Success With Single-Agent Immunosuppression for Multifocal Choroidopathies

Abstract

Purpose To evaluate the success of single-agent immunosuppression for patients with the posterior uveitides, birdshot chorioretinitis, multifocal choroiditis with panuveitis, and punctate inner choroiditis. Design Retrospective case series. Methods Setting: Tertiary care uveitis practices. Population: Patients initiated on immunomodulatory therapy. Intervention: Patients were treated with prednisone 1 mg/kg and mycophenolate 2 gm daily. Prednisone was tapered after one month. Immunosuppression was escalated to mycophenolate 3 gm daily, with addition of a second agent, as needed, to achieve treatment success. Outcome Measure: Treatment success, defined as no disease activity with prednisone dose ≥10 mg daily, at 6, 12, and 24 months. Results Twenty-seven patients were followed. Mean presentation and 2-year follow-up acuities were 20/41 and 20/42, respectively. For birdshot chorioretinitis, mean (± standard deviation) quantitative Goldmann visual field scores improved from 761±69° (IV/4 isopter) and 496 ±115° (I/4 isopter) at prese ntation, to 784 ±57° and 564 ±125°, respectively. Prednisone was successfully tapered in 95% of patients; mean prednisone doses at 1 and 2 years were 5.3 ±4.1 and 5.7 ±4.8 mg/day, respectively. At 2 years, prednisone was discontinued in 11% of patients. Treatment success was achieved in 74% of patients on one immunomosuppressant, and an additional 21% of patients on two agents, for an overall 95% success rate at 2 years. Conclusions Posterior uveitides can be treated with one agent in most patients, but the data suggest a need to escalate therapy to higher mycophenolate doses, and in one-fifth of cases add a second agent to maintain disease suppression with acceptably low prednisone doses.

Multifocal Choroiditis and Panuveitis - difficulties in diagnosis and treatment

“…When corticosteroid therapy does not have the desired effect, immunomodulatory agents represent the next category of medication used. This includes the broad categories of antimetabolites (azathioprine, methotrexate, and mycophenolate mofetil), alkylating agents (cyclophosphamide, chlorambucil), T-cell inhibitors (cyclosporine, tacrolimus) and cytokines (interferon alpha) [ 1 , 7 , 8 ].…”

Spatial agreement between Goldmann visual field defects and fundus autofluorescence in patients with birdshot chorioretinopathy

“…In these studies, modified diabetic retinopathy study (DRS) visual field scores were obtained using GVF by calculating the sum of degrees seen along each 30° meridian using I4e and IV41 objects. Using the above method of calculation, a gain of >20° in the visual field was found to occur with immunomodulatory therapy in patients with BSCR [ 10 , 25 ]. Thus, GVF testing appears to be an efficient objective measure for assessment of vision-related functional loss in patients with BSCR.…”

Antimetabolite Therapy for Uveitis

“…3,5 Despite the success with 2 g/d mycophenolate in the SITE study, 2-year follow-up in the Mount Sinai study of posterior uveitides suggested that approximately 75% of patients treated with mycophenolate would require 3 g/day to experience successful corticosteroid sparing. 4 More modern approaches often either initiate methotrexate at 15 mg/week and escalate to 25 mg/week in a single step if the lower dose is not adequately effective or use 25 mg/week; similarly, mycophenolate is administered at 2 g/day and increased to 3 g/day in a single step if the lower dose is not adequately effective or to just increased automatically to 3 g/day. 1 In this context, the First-Line Antimetabolites for Steroidsparing Treatment (FAST) research group conducted a randomized clinical trial of methotrexate vs mycophenolate as the single immunosuppressive agent for treating noninfectious intermediate, posterior, and panuveitides, the results of which are reported in this issue of JAMA.…”