubMed/MEDLINE search from 1950 through February 2007 was conducted, and manufacturer-provided data were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Animal studies and Phase II and III clinical trials evaluating the safety and efficacy of Retisert for the treatment of uveitis were considered. The data were extracted from PubMed/MEDLINE using the search terms fluocinolone acetonide, corticosteroids, intravitreal implant, uveitis, ocular steroids, and Retisert.

DATA SYNTHESIS

The findings of the clinical studies showed, with use of Retisert, a reduction in the recurrence of uveitis, improvement in visual acuity, and a decreased need for adjunctive therapy with corticosteroids and immunosuppressant agents. There are currently no studies directly comparing Retisert with other treatment options. The most commonly reported adverse events (ADEs) in clinical trials included cataracts, increased intraocular pressure, post-procedural complications associated with implant insertion, and ocular pain. Other ocular ADEs included decreased visual acuity, glaucoma, blurred vision, an abnormal sensation in the eye, eye irritation, and a change in tearing. These ADEs are similar to those seen with chronic corticosteroid therapy delivered by other ocular routes.

CONCLUSIONS

Retisert implants have been shown to deliver sufficient drug for a longer period of time compared with the traditional steroid delivery methods. Promising efficacy results show a significant reduction in recurrence rate and improvement in visual acuity for approximately 3 years after implant. However, the drug carries the risks associated with the implant procedure and with chronic exposure of the eye to steroids. Until more data on the long-term safety are known, Retisert should be reserved for patients who are no longer tolerant of or responsive to more traditional treatment modalities.

Fluocinolone acetonide implant (Retisert) for noninfectious posterior uveitis: thirty-four-week results of a multicenter randomized clinical study

PURPOSE

To report the interim 34-week safety and efficacy results of a 3-year study to evaluate an investigational intravitreal fluocinolone acetonide (FA) implant in patients with noninfectious posterior uveitis.

DESIGN

Prospective, dose-masked, dose-randomized, historically controlled, multicenter trial in patients with unilateral or bilateral disease.

PARTICIPANTS

A total of 278 patients with recurrent noninfectious posterior uveitis were randomized to receive a 0.59-mg (n = 110) or 2.1-mg (n = 168) implant. In patients with bilateral disease, the more severely affected eye received the implant.

METHODS

The implant was inserted surgically into the vitreous cavity through a pars plana incision. Follow-up visits were scheduled on day 2, week 1, and then every 4 to 6 weeks through 34 weeks after implantation. Systemic, periocular, and topical therapies were reduced as allowed by the clinical response.

MAIN OUTCOME MEASURES

The primary efficacy outcome was a comparison of the recurrence rate in the implanted eye from the 34 weeks before implantation to the 34 weeks after implantation. Visual acuity (VA), need for adjunctive therapy, and safety also were assessed.

RESULTS

Combining both doses, the FA implant reduced the rate of recurrences from 51.4% in the 34 weeks preceding implantation to 6.1% postimplantation (P<0.0001) in the study eyes. Comparatively, there was a significant increase in the recurrence rate in the fellow nonimplanted eyes from 20.3% preimplantation to 42.0% postimplantation (P<0.0001). Visual acuity was stabilized or improved in 87% of implanted eyes and generally was associated with reductions in the area of macular hyperfluorescence. The percentage of eyes that required systemic medications, periocular injections, and topical corticosteroids decreased from 52.9%, 63.0%, and 35.7%, respectively, preimplantation to 12.1%, 2.2%, and 16.5% postimplantation (P< or =0.0001 in all cases). At week 34, 51.1% of implanted eyes required ocular antihypertensive drops, and 5.8% underwent glaucoma filtering surgery. Lens opacity scores increased by > or =2 grades in 19.8% of phakic implanted eyes, and 9.9% required cataract surgery. There were no statistically significant differences in any of the parameters studied for the 0.59-mg implant, compared with the 2.1-mg implant.

CONCLUSIONS

The FA implant significantly reduced uveitis recurrences, improved VA, and decreased the need for adjunctive therapy in the studied patient population. The most common side effects included increased intraocular pressure and cataract progression.

Management of uveitis in pediatric patients: special considerations

Uveitis refers to inflammation involving the uvea or middle coat of the eye. This condition occurs uncommonly, particularly in persons aged <or=16 years. However, pediatric uveitis deserves special consideration for reasons that include the relatively poor prognosis, unique systemic associations, and various age-related treatment considerations. Accurate diagnosis requires history from both patient and parents, a complete ophthalmic examination that may require general anesthesia, and carefully selected investigations. Infections and masquerade syndromes, such as leukemia and retinoblastoma, must be excluded before treatment is commenced with immunosuppressive agents. Noninfectious anterior uveitis generally responds to topical corticosteroid and mydriatic therapy. Although used frequently in adults with posterior uveitis, periocular corticosteroid injections may require a general anesthetic, and systemic corticosteroids may cause serious adverse effects, including growth retardation, in pediatric patients. Consequently, in children, one or more corticosteroid-sparing immunosuppressive drugs are usually employed for vision-threatening noninfectious posterior eye inflammation. Methotrexate is the most commonly used systemic immunosuppressive agent for pediatric uveitis. It is effective in small retrospective clinical series, generally well tolerated, easy to administer, and inexpensive. Cyclosporin has also been used successfully in children with uveitis, being associated with a low risk of renal toxicity when used at standard doses. Although prescribed for severe ocular inflammation in adults, alkylating agents are generally contraindicated in children owing to risks including secondary malignancy, sterility and bone marrow suppression. Drugs that inhibit tumor necrosis factor-alpha have recently been used successfully to treat children with uveitis; however, in some patients there may be a risk of potentiating the ocular inflammation. Randomized clinical trials would provide valuable information about the relative efficacy of the various available treatment options.

Uveitis management: a multidisciplinary approach to assess systemic involvement and side effects of treatments

OBJECTIVE

Non-infectious uveitis is often associated with systemic diseases severe enough to require corticosteroids (CS) and immunosuppressive drugs, which have potential serious side effects.

METHODS

28 patients with non-infectious uveitis were referred by the ophthalmologist.

RESULTS

A systemic disease was found in 17/28 patients (60%): sarcoidosis in 11, spondylarthropathy in 3, Behcet's disease in 2, Crohn's disease in 1 patient. Eighteen patients received CS, 21 patients received immunosuppressive drugs. Most side effects were due to CS treatment: Cushing's syndrome in 12, cataract in 11, glucose intolerance in 3, gastric ulcus in 1, hypertension in 1, osteoporosis in 17, avascular bone necrosis in 3 patients. Prophylaxis or treatment of corticosteroids induced osteoporosis consists in calcium, 500 mg/day and vitamin D 400 IU in most of them with in addition hormone replacement therapy (n = 8) or bisphosphonates (n = 13).

CONCLUSION

Sixty percent of patients with severe uveitis had a systemic disease. CS were the most deleterious drugs in spite of bi- or tri-therapy with CS sparing immunosuppressive drugs.

The prevalence of uveitis in juvenile rheumatoid arthritis

BACKGROUND

Because asymptomatic uveitis has been an important cause of visual loss in children with juvenile rheumatoid arthritis, periodic ophthalmologic screenings of such patients have been recommended. Recently, some authors have found a decreased prevalence of uveitis in children with juvenile rheumatoid arthritis.

METHODS

We studied a total of 76 patients (63 girls and 13 boys, aged 1 to 16 years), referred to 3 pediatric ophthalmology practices between March 1976 and October 1999. Follow-up examinations were performed at intervals of 3 to 6 months according to current guidelines, during the following 6 months to 23 years (mean, 55 months).

RESULTS

Uveitis developed in 10 children (13%). Of these 10 children, 2 were symptomatic (blurred vision, discomfort) and 7 were diagnosed with uveitis at the initial visit. Only 1 patient had asymptomatic uveitis after initial negative findings on screening examination. Final visual acuity for all the compliant children in the uveitis group was better than 20/30.

DISCUSSION

The prevalence of uveitis in our study is similar to rates found by other recent authors. This decrease may reflect a tendency for systemic medications to prevent the development of ocular inflammation. We believe that screening guidelines should be reevaluated, especially for asymptomatic children with negative findings on initial examinations.