Our personal experience in a prospective study of infliximab for various types of refractory uveitis demonstrated marked efficacy as well as unexpected toxicity. Among 31 studied patients, side effects included three cases of drug-induced lupus and three thromboses (two with pulmonary emboli and one with myocardial infarction). While this study is too small to conclude that patients with uveitis are especially susceptible to toxic effects from infliximab, we speculate that patients who have localized inflammation may be more prone to adverse events from systemic inhibition of a cytokine.25
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Explore This IssueDecember 2007
TNF inhibitors reduce the frequency of uveitis in patients with AS who are prone to recurrent bouts of eye inflammation.
To date only one report has addressed the efficacy of adalimumab for uveitis. Although this report is favorable, greater study is needed before this approach is adopted widely.
Our approach is to recommend a TNF-inhibitor in the form of a monoclonal antibody for patients with uveitis who have failed other immunosuppressives and who have a systemic disease such as a spondylarthropathy that should respond to this approach. Ironically, although infliximab is not FDA-approved for JIA, high doses of infliximab are reportedly effective for the uveitis associated with JIA.
Experience using rituximab for uveitis is limited and many other biologics, such as abatacept and alefacept, are essentially unstudied. An open-label study using rituximab for scleral and orbital disease is currently underway at our institution.
While rheumatologists and ophthalmologist often speak a different language, they share a mutual responsibility for patients with systemic illness whose vision requires their combined efforts. An understanding of the ocular manifestations of rheumatic disease enables a rheumatologist to have the gratifying opportunity to protect or restore vision in a subset of patients with sight-threatening inflammation.
Dr. Pasadhika is a fellow in the ophthalmology department at Casey Eye Institute and an instructor in the ophthalmology department at Chulalongkorn University Hospital in Bangkok, Thailand. Dr. Rosenbaum is professor of medicine, ophthalmology, and cell biology and director of inflammation research at OHSU and director of the Uveitis Clinic at Casey Eye Institute.
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- Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. 2000;130:492-513.
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- Theodossiadis PG, Markomichelakis NN, Sfikakis PP. Tumor necrosis factor antagonists: preliminary evidence for an emerging approach in the treatment of ocular inflammation. Retina. 2007;27:399-413.
- Suhler EB, Smith JR, Wertheim MS, et al. A prospective trial of infliximab therapy for refractory uveitis: preliminary safety and efficacy outcomes. Arch Ophthalmol. 2005;123:903-912.