Taygan Yilmaz

PURPOSE: To establish evidence-based recommendations regarding the use of anti-Tumor Necrosis Factor alpha (TNF-α) agents for managing uveitis patients. METHODS: Medline was searched via OVID (1950 - October Week 3, 2011) using a Cochrane highly sensitive search (phases 1 and 2). Additional literature searches were also conducted incuding the following databases: the Cochrane, LILACS and the TRIP Database. RESULTS: A total of 54 studies met all of the inclusion criteria and were included in this review. A different level of recommendation and evidence is assigned to each anti-TNF-α agent. The overall rate of reported side effects with anti-TNF-α agents for the treatment of uvetis which required discontinuation of therapy was 2.2% (26/1147 patients). CONCLUSION: Based on the evidence gathered, infliximab and adalimumab seem to be effective in the management of immune-mediated uveitis. Further randomized studies evaluating the efficacy of these agents are warranted. It is the most common cause of inflammatory eye disease, with an estimated prevalence of 115 cases per 100,000 persons. Endogenous or associated with a systemic disease, noninfectious uveitis accounts for approximately 75% of total cases comprising of a heterogeneous group of inflammatory conditions responsible for about 10% of legal blindness in developed nations. Endogenous uveitides are thought to have an autoimmune component mediated by T lymphocytes specific to intraocular antigens that have failed to successfully pass basic processes designed to maintain self-tolerance.

PURPOSE: To retrospectively report a 12-month follow up for combined therapy with systemic cyclosporine A (CSA) and mycophenolate mofetil (MM) in treatment of patients with birdshot retinochoroidopathy (BSRC). PARTICIPANTS: Ninety-eight eyes of patients who received CSA and MM for the treatment of BSRC were included in the study. METHODS: All patients were followed for at least five visits during the study, or until treatment failure, or loss of follow-up. Clinical data were analysed using a Student paired t-test, Wilcoxon signed-rank test, McNemar's test, and Kaplan -Meier survival curve. Side effects related to therapy were also recorded. Main outcome measures included best-corrected logarithm of the minimum angle of resolution visual acuity, vitreous inflammation, fluorescein angiography pathologic features, and electroretinogram recordings. RESULTS: Vitreous inflammation scores at baseline and at 1 year were statistically significantly reduced in both eyes (p<0.001; p=0.001). The presence of angiographic leakage at the 1-year follow-up was significantly reduced (p=0.004). However, the presence of cystoid macular oedema (p=0.32) and comparison of electroretinogram 30-Hz amplitude revealed no significant reduction between baseline and 1-year values for either eye (p=0.61, p=0.87); nonetheless, 30-Hz implicit times were statistically significantly shorter at the end of follow-up for both eyes (p<0.001, p=0.035). Thirty-one patients (67.4%) achieved inflammation control at the 1-year endpoint. Side effects were transient, and resolved after lowering or withholding IMT for a few weeks in the majority of patients. CONCLUSIONS: These results suggest that combined IMT with CSA and MM for BSRC is well tolerated and associated with long-term control of inflammation.

PURPOSE: Comparison of pars plana vitrectomy (PPV) with immunomodulatory therapy (IMT) for patients with intermediate uveitis (IU). METHODS: A prospective, randomized pilot study was performed on patients with recalcitrant IU associated with degradation of visual acuity (VA) despite standard treatment. Outcome measures (VA, intraocular pressure, anterior chamber and vitreous cellular infiltrate) were collected. RESULTS: Sixteen patients (18 eyes) were randomized to the PPV IMT group. Nine of 11 eyes (82%) treated with PPV showed resolution of inflammation at follow-up, at 5.93 years. Four of 7 eyes (57%) given IMT had persistent inflammation requiring subsequent PPV. PPV patients showed greater improvement in Snellen line, IOP, and vitreous cell reduction. Three PPV patients had cystoid macular edema (CME) initially; all resolved postoperatively. CME improved in 2 of 3 eyes using IMT. CONCLUSIONS: A higher percentage of patients treated with PPV had improvement of uveitis compared to those given IMT. A multicentered clinical trial is needed to confirm and statistically validate these conclusions.

PURPOSE: Uveitis is a major cause of ocular morbidity in developed countries. It has been demonstrated that macular edema is a significant cause of decreased visual acuity and macular edema in these patients. In this article, we evaluate the long-term outcome of intravitreal bevacizumab in the treatment of refractory uveitic macular edema. METHODS: In this retrospective, noncomparative, interventional case series, uveitic patients with macular edema who were refractory to conventional therapy and who were treated with intravitreal bevacizumab were identified and assessed. Best-corrected visual acuity and optical coherence tomography central macular thickness measurements were collected and analyzed with correlative statistical analysis, including the use of Student paired t-test, Kaplan-Meier, and linear regression analysis. RESULTS: Twenty-nine eyes of 27 patients with diverse uveitic etiologies were analyzed and followed up at 1 year. Thirteen patients received a single intravitreal bevacizumab injection. Six patients required a second intravitreal bevacizumab injection, while 10 patients received combination therapy of intravitreal bevacizumab and triamcinolone acetonide. Baseline mean logMAR visual acuity was -0.59. At 1 year, the mean logMAR visual acuity was -0.42-/+ 0.36 (p=0.0045). Baseline mean central macular thickness was 383.66 microm. At 1 year, the mean thickness was 294.32-/+110.87 (p=0.0007). CONCLUSIONS: Intravitreal bevacizumab is a useful and therapeutically beneficial agent in the treatment of refractory uveitic macular edema. Some patients will require adjunctive intravitreal bevacizumab injections or the use of combination therapy with intravitreal triamcinolone acetonide.