MICROBIOME AND UVEITIDES. A REVIEW

Microorganisms inhabiting all surfaces of mucous membranes and skin and forming a complex ecosystem with the host is called microbiota. The term microbiome is used for the aggregate genome of microbiota. The microbiota plays important role in the mechanisms of number of physiological and pathological processes, especially of the hosts immune system. The origin and course of autoimmune diseases not only of the digestive tract, but also of the distant organs, including the eye, are significantly influenced by intestinal microbiota. The role of microbiota and its changes (dysbiosis) in the etiopathogenesis of uveitis has so far been studied mainly in experimental models. Reduction of severity of non-infectious intraocular inflammation in germ-free mice or in conventional mice treated with broad-spectrum antibiotics was observed in both the induced experimental autoimmune uveitis model (EAU) and the spontaneous R161H model. Studies have confirmed that autoreactive T cell activation occurs in the intestinal wall in the absence of retinal antigen. Recent experiments focused on the effect of probiotic administration on the composition of intestinal microbiota and on the course of autoimmune uveitis. Our study group demonstrated significant prophylactic effect of the administration of the probiotic Escherichia coli Nissle 1917 on the intensity of inflammation in EAU. To date, only a few studies have been published investigating intestinal dysbiosis in patients with uveitis (e.g., in Behcets disease or Vogt-Koyanagi-Harada syndrome). The results of preclinical studies will be presumably used in clinical practice, mainly in the sense of prophylaxis and therapy, such as change in the lifestyle, diet and especially the therapeutic use of probiotics or the transfer of faecal microbiota.

IMMUNE-MEDIATED INTRAOCULAR INFLAMMATION. A REVIEW

Immune mediated inflammatory diseases are categorized into autoimmune and autoinflammatory. Autoimmune etiology is represented by autoreactive lymphocytes or autoantibodies, e.g. primary Sjögrens syndrome or rheumatoid arthritis. Ocular specific diseases with presumed autoimmune origin are sympathetic ophthalmia or birdshot chorioretinopathy. Autoinflammatory diseases are caused by mutations in regulatory genes for specific immunity. Hereditary periodic fevers represent monogenic autoinflammatory diseases; eye specific is Blau syndrome also named sarcoidosis with early onset. This article reviews the actual knowledge about immune mediated uveitides, their immunological mechanisms and the possible trigger role of infection in autoimmune inflammation. Immune privilege provides a protection of the eye against any strong immune reaction to foreign antigen, based on physical, immune, humoral and molecular mechanisms. Antigens hidden within the eye are revealed in case of damage of hematoretinal barrier caused by infection or mechanical insult. These ocular antigens have not been set as tolerable during the development and immune reaction is initiated subsequently. Current studies demonstrate that uveogenic trigger might be generated by own microbiome, particularly when dysregulated, so called dysbiosis. There is a known association between idiopathic inflammatory bowel disease with ankylosing spondylitis and anterior uveitis in humans. Intensive research is focused on microbiome and immune mediated inflammatory disease to influence therapeutically the intestinal microbiome. The animal models are used to study the immunopathological mechanisms of uveitis and the new therapeutic strategies, because of relatively low incidence of immune mediated uveitis in humans.

IMMUNE-MEDIATED INTRAOCULAR INFLAMMATION. A REVIEW

Immune mediated inflammatory diseases are categorized into autoimmune and autoinflammatory. Autoimmune etiology is represented by autoreactive lymphocytes or autoantibodies, e.g. primary Sjögrens syndrome or rheumatoid arthritis. Ocular specific diseases with presumed autoimmune origin are sympathetic ophthalmia or birdshot chorioretinopathy. Autoinflammatory diseases are caused by mutations in regulatory genes for specific immunity. Hereditary periodic fevers represent monogenic autoinflammatory diseases; eye specific is Blau syndrome also named sarcoidosis with early onset. This article reviews the actual knowledge about immune mediated uveitides, their immunological mechanisms and the possible trigger role of infection in autoimmune inflammation. Immune privilege provides a protection of the eye against any strong immune reaction to foreign antigen, based on physical, immune, humoral and molecular mechanisms. Antigens hidden within the eye are revealed in case of damage of hematoretinal barrier caused by infection or mechanical insult. These ocular antigens have not been set as tolerable during the development and immune reaction is initiated subsequently. Current studies demonstrate that uveogenic trigger might be generated by own microbiome, particularly when dysregulated, so called dysbiosis. There is a known association between idiopathic inflammatory bowel disease with ankylosing spondylitis and anterior uveitis in humans. Intensive research is focused on microbiome and immune mediated inflammatory disease to influence therapeutically the intestinal microbiome. The animal models are used to study the immunopathological mechanisms of uveitis and the new therapeutic strategies, because of relatively low incidence of immune mediated uveitis in humans.

IMMUNE-MEDIATED INTRAOCULAR INFLAMMATION. A REVIEW

Immune mediated inflammatory diseases are categorized into autoimmune and autoinflammatory. Autoimmune etiology is represented by autoreactive lymphocytes or autoantibodies, e.g. primary Sjögrens syndrome or rheumatoid arthritis. Ocular specific diseases with presumed autoimmune origin are sympathetic ophthalmia or birdshot chorioretinopathy. Autoinflammatory diseases are caused by mutations in regulatory genes for specific immunity. Hereditary periodic fevers represent monogenic autoinflammatory diseases; eye specific is Blau syndrome also named sarcoidosis with early onset. This article reviews the actual knowledge about immune mediated uveitides, their immunological mechanisms and the possible trigger role of infection in autoimmune inflammation. Immune privilege provides a protection of the eye against any strong immune reaction to foreign antigen, based on physical, immune, humoral and molecular mechanisms. Antigens hidden within the eye are revealed in case of damage of hematoretinal barrier caused by infection or mechanical insult. These ocular antigens have not been set as tolerable during the development and immune reaction is initiated subsequently. Current studies demonstrate that uveogenic trigger might be generated by own microbiome, particularly when dysregulated, so called dysbiosis. There is a known association between idiopathic inflammatory bowel disease with ankylosing spondylitis and anterior uveitis in humans. Intensive research is focused on microbiome and immune mediated inflammatory disease to influence therapeutically the intestinal microbiome. The animal models are used to study the immunopathological mechanisms of uveitis and the new therapeutic strategies, because of relatively low incidence of immune mediated uveitis in humans.

IMMUNE-MEDIATED INTRAOCULAR INFLAMMATION. A REVIEW

Immune mediated inflammatory diseases are categorized into autoimmune and autoinflammatory. Autoimmune etiology is represented by autoreactive lymphocytes or autoantibodies, e.g. primary Sjögrens syndrome or rheumatoid arthritis. Ocular specific diseases with presumed autoimmune origin are sympathetic ophthalmia or birdshot chorioretinopathy. Autoinflammatory diseases are caused by mutations in regulatory genes for specific immunity. Hereditary periodic fevers represent monogenic autoinflammatory diseases; eye specific is Blau syndrome also named sarcoidosis with early onset. This article reviews the actual knowledge about immune mediated uveitides, their immunological mechanisms and the possible trigger role of infection in autoimmune inflammation. Immune privilege provides a protection of the eye against any strong immune reaction to foreign antigen, based on physical, immune, humoral and molecular mechanisms. Antigens hidden within the eye are revealed in case of damage of hematoretinal barrier caused by infection or mechanical insult. These ocular antigens have not been set as tolerable during the development and immune reaction is initiated subsequently. Current studies demonstrate that uveogenic trigger might be generated by own microbiome, particularly when dysregulated, so called dysbiosis. There is a known association between idiopathic inflammatory bowel disease with ankylosing spondylitis and anterior uveitis in humans. Intensive research is focused on microbiome and immune mediated inflammatory disease to influence therapeutically the intestinal microbiome. The animal models are used to study the immunopathological mechanisms of uveitis and the new therapeutic strategies, because of relatively low incidence of immune mediated uveitis in humans.

Recommendations for the Management of Uveitis Associated With Juvenile Idiopathic Arthritis: The Czech and Slovak adaptation of SHARE Initiative

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is its most important extra-articular manifestation. Evidence-based recommendations are available only to a limited extent and therefore JIA associated uveitis management is mostly based on physicians experience. Consequently, treatment practices differ widely, both nationally and internationally. Therefore, an effort to optimize and publish recommendations for the care of children and young adults with rheumatic diseases was launched in 2012 as part of the international project SHARE (Single Hub and Access Point for Pediatric Rheumatology in Europe) to facilitate clinical practice for paediatricians and (paediatric) rheumatologists. The aim of this work was to translate published international SHARE recommendations for the diagnosis and treatment of JIA associated uveitis and to adapt them for use in the Czech and Slovak Republics. International recommendations were developed according to the standard methodology of the European League against Rheumatism (EULAR) by a group of nine experienced paediatric rheumatologists and three experts in ophthalmology. It was based on a systematic literature review and evaluated in the form of an online survey and subsequently discussed using a nominal group technique. Recommendations were accepted if > 80% agreement was reached (including all three ophthalmologists). A total of 22 SHARE recommendations were accepted: 3 on diagnosis, 5 on disease activity assessment, 12 on treatment and 2 on future recommendations. Translation of the original text was updated and modified with data specific to the czech and slovak health care systems and supplemented with a proposal for a protocol of ophthalmological dispensarization of paediatric JIA patients and a treatment algorithm for JIA associated uveitis. Conclusion: The aim of the SHARE initiative is to improve and standardize care for paediatric patients with rheumatic diseases across Europe. Therefore, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated based on the evidence and agreement of leading European experts in this field.

Ocular Manifestations of Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis (GPA), formerly known as Wegeners granulomatosis, is an autoimmune vasculitis of small vessels, presenting as necrotizing granulomatous inflammation especially of the upper and lower respiratory tract and necrotizing glomerulonephritis. GPA affects more often Caucasians in northern states, predominantly is affected the age-range group of 50 - 60 years. GPA may affect any organ; the eye symptoms are stated in the range of 16-78 %. The eye symptoms are very variable, and in up to 27 % they are the first sign of undiagnosed GPA. The etiology of GPA was not until now explained. Anti-neutrophil cytoplasmic antibodies (ANCA) play important role in the pathogenesis of this disease. GPA is ranked among ANCA associated vasculitis. The GPA is diagnosed on the basis of clinical signs and symptoms of systemic vasculitis, laboratory and histological tests and imaging studies. Immunomodulative therapy made a contribution to the improvement of GPA prognosis in the last decades; biological treatment reaches the prominence of the GPA treatment procedures. Good collaboration with other specialties is necessary for the early diagnosis and treatment of this life and vision threating disease. The ophthalmologist in the collaboration with specialists of other medical branches may take an important part in the GPA diagnostics, monitoring of the diseases course, or adverse affects of the medication. This paper pays attention to the eye symptoms of the GPA; the literature is supplemented with own photographs of GPA eye symptoms in patients followed up at the Department of Ophthalmology, First medical faculty, Charles University and General Faculty Hospital in Prague, Czech Republic, E.U. Key words: Granulomatosis with polyangiitis (GPA), orbit, scleritis, peripheral ulcerative keratitis (PUK), immunomodulation.

[Cytomegalovirus retinitis in HIV negative patients - retrospective study]

AIM

To evaluate own experience with the diagnosis and treatment of cytomegalovirus (CMV) retinitis in HIV negative patients with immunodeficiency.

METHODS

Retrospective study and case reports.

RESULTS

In the Centre for diagnosis and treatment of Uveitis 1869 patients with uveitis we have examined from June 2003 to June 2012. CMV retinitis was diagnosed in 7 patients (1 woman and 6 men) according to the typical clinical findings and history of immunodeficiency. In 2 atypical findings was the diagnosis confirmed by determination of DNA pathogen in vitreous sample (a patient with non-Hodgkin lymphoma) or by positive serology (CMV in leukocytes - indolent form of CMV retinitis in a patient with systemic lupus erythematosus). In 8 cases we found fulminant form, in 1 case indolent form of CMV retinitis. The average age of patients was 39,1 years (18-51 years old), ratio of men to women 6 : 3. In 6 of 9 cases we noticed bilateral retinitis. The average period of observation in our study was 15,8 months (1-48 months). Five of our patients underwent bone marrow transplantation, 2 patients were treated with systemic immunosuppressive drugs (colitis ulcerosa, systemic lupus erythematosus) and 2 patients had chemotherapy for lymphoma. The initiation or modification of treatment (gancyklovir p.o./i.v., foscarnet i.v.) was consulted and coordinated with others specialists. After initiation of treatment we followed-up 7 patients. In 4 eyes of 3 patients (31 %) the improvement of visual acuity was documented, in 5 eyes of 5 patients (38 %) the visual acuity was stabilized. The worsening of vision in 4 eyes of 3 patients (31 %) was caused by complications without any connection to virostatic therapy. All of our patients, who underwent bone marrow transplantation, died within 12 months since the diagnosis of CMV retinitis was determined.

CONCLUSION

The diagnosis of CMV retinitis only in 9 cases (0,48% of all uveitic patients) confirms the rare occurrence of this retinitis. The important tool to the diagnosis of CMV retinitis is the history of immunodeficiency. In an atypical findings, the analysis of intraocular fluids or serological tests could help to the final diagnosis. The occurrence of CMV retinitis signify a very unfavourable prognosis for patients who underwent bone marrow transplantation and these patients died within 12 months since CMV retinitis has been diagnosed. The management of the therapy requires close interdisciplinary cooperation.

[Retinitis pigmentosa mimicking uveitis. A case report]

PURPOSE

To describe a case report of a 23-year-old patient with retinitis pigmentosa (RP) misdiagnosed as uveitis.

METHODS

A comprehensive eye examination including automated visual field assessment, contrast sensitivity, colour vision discrimination, ultrasound examination (US), spectral domain optical coherence tomography (SD-OCT) and full-field electroretinography (ERG) was performed in a patient diagnosed elsewhere as having intermediate uveitis because of the observation of a cellular reaction in the anterior chamber, bilateral cystoid macular oedema and suspected left optic disc swelling.

RESULTS

The patient reported nyctalopia. The best corrected visual acuity in both eyes was 6/12. Concentric visual field constriction was detected bilaterally (less than 25 degrees in the right eye and 15 degrees in the left eye). Fundus examination revealed a few pigment clumps and cystoid macular edema in both eyes confirmed by SD-OCT. Contrast sensitivity was decreased to 1,20 in the right and 0,9 in the left. No colour vision disturbance was present. The B scan ultrasound showed left optic disc drusen. Rod ERG responses were bilaterally not detectable and cone ERGs were abnormally reduced. Based on the examination results, a diagnosis of nonsyndromic RP was made.

CONCLUSION

Clinicians should be aware of various manifestations of RP, including mild inflammation, to avoid possible confusin with uveitis.

[Acute retinal necrosis]

AIM

The paper documents the cumulating appearance of 3 cases of the acute retinal necrosis (ARN) during one-year period at the district (local) eye department. It concerns the etiology, the treatment, evaluates its results and reveals the recommendations for the clinical practice.

METHODS

retrospective study.

RESULTS

The ARN was diagnosed in 3 patients (2 woman and 1 man) at the age of 29, 43, and 58 years. Uveitis was unilateral in all cases. All three patients were treated early with adequate systemic antiviral (acyclovir) and corticosteroids treatment, which caused improving of the clinical findings and visual acuity as well. In 2 patients, pars plana vitrectomy was performed. Despite the long-lasting chronic combined medication, during the follow-up period in these 2 patients the decrease of the visual acuity occurred.

CONCLUSION

ARN is very rare, vision-threatening viral disease. The appearance of 3 cases of ARN at a local hospital is unusual. The diagnosis may be established according to the characteristic clinical findings and to its development. To determine the pathogen (varicella zoster virus in 70 %, herpes simplex virus in almost 30 %, and cytomegalovirus very rarely) is not critical for the diagnosis establishment. The early use of specific virostatic drugs is the key assumption for optimal ARN treatment, as it happened in our patients. Contrary to the adequate treatment, retinal complications may occur, and often, even after successful pars plana vitrectomy, the decrease of visual functions is possible. For the ophthalmologic practice, it is important to remember, that in case of ARN suspicion, it is urgent to start the virostatic treatment and to add corticosteroids not earlier than after 24-48 hours. In case of complications, it is necessary to contact the specialized vitreoretinal center immediately. It is necessary to inform the patient about very serious condition of the infected eye and its uncertain prognosis contrary to the adequate treatment, and about the danger to the opposite eye in case of delay of missing treatment. In case of herpetic anterior uveitis, the fundus examination, including the periphery of the retina is important.

[Eye and inflammatory bowel diseases]

AIM

To point out the wide range of ocular features of inflammatory bowel diseases (IBD), focusing on uveitis.

METHODS

A retrospective study.

RESULTS

In the Centre for diagnosis and therapy of uveitis of our Ophthalmology Department, we have in years 2003-2010 followed in total 18 patients with intraocular inflammation associated with IBD: anterior uveitis (14), vasculitis (1), panuveitis (1), infectious uveitis as a secondary complication of systemic immunosuppressive therapy (2). The most often diagnosis was mild to moderate recurrent acute anterior uveitis. We have noticed more severe course of uveitis in patients with the HLA B27 positivity. Part of this paper consists of an overview of other ocular manifestations of IBD and current available therapeutical strategies.

CONCLUSION

Ocular manifestations of IBD can be a valuable signal of the activity of the primary disease. The knowledge of the ocular manifestations of these systemic diseases and of possible complications is required for successful interdisciplinary care of patients with IBD. While local treatment is fully in hands of an ophthalmologist, the form and extent of the systemic treatment is necessary to coordinate with gastroenterologists.

[Current therapeutic approach in non-infectious uveitis]

The aim of this paper is to summarize current therapeutic approach in non-infectious uveitis. It focuses on different immunosuppressive/immunomodulatory treatment modalities and address' its adverse effects.

[Malignant masquerade syndromes]

PURPOSE

To evaluate our experience with the diagnosis and treatment of malignant masquerade syndromes.

METHODS

A retrospective study of 46 patients treated for malignant masquerade syndromes at our Department for Diagnosis and Treatment of Uveitis, 1st Faculty of Medicine in Prague, between 1995 and 2008, was performed.

RESULTS

Eighty-nine patients with masquerade syndromes (7.2%) from all 1233 patients with uveitis were included. Malignant masquerade syndromes were recognized in 46 patients (22 females and 24 males, mean age 55 years). The most frequent cause of malignant masquerade syndromes was intraocular non-Hodgkin lymphoma (26 patients). The primary diagnosis was idiopathic uveitis in many cases. The most valuable diagnostic procedure was analysis of intraocular fluids.

CONCLUSION

Diagnosis of masquerade syndromes should be considered in all patients with idiopathic corticosteroid-resistant chronic uveitis. Timely diagnosis and treatment may in case of malignant masquerade syndromes improve prognosis and sometimes gain control over this potentially lethal disease.

[Benign masquerade syndromes in differential diagnosis of uveitis]

PURPOSE

To present our experience with the diagnosis of benign masquerade syndromes, to evaluate the prevalence, clinical features and diagnostic tests.

METHODS

A retrospective study of 42 patients treated for benign uveitis masquerade syndromes at our Department for DIAGNOSIS AND TREATMENT OF UVEITIS: 1st Faculty of Medicine in Prague, between 1996 and 2006, was performed.

RESULTS

Seventy-nine patients with masquerade syndromes (7.1%) from all 1112 patients with uveitis were included. Malign masquerade syndromes were recognized in 37 patients (19 females and 18 males, mean age 55 years) and benign masquerade syndromes in 42 patients (23 females and 19 males, mean age 33.7 years). The most frequent cause of benign masquerade syndromes was a group of vascular anomalies (22 patients). The primary diagnosis was infectious or idiopathic uveitis in many cases.The most valuable diagnostic procedures were fluorescein angiography and analysis of intraocular fluids.

CONCLUSION

Diagnosis of masquerade syndromes should be considered in all patients with idiopathic corticosteroid-resistant chronic uveitis. Timely diagnosis and treatment may improve the prognosis of masquerade syndromes.

[Chronic postoperative endophthalmitis]

PURPOSE

To evaluate our experience with the diagnosis and the treatment of chronic postoperative endophthalmitis.

METHODS

A retrospective study.

RESULTS

The authors present three cases of chronic postoperative endophthalmitis following cataract surgery. Propionibacterium species has been determined as the causative agent in two patients. All patients were men; the mean age was 75 years (from 73 to 78 years). The mean time period from the cataract operation to the onset of intraocular inflammatory signs was 5 months (from 2 to 9 months). Pars plana vitrectomy with intravitreal administration of antibiotics and intraocular lens explantation with total capsulectomy were performed. This treatment led to the reduction of the intraocular inflammatory reaction and to the improvement of the visual acuity.

CONCLUSION

The effective treatment of chronic postoperative endophthalmitis caused by Propionibacterium species is a combined operation--intraocular lens explantation with total capsulectomy and pars plana vitrectomy with intravitreal administration of antibiotics.

[Infliximab in the treatment of Wegener's granulomatosis: case report]

PURPOSE

to evaluate the efficacy of monoclonal anti-tumor necrosis factor alpha antibody infliximab in treatment of refractory Wegene's granulomatosis. Clinical manifestations of Wegener's granulomatosis at the time of infliximab initiation were: proptosis of both eyes due to progressive retrobulbar granulomas, visual impairment, optic disc edema, progressive diplopia, sinus and renal involvement. The disease was refractory to a treatment with various immunosuppressants, including intravenous cyclophosphamide or high doses of mycophenolate mofetil in combination with corticosteroids.

METHODS

Observational case report.

RESULTS

the patient received six infusions of infliximab (3 mg/kg) in addition to low doses of oral cyclophosphamide and corticosteroids. The interval between the first two infusions was 1 week. The interval between the second and third infusions was 4 weeks, thereafter 8, 12 and 34 weeks. Following the third infusion of infliximab the remission of Wegener's granulomatosis was seen. After the regression of retrobulbar granulomas visual acuity increased, ocular motility improved, diplopia and optic disc edema decreased. Remission has been maintained for 17 months. Infliximab was well tolerated during the short-term follow-up.

CONCLUSION

Infliximab successfully induced remission in case of sight-threatening Wegener's granulomatosis in our patient. It seems that infliximab provides more effective therapeutic option in treatment of Wegener's granulomatosis refractory to standard immunosuppression and offers better perspectives for patients with previously poor prognosis. Furthermore, it enables reducing the exposure to immunosuppressive drugs.

[Sympathetic ophthalmia]

PURPOSE

To evaluate the efficacy of treatment on prevention of disease development and protection of visual outcomes in patients suffering from sympathetic ophthalmia.

METHODS

Retrospective case.

RESULTS

Four patients with sympathetic ophthalmia were treated in our department from 1999 to 2004. All patients were men with the mean age 27.5 years (15-49 years). In two patients, there was a history of penetrating eye injury prior to the onset of sympathetic ophthalmia, in other two patients sympathetic ophthalmia occurred after eye surgery (pars plana vitrectomy), with no previous ocular trauma. Two patients were treated with monotherapy of corticosteroids; other two patients were commenced on combined immunosuppression. In all these cases, the therapy was effective.

CONCLUSION

Sympathetic ophthalmia is a rare, sight-threatening eye disease. Among the triggering factors dominates penetrating eye injury, however, there is currently an increase in the number of cases with sympathetic ophthalmia following eye surgery, mainly pars plana vitrectomy. Early introduction of immunosuppressive treatment can get the disease under control, prevent the development of intraocular inflammation and improve visual outcomes.