Using rituximab for eye patients

A new approach could obviate the need for steroids in idiopathic orbital inflammation

Sean Henahan

Posted: Friday, July 13, 2018

Treatment with rituximab, a drug normally associated with the treatment of non-Hodgkin’s lymphoma or rheumatoid arthritis, can provide rapid resolution of symptoms in idiopathic dacryoadenitis, a form of idiopathic orbital inflammation, according to a report presented at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting in Honolulu.
Following a report that intralesional rituximab proved useful in the treatment of ocular adnexal lymphoma, US researchers conducted a study in nine patients with confirmed idiopathic orbital inflammation. Patients received a single intralesional injection of rituximab (50mg/1mL). Patients were followed for at least six months with serial exams and MRI studies. The investigators used the modified Werner classification for the grading of orbital inflammation to measure disease activity. Patients who were pregnant, or younger than 18 years of age, or with evidence of acute vision loss were excluded from the protocol.
Nine patients, five men and four women, participated in the study. Patients had symptoms for about 10 days before beginning treatment. Every patient had a complete resolution of disease within four weeks of starting treatment. The mean orbital inflammation score declined steeply after treatment, reaching a high level of statistical significance (p<0.005). One patient relapsed at eight months. That patient was given another injection and had resolution of disease.
“I think this represents a step beyond steroids. We feel this data is very promising and warrants prospective trials in the future comparing this with the current standard of care. Local injection of rituximab spares patients the side-effects of high-dose systemic corticosteroid treatment,” said Charles Miller MD, PhD, of the State University of New York Downstate, US, in an interview with EuroTimes.

This was the first report of using intralesional rituximab for idiopathic orbital inflammation. Intralesional administration can be done under direct visualisation in the clinic, injecting into the palpebral lobe of the lacrimal gland. Patients first receive topical proparacaine and lidocaine gel, left on the conjunctival surface for a minute prior to injection, he explained.
The fact that no patient experienced side-effects associated with rituximab treatment is noteworthy. Rituximab (Rituxan, Genentech) is a genetically engineered chimeric murine/human monoclonal IgG1 kappa antibody directed against the CD20 antigen. When given intravenously in the treatment of rheumatoid arthritis or B-cell non-Hodgkin’s lymphoma, side-effects can include fever, rigors and chills.
Idiopathic orbital inflammation is the most common painful orbital mass seen in adults. The benign condition presents as a marginated mass-like enhancing soft tissue involving any area of the orbit. Associated problems include proptosis, oedema and diplopia. It is essentially a diagnosis of exclusion, once infectious, inflammatory and neoplastic entities have been ruled out, he explained.

Charles Miller: