Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

Topic: An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. Clinical Relevance: The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. Methods: An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. Results: In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. Conclusions: Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents

Retinopathy of Prematurity; Risk Factors, Prognosis and Treatment

ScopusTr-Dizi

Beware of the unilateral red eye: don't miss blinding uveitis

A 6-year-old girl presented to her general practitioner with a red left eye. She reported no pain or irritation, but did have difficulty seeing into the distance with blurring of vision in the affected eye. Associated with this symptom was the onset of neck stiffness with limitation in neck flexion and rotation. This had increased gradually over the preceding month and was most problematic in the morning. There were no associated fevers, rashes, gastrointestinal or genitourinary symptoms. She had been well in the past, was not taking any medications, and her vaccinations were up to date. Her elder sister had been diagnosed with juvenile idiopathic arthritis (JIA) at the age of 18 months, her mother had type 1 diabetes mellitus. A maternal aunt had been diagnosed with rheumatoid arthritis 4 years earlier. Examination revealed inflamed palpebral conjunctivae in the left eye, and mild restriction in the range of neck rotation and flexion. There were no other findings. The patient was diagnosed with conjunctivitis and intermittently prescribed chloramphenicol eye drops over 3 months. The neck discomfort continued over this period, despite physiotherapy. Ultrasonography of the neck showed no abnormalities apart from “unusual lymphadenopathy”. This finding prompted a referral to a paediatric oncologist who believed uveitis should be considered in light of the child’s family history of JIA. She was referred for an ophthalmologist’s opinion. At ophthalmological review, her vision was 6/7.5 in the right eye and 6/12 in the left eye. There was band keratopathy (see Box 1) present in the region of the visual axis and the pupil was adherent to the lens by posterior synechiae. The child’s vision continued to deteriorate to 6/24 in the left eye despite treatment with topical dexamethasone 0.1% and atropine 1%. She was referred to the rheumatology service. The rheumatologist found that the child had an elevated erythrocyte sedimentation rate of 43 mm/hour (normal range, 0–20 mm/hour), but the C-reactive protein concentration was within normal limits at 4 mg/L (normal range, 0–10 mg/L). The antinuclear antibody (ANA) titre was strongly positive at over 1:2560, and showed a homogenous pattern. The double-stranded DNA titre (Farr assay) was within normal limits at < 5 U/mL (normal range, < 11 U/mL). The extractable nuclear antigen screen was negative. Treatment with non-steroidal anti-inflammatory drugs resulted in little improvement, so therapy with oral prednisolone and pulse methylprednisolone was commenced. We saw her when she was admitted for the first of 3 methylprednisolone pulses (625 mg intravenously). Vision in the right eye was 6/9 and in the left it was 6/36. Topical medication was continued and the vision in the left eye improved modestly to 6/24. She was then discharged on topical treatment, and systemic treatment with 2.5 mg methotrexate weekly was commenced. This increased to 7.5 mg weekly over one month. At the most recent review, conducted at the time of the final dose of intravenous methylprednisolone, the vision was stable at 6/6, the intraocular pressure was within normal limits and the anterior chamber appeared quiet, the band keratopathy had partially resolved, but the posterior synechiae remained. The neck symptoms had resolved.Shane R Durkin and Theresa M Caseyhttp://www.mja.com.au/public/issues/182_06_210305/contents_210305.htm

Is Activated Factor Vii Associated with Retinal Vein Occlusion?

Aim-To determine whether a newly identified thrombophilia factor, activated factor VII (FVIIa), is associated with retinal vein occlusion (RVO). Methods-54 consecutive cases with RVO seen between March and September 1999 were included in the study. 22 cases had central retinal vein occlusion (CRVO) and 32 had branch retinal vein occlusion (BRVO). Ophthalmoscopic examination with detailed medical history was followed by blood analyses for liver and renal functions, cholesterol, triglycerides, complete blood count, and coagulation factors including protein C activity, free protein S, antithrombin III, fibrinogen, and factor VIIa (FVIIa). Data were compared with those of the control group, composed of 19 cases under ophthalmological follow up for refractive errors, presbyopia, or senile cataract. Results-Hypertension was highly prevalent in cases with BRVO. Complete blood count, and liver and kidney function tests were within normal limits in the study group. Two cases had low protein C activity, and one had low free protein S. FVIIa levels were significantly higher in the RVO group than in the control group (p=0.0004). There was no significant difference in FVIIa levels between the CRVO and BRVO groups (p=0.51). Conclusion-No haematological parameter except FVIIa differed significantly from that of the control group. Elevation of FVIIa level may play a part in the pathophysiology of both CRVO and BRVO.WoSScopu

Safety and Efficacy of Gevokizumab in Patients With Behçet’S Disease Uveitis: Results of an Exploratory Phase 2 Study

Scopu