5 intriguing ARVO abstracts about uveitis

At the 2016 Association for Research in Vision and Ophthalmology (ARVO) meeting in Seattle, about 100 uveitis and uveitis-related papers and posters were presented by researchers from around the world. The presentations covered a wide range of research initiatives that are underway to treat–or at least understand how to address–uveitis.

Here are five intriguing abstracts of research that were presented at the meeting.

1. Treatment of noninfectious uveitis with sirolimus

In a 24-month period, there were few adverse events associated with intravitreal sirolimus used as monotherapy for the treatment of active non-infectious uveitis, reported Stephan R. Thurau, MD, of the Ludwig-Maximillans University, Munich, Germany.

The research was part of SAKURA Study 1, a phase III, randomized, multinational study to analyze the safety and efficacy of intravitreal sirolimus to treat active noninfectious uveitis in the posterior segment. The 348 eyes included in the study were randomized 1:1:1 to injections (44 µm, 440 µm, or 880 µm) every 2 months, and then followed up with open-label injections of 880 µm at months 6, 8, and 10. Subjects who had a clinical benefit continued to receive injections of 880 µm as needed, starting at month 12.

There were 60.6% of study eyes receiving treatment in the open-label treatment or PRN retreatment periods. The open-label or open-label PRN retreatment subjects were balanced among the three treatment groups.

Ocular adverse events decreased in the entire open-label treatment periods compared with the double-masked treatment period. Serious ocular events (>2%) included uveitis (5.8%), posterior uveitis (3.8%), noninfectious endophthalmitis (3.2%), cataract (2.3%), and medication residue (2.3%). Serious events related to the study medication included uveitis (2.6%), non-infectious endophthalmitis (2.3%), and medication residue (2.3%).

2. OCT angiography study of the iris in anterior uveitis

With the use of optical coherence tomography (OCT) angiography, iris flow density seems to consistently increase with the increased degree of inflammation in the anterior chamber, reported Francesco Pichi, MD, of the San Giuseppe Hospital, University Eye Clinic, Bologna, Italy.

Investigators included 100 patients with acute anterior uveitis, 100 patients with quiet recurrent anterior uveitis, and 100 normal age-matched subjects. All were scanned using the AngioVue OCTA system (Optovue Inc.) and the split-spectrum amplitude decorrelation angiography algorithm. Subjects had scans of 4 quadrants in each eye by a trained operator.

Investigators found good repeatability (kappa coefficient, 0.71) for flow density assessment of iris vasculature measurements. Iris blood flow density measurements were compared in the active uveitis group versus normal patients (temporal iris flow density, 76.17% versus 46.44%; nasal iris blood flow density, 72.09% versus 42.06%).

In 100 patients with quiet recurrent anterior uveitis, a mean iris blood flow density over 55.8% was positively correlated with a reactivation of inflammation within 13.2 days. Reactivation was defined as >1+ anterior chamber cells.

“As ciliary flush detected by clinical examination precedes active uveitis, an increased iris flow density seems to be predictive of a reactivation of a quiescent recurrent uveitis,” the investigators concluded.

3. Association of vitamin D levels with noninfectious uveitis

Lower levels of vitamin D were associated with an increased risk for noninfectious uveitis in a retrospective study, according to Lindsay Grotting, MD, of Massachusetts Eye and Ear, Boston, and co-investigators.

Investigators aimed to determine an association between vitamin D levels and the development of noninfectious uveitis, because noninfectious uveitis is theorized to be caused by immune dysfunction. Vitamin D has an important role in the innate and adaptive immune system and contributes to the etiology of T-cell mediated autoimmune diseases through the upregulation of anti-inflammatory T helper cells type 2 and the suppression of T helper cells type 1, they reported.

Patients with and without noninfectious uveitis were identified from the Massachusetts Eye and Ear Infirmary electronic medical record and Uveitis Database. Control patients were those seen for refractive error or cataracts without any uveitis history.

Vitamin D levels were measured, and clinical and demographic information were collected. There were 53 noninfectious uveitis patients identified, along with 50 controls without uveitis.

 “Uveitis patients had lower mean vitamin D levels: 26.2 ng per ml in cases versus 35.7 ng per ml in controls,” the investigators wrote. “The odds of developing uveitis were 6% lower for every 1-unit increase in vitamin D level.”

4. Characteristics of MS-associated uveitis

Patients with multiple sclerosis (MS) who use immunomodulatory agents with concurrent uveitis may have a visual prognosis that differs from patients who are not systemically treated, reported Himanshu Banda, MD, of Emory University, Atlanta, and coinvestigators.

Investigators used a retrospective, observational clinical chart review to understand changes in patients with MS-associated uveitis. They also compared visual acuity outcomes of patients who did or who did not use systemic immunomodulatory therapy.

Ten patients were included, and all were female. Ninety percent of cases were bilateral; 70% had intermediate uveitis, 20% had panuveitis, and 10% had anterior uveitis. Seven patients had used immunomodulatory therapy for MS when uveitis was diagnosed.

Thirty percent of cases received topical steroid treatment, 60% used periocular steroids, and systemic therapy–such as corticosteroids or mycophenolate mofetil­–was used in 30%.

Two patients used a fluocinolone acetonide intravitreal implant after they failed multiple periocular steroid injections. There was a worse visual outcome in 2 patients treated locally for uveitis who did not start systemic immunomodulatory therapy after the MS diagnosis.

“A multispecialty approach to MS uveitis research may help identify patterns between treatment modalities and visual acuity outcomes,” the investigators concluded.

5. Effect of surgical outcomes in patients with uveitic glaucoma

Investigators found no significant difference in the success rate between trabeculectomies and glaucoma drainage implants in the management of uveitic glaucoma.

Led by Hye Jin Kwon, MD, of the Royal Victorian Eye and Ear Hospital, East Melbourne, Australia, the retrospective research examined the effect of uveitic activity at the time of surgery or after surgery on surgical outcomes.

The chart review of 82 consecutive cases with uveitic glaucoma included patients who had a trabeculectomy (54 eyes) or glaucoma drainage implant surgery (28 eyes) between 2006 and 2014.

Of the implant surgeries, 12 were primary. Thirty-seven percent of trabeculectomy patients and 57.1% of glaucoma drainage implant patients had anterior uveitis; 65.9% of trabeculectomy patients were steroid responders, as were 34.1% of glaucoma drainage implant patients. There was a higher rate of absolute success in the trabeculectomy group (48.1% trabeculectomy versus 21.4% for glaucoma drainage implants).

“Uveitic activity at the time of surgery was not associated with increased risk of failure in our trabeculectomy group,” the investigators reported. “Overall, uveitic flare up was observed in 43.9% of all cases following surgery.” Among those with a uveitic flare up, there was a trend for a decreased success rate.