Biological agents in treatment of uveitis
Mohamed Taher Abdel Hakim Mohamed;
Abstract
Uveitis is a general term describing inflammation of one or all parts of the uveal tract causing serious effects on vision, either by acute ocular inflammation or by its sequelae, such as cataract, glaucoma and retinal vascular ischaemia. Making uveitis one of the major causes of visual loss. Uveitis can be broadly classified into those associated with infections and uveitis of a non-infectious aetiology.
Uveitis is usually categorized anatomically into anterior, intermediate, posterior and panuveitic forms. The International Uveitis Study Group designed a simplified clinical classification system for uveitis based on etiological criteria. It has 3 main categories: Infectious, Non-infectious and Masquerade.
Infectious uveitis is more common in the developing world, accounting for 30-50% of all cases of uveitis. The most common infectious etiologies encountered are toxoplasmosis, tuberculosis, onchocerciasis, cysticercosis, leprosy and leptospirosis. In developed countries, infectious uveitis account for a much smaller number of cases, mostly as a result of infection with herpes virus and toxoplasmosis.
The most common causes of non-infectious uveitis include Fuchs heterochromic iridocyclitis, birdshot chorioretinopathy, sympathetic ophthalmia, sarcoidosis, multifocal choroiditis, Vogt-Koyanagi-Harada syndrome, serpiginous choroiditis and Behçet’s disease.
Uveitis work up starts with an elaborate history taking. Empathetic history taking will increase patient’s rapport and confidence and usually offer clues and insights into the type of uveal disease with which one is suffering. It is estimated that over 70% of diagnosis can be made on the basis of detailed medical history and meticulous clinical work up alone. Family history may suggest a correct diagnosis when dealing with tuberculosis or congenital disorders. Systemic history evaluation helps to offer possible systemic association with ocular involvement. Evaluation of the patient’s social history may alert the physician to the possibility of endemic diseases, venereal disease, or Acquired Immuno Deficiency Syndrome. It is often the clinical acumen of the ophthalmologist that points out the diagnosis, that is further confirmed or ruled out by a tailored laboratory approach.
Traditionally, corticosteroids are the mainstay treatment in immune-mediated uveitis. Although they provide a highly effective reduction in inflammation, its wide range of significant side effects precludes long-term usage in high doses. Conventional “steroid-sparing agents” such as antimetabolites, alkylating agents and T-cell inhibitors have proven anti-inflammatory effect associated with improvement in clinical symptoms and quality of life. However, these agents have potentially serious side effects and patients treated with these medications require careful monitoring for electrolyte imbalances, transaminitis and blood dyscrasias.
Biological agents are a new promising option for patients either unresponsive to, or unable to tolerate conventional immunosuppressive therapies. Biological therapy is a type of treatment that stimulates or restores the ability of the natural immune system to fight infections and diseases. Biological therapy is thus any form of treatment that utilizes the body's natural abilities that constitute the immune system to fight infections and diseases.
Scientific research has identified the key role played by pro-inflammatory chemokines in non-infectious ocular inflammation, such as tumour necrosis factor alpha, interleukins 1, 2 and 6 and interferon gamma. Biologic treatment of uveitis can be accomplished with the tumor necrosis factor inhibitors (infliximab, etanercept and adalimumab), followed by the interleukin-2 receptor blocker daclizumab. Other biologic agents are designed to counteract the secretors of these chemokines; T- and B-cells, thereby aiming to prevent a downward cascade of inflammation.
Uveitis is usually categorized anatomically into anterior, intermediate, posterior and panuveitic forms. The International Uveitis Study Group designed a simplified clinical classification system for uveitis based on etiological criteria. It has 3 main categories: Infectious, Non-infectious and Masquerade.
Infectious uveitis is more common in the developing world, accounting for 30-50% of all cases of uveitis. The most common infectious etiologies encountered are toxoplasmosis, tuberculosis, onchocerciasis, cysticercosis, leprosy and leptospirosis. In developed countries, infectious uveitis account for a much smaller number of cases, mostly as a result of infection with herpes virus and toxoplasmosis.
The most common causes of non-infectious uveitis include Fuchs heterochromic iridocyclitis, birdshot chorioretinopathy, sympathetic ophthalmia, sarcoidosis, multifocal choroiditis, Vogt-Koyanagi-Harada syndrome, serpiginous choroiditis and Behçet’s disease.
Uveitis work up starts with an elaborate history taking. Empathetic history taking will increase patient’s rapport and confidence and usually offer clues and insights into the type of uveal disease with which one is suffering. It is estimated that over 70% of diagnosis can be made on the basis of detailed medical history and meticulous clinical work up alone. Family history may suggest a correct diagnosis when dealing with tuberculosis or congenital disorders. Systemic history evaluation helps to offer possible systemic association with ocular involvement. Evaluation of the patient’s social history may alert the physician to the possibility of endemic diseases, venereal disease, or Acquired Immuno Deficiency Syndrome. It is often the clinical acumen of the ophthalmologist that points out the diagnosis, that is further confirmed or ruled out by a tailored laboratory approach.
Traditionally, corticosteroids are the mainstay treatment in immune-mediated uveitis. Although they provide a highly effective reduction in inflammation, its wide range of significant side effects precludes long-term usage in high doses. Conventional “steroid-sparing agents” such as antimetabolites, alkylating agents and T-cell inhibitors have proven anti-inflammatory effect associated with improvement in clinical symptoms and quality of life. However, these agents have potentially serious side effects and patients treated with these medications require careful monitoring for electrolyte imbalances, transaminitis and blood dyscrasias.
Biological agents are a new promising option for patients either unresponsive to, or unable to tolerate conventional immunosuppressive therapies. Biological therapy is a type of treatment that stimulates or restores the ability of the natural immune system to fight infections and diseases. Biological therapy is thus any form of treatment that utilizes the body's natural abilities that constitute the immune system to fight infections and diseases.
Scientific research has identified the key role played by pro-inflammatory chemokines in non-infectious ocular inflammation, such as tumour necrosis factor alpha, interleukins 1, 2 and 6 and interferon gamma. Biologic treatment of uveitis can be accomplished with the tumor necrosis factor inhibitors (infliximab, etanercept and adalimumab), followed by the interleukin-2 receptor blocker daclizumab. Other biologic agents are designed to counteract the secretors of these chemokines; T- and B-cells, thereby aiming to prevent a downward cascade of inflammation.
Other data
| Title | Biological agents in treatment of uveitis | Other Titles | العوامل البيولوجية في علاج التهاب القزحية | Authors | Mohamed Taher Abdel Hakim Mohamed | Issue Date | 2014 |
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