New Uveitis Disease Activity Index Developed By Multidisciplinary Group

In an article published online in Rheumatology International, researchers from multiple universities in Spain presented a new disease activity index for patients with uveitis.¹

Uveitis encompasses a range of diseases involving intraocular inflammation of the uvea and other ocular structures such as the retina and vitreous cavity. It is the third most common cause of blindness in developed nations, accounting for an estimated 10%-20% of cases in the US.² In many patients with rheumatic diseases–including spondyloarthropathies and Behçet’s disease–uveitis is an extraarticular manifestation that can lead to significant morbidity. In those 2 diseases in particular, uveitis may be the main source of the primary disease’s symptoms, which indicates the importance of interdisciplinary collaboration between ophthalmologists and rheumatologists in evaluating and treating such patients.

A previous review found considerable heterogeneity of primary outcomes in uveitis trials and emphasized the need for the development of standardized outcome measures for these studies. Such measures are similarly lacking in uveitis treatment, and uveitis activity “is not recorded by the usual articular indexes that are used by rheumatologists to monitoring disease activity and function such as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), or Ankylosing Spondylitis Disease Activity Score (ASDAS),” note the authors of the new guidelines.

Thus, it is challenging to accurately compare treatment efficacy and response. Though the Standardization of Uveitis Nomenclature Working Group (SUN) criteria have become the standard in uveitis research, these “only take into account inflammation in the anterior chamber and vitreous haze when defining uveitis activity,” wrote the present authors.

To that end, an interdisciplinary working group of 8 ophthalmologists and 7 rheumatologists aimed to create a uveitis disease activity index (UVEDAI) to include domains of disease activity that they deemed important, according to the criteria set forth by the Outcome Measures in Rheumatology Clinical Trials (OMERACT).

After they developed the model, it was tested it in 195 patients (54% female) across 9 multidisciplinary hospital units. The primary endpoint was defined as inflammatory activity of uveitis, defined as any intraocular inflammation, which was categorized as mild, moderate or severe by the ophthalmologist overseeing the assessment.

Moderate disease activity was found in 48% of patients, while 39% showed mild activity, and 13% showed severe activity. More severe activity levels were observed in patients with the following characteristics:

·         High degrees of anterior chamber cell grade

·         High degrees of vitreous haze

·         Central macular edema over 315μm

·         Inflammatory vessel sheathing

·         Papillitis

·         An elevated number of choroidal/retinal lesions

·         Higher patient evaluation of symptoms

The discriminatory capacity of the model was determined to be 87% (95% confidence interval [CI], 82–92%) for distinguishing patients with mild disease activity from those with moderate or severe activity, and it was 90% (95% CI, 84–95%) for distinguishing patients with mild or moderate activity from those with severe activity.

To use this tool, clinicians “will only need to substitute the values for AC cell grade, vitreous haze, macular edema, inflammatory vessel sheathing, patient evaluation, papillitis and the number of choroidal/retinal lesions in the formula given, and with the score obtained, to classify a patient’s uveitis disease activity level according to the established cut points: ≤1 × 05: mild; 1 × 06 to ≤4 × 86: moderate; ≥4 × 87: severe,” according to the paper.

Though additional studies will be needed to validate the UVEDAI, the authors believe it will be useful in both clinical practice and research.

Summary and Clinical Applicability

The newly developed uveitis disease activity index (UVEDAI) was found to have high discriminatory capacity in differentiating patients with varying levels of disease activity, and it may prove to be useful in both clinical and research settings. 

Limitations

• Reliance on ophthalmologists’ clinical judgment to categorize inflammatory uveitis activity due to current lack of other diagnostic gold standard

Reference

1. Pato E, Martin-Martinez MA, Castelló A, et al. Development of an activity disease score in patients with uveitis (UVEDAI). Rheumatol Int. 2016 Nov 4. doi: 10.1007/s00296-016-3593-1 [Epub ahead of print]
2. Weill Cornell Medical College. Uveitis. Retrieved on 12/7/16 from http://weillcornelleye.org/library/uveitis.html

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