Outcomes of Early Versus Late Immunomodulatory Treatment in Patients With HLA-B27-Associated Chronic Uveitis

Abstract

Abstract: : Purpose: To evaluate the outcomes of early versus late immunomodulatory treatment (IMT) in patients with HLA-B27-associated chronic uveitis Materials-Methods: We reviewed the medical records of 72 patients with HLA-B27-associated chronic uveitis (inflammation lasting longer than three months), who received IMT at the Ocular Immunology & Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1998 to October 2002. We recorded age at the time of first visit, age at the onset of uveitis, gender, laterality and localization of uveitis, possible associated systemic disease, severity of inflammation at presentation, at the beginning of IMT treatment and at last follow up, number of flares before, during and after IMT treatment, best corrected visual acuity at presentation, at the initiation of IMT treatment and at last follow up. Results: Two patients were excluded from the study because of inadequate follow-up. The median time between diagnosis and start of IMT was 3.05 years. Patients were devided in two groups: Group A: patients in whom initiation of IMT was within the first three years (34 patients), and Group B: patients in whom initiation of IMT was after three years from the disease onset (36 patients). There was a statistically significant improvement in lines of visual acuity in the late treated group (p=0.017, Wilcoxon Rank Sum test), but additionally a significant difference in the prevalence of glaucoma between the two group (23.5% in the early and 44.4% in the late treated group). Late treated patients experience more flare-ups before adequate control of inflammation with IMT (Mean number of flare-ups for the early treated group prior to the initiation of IMT treatment was 1.38±2.24 SD and after IMT treatment 1.11±3.47 SD. In the late treated group the mean number of flares prior to treatment for each patient was 5.52±6.023 SD and post treatment 1.00± 1.12 SD. There was also a statistically significant difference in the number of flare-ups during IMT treatment between early and late treated patients: thirteen (36.1%) of the 36 patients in the early treated group and 21 (58.3%) of the 36 patients in the late treated group, had at least one flare up while on IMT (p=0.098, Fisher's exact test). Conclusions: Immunomodulatory therapy is an effective treatment for severe HLA-B27 uveitis that fails to respond to conventional steroid treatment. Introduction of IMT prior to 3 years following the disease onset may prevent the adverse effects of steroids (cataract, glaucoma) and may reduce the likelihood of repeated recurrences of the uveitis.

Keywords: immunomodulation/immunoregulation • drug toxicity/drug effects • uveitis-clinical/animal model