Latest news on Uveitis and its treatme

[Mike Bartolatz]

Uveitis Specialty News and Views - September 2003

Intravitreal triamcinolone as an adjunct to pars plana vitrectomy
Infliximab (Remicade)
Uveitis in Pregnancy
Intraocular lymphoma
Antibiotics for Toxoplasmic Retinochoroiditis
Mycophenolate Mofetil as an Immunomodulatory Agent in the Treatment of Chronic Ocular Disorders



Intravitreal triamcinolone as an adjunct to pars plana vitrectomy

Triamcinolone acetonide (TA) appears to be a potentially excellent adjunct to vitrectomy in difficult cases of pars planitis. During the performance of a pars plana vitrectomy (PPV) on 6 patients with uveitis and proliferative vitreoretinopathy (PVR), Sonoda and colleagues found that TA improved the visibility of the posterior hyaloid, facilitating its resection. The investigators intentionally left 4 mg of Kenalog or TA in situ in 4 of 6 patients to reduce postoperative eye inflammation. Almost all traces of TA had disappeared after a month. Although the long-term effects are unknown, TA assisted PPV appears to be superior to conventional treatments for PVR associated uveitis.

REFERENCE:

Sonoda KH, Enaida H, Ueno A, Nakamura T, Kawano YI, Kubota T, Sakamoto T, Ishibashi T. Pars plana vitrectomy assisted by triamcinolone acetonide for refractory uveitis: a case series study. Br J Ophthalmol. 2003;87(8):1010-4.


Infliximab (Remicade)

In a study of the efficacy of infliximab or Remicade in the treatment of refractory posterior uveitis, Joseph et al reported that 4 of 5 patients experienced a remission of posterior uveitis after 6 months of treatment. In fact, visual recovery was so complete that the patients discontinued all other forms of immunosuppressive therapy. While 6 months is a relatively short follow-up period, the results are nevertheless impressive. Anecdotal reports also seem to indicate that infliximab is superior to etanercept for most uveitis patients, but the long-term effectiveness of such new therapies is still unknown.

REFERENCE:

Joseph A, Raj D, Dua HS, Powell PT, Lanyon PC, Powell RJ. Infliximab in the treatment of refractory posterior uveitis. Ophthalmology. 2003;110(7):1449-53.


Uveitis in Pregnancy

In reviewing 76 pregnancies in 50 women with uveitis, Rabiah and Vitale diagnosed Vogt-Koyanagi-Harada disease (VKH) in 23, Behcet in 10, and idiopathic uveitis in 17 patients.

In the VKH patients 79% of those studied experienced flare-ups of uveitis within the first four months of pregnancy with a lesser peak at eight to nine months. Seven of the 23 VKH patients even presented symptoms of new onset uveitis in the first trimester. In Behcet patients, uveitis flare-ups occurred throughout pregnancy in about half of the patients; however when Rabiah and Vitale focused on first study pregnancies, six of ten flare-ups occurred in early pregnancy. Of the 17 idiopathic patient pregnancies, uveitis flare-ups occurred primarily in the first four months of pregnancy in about three-quarters of the patients. Most of these were not explainable by changes in medications.

Patients tended to do better in late pregnancy, but post partum flare-ups occurred in the first three months after delivery in Behcet and VKH patients; Behcet patients particularly experienced flare-ups in the first month of post partum. Flare-ups were less common in the idiopathic group post partum, nor did they cluster in the first three months. Admittedly, though, there was insufficient data on 33% of the idiopathic uveitis cases.

Overall, the data is somewhat difficult to interpret and apply, as some of the patients had previous pregnancies and varying prior courses of uveitis. There was also insufficient data in some categories, as may be expected in a retrospective review. Rabiah and Vitale, however, succeeded in communicating a valid and important message: women and their physicians should be aware that in the critical period of early pregnancy the possibility of a uveitis flare up is a significant concern. Early, frank, and detailed discussions with uveitis patients of child-bearing age are very important.

REFERENCE

Rabiah PK, Vitale AT. Noninfectious uveitis and pregnancy. Am J Ophthalmol. 2003;136(1):91-8.


Intraocular lymphoma

In the article “Intrathecal Chemotherapy for Recurrent Central Nervous System Intraocular Lymphoma” Mason and Fischer report that two patients with central nervous system (CNS) intraocular lymphoma responding to an intrathecal combination of Ara-C and methotrexate experienced a complete remission of their cancer. Both patients had had previous radiation therapy and recurrent CNS intraocular lymphoma. Follow-up of more than five years showed no recurrence of CNS intraocular lymphoma. This may be an important therapy for these patients. The rarity of this condition makes randomized treatments difficult, but a national collaborative study could be developed.

REFERENCE

Mason JO, Fischer DH: Intrathecal Chemotherapy for Recurrent Central Nervous System Intraocular Lymphoma. Ophthalmology. 2003;110(6):1241-4.


Antibiotics for Toxoplasmic Retinochoroiditis

Despite a lack of evidence to support antibiotic therapy outlined in an article by Stanford et al., many ophthalmologists continue to use antibiotics to treat toxoplasmic retinochoroiditis. In fact, according to Grigg, Ganatra, Boothroyd, et al. (2001: 184(5), pp. 633-9), there exists a wide range of therapies for ocular toxoplasmosis, because various strains of this disease exist, and each is sensitive to various types of antibiotics.

In sight-threatening toxoplasmosis, some ophthalmologists employ a quadruple therapy of sulfadiazine, clindamycin, pyrimethamine, and prednisone. For non-sight threatening toxoplasmosis, others sometimes use zithromax or minocycline, or they administer no treatment at all. Finally, high-risk patients may receive Bactrim DS for prophylaxis; Bactrim DS for non-macular/nerve-threatening disease in combination with steroids for reducing vitritis/CME; clindamycin for macular disease that does not impinge on fixation; and pyrimethamine, azithromycin, and leukovorin for vision-threatening diseases.

REFERENCES

Stanford MR, See SE, Jones LV, et al. Antibiotics for toxoplasmic retinochoroiditis: an evidence-based systematic review. Ophthalmology. 2003;110(5):926-31.

Grigg ME, Ganatra J, Boothroyd JC, Margolis TP. Unusual abundance of atypical strains associated with human ocular toxoplasmosis. J Infect Dis. 2001;184(5):633-9.


Mycophenolate Mofetil as an Immunomodulatory Agent in the Treatment of Chronic Ocular Disorders

A retrospective study from Ocular Immunology Service at the Massachusetts Eye and Ear Infirmary (Ophthalmology 2003;110:1061-1065) looked at the use of Mycophenolate in 54 patients with various forms of uveitis. Mycophenolate was found to be useful as both a single agent and in combination with other drugs, and acted as a steroid-sparing agent. They reported 65% of the patients had control of the ocular inflammation, as has been previously reported with other immunomodulatory agents. Ten patients stopped the Mycophenolate treatment due to non-severe, non-permanent adverse reactions, and 44% had some type of problem with the medication.

As in any retrospective report, the conclusions must be considered tentative. The follow up time was relatively short (mean duration of therapy was 7 months) and no patient was followed for more than 24 months. The differing forms of uveitis in treated patients limits the ability to evaluate the effectiveness of Mycophenolate in patients with certain disease processes. As concluded by the authors, this medication has merit and should be considered in the treatment of patients with chronic uveitis.


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