The goal of this project is to develop improved methods for the diagnosis and treatment of ocular inflammatory diseases in human patients of all ages including uveitis, scleritis, inflammatory diseases of the ocular surface, and intraocular malignancies. Over the past year clinical studies have continued to focus on examining the effectiveness of new therapeutic agents with a milder safety profile than that offered by currently available standard immunosuppressive medications. This year we have initiated our experience with infliximab (Remicade), a chimeric human/murine monoclonal antibody that neutralizes the biologic activity of TNF-alpha for the treatment of Behcet's disease, scleritis, and posterior segment uveitis including retinal vasculitis. Although infliximab seems to be an effective alternate therapy for the treatment of ocular inflammatory disease the potential for ocular complications may limit the usage of the agent. Clinical studies with daclizumab (HAT, Zenapax), a humanized monoclonal anti-IL-2 receptor antibody, are ongoing in patients with non-infectious intermediate and posterior uveitis. Previously given by intravenous infusions, patients treated with daclizumab are now benefited from the convenience of a new subcutaneous formulation of the drug given every 2-4 weeks while maintaining the same therapeutic efficacy offered by the intravenous formulation. Future intramural and multicenter clinical trials evaluating daclizumab for the treatment of patients with active uveitis are now being planned. Other clinical studies in development include evaluating the therapeutic efficacy of infliximab and daclizumab for the treatment of active scleritis and anakinra (Kineret), a IL-1 receptor antagonist, for the treatment of anterior uveitis in children and adults. In addition to systemic therapy with corticosteroids, ocular inflammatory disease can be treated with corticosteroids given topically or by injection in or around the eye. In the past year we have verified previous work showing that subconjunctival steroids can be effective local therapy for the treatment of non-necrotizing scleritis in patients without a history of increased intraocular pressure or glaucoma. We also demonstrated that mycophenolate mofetil, a selective inhibitor of T and B lymphocytes can be used as an effective steroid sparing agent in patients with active scleritis. Animal studies to evaluate new immunosuppressive agents with a mechanism similar cyclosporine but lacking the nephrotoxic effects are planned that will hopefully translate into human trials. This year we have continued to exploit the utility of the intraocular assessment of IL-10 and IL-6 for the diagnosis and management of primary intraocular lymphoma (PIOL). We analyzed vitreal cytokine levels from 35 PIOL and 64 uveitic patients and found a cutoff point in disease diagnosis with an IL-10 to IL-6 ratio greater than 1.0 for PIOL. The sensitivity and specificity of the cutoff rule are74.3% and 75.0%, respectively. In a patient with recurrent PIOL treated with intravitreal methotrexate the intraocular IL-10 to IL-6 ratio correlated with the presence of tumor clinically and were helpful in the determination that the patient's PIOL had become resistant to methotrexate. Using immunohistochemistry with confocal microscopy we examined the patient's resistant PIOL cells and determined that aberrant expression of the methotrexate resistant protein and decreased expression of the reduced folate carrier and folate binding proteins on the lymphoma cells we the likely cause of the acquired methotrexate resistance. A recently developed animal model for PIOL holds the promise of offering new insights into the pathogenesis and treatment of this disease. Finally, using immunopathologic techniques we were able to demonstrate the cause of retinal degeneration in two patients. In the first patient autoantibodies reactive againstt the retina were shown to react against cellular components the patients mature teratoma that was discovered in the process of a systemic work. In the second case of a patient with a known diagnosis of Waldenstrom macroglobulinemia we were able to demonstrate of antibodies reactive against the retinal photoreceptors that were the likely cause of her retinal degeneration.
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