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Uveitis, iridociklitis- sve na temu lječenja oka

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 PostPoslano: 10-03-2009 10:13  Citiraj (i odgovori)  
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Selen i Cink kod kroničnog uveitisa

Istraživanje je pokazalo da pacijenti s kroničnim i ponavljajućim uveitisom imaju snižene nivoe nekih elemenata u tragovima: Selena i Cinka!

http://findarticles.com/p/articles/mi_m ... _n19170701

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Terapija u Mrtvom moru
http://www.dmz-medical-spa.com/index.ph ... ge_from=99

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Therapeutic Algorithm for Recurrent Anterior Non-granulomatous(e.g. HLA-B27-Associated) "Autoimmune" Uveitis
C. Stephen Foster, M.D.

http://www.uveitis.org/medical/treatment/algo1.html

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Avoiding natural light exposure to skin is essential

If you have any symptoms of eye inflammation (dry eyes, cataracts, increased ocular pressure, etc.), even in the absence of symptoms of photosensitivity and while taking the precaution of wearing adequate eye protection, it is essential that you avoid sunlight falling on your skin.

Natural light has very little effect on 25-D. A small amount of 25-D may be generated by exposure to sunlight.

Sunlight catalyzes the production of the Vitamins D from 7-dehydro-cholesterol in the skin. In healthy folks a significant amount of 25-D will be generated, but in folks with Th1 disease that will energetically be converted to 1,25-D by the disease process, and 1,25-D is thus the resulting primary product. In healthy folks there will be remanent 25-D generated.

1,25-D is directly synthesized from 7-dehydrocholesterol when sunlight falls on the keratinocytes of the skin. Because the keratinocytes of Th1 patients are parasitized by CWD bacteria, they produce interferon-gamma (which is part of the bacterial defense mechanism) and TNF-alpha. These cytokines cause the cells of Th1 patients to produce much more 1,25-D in their skin than healthy folks. In patients with Th1 inflammation, the production, by sunlight, of 1,25-D in the skin predominates the production of 25-D. Studies show that all 25-D produced in the skin from sunlight is hydroxylated directly into 1,25-D, leaving no 25-D to be stored in fatty tissues.

"The keratinocytes of the skin can, by comparison, make 1,25-D directly from 7-dehydro-cholesterol, and they do this when exposed to sunlight. Because the final stage of this reaction is also catalyzed by any Interferon-gamma from any inflammation paracrine to the keratinocytes, any and all 25-D which is made from sunlight is energetically converted to 1,25-D (OK, well, NEARLY all ). Thus sunlight is not usually a significant contributor to the 25-D levels of Th1 patients. " ..Trevor..

Therefore, you cannot judge your level of photosensitivity by your level of 25-D.

The increase in 1,25-D due to sun exposure will increase inflammation everywhere, including your eyes. This may not be felt as photosensitivity but will be evident in other ways such as increase eye pressure

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 PostPoslano: 14-04-2009 12:22  Citiraj (i odgovori)  
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http://www.svjetlost.hr/default.aspx?id=142

Pitanje postavljeno Poliklinic svjetlost

Sa otprilike 3 godine života oboljela sam od juvenilnog reumatoidnog artritisa zbog kojeg sam uzimala kortikosteroide. To je za posljedicu imalo pojavu sive katarakte na desnom oku. Mene bi zanimalo da li bi mogla ponovno progledati na to oko iako mrenu imam već 25 godina i staklovina je nepomična? Da li postoji neki tretman koji bi, uz operaciju mrene, vratio staklovini njezinu funkciju?Također bi me zanimalo koliko bi cijeli tretman koštao i ako ponovni vid nije moguć koliko bi koštala takva "estetska" operacija?


Odgovor

Liječenje kortikosteroidima može dovesti do stvaranja katarakte. Bez obzira koliko katarakta traje ako su drugi dijelovi oka vitalni, nakon operacije pacijent će progledati. Kad spominjete nepomičnu staklovinu, ne znam na što mislite. Ako se radi o zamućenju staklovine zbog uveitisa, ta se zamućenja mogu ukloniti vitrektomijom. Ukoliko se odigla i mrežnica i tj. nastupila i ablacija retine, tada nakon toliko vremena bi ablacija retine učinila nepopravljivo oštećenje retine i operacija vitrektomije ne bi mogla vratiti vid. U tom slučaju samo estetska operacije mrene (da se ukloni bijeli refleks zjenice ) dolazi u obzir.
Operacija mrene košta 8000kn + vitrektomija 16000 = 24000 to bi bio "cijeli tretman" kako vi kažete. Samo estetska operacija mrene košta kao i svaka operacija mrene 8000kn.

Dakle, trebate doći na pregled da se utvrdi vitalitet dubinskih struktura oka, što se može utvrditi ma kako gusta mrena bila. Tada se može odlučiti o strategiji daljenjg liječenja i eventulnoj prognozi.

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Methotrexate is an effective treatment for chronic uveitis *** with juvenile idiopathic arthritis

Authors: Ivan Foeldvari, Angela Wierk
OBJECTIVE: To *** the effectiveness of methotrexate (MTX) in the treatment of juvenile idiopathic arthritis (JIA) *** uveitis, which is still one of the most common causes of visual impairment. METHODS: A retrospective chart review of patients with the diagnosis of uveitis *** with JIA between July 1, 2002, and December 31, 2002. RESULTS: Four hundred sixty-seven patients with JIA were followed. Thirty-eight had uveitis: 31 *** with oligoarticular JIA and 7 with psoriatic JIA. Twenty-five of the 38 patients received MTX; in 23 patients uveitis was the indication for MTX therapy. In the MTX treated group 46/50 eyes had uveitis, the mean (range) age at onset of uveitis was 7.82 years (1.8-15.8), and the mean age at onset of arthritis was 7.25 years (1.25-15.7). MTX treatment was started an average of 11.4 months (0-72) after the onset of uveitis. The mean MTX dose was 15.6 mg/m2. Remission occurred after 4.25 months (1-12). Mean duration of remission was 10.3 months (3-27). The total duration of MTX therapy was 661 months and patients were in remission for 417/661 months. In 6 patients MTX was discontinued after 12 months of remission. Four patients were still in remission after 7.5 months (1-14). CONCLUSION: MTX seems to be an effective therapy for JIA *** uveitis.

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Type of vitamin B1-Benfotiamene could treat common cause of blindness (Uveitis)

University of Texas Medical Branch at Galveston ^ | Apr. 23, 2009 |

GALVESTON, Texas — University of Texas Medical Branch at Galveston researchers have discovered that a form of vitamin B1 could become a new and effective treatment for one of the world's leading causes of blindness.

Scientists believe that uveitis, an inflammation of the tissue located just below the outer surface of the eyeball, produces 10 to 15 percent of all cases of blindness in the United States, and causes even higher rates of blindness globally. The inflammation is normally treated with antibiotics or steroid eye drops.

In a paper appearing in the May issue of the journal Investigative Ophthalmology and Visual Science, however, the UTMB researchers describe striking results achieved with benfotiamene, a fat-soluble form of vitamin B1. In their experiments, they first injected laboratory rats with bacterial toxins that ordinarily produce a reaction mimicking uveitis. When those rats are fed benfotiamene, they fail to develop any signs of the inflammatory disorder.

"Benfotiamene strongly suppresses this eye-damaging condition and the biochemical markers we *** with it," said UTMB *** professor Kota V. Ramana, senior author of the study. "We're optimistic that this simple supplementation with vitamin B1 has great potential as a new therapy for this widespread eye disease."

The researchers' data shows benfotiamene works by suppressing the activation of a crucial signaling molecule called NF-kappa B, which is normally triggered by the stress caused by infection. Shutting down NF-kappa B, they said, prevents the runaway production of inflammatory proteins that generates uveitis.

Benfotiamene's low cost, rapid absorption by the body and lack of negative side effects make it an ideal candidate for uveitis prevention, according to Ramana.

"Already, clinical trials have shown that benfotiamene is absorbed better than thiamine [the most common form of vitamin B1] and significantly improved diabetic polyneuropathy in patients, and it's already taken as a supplement for diabetic complications," Ramana said.

http://www.freerepublic.com/focus/chat/2236420/posts

Fat soluble form of B1 may treat uveitis
Posted on: Friday, 24 April 2009, 18:12 CDT

U.S. researchers say there may be a low cost, easily absorbed treatment for uveitis -- a cause of blindness -- that has few side effects.

Uveitis -- an inflammation just below the outer surface of the eyeball which causes 10 percent to 15 percent of U.S. blindness and even higher rates of blindness globally -- is usually treated with antibiotics or steroid eye drops.

In animal studies, researchers at the University of Texas Medical Branch at Galveston found benfotiamene -- a form of vitamin B1 that is fat soluble -- fed to laboratory rats with bacterial toxins that ordinarily produce a reaction mimicking uveitis, failed to develop any signs of the inflammatory disorder.

Benfotiamene strongly suppresses this eye-damaging condition and the biochemical markers we *** with it, study senior author Kota Ramana says in a statement. We're optimistic that this simple supplementation with vitamin B1 has great potential as a new therapy for this widespread eye disease.

The study, published in Investigative Ophthalmology and Visual Science, found benfotiamene works by suppressing the activation of a crucial signaling molecule called NF-kappa B, which is normally triggered by the stress caused by infection.

Shutting down NF-kappa B, the researchers say, prevents the runaway production of inflammatory proteins that generates uveitis

O B vitaminima
http://prirodnilek.com/vitamin_b1

Preporučene dnevne doze za vitamin B1 su: za djecu
1 - 3 godine: 0.5 mg/dan
4 - 8 godine: 0.6 mg/dan
9 - 13 godine: 0.9 mg/dan

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Visual prognosis in children with chronic anterior uveitis and arthritis.

OBJECTIVE. To determine the visual and ocular prognosis for children with uveitis and chronic arthritis and in patients with uveitis with juvenile rheumatoid arthritis (JRA) or juvenile psoriatic arthritis (JPsA) and to evaluate risk factors *** with ocular complications.

METHODS. We studied 49 children with chronic arthritis having greater than 2 years ophthalmological followup from onset of uveitis. Visual acuity and ocular complications (band keratopathy, synechiae, cataracts, glaucoma, or phthisis bulbi) were documented. For the 45 patients with JRA/JPsA, the antinuclear antibody and HLA status, time and mode of onset, and the course of uveitis, were evaluated as risk factors for developing complications. RESULTS. Mean followup was 9.4 years from diagnosis of uveitis (82 affected eyes). Ocular complications developed in 27 eyes (33%). Visual impairment (corrected acuity 20/50 or worse), occurring only in the presence of complicated uveitis, was present in 12 eyes (15%). Of 45 patients with JRA/JPsA, over 95% developed uveitis within 5 years of onset of arthritis. Those with complicated uveitis (n = 13, mean followup 8.6 years) and uncomplicated uveitis (n = 32, mean followup 10 years) were compared: factors significantly *** with complicated uveitis were (1) a chronic course of uveitis (2) JPsA (3) diagnosis of uveitis prior to, or at the time of arthritis onset (4) symptomatic onset.

CONCLUSION. The risk of developing uveitis 5 years after the onset of JRA/JPsA is small. Although ocular complications were common (33%) among patients with uveitis, normal vision was maintained or correctable for over half of them. Those with uveitis and risk factors for developing ocular complications may need close ophthalmological scrutiny.

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čekaju se rezultati studije

Cyclosporine A in the Treatment of Juvenile Idiopathic Arthritis (JIA) *** Chronic Anterior Uveitis
This study has been completed.


http://clinicaltrials.gov/ct2/show/results/NCT00404482

http://rheumatology.oxfordjournals.org/ ... l/40/8/907

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Zadnja izmjena: kate; 19-07-2009 19:56; ukupno mijenjano 1 put/a.

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Thalidomide Effectiveness for Bilateral Chronic Idiopathic Anterior Uveitis in a Three-Year-Old Child
Fulvio Parentina, Stefano Da Pozzoa, Loredana Leporeb, Paolo Perissuttia
Department of Ophthalmology and
bPediatric Rheumatology Unit, Children's Hospital 'Burlo Garofolo', Trieste, Italy
The authors report their experience with thalidomide in the treatment of a bilateral chronic idiopathic uveitis, in a 3-year-old female. This case was complicated by the presence of a cataract and an iris neovascularization in the right eye; furthermore it was partially unresponsive to a conventional anti-inflammatory and immunosuppressive therapy. Oral thalidomide induced slow but dramatic regression of the inflammation, and a significant reabsorption of neovascular tufts, both in slitlamp examination and on iris fluorescein angiography. The authors emphasize the efficacy of thalidomide as anti-inflammatory agent and as inhibitor of neoangiogenesis, reporting the recent literature about the use of this drug in ophthalmology

Even if its frequency is relatively low, endogenous uveitis is the most common inflammatory disease of the uveal tract in children; early diagnosis and treatment can significantly improve the visual prognosis [1]. In most cases of anterior uveitis, it is not possible to identify an etiology and the definition of idiopathic uveitis is given. For these latter forms, steroids are the cornerstone of treatment; in severe sight-threatening forms, cytotoxic drugs can be added as steroid-sparing agents [2, 3]. Even if effective in treating intraocular inflammation in the majority of cases, when administered for long periods, both these substances can induce significant ocular and systemic side effects, such as cataract or intraocular pressure elevation on one side [4, 5] and leukopenia and thrombocytopenia, renal or hepatic damage and secondary malignancies on the other [6]. Unfortunately, in some cases children are referred to the ophthalmologist when intraocular inflammation has already become chronic and uveitis-related complications have already occurred; in our case, dense cataract, posterior diffuse synechiae and band keratopathy were detectable, but no specific etiology was identifiable. However, after an unsatisfactory response to steroids alone and then to their *** with cyclosporine A, inflammation reacted well to oral thalidomide, a molecule recently rediscovered after a beneficial effect upon a variety of systemic inflammatory and autoimmune disorders had been described [7].

A 3-year-old female was referred to our center by her family physician because of a right leukocoria. Visual acuity was light perception in the right eye and 20/80 in the left. On slitlamp biomicroscopy, the right eye showed a dense cataract as well as a band keratopathy, in addition to diffuse posterior synechiae (fig. 1) with neovascular tufts near the pupillary margin, as confirmed on iris fluorescein angiography (IFA; fig. 2, 3). The left eye had an incipient posterior subcapsular opacity, posterior synechiae and band keratopathy. A 3+ cellular reaction and flare were detectable in the anterior chamber of both eyes; intraocular pressure on a pneumotonometer was 12 mm Hg in the right eye and 14 mm Hg in the left. While vitreoretinal structures of the right eye were not visible, those of the left eye showed no sign of inflammation. On physical examination neither joint pain nor swelling were detectable, nor was fever or skin rash. On laboratory tests, no leukocytosis or anemia was present; furthermore, the child was negative for antinuclear antibodies as well as for rheumatoid factor and for HLA-B27 antigen. The sedimentation rate was 8 mm/h and C-reative protein was absent. Urinalysis revealed no significant alteration; a tuberculin skin test was negative as well as chest X-ray. Serologic tests for herpetic and luetic etiology were negative. The child had no history of previous ocular trauma with lens injury and phacoanaphylactic uveitis was ruled out. No other specific etiology such as Lyme disease, sarcoidosis, psoriasis or inflammatory bowel disease was identifiable and then a chronic idiopathic anterior uveitis was diagnosed.

Topical dexamethasone 0.2% (four times a day OU) and atropine sulfate 0.5% eyedrops (twice a day OU) as well as periocular betamethasone 1.5 mg a day and oral prednisone 20 mg daily (1 mg/kg) were started. After 4 weeks of treatment, inflammation showed a partial regression, but left eye visual acuity became reduced to 20/200 due to an increased nuclear opacity of the lens, and a progressive systemic intolerance to steroids appeared with weight gain secondary to fluid retention. Then, contemporarily to a tapering of systemic and periocular steroids, oral cyclosporine A 100 mg daily (5 mg/kg) was started. Inflammation showed a further reduction, but still a 2+ reaction with a slight flare was visible. At this point, 3 months from the first observation, after obtaining the parents' informed consent, an oral treatment with thalidomide (50 mg daily), in *** with oral cyclosporine A 70 mg daily (3.5 mg/kg) as a maintenance dose, was started. This therapeutic regimen was continued for 2 months and uveitis had a slow but dramatic regression; the left eye regained a visual acuity of 20/50, and a significant reabsorption of neovascular tufts both on slitlamp examination and on IFA was noted (fig. 4). The persistent mild-degree intraocular inflammation allowed to perform an extracapsular cataract extraction (ECCE) in the right eye, without significant intrasurgical or postsurgical complication. Eighteen months after the first observation, no inflammation relapse has ever been noted and the right eye best-corrected visual acuity is 20/40; current treatment is oral cyclosporin 50 mg daily (2 mg/kg) and its tapering will soon be considered. No thalidomide-induced side effect has ever occurred. At the last follow-up visit, laboratory findings and general clinical examination have remained absolutely negative for any specific etiology of uveitis.


In the late 1950s and early 1960s, when taken as a sedative by women in the first trimester of pregnancy, thalidomide displayed its teratogenic effect producing thousands of newborns with limb defects. Recently, this molecule has been rediscovered for its potent effect in a wide spectrum of autoimmune and inflammatory disorders, such as graft-versus-host disease, rheumatoid arthritis, cutaneous lupus erythematosus, ankylosing spondylitis, inflammatory bowel disease and mucocutaneous lesions in Behçet syndrome [4, 7]. For this latter disease, a recent report about a 7-month-old infant relates a favorable outcome [8]. Differently from steroids and cytotoxic drugs, thalidomide acts as an immunomodulator rather than as an inhibitor, without any evident toxic effect upon immune cells and system. It inhibits the production of tumor necrosis factor-, downregulates T lymphocyte surface molecule, inhibits lymphocyte proliferative responses to alloantigens and mitogens and lowers the CD4:CD8 peripheral T lymphocyte ratio [9, 10, 11, 12]. Furthermore, previous research emphasized the antiangiogenic effect of this molecule [13].

Our case of bilateral idiopathic anterior uveitis occurred in a preschool female child referred to our center with unacceptable delay; her already chronic eye inflammation responded only partially to both topical, periocular and systemic steroids, and then to the addition of oral cyclosporine A, and steroid-related ocular and systemic side effects occurred. Oral thalidomide, administered for 2 months, produced an impressive, even if slow, resolution of uveitis, without any side effects; furthermore, this fact allowed to remove the right eye cataract under safe conditions of intraocular inflammation and restore a clear visual axis. An additional finding worth mentioning is the likely thalidomide effect on iris neovascular tufts; while being a rare anterior uveitis feature, new iris vessels have previously been reported in patients with long-lasting inflammation [14, 15]. In our patient, it can be hypothesized that thalidomide expressed its antiangiogenic effect.

To the best of our knowledge this is the first report about a beneficial effect of thalidomide on idiopathic anterior uveitis in a child. In our opinion, the introduction of oral thalidomide in daily clinical practice must be preceded by a serious prospective multicenter trial in order to precisely define its role as an effective treatment for severe forms of intraocular inflammation with respect to steroids and cytotoxic agents. Up to that moment, only a prudent administration, limited to those cases in which other well-known therapeutic protocols appear insufficient or not well tolerated, is acceptable. However, due to the apparent absence of side effects at the daily dose of 50 mg and to its mechanism of action, thalidomide appears as a promising powerful therapeutic weapon for severe inflammatory sight-threatening eye disease, even in children.

http://content.karger.com/ProdukteDB/pr ... tNr=224269

http://clinicaltrials.gov/ct2/show/NCT00314665

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Zadnja izmjena: kate; 19-07-2009 20:31; ukupno mijenjano 3 put/a.

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http://www.uveitis.org/medical/articles ... uveit.html


Immunomodulatory Therapy for Children With Steroid-Resistant or Steroid-Dependent Uveitis
C. Stephen Foster, M.D.

The purpose of this presentation is to provide to you the results of an *** given to me by Dr. Holland, namely, to review the matter of immunomodulatory therapy in children, in particular in children with uveitis. In an effort to discharge this responsibility given to me, I reviewed the literature relevant to pediatric immunomodulatory therapy for non-malignant, non-ocular disease in an effort to determine, to the extent possible, information regarding the safety of such therapy for children with non-malignant disease. Additionally, I have reviewed the literature on immunomodulatory therapy in children with ocular inflammatory disease. The central question I have tried to address is that of, Êwhat is the evidence supporting the efficacy and safety for immunomodulatory therapy for steroid-resistant or steroid-dependent ocular inflammatory disease?ˆ

A computer-based (MEDLINE), search of the database from the National Library of Medicine, Bethesda, Maryland, of the literature from 1970 to 2000 on the use of immunomodulatory therapy in non-ocular, non-malignant disease in children, and in the use of immunomodulatory therapy in ocular inflammatory disease in children was conducted. An attempt at analyzing reported side effects, toxicity, and complications was made. Additionally, an analysis of our experience in pediatric immunomodulatory therapy over the past 25 years was performed.

The non-ocular, non-malignant disorders for which immunomodulatory therapy was prescribed which I reviewed included solid organ and bone marrow transplants, rheumatic disorders, vasculitis disorders, including childhood Wegenerÿs granulomatosis, polyarteritis nodosa, and Adamantiades-Beh¨etÿs disease, dermatologic disorders, including childhood pemphigus vulgaris and psoriasis, asthma and nephrotic syndrome. Three-thousand, one-hundred and eight publications were reviewed. It became immediately apparent that a variety of impediments to clarity of analysis existed for many of the non-ocular, non-malignant disorders for which immunomodulatory therapy might be prescribed. For example, 1,074 publications on solid organ and bone marrow transplantation were reviewed. But multiple immunomodulatory therapy agents, combined into Êrecipesˆ were employed for each patient in each of those publications. Additionally, underlying illness which led to the transplant also confounded the picture. And finally, concurrent use of chronic systemic steroid confused matters.1-10 Clear data to emerge from this analysis, however, include: major medication induced nephrotoxicity and neurotoxicity was common in children treated with either cyclosporin or with tacrolimus (FK506) for prevention of solid organ transplant or bone marrow transplant rejection or in treatment of nephrosis;1,9 infection was relatively common in children treated concomitantly with systemic steroid and an immunosuppressant;5 mycophenolate mofetil at 600 mg/m2+ bid is subtherapeutic (more acute renal allograft rejections) and more toxic than are therapeutically effective doses of azathioprine.5

Of the childhood rheumatic diseases *** (juvenile idiopathic arthritis, systemic lupus erythematosus, relapsing polychondritis, localized scleroderma and polymyositis), the best data emerge from the juvenile idiopathic arthritis (JIA) literature. Two hundred and thirty-three publications on the matter of immunomodulatory therapy for JIA were reviewed. Methotrexate was the immunomodulatory agent used most commonly, by far.11-14 However, publications on the use of cyclosporin, azathioprine, and chlorambucil were also useful.

Ruperto and *** studied 132 children with JIA treated with methotrexate, with no reported clinically significant drug-induced complications. Woo and colleagues12 reported that one of the 27 children with JIA treated with 15-20 mg/m2 methotrexate required drug discontinuation secondary to rising liver enzymes after the patient contracted hepatitis A.

Giannini and *** studied 127 children with juvenile idiopathic arthritis, 86 of whom were treated with methotrexate (Êlow doseˆ or Êvery low doseˆ), comparing both efficacy and side effects with an additional 41 children treated with placebo in a double-blind placebo-controlled trial. Only three children treated with methotrexate discontinued therapy because of side effects, and none had significant toxicity. The side effects included gastrointestinal upset and oral mucosal aphthous ulceration. All side effects were graded as either mild or moderate in severity, except for 2 episodes of stomach pain graded as severe in a patient receiving placebo.

Laxer concludes, in his summary on the matter14 that methotrexate therapy for JIA is the mainstay of treatment of that disease because of both its efficacy and its safety, pointing out that liver toxicity is very uncommon, as are osteopathy, embryopathy and malignancy, with any even remote *** with the latter being controversial and unclear.

Weiss, Wallace, and Sherry, in their 1998 publication, reported on 7 children with steroid-dependent uveitis and cataract and glaucoma, whom they treated with methotrexate, in a dose to 1mg/kg/week given subcutaneously.15 Uveitis was controlled in six of the seven patients, allowing steroid to be discontinued or at least dramatically reduced. The time to response was 1-4 months. Three of seven patients had rising serum aminotransferase levels during the appropriate monitoring, necessitating dose reduction of the methotrexate; no patient required discontinuation of medication because of complications. Weiss and *** conclude that early use of methotrexate may allow for complete suppression of JIA-associated uveitis and reduce the cumulative exposure to corticosteroids in refractory cases.

We had previously reported similar findings and recommendations in a 1992 article, and in an expanded series on 160 patients with uveitis treated with methotrexate;16,17 ÂÂforty of these patients were children. Our data confirmed the safety profile of this drug, and further emphasized its utility in control of uveitis in patients with steroid-dependent uveitis. However, the group of children in whom the highest proportion failed to completely respond to methotrexate were those with juvenile idiopathic arthritis; in this group of patients, 75% responded to this drug, while 25% required the addition of a second agent or a switch to an alternative agent.17

Good, easily analyzable data could not be obtained from the publications relating to Adamantiades-Beh¨etÿs disease, Wegenerÿs granulomatosis, polyarteritis nodosa, Churg-Strauss syndrome, Goodpastureÿs syndrome, Crohnÿs disease, pemphigus vulgaris, eczema, psoriasis, epidermolysis bullosa acquisita, asthma, or autoimmune hepatitis.18-26 However, excellent, easily usable data emerged from an analysis of the literature on nephrotic syndrome (see below). Six-hundred and seventy-four publications on the matter of nephrotic syndrome were reviewed. The immunomodulatory agents typically employed in the care of children with frequently relapsing, steroid-dependent nephrotic syndrome included cyclosporin, cyclophosphamide, and chlorambucil. The cyclophosphamide regimens involved in the studies included 5mg/kg/day by mouth, or 75mg/m2/day by mouth for up to 52 weeks. The chlorambucil doses employed in the trials analyzed included 0.2mg/kg/day and 0.3mg/kg/day. The cyclosporin dose employed was 6mg/kg/day.

Analysis of adverse effects in a meta-analysis by Durkan and *** disclosed the following.27 Chlorambucil at 0.3mg/kg/day is highly toxic and frequently *** with unacceptable levels of leukopenia. Cyclosporin at 6mg/kg/day is frequently *** with nephropathy, hypertension, hirsutism, and gum hypertrophy; lesser doses are ineffective for inducing remission in nephrotic syndrome. Therefore, cyclosporin is believed by the authors to be inappropriate for this indication.

The meta-analysis showed that the relative risk for nephrotic syndrome relapse was 0.44 following cyclophosphamide therapy, so that the risk of relapse is reduced from 100% to 40%, i.e., 60 fewer children relapse for each 100 treated. For every 100 treated, one will develop an infection and four will develop cystitis. Therefore, a risk/benefit analysis is highly appropriate before any child is committed to cyclophosphamide therapy. For example, children who relapse only once during the first six months after an initial course of prednisone therapy have only a 10% risk of becoming a frequent relapser, i.e., 10 of 100. Cyclophosphamide therapy would reduce this risk by 60%, and so only 6 of 100 such children would benefit from cyclophosphamide therapy, while the number suffering adverse effects would remain unchanged. Therefore, the risk/benefit ratio would be acceptable only for children with frequently relapsing syndrome. A similar exercise in estimating a risk/benefit ratio in considering steroid-sparing immunomodulatory therapy for children with uveitis is clearly appropriate.

An estimate of the risk/benefit ratio in children with juvenile idiopathic arthritis with dependency on steroid versus moving on to low dose once weekly methotrexate therapy is straightforward. The data on safety and efficacy of methotrexate therapy for this indication are clear, and clearly indicate that the risk/benefit ratio calculation for children whose arthritis is steroid-dependent or treatment-resistant favors moving along to methotrexate immunomodulatory therapy. Similarly, the same estimate of risk versus benefit can be done for children with JIA-associated iridocyclitis. Just as in the case of children with nephrotic syndrome, not every child with JIA-associated iridocyclitis is destined to have a chronic, or recurrent, or conventional-treatment-resistant course. But good data exist regarding prognosticators for identifying patients whose JIA-associated uveitis is more likely than not to be chronic, recurrent, or Êstubbornˆ. Kanski and others for example, have suggested that those JIA patients who develop uveitis prior to the onset of arthritis have a worse prognosis than those in whom arthritis develops first.28

Wolfe and *** attempted to analyze visual prognostic factors in 51 patients with JIA-associated uveitis by dividing their patients into mild or advanced uveitis subgroups. Those who had posterior synechiae and active inflammation at the time of presentation to the ophthalmologist had a worse long-term outcome than did those who had no active inflammation at first evaluation.29 Edelsten and *** recently reported on their study of 163 patients with JIA-associated uveitis, in an attempt to evaluate baseline risk factors predictive of severity and chronicity of the uveitis. Like Wolfe, these researchers found that complications and a generally poor outcome were significantly more common in those patients who had uveitis at the time of their initial screening visit with the ophthalmologist. Further, they confirmed the observations of others that the more severe the uveitis was at presentation, the more likely vision-damaging complications would ensue throughout the course of the patientÿs disease.

Our work on this matter,31 based on our analysis of 43 patients with JIA-associated uveitis identified those patients referred to to Dr. Foster as being comprised of 93% with chronic uveitis, 5% with recurrent uveitis, and 2% with an acute monophasic disease course. The mean overall duration of the uveitis was 146 months, with females suffering from a significantly longer duration of active disease than did males. The female ***, longer duration of uveitis, younger age at uveitis onset, and longer delay between onset of uveitis and presentation to a uveitis subspecialist were *** significantly with visual acuity impairment. The same factors, along with dependence on corticosteroids (lack of treatment with systemic antiinflammatory medication aside from steroids) were correlated strongly with a final visual acuity outcome of less than 20/40. We concluded that earlier case identification and referral to a uveitis specialist trained and prepared to engage in immunomodulatory therapy of such patients had the best chance of minimizing the likelihood of visual impairment in patients with JIA-associated uveitis. Therefore, the 12-year-old boy who is HLA-B27 negative, ANA negative, with oligoarticular juvenile idiopathic arthritis who has 2 or 3 mild episodes of anterior uveitis clearly should not be advanced to methotrexate immunomodulatory therapy for care of his eye disease. On the other hand, such a patient with severe uveitis at the outset, which is still requiring topical with or without regional injection or systemic steroid 6 months after the first visit to the ophthalmologist should seriously be considered for advancement to methotrexate. Similarly, the 2-year-old female who is ANA positive with oligoarticular arthritis, found on initial screening examination to have significantly impaired visual acuity in one eye, with posterior synechiae in both eyes and a significant cataract in one eye should almost certainly be seriously considered for methotrexate therapy almost immediately.

The meta-analysis study by Latta and *** analyzed 38 studies involving 1504 children and 1573 courses of cytotoxic drug therapy. The regimens involved in those 38 studies included cyclophosphamide at a dose of 2-5mg/kg/day or chlorambucil at 0.1-0.2mg/kg/day.

Leukopenia was common, but generally as a desired Êside effectˆ of effective alkylating therapy. Infection developed in 1.5% of patients on cyclophosphamide, but in 6.3% of patients receiving chlorambucil. Additionally, 0.2% of patients on cyclophosphamide developed a malignancy, while 0.6% of patients on chlorambucil therapy did so. Three percent of patients on chlorambucil therapy developed a seizure disorder, and 2.2% of patients on cyclophosphamide developed cystitis.

The authors conclude that the margin between effective treatment and a dose toxic to the patient is too narrow for chlorambucil, and that therefore cyclophosphamide is the preferred therapy for steroid-dependent, frequently relapsing nephrotic syndrome.

Additional matters of significant interest to us within ophthalmology confronted by the need to decide about alkylating therapy are gonadal toxicity and secondary malignancy. Guesry concludes that the margin between effective treatment and a dose toxic to the gonads was smaller with chlorambucil than with cyclophosphamide.33 He estimates that 17mg/kg chlorambucil cumulative dose with concurrent steroid use is safe for the gonads of males, while 200mg/kg of cyclophosphamide could be used safely. The gonadal toxicity of cytotoxic therapy was less severe in females than in males in his study, and pregnancies had been reported after cumulative doses of up to 525mg/kg of cyclophosphamide and after up to 28mg/kg for chlorambucil.

Nephrotic syndrome has been *** with lymphoma, and 2 children with nephrotic syndrome without cytotoxic therapy have had leukemia. Therefore, attributing malignancy in nephrotic syndrome treated with immunomodulatory therapy is complicated. Fourteen of 1504 children reported in the meta-analysis of Latta et al32 developed a malignancy, and some of the malignancies were ones that one would not traditionally *** with being a consequence of alkylating therapy.

Additionally, in some of the cases, the doses of alkylating agent had been quite low, calling into question the relationship between the alkylating therapy and the malignancy. But it seems clear that a relationship can exist, and, further, that the higher the cumulative dose, the more likely a leukemia may develop. Chlorambucil, in particular, has been *** with leukemia. But at the doses and durations typically employed in children with ocular inflammatory disease, this appears not to be a significant issue.

Latta et al recommend that the criteria for treating children with nephrotic syndrome with cytotoxic therapy should include a frequently relapsing nature of the nephrotic syndrome, the development of steroid toxicity, such as cataract and growth failure and Cushingoid status, and/or the development of psychological complications from the use of steroid.32 Cyclophosphamide is preferred over chlorambucil, with oral cyclophosphamide at a dose of 2-3mg/kg/day, keeping the white count above 3000 cell/m3, and employing alternative day steroid concomitantly. Latta suggests aiming for less than 300mg/kg cumulative dose in males.32

Pulse intravenous cyclophosphamide therapy may, in fact, be the best approach of all in this setting of frequently relapsing nephrotic syndrome. Gulati et al reported on this strategy of treating 51 children with steroid-dependent, frequently relapsing nephrotic syndrome.34 The mean age of the children was 4 years, and the dose employed was 500mg/m2/month for six months, with a 5-year follow up. The authors concluded that this is a safe and effective way of administering alkylating therapy, comparable in efficacy to oral daily cyclophosphamide, with 40% less cumulative dose, and therefore fewer side effects. The side effects included nausea and vomiting at the time of infusion (5%), alopecia (8%), leukopenia (4%), pneumonitis (2%), and infection (2%). No patient discontinued therapy due to a side effect. Mok et al similarly extol the virtues of pulse intravenous cyclophosphamide in their care of children with diffuse proliferative lupus glomerulonephritis.35 They studied 55 patients, 22 receiving intravenous cyclophosphamide and 33 receiving oral cyclophosphamide. The patients receiving IV pulse cyclophosphamide never developed cystitis, whereas 5% of the patients receiving oral cyclophosphamide did. Half the menstruating females on oral cyclophosphamide developed oligomenorrhea, whereas only 25% of those receiving IV pulse cyclophosphamide did.

Finally, Lehman and Onel additionally speak to the matter of intermittent intravenous pulse cyclophosphamide in the care of children with systemic lupus erythematosus nephritis.36 Sixteen children with systemic lupus erythematosus *** glomerulonephritis were treated with intravenous pulse cyclophosphamide for 36 months. The regimen involved a dosage of 500-750mg/m2 monthly for six months, followed by that same dose every 3 months for the succeeding 30 months. Side effects included nausea during the infusion (this was typically controllable and necessitated no change in therapy) alopecia (none to the extent of complete baldness), and leukopenia (an inescapable and, frankly, essential Êside effectˆ from cyclophosphamide therapy, without which the therapeutic effect will never be achieved). No child withdrew from therapy during the entire course of treatment, no instances of cystitis were encountered, no female reaching pubescence developed amenorrhea, and no patient has developed a malignancy.

Rosenbaum37 applied this approach, but at reduced dose, for 11 adults with steroid-resistant uveitis, reporting that five of the 11 benefited from this approach. We, on the other hand, have been very impressed at both the safety and the efficacy of intravenous pulse cyclophosphamide therapy in the care of patients whose uveitis has failed to adequately respond not only to systemic and regional steroid therapy, but has also failed to remit with more conventional, orally administered immunomodulatory agents, such as methotrexate, cyclosporin, azathioprine and mycophenolate mofetil.38

CONCLUSIONS

Abundant reliable published evidence exists in the worldÿs peer-reviewed literature attesting to the safety of several immunomodulatory agents for treating both ocular and systemic non-malignant inflammatory disease. Some agents are clearly safer than others. For example, methotrexate has an extraordinary safety record in the care of patients with such disorders. Cyclosporin is more toxic in children at therapeutic doses. Mycophenolate mofetil, an immunomodulatory agent quite useful in the care of adults with ocular inflammatory disease39,40 is more toxic to children than is azathioprine or methotrexate.3 Cyclophosphamide, particularly given in the intravenous pulse mode, is clearly superior, at least from a safety standpoint, to daily oral cyclophosphamide and to daily oral chlorambucil.

RECOMMENDATIONS

1. Ophthalmologists should acquaint themselves with the literature references herein. Ophthalmologists should acquaint themselves with the evidence-based medicine recommendations of the American Uveitis Society regarding the wisdom of immunomodulatory therapy for specific ocular inflammatory disorders.41

2. Ophthalmologists should acquaint themselves with the recommendations of the International Uveitis Study Group on this matter as well, with specific reference to the disorders and situations in which this Society considers the use of immunomodulatory agents mandatory.42

3. The American Academy of Ophthalmology should publish Preferred Practice Guidelines which highlight these findings and the recommendation of these two specialty groups.

4. Chairmen of Departments of Ophthalmology should recruit to their faculties ocular immunologists who have been specifically trained to care for patients, including children with uveitis, in ways consistent with the principles promoted by the American Uveitis Society and by the International Uveitis Study Group, not only to deliver such care, but also to ensure that succeeding generations of residents in training in ophthalmology will be better educated about the safety and indications for such therapy and about the collaborative strategies they may employ effectively with chemotherapists prepared to take responsibility for the details of prescribing and monitoring such therapy.

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Anita Moorjani "Ponovno rodjena"


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Upalne promjene na oku su česte u reumatskim bolestima.
One se mogu javiti prije pojave reumatskih tegoba, ali češće nastaju u toku liječenja upalnog reumatizma.


Bolesti kod kojih se najčešće razvijaju promjene na oku su :
Sy Sjogren koji najčešće uključuje reumatoidni artritis i sistemski eritemski lupus, zatim ankilozantni spondilitis, Reiterova bolest, dermatomiozitis, polimijalgija reumatika te neki lijekovi kao što su kortikosteroidi i antimalarici.



U Sjogrenovu sindromu /sicca sindrom/ nastaje keratokonjunktivitis sicca, odnosno suhoća očiju. Bolesnik ima osjećaj da mu je pijesak u očima.



U reumatoidnom artritisu prisutan je sicca sindrom /u sklopu Sjogrena/ te skleritis, nekrotizirajući skleritis te episkleritis kod vaskulitisa.



U reumatoidnom artritisu kod djece javlja se iridociklitis koji može biti akutni i kronični.
U ankilozantnom spondilitisu /Bechterew/ prisutan je akutni iridociklitis.
Reaktvni artritisi /Reiterov sindrom najčešće stvaraju konjunktivitise, a u sistemskom eritemskom lupusu osim sicca sindroma nastaje i oštećenje vidnog živca kao i u polimijalgiji reumatici u koje je došlo do afekcije temporalnih arterija.



Kod dermatomiozitisa nazočna su cistoidna tjelešca.


Upotrebom kortikosteroida /Decortin, Medrol../ u liječenju reumatskih bolesti možemo izazvati stvaranje katarakte /mrene/, a duga uporaba antimalarika /Resochin/ provocira nastanak keratopatije i retinopatije.


dr Olga Novak

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dobar dan... ja sam stara Dragica ...samo igram za tim ozdravljenje pa otud broj 1:-)


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I priče kruže da odrasli reumatičari nemaju ili teže imaju upale oka,
e pa evo izgleda da mogu imati itekako problema.
Ovo stavljam iz jednog razloga da nešto naučimo,jer danas svaka druga odrasla osoba boluje od reume.

http://www.zzjzpgz.hr/nzl/29/oko.htm

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dobar dan... ja sam stara Dragica ...samo igram za tim ozdravljenje pa otud broj 1:-)


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To examine the occurrence and characteristics of uveitis in patients with recently diagnosed juvenile chronic arthritis (JCA).

The study covered the new cases detected with JCA (426 children), all of whom were referred to an ophthalmologic consultation during 1989 to 1996 at the Pediatric Department of the Rheumatism Foundation Hospital, Heinola, Finland.

The children with JCA were followed by ophthalmologic and pediatric examinations two to four times a year. The type and course of arthritis and presentation and characteristics of uveitis were examined prospectively.

Results
Uveitis was detected in 104 of 426 children (24%). Two thirds of all patients and the same proportion of those with uveitis were girls. Proportionally, uveitis was found to be as common among children with oligoarthritis (27%) as among those with seronegative polyarthritis (25%). Antinuclear antibodies (ANA) were detected significantly more frequently in patients with uveitis (66%) than among those without uveitis (37%) (P < 0.001). The uveitis was asymptomatic in 99 cases; only 5 children had episodes of acute anterior symptomatic uveitis. Uveitis was found before or within 3 months from the onset of recent arthritis in 51 of 104 children (49%) and later on in 53 of 104 children (51%). The mean age at diagnosis of uveitis was 5.9 years (range, 1.1–17.7; median, 4.9 years).

The mean period from the diagnosis of JCA to the diagnosis of uveitis was 1.1 years (range, −2.4–6.5; median, 0.3 years). The mean age at diagnosis of JCA was 4.8 years (range, 0.6–15; median, 3.2 years) among those with uveitis and 7.3 years (range, 0.9–16; median, 6.7 years) among those who did not have it (P < 0.001). Uveitis was ongoing in 63 children at the end of the follow-up period.

The mean follow-up time was 4.5 years (range, 0–9.7) for all children and 5.6 years (range, 1.3–9.6) for those with uveitis. In most instances, the visual prognosis was good. In 25 of 104 patients (24%) one or more complications of uveitis were found, but in only three children did the visual acuity decrease to 20/60 or less, and none became blind. All the other patients had visual acuity ≥ 20/40.

Conclusions
In this patient group, uveitis in JCA frequently appeared very early after the onset of arthritis. The uveitis was significantly more common in patients with an early onset of arthritis combined with ANA positivity. The proportion of children with uveitis was as large in those with polyarthritis as in those with oligoarthritis, with no predilection to girls.

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Anita Moorjani "Ponovno rodjena"


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U indiji
http://www.ijo.in/article.asp?issn=0301 ... Sudharshan

Aim: Juvenile idiopathic arthritis (JIA) *** uveitis is one of the most common causes of visual morbidity in children. We report the systemic, clinical and investigational features of a cohort of all cases of JIA *** uveitis seen at our referral uveitis clinic between 1988 and 2004.

Study Design: Retrospective case series Materials and Methods: All patients of JIA seen at the uveitis clinic of tertiary eye care hospital, between 1988 and 2004 with minimum follow up of 3 months were included. Complete history and ophthalmic evaluation and findings on each visit were noted. Ocular complications were identified and recorded. Results of laboratory investigations and diagnostic as well as therapeutic procedures were analyzed. A rheumatologist managed systemic status.

Results: There were 40 patients (64 eyes) with JIA. Thirty four patients (85%) had pauciarticular type and 6 patients (15%) had polyarticular type of JIA. Complicated cataract and band shaped keratopathy were seen in 38 eyes (63%) and 37 eyes (62%) respectively. Twenty-two patients (17 bilateral and 5 unilateral) were treated with immunosuppressives and in 19 of these patients, the disease went into remission. Twenty-three eyes (38%) had improvement in visual acuity while in 27 eyes (45%), the vision remained stable and in 10 eyes (17%), vision deteriorated despite therapy.

Conclusion: In India, JIA *** uveitis commonly presented in pauciarticular type with preponderance in males. Rheumatoid arthritis factor and anti nuclear antibodies were not as common as compared to the western population. Among long-term treatment options, immunosuppressives are a better choice. Ocular surgery was performed when mandatory for visual rehabilitation

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