Novel therapeutic targets in uveitis

Autoimmune posterior uveitis is a potentially blinding ocular disorder characterized by inflammation of the choroid and retina. Etiology is unknown and is assumed to be autoimmune and proposed to involve activation of autoreactive retinal-peptide specific T-cells, blood-retinal barrier breakdown, further leukocyte recruitment and ensuing ocular inflammation. The P2X7 receptor is a transmembrane purinergic receptor activated by high concentrations of ATP. Expression is ubiquitous with highest expression in immune cells. Stimulation results in the production and release of pro-inflammatory cytokines and potentiates leukocyte recruitment. Differences in mechanisms of P2X7 regulation in macrophages, dendritic cells and T cells were explored in vitro. Dendritic cells and macrophages have been proposed to release IL-1β through the NLRP3 inflammasome, requiring TLR4 stimulation followed by P2X7 stimulation. Dendritic cells were found to release IL-1β with TLR4 stimulation only, unlike macrophages which required additional P2X7 stimulus. Potential mechanisms of P2X7 regulation were explored, and it was found that T cells and not macrophages or dendritic cells exhibited significantly potentiated P2X7 mediated dye uptake upon lipid raft disruption. These results suggested a role for lipid rafts in P2X7 regulation in T cells. In vivo experiments utilized animal models of anterior, posterior and pan-uveitis. Mice deficient in P2X7 were protected against developing severe posterior uveitis, and treatment of mice with established EAU with P2X7 specific antagonist A438079 prevented the development of severe panuveitis. Finally, the role of the spleen tyrosine kinase (SYK) was investigated in murine posterior uveitis. Recent research implicates potential crossover of the P2X7 and SYK signalling pathways. SYK inhibition with the specific inhibitor fostamatinib did not prevent the development of uveitis in mice.Open Acces

Efficacy and safety of intravitreal anti-tumour necrosis factor drugs in adults with non-infectious uveitis - a systematic review

Anti-tumour necrosis factor (TNF) drugs have been extensively used in non-infectious uveitis (NIU), when corticosteroids or conventional immunosuppressive drugs cannot adequately control inflammation or intolerable side-effects occur. However, systemic anti-TNF therapies are also associated with a myriad of side-effects. Therefore, intravitreal administration of anti-TNF biologics has been employed to minimize patient morbidity and systemic adverse effects, while maintaining therapeutic effectivity. We undertook a systematic review to determine evidence of efficacy and safety of intravitreal administration of anti-TNF drugs in adults with NIU. We conducted this systematic review according to the PRISMA guidelines. The protocol was registered with PROSPERO (CRD42016041946). We searched CENTRAL, MEDLINE and EMBASE, from inception to April 2017, as well as clinical trial registries and grey literature. The qualitative analysis included all studies of adult patients with a diagnosis of NIU and who received intravitreal anti-TNF drugs with a 4-week minimum follow-up. A total of 4840 references were considered for title and abstract screening. Seven full texts were screened, and five studies were considered for analysis. All studies were open-label, single-centre, prospective, non-randomized, interventional case series with a follow-up between 4 and 26 weeks, employing either adalimumab in two studies and infliximab in three. Three studies showed a treatment effect of anti-TNF intravitreal injections, while one study revealed short-term improvement and one study revealed no efficacy of anti-TNF intravitreal therapy. None of the studies reported ocular adverse effects but only two studies included electrophysiological assessment in the safety analysis and no study assessed systemic human anti-drug antibodies. The available evidence is not sufficiently robust to conclude about the clinical effectivity of intravitreal anti-TNF in NIU and so no recommendation can be made. In conclusion, intravitreal injection of anti-TNF antibodies remains a possible treatment option to be explored through robust clinical investigation