Care. Education. Research. A Center of Excellence for Uveitis

BY ALBERT T. VITALE, MD

The overarching mission of the Moran Eye Center’s Uveitis Division consists of three parts: to provide state-of-the-art, comprehensive, timely, and compassionate care to patients suffering from uveitis; to serve as leaders in the clinical education of uveitis locally, nationally, and internationally; and to contribute to the field through collaborative and investigator-initiated clinical research.

PATIENT CARE

The physicians in our division, Akbar Shakoor, MD, Marissa B. Larochelle, MD, and I, together with our uveitis fellow, provide a prodigious amount of direct patient care, both medical and surgical. Our team treats individuals of all ages suffering from various complex ocular inflammatory and infectious or masquerading neoplastic diseases and their complications.

The only program of its kind in the Mountain West, our division is nationally recognized as a regional referral center of excellence, working in collaboration with University of Utah Health rheumatology (adult and pediatric), infectious diseases, and Huntsman Cancer Institute specialists. We endeavor to provide personalized and complete care.

Our collective training and experience in uveitis and vitreoretinal diseases and comprehensive ophthalmology and complex cataract surgery is unique. We can provide the most advanced diagnostic modalities and therapeutic approaches, individualized to patients, their specific ocular or systemic disease, or both, and address the potential side effects of treatment.

Specifically, these include:

• Diagnostic intraocular tissue sampling with molecular analysis.

• The use of established systemic conventional and newly available biologic steroid-sparing medications.

• Appropriate use of primary and adjunctive corticosteroid injections, including sustained-release intravitreal inserts and implants.

• Visual rehabilitation of the structural ocular complications of uveitis in the anterior and posterior segment employing advanced cataract and vitreoretinal surgical techniques.

EDUCATION

Our educational mission begins with ophthalmology residents who gain exposure to uveitis through structured rotations on the uveitis and retina services and a unique approach to didactic instruction known as a “flipped classroom format.” Dr. Larochelle is a leader in developing a curriculum for this format, which emphasizes interactive learning.

Dr. Shakoor established and is the head of Moran’s Association of University Professors of Ophthalmology-accredited uveitis fellowship program, in its fifth year, as well as a six-month international fellowship program. These have become highly competitive and attracted superb fellows who have gone on to excellent academic and private practice positions in uveitis.

Our team has also served in various leadership roles in national ophthalmology organizations (see list at end of story), including hosting the American Uveitis Society (AUS) Winter Meeting and Uveitis Fellow’s Forum in January 2020. These meetings are central to the AUS national educational mission and are highly popular and widely attended.

RESEARCH

The research activity of the Uveitis Division has involved participation in multiple pivotal randomized controlled trials (RCTs) sponsored by the National Eye Institute (NEI) and industry, as well as investigator-initiated studies, collaborative case series, and reports.

As a part of the Multicenter Uveitis Steroid Treatment (MUST) consortium, we have contributed to the important results of the two- and seven-year follow-up studies of the MUST trials. These studies compared the outcomes of systemic treatment with conventional immunomodulatory therapy (IMT) to the local therapy with the fluocinolone acetonide implant for the treatment of noninfectious intermediate, posterior and panuveitis.

More recently, we have been vanguard clinics for two NEIsponsored RCTs investigating the safety and efficacy of steroidal and non-steroidal regional and intravitreal therapy for uveitic macular edema (UME), a leading cause of visual impairment. The Periocular and Intravitreal Corticosteroid Trial (POINT) recently compared periocular triamcinolone acetonide (PTA), intravitreal triamcinolone acetonide (ITA), and the intravitreal dexamethasone implant (IDI) as initial therapy for UME. The trial concluded that while all three approaches were effective, both intravitreal therapies were superior to the periocular treatment for reducing UME and improving visual acuity, with similar safety profiles for the intravitreal groups.1

A companion RCT, the Macular Edema Ranibizumab vs. Intravitreal Anti-inflammatory Therapy (MERIT) trial, is exploring the safety and efficacy of IDI to non-steroidal alternatives ranibizumab and methotrexate in eyes with quiescent uveitis.

Having been involved in the VISUAL I and II trials sponsored by industry partner AbbVie Inc., which led to the FDA approval of the first biologic agent, adalimumab, for the treatment of noninfectious intermediate, posterior and panuveitis, we are currently enrolling patients in the NEI-sponsored Adalimumab vs. Conventional Immunosuppression for Uveitis (ADVISE) trial. Likewise, we are ready to enroll patients in the Adalimumab in Juvenile Idiopathic Arthritis-Associated Uveitis Stopping Trial (ADJUST), an RCT to study the recurrence rate of ocular inflammation in patients with quiescent, juvenile idiopathic arthritis-associated uveitis. (See a full list of Uveitis Division clinical trials at the end of this story.)

Within our division and in collaboration with other investigators, we have recently published widely on diverse subjects of interest to those in the field of uveitis, including our 13 year-experience with combined phacoemulsification and pars plana vitrectomy for the treatment of cataracts in patients with noninfectious uveitis.2-7

Our current uveitis fellow and Heed award recipient, Wen Fan Hu, MD, PhD, and Dr. Larochelle are studying the outcomes of uveitic cataract surgery using intraoperative intracameral tPA.

Our previous fellow, Inna Stoh, MD, PhD, co-authored a chapter on cataract surgery in uveitis with Dr. Larochelle.

Another former fellow, Christopher Conrady, MD, PhD, and myself, in collaboration with Stephen Anesi, MD, and C. Stephen Foster, MD, contributed the most comprehensive chapter on “Pediatric Uveitis” to date for Pediatric Retina, edited by Mary Elizabeth Hartnett, MD, director of Pediatric Retina at Moran.

Finally, Katherine Hu, MD, a current ophthalmology resident, and Dr. Larochelle have spearheaded a protocol to institute standard ophthalmic screenings for all pediatric and adult bone marrow, stem cell, or organ transplanted patients for the detection of CMV retinitis ocular infection.

Dr. Vitale directs Moran’s Uveitis Division and specializes in diagnosing and treating uveitis and other infections and inflammatory diseases of the eye. He is co-author of the definitive text on the subject with Dr. C. Stephen Foster, titled “Diagnosis and Treatment of Uveitis.”

NATIONAL LEADERSHIP ROLES

Dr. Vitale:

• American Uveitis Society (AUS) Executive Committee • Immediate Past President of AUS

• Recent Chair and Co-Chair of the American Academy of Ophthalmology Uveitis Subspecialty Day

• Co-Chair of the AUS Winter Meeting in Park City

• Chair of the Uveitis Fellow’s Forum (UFF)

Dr. Shakoor:

• AUS Executive Committee

ONGOING UVEITIS CLINICAL TRIALS

• Vitreous Biopsy Analysis PI: Akbar Shakoor, MD

• Macular Edema Ranibizumab v. Intravitreal Anti-inflammatory Therapy (MERIT) Trial PI: Albert T. Vitale, MD

• Adalimumab vs. Conventional Immunosuppression for Uveitis (ADVISE) Trial PI: Albert T. Vitale, MD

• Adalimumab in Juvenile Idiopathic Arthritis-Associated Uveitis Stopping Trial (ADJUST) PI: Albert T. Vitale, MD

• Machine Learning Algorithm for Electroretinography Sorting PI: Akbar Shakoor, MD

UVEITIS FELLOW 2020-21

Wen Fan Hu, MD, PhD, joins the Moran Eye Center as the 2020-2021 Uveitis Fellow following residency at Massachusetts Eye and Ear. She completed her medical and doctorate degrees at Harvard University and undergraduate studies at Yale. Dr. Hu was recently named a 2020-2021 Heed Fellow to support her postgraduate fellowship training and academic pursuits.

CITATIONS

1. Thorne JE, et al. Periocular Triamcinolone vs. Intravitreal Triamcinolone vs. Intravitreal Dexamethasone Implant for the Treatment of Uveitic Macular Edema: The PeriOcular vs. INTravitreal Corticosteroids for Uveitic Macular Edema (POINT) Trial. Ophthalmology. 2019 Feb.; 126(2):283-295.

2. Conrady CD, et al. Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients with Noninfectious Uveitis. Journal of VitreoRetinal Diseases. 2020; 4(5):393-400.

3. Conrady CD, et al. Long-Term Visual Outcomes of Endophthalmitis and the Role of Systemic Steroids in Addition to Intravitreal Dexamethasone. BMC Ophthalmology. 2020 May 6;20(1):181.

4. Kutluturk I, et al. The Clinical Characteristics of Unilateral Placoid Pigment Epitheliopathies. Ocular Immunology and Inflammation. 2020 Feb. 20:1-8.

5. Conrady CD, et al. Checkpoint Inhibitor-Induced Uveitis: A Case Series. Graefes Archive for Clinical and Experimental Ophthalmology. 2018 Jan.;256(1):187-191.

6. Conrady CD, Shakoor A. Rituximab-Associated Retinal Occlusive Vasculopathy: A Case Report and Literature Review. Ocular Immunology and Inflammation. 2020 May 18;28 (4):622-625.

7. Conrady CD, et al. The First Case of Trypanosoma Cruzi-Associated Retinitis in an Immunocompromised Host Diagnosed with Pan-Organism Polymerase Chain Reaction. Clinical Infectious Diseases. 2018 June 18;67(1):141-143.