Treatment of ocular inflammation in children

Nanotechnological approaches to improve corticosteroids ocular therapy

The administration of corticosteroids is the first-line treatment of the clinical conditions with ocular inflammation. Nonetheless, ocular physiological mechanisms, anatomical barriers and corticosteroid properties prevent it from reaching the target site. Thus, frequent topical administered doses or ocular injections are required, leading to a higher risk of adverse events and poor patient compliance. Designing novel drug delivery systems based on nanotechnological tools is a useful approach to overcome disadvantages associated with the ocular delivery of corticosteroids. Nanoparticle-based drug delivery systems represent an alternative to the current dosage forms for the ocular administration of corticosteroids, since due to their particle size and the properties of their materials, they can increase their solubility, improve ocular permeability, control their release and increase bioavailability after their ocular administration. In this way, lipid and polymer-based nanoparticles have been the main strategies developed, giving rise to novel patent applications to protect these innovative drug delivery systems as a product, its preparation or administration method. Additionally, it should be noted that at least 10 clinical trials are being carried out to evaluate the ocular application of different pharmaceutical formulations based on corticosteroid-loaded nanoparticles. Through a comprehensive and extensive analysis, this review highlights the impact of nanotechnology applications in ocular inflammation therapy with corticosteroids.

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

Ocular anti-inflammatory activity of prednisolone acetate loaded chitosan-deoxycholate self-assembled nanoparticles

Background and purpose: Conventional topical ophthalmic aqueous solutions and suspensions are often associated with low bioavailability and high administration frequency, pulsatile dose and poor exposure to certain ocular parts. The aim of this study was to develop an ophthalmic nanoparticles loaded gel, for delivering prednisolone acetate (PA), to increase dosing accuracy, bioavailability, and accordingly, efficiency of PA in treating inflammatory ocular diseases. Methods: A novel formulation of self-assembled nanoparticles was prepared by the complexation of chitosan (CS) and, the counter-ion, sodium deoxycholate (SD), loaded with the poorly-water-soluble PA. Particle size, zeta potential, encapsulation efficiency (EE) and drug loading content (LC) of prepared nanoparticles were assessed. Moreover, the nanoparticles were characterized using differential scanning calorimetry (DSC) and Fourier transform infrared spectroscopy (FTIR). Drug release and eye anti-inflammatory potential of the prepared novel formulation was investigated. Results: Mean particle size of the nanoparticles have dropped from 976 nm ±43 (PDI 1.285) to 480 nm ±28 (PDI 1.396) when the ratio of CS-SD was decreased. The incorporation of 0.1-0.3% of polyvinyl alcohol (PVA), in the preparation stages, resulted in smaller nanoparticles: 462 nm ±19 (PDI 0.942) and 321 nm ±22 (PDI 0.454) respectively. DSC and FTIR results demonstrated the interaction between CS and SD, however, no interactions were detected between PA and CS or SD. Drug release of PA as received, in simulated tears fluid (pH 7.4), showed a twofold increase (reaching an average of 98.6% in 24 hours) when incorporated into an optimized nanoparticle gel formulation (1:5 CS-SD). Conclusion: The anti-inflammatory effect of PA nanoparticles loaded gel on female guinea pig eyes was significantly superior to that of the micronized drug loaded gel (P < 0.05).

Causes of uveitis in children without juvenile idiopathic arthritis

BACKGROUND

The purpose of this study was to report the demographics, disease characteristics, treatments, and visual outcomes of pediatric uveitis patients without juvenile idiopathic arthritis managed in a tertiary medical center.

METHODS

A retrospective, observational study was performed in pediatric uveitis patients without juvenile idiopathic arthritis and aged 0-18 years, who were seen at the University of Virginia from 1984 to 2014.

RESULTS

Thirty-nine pediatric uveitis patients (57 eyes) were identified. The patient population was 51.28% female, 51.28% Caucasian, and 33.33% African American. The mean age at diagnosis was 11.9 years. The mean duration of follow-up was 3.11 years. The mean number of visits to the clinic was 10.41. Of 57 eyes, 31 (54.39%) had anterior uveitis, 12 (21.05%) had intermediate uveitis, nine (15.79%) had posterior uveitis, and five (8.77%) had panuveitis. The leading diagnoses were traumatic uveitis (25.64%), undifferentiated anterior uveitis (17.95%), undifferentiated intermediate uveitis (15.38%), HLA-B27-associated anterior uveitis (7.69%), and herpetic anterior uveitis (7.69%). Systemic associations included sarcoidosis, ulcerative colitis, and psoriatic arthritis (n=3). The most common treatment modalities included local steroids (66.67%), systemic steroids (23.08%), and antimetabolites (20.51%). Ocular hypertension was found in five (12.82%) patients. Ocular surgery was performed in six (15.38%) patients. Mean best-corrected visual acuity (BCVA) at baseline across all anatomical locations was 0.458 logMAR, and was 0.411 logMAR at final follow-up. Mean BCVA improved during follow-up in all but the anterior uveitis group. The mean baseline intraocular pressure was 14.27 mmHg, and was 14.22 mmHg at final follow-up.

CONCLUSION

Uveitis in childhood is a vision-threatening group of inflammatory disorders arising from numerous etiologies that vary geographically and historically. Because of the high burden of disease, the difficulty of making precise etiologic diagnoses, and the complicated management, it is imperative that affected children be referred to and closely monitored by uveitis specialists to prevent devastating ocular damage. This study found that BCVA and intraocular pressure did not vary significantly during follow-up, suggesting that close management by an ophthalmologist may prevent adverse visual outcomes, and highlighted the high prevalence of traumatic uveitis in children, which tends to have good visual outcomes.

High dose infliximab in the treatment of refractory uveitis: does dose matter?

Background. Infliximab (INF) has been shown to be beneficial in treating refractory uveitis, however, no data exist on optimal dosing and the efficacy of higher dosing. Objectives. To compare the efficacy of low-dose (LD) (<10 mg/kg), moderate-dose (MD) (≥10–15 mg/kg), and high-dose (HD) INF (≥15–20 mg/kg) in the treatment of uveitis. Methods. Retrospective chart review children with uveitis diagnosed at Childrens Hospital Los Angeles and Millers Children's Hospital, CA, USA. Results. Of the 34 INF-treated children, 6 patients received LD, 19 received MD, and 9 received HD. Average disease duration prior to therapy was 10.6, 24.6, and 37.1 months each group, respectively. Topical steroids were discontinued after an average of 3 months, 9.5 months, and 10.2 months in the LD, MD, and HD groups, respectively. We found that 66% of patients receiving LD, 42% of MD, and 66% receiving HD INF failed therapy and required either dose escalation or alternate medication for disease control. Conclusions. INF is beneficial in the treatment of uveitis, and dose escalation up to 4 times above the approved dose is often necessary to achieve disease control in patients with uveitis. Doses < 10 mg/kg every 4 weeks may not be sufficient to control disease.

Loteprednol and tobramycin in combination: a review of their impact on current treatment regimens

IMPORTANCE OF THE FIELD

The treatment of ocular inflammation continues to be a challenge. Topical corticosteroids are effective in reducing ocular inflammation but are limited by adverse events including elevation of intraocular pressure, development of cataracts, glaucoma and inhibition of wound healing with associated risk of infection. Loteprednol etabonate (LE) is a unique C-20 ester corticosteroid designed to produce a predictable therapeutic effect with a low incidence of side effects. Zylet (LE/T) a combination of LE and tobramycin (T) is indicated for the treatment of steroid-responsive ocular inflammatory conditions in which there exists either superficial bacterial ocular infection or a potential risk of bacterial infection.

AREAS COVERED IN THIS REVIEW

The current review of the literature (Medline and the Cochrane Library, 1996 - 2009) examines the safety and efficacy of LE/T in the treatment of ocular inflammation.

WHAT THE READER WILL GAIN

Studies with either LE or LE/T indicate that LE has a lower risk of IOP elevation compared with C-20 ketone corticosteroids owing to its rapid de-esterification to inactive metabolites. LE also lacks the ability to form Schiff base intermediates with lens proteins, a common first step in cataractogenesis. LE/T was noninferior to dexamethasone 0.1%/tobramycin 0.3% in the treatment of blepharokeratoconjunctivitis.

TAKE HOME MESSAGE

LE/T may be a safer treatment option for ocular inflammation in which there is risk of superficial bacterial infections.

Ocular complications of childhood rheumatic diseases: nonuveitic inflammatory eye diseases

Ocular involvement is common in pediatric rheumatologic diseases, supporting the concept that these conditions do not manifest in isolation but are components of a multisystem inflammatory process. It remains unclear why the eye and its adjacent tissues become a target during paninflammatory disease. Pediatric rheumatologists must recognize ocular disorders, as these conditions significantly concern the treatment team managing serious cases of inflammatory eye disease. Close collaboration between the treating rheumatologist and ophthalmologist is required to prevent potentially devastating outcomes. Therapeutic interventions, such as topical steroids, systemic immunosuppressants, and biologics, must balance the necessity of controlling ocular inflammation and treatment-related adverse effects. This article-the second in a series on ocular complications of childhood rheumatic diseases-reviews the presentation and management of the more common nonuveitic inflammatory ocular manifestations of childhood rheumatologic disease.

Surprising up-regulation of P-selectin glycoprotein ligand-1 (PSGL-1) in endotoxin-induced uveitis

P-selectin glycoprotein ligand-1 (PSGL-1) is constitutively expressed on leukocytes and was thought to be down-regulated with cell activation. However, this work shows the surprising finding of functional PSGL-1 up-regulation during acute inflammation. PSGL-1 function was studied in our autoperfusion assay, in which blood from a mouse carotid flows through a microchamber coated with a fixed density of P-selectin. Under the inflammatory conditions--uveitis induced by systemic lipopolysaccharide injection--we recorded significantly reduced leukocyte rolling velocity, which suggests PSGL-1 up-regulation; however, flow cytometry showed reduced PSGL-1. When bound leukocytes were released from the vasculature by PSGL-1 blockade, a large peripheral blood leukocyte (PBL) population showed elevated PSGL-1, which could account for the reduced PSGL-1 in the remaining unbound population. In the eye, systemic blockade of PSGL-1 with a monoclonal antibody or recombinant soluble PSGL-1 drastically reduced the severe manifestations of uveitis. Furthermore, PSGL-1 blockade was significantly more effective in reducing retinal leukostasis than was P-selectin blockade. Our results provide surprising evidence for functional PSGL-1 up-regulation in PBLs during acute inflammation. The temporal overlap between PSGL-1 and P-selectin up-regulation reveals an as yet unrecognized collaboration between this receptor-ligand pair, increasing efficiency of the first steps of the leukocyte recruitment cascade.

Effects of loteprednol/tobramycin versus dexamethasone/tobramycin on intraocular pressure in healthy volunteers

PURPOSE

To compare the steroid-induced intraocular pressure (IOP) and other ocular adverse effects of loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension with those of dexamethasone 0.1% and tobramycin 0.3% ophthalmic suspension.

METHODS

Three hundred six healthy volunteers received either loteprednol etabonate/tobramycin (n = 156) or dexamethasone/tobramycin (n = 150) at 4-hour intervals 4 times a day in both eyes for 28 days in this randomized, double-masked, multicenter, parallel-group trial. IOP, visual acuity (VA), and ocular health were assessed at all study visits (days 1, 3, 8, 15, 22, and 29), whereas undilated direct ophthalmoscopy was completed at the baseline and final visits. Adverse events (AEs) were assessed at all follow-up visits.

RESULTS

The number of subjects experiencing IOP increases of >or=10 mm Hg from baseline at any study visit for the loteprednol etabonate/tobramycin group (3 subjects, 1.95%) was significantly lower than that for the dexamethasone/tobramycin group (11 subjects, 7.48%; P = 0.0280), as were mean changes from baseline IOP (P < 0.05 at all visits). The lowest VA recorded for any subject at any visit was 20/40 and reductions of >or=2 lines at any visit were observed in 14 (4.55%) eyes for loteprednol etabonate/tobramycin and in 23 (7.82%) eyes for dexamethasone/tobramycin (P = 0.1257). Both treatments were well tolerated.

CONCLUSIONS

Loteprednol/tobramycin was significantly less likely to produce elevations in IOP than was dexamethasone/tobramycin in healthy subjects treated for 28 days. Both loteprednol etabonate/tobramycin and dexamethasone/tobramycin were well tolerated with low risks for systemic AEs and ocular AEs other than elevation in IOP for dexamethasone/tobramycin.

Pediatric rheumatology for the adult rheumatologist II: uveitis in juvenile idiopathic arthritis

Uveitis is an important and frequent extra-articular manifestation of juvenile idiopathic arthritis (JIA) that may result in poor visual outcome. Without early detection and aggressive therapy, the uveitis and topical steroid therapy used to treat it may result in cataracts, glaucoma, and even blindness. Fortunately, a variety of systemically administered anti-inflammatory agents have been found useful for the treatment of JIA associated uveitis. Methotrexate is often the first line disease modifying systemic agent used to help wean topical corticosteroids, but when this is not sufficiently effective there are a variety of other systemic medicines available. In particular, one of the tumor necrosis factor-alpha inhibitors, infliximab, has shown some promising results in difficult to treat JIA associated uveitis. With early screening and detection combined with aggressive therapy in difficult to treat cases, the morbidity associated with uveitis as part of JIA is on the decline.

Ocular complications of childhood rheumatic diseases: uveitis

Ocular involvement is common in pediatric rheumatologic diseases, supporting the concept that these conditions cannot be understood simply as isolated entities, but rather as multisystem disorders. The reasons for the breach of the eye-brain barrier and the targeting of the usually well-shielded eye during a pan-inflammatory process remains unclear. Pediatric rheumatologists should become familiar with these ocular disorders, because as important members of the treatment team, they manage more serious cases of inflammatory eye disease. A close collaboration between the treating rheumatologist and the ophthalmologist is essential to prevent potentially devastating outcomes. Therapeutic interventions such as topical steroids, systemic immunosuppressants, and biologics must balance the necessity of controlling ocular inflammation and the adverse effects of these treatments on a growing child.