Eyeworld

EW SECONDARY FEATURE 73 Research finds major links between smoking and more active uveitis S moking increases the risk of coronary heart disease, stroke, and lung cancer, but now, ophthalmolo- gists should be concerned about risks related to uveitis. "Smoking is associated with uveitis activity, leading to increased need for steroid eyedrops and in- creased incidence of cataract and macular edema," according to a re- port by Martin Roesel, M.D., Department of Ophthalmology, St. Franziskus Hospital, Muenster, Ger- many. "Results highlight the need to encourage uveitis patients to stop or at least to reduce their smoking." Although it is unclear whether smoking is involved in the patho- genesis of uveitis, smoking appears to somehow play a role in disease ac- tivity, Dr. Roesel noted. His report appeared online in January in Graefe's Archive for Clinical and Exper- imental Ophthalmology. One ophthalmologist dealing with smokers with ophthalmic dis- ease reports that many attempts to get them to quit have been—not surprisingly—frustrating. Smoking with uveitis Smoking has a history of negatively impacting autoimmune diseases. "Among the autoimmune diseases, smoking was proven to be associated with an increased risk of Crohn's disease, greater severity of fibromyal- gia, and higher risk for extraintesti- nal manifestations in ulcerative colitis," Dr. Roesel reported. Studies have also associated smoking with the development and severity of rheumatoid arthritis, he noted. But what—if any—impact does smoking have on uveitis itself? Dr. Roesel and colleagues ana- lyzed 350 patients with noninfec- tious uveitis, of which 155 patients (32.9%) were smokers. "Uveitis developed earlier in smokers than in nonsmokers," Dr. Roesel reported. "Smokers have ac- tive uveitis more often." Not all news was bad news for smokers. There was no difference in the number of eyes affected (i.e., unilateral or bilateral involvement) between the groups. Visual acuity was also comparable between groups. The number of cigarettes smoked per day did not reach stas- tistical significance in terms of im- pact on uveitis, but it almost did (p=0.052). "Smoking intensity (cigarettes per day) just failed to reach the level of significance, but we observed the trend that with increasing numbers of cigarettes, the risk for inflamma- tory uveitis activity was also in- creased," Dr. Roesel reported. "Consequently, smokers required more corticosteroid eyedrops than nonsmokers." Pack years also factored into dis- ease. "With regard to uveitis compli- cations, we found the number of pack-years to be significantly associ- ated with the presence of macular edema," Dr. Roesel reported. "How- ever, the sole fact of smoking was not associated with macular edema or cataract, indicating a dose-depen- dent relation." It's difficult, nonetheless, to pin- point what exactly exacerbates uveitis in terms of smoking ele- ments. "It remains speculative whether smoking might at least in some cases be involved in the pathogenesis of the disease, as we do not really know much about the pathogenesis of noninfectious uveitis, and as to- bacco contains many different ingre- dients," Dr. Roesel reported. "We do not know why some patients have bilateral uveitis whereas in others only one eye is affected. In the pres- ent study, the number of patients with bilateral uveitis was compara- ble and did not depend on the smoking habits." However, smoking definitively impacted uveitis in this study, al- most by definition. "The most reli- able criterion for uveitis activity in patients with anterior uveitis is the presence of inflammatory cells in the anterior eye chamber," Dr. Roesel noted. "In the present study, smokers with anterior uveitis had significantly more often cells in the anterior chamber compared to non- smokers with anterior uveitis." The problem remains that it's extremely difficult to get patients to quit smoking, said John D. Sheppard, M.D., professor of oph- thalmology, microbiology, and im- munology, Eastern Virginia Medical School, Norfolk, Va. "I advise all of my patients to stop smoking," Dr. Sheppard said. "I have found that lifelong smokers are extremely difficult to manage. I spent a lot of time in the early part of my career trying to get patients to quit with horribly limited success." Dr. Sheppard prescribed medica- tions to wean patients off nicotine, but often to no avail, he said. "I was very frustrated by my in- ability to curb their addictive behav- ior," Dr. Sheppard said. There are other factors that con- tribute to uveitis, and they can also be problematic to eradicate. "Stress also contributes to uveitis," Dr. Sheppard said. "We have no idea how to measure that or intervene." Another important factor is diet. "It's well known that most autoim- mune diseases are exacerbated by a poor diet," Dr. Sheppard said. "High, non-essential fatty acid intake is deleterious." EW Editors' note: Drs. Roesel and Sheppard have no financial interests related to their comments. Contact information Roesel: m.roesel@uveitis-zentrum.de Sheppard: 757-622-2200, docshep@hotmail.com February 2011 October 2011 RETINA by Matt Young EyeWorld Contributing Editor Report finds smoking increases uveitis risks 68-75 Feature 2 AMD_EW October 2011-DL2_Layout 1 9/29/11 3:48 PM Page 73

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