a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(7):222–226
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Letters to the Editor
Biological therapy in sympathetic ophthalmia refractory to combined immunosuppressive treatment夽 Terapia biológica en oftalmía simpática refractaria a tratamiento inmunosupresor combinado Dear Sir: The objective of this communication is to report on the efficiency and advantages of the anti-TNF biological drug (adalimumab) in sympathetic ophthalmia (OS), bilateral panuveitis in which this treatment has not yet been described in world literature. A 40-year-old woman exhibiting sympathetic ophthalmia in the right eye with 2 years evolution after left eye retina detachment surgery failure. Despite systemic treatment with prednisone 30–90 mg/day, methotrexate 15 mg/week and cyclosporine 150 mg/day, the inflammation persisted, exhibiting in the ocular fundus multiple Dalen-Fuchs nodules as well as serous neuroepithelium in the entire macular area, as evidenced by optic coherence tomography (OCT). Fluorescein angiography revealed large contrast diffusion at the peripapillary level and multiple focal exudation points corresponding to said Dalen-Fuchs nodules. At that time, the visual acuity of the patient was of light perception. Intravitreal treatment was established with 3 triamcinolone injections (Trigón® ) (4 mg/0.1 ml) at 1 month intervals, with the patient exhibiting temporary improvement. Considering the resistance and after discarding active tuberculosis and latent hepatitis B, systemic immunosuppressant treatment was established with subcutaneous adalimumab 40 mg (Humira® ) on alternate weeks. This achieved the remission of the condition and stability for the past 18 months, with the virtual disappearance of the chorioretinal infiltration lesions as well as the total reapplication of the retina at the posterior pole level and the reduction of focal and peripapillary diffusion in angiography (Figs. 1 and 2).
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Fig. 1 – Comparison between the condition of the neuro epithelium detachment comprising the entire posterior pole, before and after treatment with adalimumab.
Please cite this article as: López-Prats MJ, et al. Terapia biológica en oftalmía simpática refractaria a tratamiento inmunosupresor combinado. Arch Soc Esp Oftalmol. 2011;86:222–26.
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Fig. 2 – At the angiographic level, after 5 months of treatment, considerable improvement of the right eye ocular fundus can be seen. At the right, the serous detachment is completely gone, as well as a clear reduction of the peripapillary diffusion and the absence of focal exudation points.
The soluble tumor necrosis factor (TNF) is a natural cytokine that intervenes in normal inflammatory and immunological responses. Adalimumab (Humira® ) is a recombinant human monoclonal antibody that bonds with the soluble tumor necrosis factor (TNF-alfa9) with high specificity and affinity and neutralizes its biological function.1 It is indicated for treatment of rheumatologic diseases. According to the recently published description by DíazLlopis et al., adalimumab would be the choice for the biological treatment of uveitis, exhibiting considerable advantages compared to infliximab, such as ease of application (on an outpatient basis due to being subcutaneous) and low periodicity (2 weeks), as well as the lower risk of adverse reactions as it is a completely humanized monoclonal antibody. In addition, its high efficiency and the vast experience in its use raise the possibility of considering it as second or third line treatment.1,2 Various drugs have been utilized for managing SO. Early corticoids treatments in combination with other immunosuppressant agents such as chlorambucyl, cyclophosphamide, azathiprine an cyclosporine can produce improvements in vision.1 However, poor residual visual acuity is associated to glaucoma, macular chorioretinal scars or persistent uncontrollable inflammation as in the present case. This letter presents the first case described in world literature evidencing an objective success of adalimumab as a treatment for SO. No side effects have been observed in the
midterm, allowing for a reduction of the corticoids dosage down to a maintenance regime of 10 mg/day.
references
1. Díaz-Llopis M, Gallego-Pinazo R, García-Delpech S, Salom-Alonso D. General principles for the treatment of non-infectious uveitis. Inflamm Allergy Drug Targets. 2009;8:260–5. 2. Díaz-Llopis M, Amselem L, Romero FJ, García-Delpech S, Hernández ML. Tratamiento con Adalimumab—nuevo antiTNF—del síndrome de Vogt Koyanagi-Harada. Arch Soc Esp Oftalmol. 2007;82:131–2.
M.J. López-Prats a,∗ , D. Salom a , E. Sanz-Marco a , S. García-Delpech a , P. Udaondo a , M. Díaz-Llopis a,b a
Servicio de Oftalmología, Hospital Universitario y Politécnico La Fe, Valencia, Spain b Facultad de Medicina, Universidad de Valencia, Valencia, Spain ∗ Corresponding
author. E-mail address: susa
[email protected] (M.J. López-Prats).
2173-5794/$ – see front matter © 2011 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved. doi: 10.1016/j.oftale.2011.02.004
