Intraocular Inflammation Control and Changes in Retinal and Choroidal Architecture in Refractory Non-Infectious Uveitis Patients after Adalimumab Therapy

Effect of adalimumab on choroidal thickness and choroidal vascularity index in eyes with non-infectious uveitis using enhanced-depth imaging optical coherence tomography

OBJECTIVE

To evaluate the effect of adalimumab (ADA) on choroidal thickness (ChT) and choroidal vascularity index (CVI) in eyes with non-infectious uveitis (NIU).

METHODS

Thirty-seven eyes with NIU including Behçet disease (BD), sarcoidosis, ankylosing spondylitis (AS), juvenile idiopathic arthritis and idiopathic arthritis, 38 eyes of non-uveitic (NU) patients including BD, AS and rheumatoid arthritis, and 40 healthy control eyes were included. ADA was used for anti-TNF-naive adult (80 mg) or paediatric (40 mg) patients with refractory NIU, then 40 mg every 2-week (20 mg in children<30 kg) with controls at weeks 1, 4, 12, and 24. Images were used to measure central, nasal, and temporal ChT, and the luminal area (LA), stromal area, and total choroidal area (TCA) were analysed using enhanced-depth imaging optical coherence tomography (EDI-OCT) by ImageJ software. The CVI was then calculated as the ratio of LA to TCA.

RESULTS

Mean ages were similar between the groups. Mean (SE) subfoveal ChT measurements for each location were also similar (for each, p > 0.05). However, calculated CVI values in eyes with NIU (0.63 ± 0.007) were significantly (p < 0.001) lower than NU eyes (0.66 ± 0.006) and controls (0.70 ± 0.007) (p < 0.001). Moreover, CVI was significantly lower in NU eyes compared to controls (p < 0.001). There were no significant CVI changes between the consecutive visits after ADA therapy in eyes with NIU (for each, p > 0.05).

CONCLUSIONS

Decreased CVI in NIU and NU eyes indicates that systemic inflammation affects the choroidal vasculature and perfusion both in the presence and absence of ocular involvement. Although CVI may be used as a possible novel tool in monitoring ocular involvement and progression of NIU, CVI does not seem to be a biomarker for treatment monitoring in NIU.

Impact of adalimumab in patients with active non-infectious intermediate, posterior, and panuveitis in real-life clinical practice: HOPE study

BACKGROUND/AIM

This study evaluated real-life adalimumab impact in patients with active non-infectious intermediate, posterior, or panuveitis (NIIPPU).

METHODS

Adults with active NIIPPU received adalimumab in this prospective, observational study (06/2017-04/2020). Patients were evaluated at baseline (V0) and four follow-up visits over 12 months (V1-V4).

PRIMARY ENDPOINT

proportion of patients achieving quiescence (anterior chamber (AC) cells grade and vitreous haze (VH) grade≤0.5+ in both eyes, no new active chorioretinal lesions) at any follow-up visit. Secondary endpoints: proportion of patients achieving quiescence at each visit; proportion of patients maintaining response; and proportion of patients with flares. Workability, visual function, healthcare resource utilisation, and safety were evaluated.

RESULTS

Full analysis set included 149 patients. Quiescence at any follow-up visit was achieved by 129/141 (91%) patients. Quiescence at individual visits was achieved by 99/145 (68%), 110/142 (77%), 102/131 (78%), and 99/128 (77%) patients at V1-V4, respectively. Number of patients in corticosteroid-free quiescence increased from 51/147 (35%; V1) to 67/128 (52%; V4; p<0.05). Proportion of patients with maintained response increased from 89/141 (63%; V2) to 92/121 (76%; V4; p<0.05) and proportion of patients with flare decreased from 25/145 (17%; V1) to 13/128 (10%; V4; p=0.092). Workability and visual function improved throughout the study. Proportion of patients with medical visits for uveitis decreased from 132/149 (89%; V0) to 27/127 (21%; V4). No new safety signals were observed.

CONCLUSION

These results demonstrated adalimumab effectiveness in improving quality of life while reducing economic burden of active NIIPPU.

The evaluation of the efficacy of adalimumab in refractory non-infectious uveitis with ultra-widefield fundus fluorescein angiography

AIM

To investigate the efficacy of adalimumab in the cases with refractory non-infectious uveitis and evaluate retinal vascular leakage changes on ultra-widefield fundus fluorescein angiography.

METHODS

Twenty-three patients with refractory uveitis were included in study.

RESULTS

Forty-four eyes of 23 patients with non-infectious uveitiswere evaluated. Clinically active inflammation was present in 19 eyes (43.18%), while 25 (56.8%) were inactive. The mean drug burden was a 9.91 ± 3.78 (5-21) in baseline, 7.3 ± 4.25 at third and 8.0 ± 4.71 at sixth month (p = 0.022). The mean choroidal thickness was 256.65 ± 43.63 μm in baseline, 240.49 ± 36.73 μm at third and 224.81 ± 34.91 μm at sixth month (p ≤ 0.05). In terms of leakage extend, leakage was initially present in a mean of 2.95 ± 4.55 clock hours, 2.41 ± 3.91 at third and 1.76 ± 3.44 at sixth month (p < 0.001).

CONCLUSION

Adalimumab was found to be effective in establishing inflammation control by reducing drug burden, controlling retinal vascular leakage and choroidal inflammation in refractory uveitis.

Changes in choroidal imaging parameters following adalimumab therapy for refractory noninfectious uveitis

PURPOSE

To evaluate the short-term change in choroidal structure following adalimumab (ADA) treatment in refractory noninfectious uveitis.

METHODS

This was a retrospective study of 33 eyes from 18 patients with refractory noninfectious uveitis. Subfoveal choroidal thickness (SFCT), the choroidal stromal index (CSI) defined as the proportion of stromal area to the total choroidal area were used as choroidal imaging parameters and were evaluated by enhanced depth imaging optical coherence tomography (EDI-OCT). The change in these parameters in the 2 months following initiation of ADA was analysed. A linear mixed-effect model was used to assess the effect of ADA treatment.

RESULTS

The causes of uveitis were Vogt-Koyanagi-Harada disease (VKHD) (42.4%), presumed autoimmune retinopathy (15.2%), others (12.1%) and unclassified (30.3%). In the analysis of all eyes, the SFCT was 309.7 ± 113.1 μm at baseline, 295.7 ± 114.5 μm at 1 month and 275.2 ± 98.8 μm at 2 months after ADA initiation (P < 0.001). The CSI was 0.275 ± 0.050 at baseline, 0.273 ± 0.068 at 1 month and 0.273 ± 0.046 at 2 months (P = 0.785). In the subgroup analysis, the SFCT decreased significantly from baseline to 2 months in VKHD eyes (P = 0.007) and unclassified eyes (P = 0.034). There was no significant change in CSI in either subgroup.

CONCLUSIONS

In the assessment of short-term response to ADA treatment in uveitic eyes, using EDI-OCT, the SFCT appears to be more effective as a choroidal imaging biomarker than the CSI, especially in VKHD eyes.

Biotherapies in Uveitis

Non-infectious uveitis (NIU) represents one of the leading causes of blindness in developed countries. The therapeutic strategy aims to rapidly control intra-ocular inflammation, prevent irremediable ocular damage, allow corticosteroid sparing and save the vision, and has evolved over the last few years. Anterior NIU is mostly managed with topical treatment in adults. However, for intermediate, posterior and pan-uveitis, notably when both eyes are involved, systemic treatment is usually warranted. Biotherapies are recommended in case of inefficacy or non-tolerance of conventional immunosuppressive drugs in non-anterior NIU. Anti-tumor necrosis factor alpha (anti-TNF-α) agents are by far the most widely used, especially adalimumab (ADA) and infliximab (IFX). In case of sight-threatening uveitis in Behçet's disease or in case of risk of severe recurrences, respectively IFX and ADA may be recommended as first-line therapy. Many questions are left unanswered; how long to treat NIU, how to discontinue anti-TNF-α agents, what biologic to use in case of anti-TNF-α failure? The objective of this review is to present an updated overview of knowledge on the use of biological treatments in NIU.