Birdshot Chorioretinopathy : Prospective Follow-up and Immunogenetic Studies(CO-BIRD)

Posterior Uveitis Clinical Trial

— CO-BIRD  

Official title:

Longitudinal Cohort Study of Patients With Birdshot Chorioretinopathy.

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05153057
• Other study ID #: NI16002
• Status: Recruiting
• Start date: November 2, 2004
• Est. completion date: December 31, 2030

Study information

• Verified date: October 2022
• Source: Assistance Publique - Hôpitaux de Paris
• Contact: Souhila KECILI, MSc
• Phone: +33 1 58412898
• Email: souhila.kecili[@]aphp.fr
• Is FDA regulated: No
• Study type: Observational

Clinical Trial Summary

The purpose of this study is twofold:

1. To analyze the clinical features of a cohort of patients with birdshot chorioretinopathy (BCR), an inflammatory bilateral ocular disease, affecting the choroid and the retina.

Various imaging techniques will be used to assess the effect of the disease on the retina and the choroid.

A standardized assessment of the visual function will be performed with visual acuity, visual field and color vision testing. The quality of life of the patients will be evaluated with the VFQ-25 questionnaire.

These analyses will help delineating different forms of the disease among its heterogeneous presentations.

2. To identify predisposing factors for the disease. The condition is unique from the immunogenetic standpoint by its association with the HLA-A29 allele, which is the strongest link between an HLA class I antigen and a disease. To date, however, the mechanisms leading to birdshot chorioretinopathy remain unknown. GWAS (Genome Wide association Study) based on DNA of the cohort patients will be performed with the aim to identify other susceptibility genes associated with BCR.

Description:

Birdshot chorioretinopathy is a bilateral chronic posterior uveitis that has been named in 1980. The "birdshot lesions" are the hallmark of the disease. In their most typical aspect these lesions are ovoid shaped hypopigmented spots at the level of the choroid.

One of the main difficulties of the diagnosis lies in the spectrum of presentations of the disease. The typical birdshot lesions are ovoid with their main axis oriented toward the optic disc. However, some are round and the can be clearly seen on fundus examination while others can be limited to subtle depigmentations. Typical lesions are one-quarter to one-half disc diameters, but confluent lesions may yield larger areas of depigmentation that are difficult to recognize. Although the typical lesions are depigmented, their presentation may change over time and pigment or atrophy may replace the initial cream-colored spots. The typical location, or the most easily seen location of the spots, is nasal to the optic disc. However, involvement of the posterior pole inside the temporal arcade is also possible. The spots usually predominate in the mid-periphery, but may also extend to the equator. A standardized classification of the birdshot lesions according to their size, their number, their pigmentation and their localization has been suggested to help in the categorization of the various disease presentations and for the longitudinal follow-up of affected patients. Spots clearly visible at the time of the diagnosis may disappear later. Hence, if the diagnosis of the birdshot chorioretinopathy is not made when spots are clearly visible, later presentations may not meet the definition commonly used for the disease. The disappearance of birdshot spots after treatment has been documented, but the effect of treatment on spots has not yet been assessed in large cohorts of patients. Indocyanine green angiography has been suggested as a reliable method to detect spots. However, it remains to be validated by a randomized assessment comparing indocyanine green angiography to color photographs for the detection of birdshot lesions.

Fluorescein angiography is useful in patients with birdshot chorioretinopathy to assess disease activity. In active disease, angiographic findings include leakage of the retinal veins, macular edema and optic disk hyperfluorescence. These findings are not disease specific, but they require a careful examination of the fundus seeking subtle spots when birdshot lesions are not obvious.

Given the above, the first goal of our prospective cohort study is to assess the heterogeneity of the disease, its spectrum of presentation and its evolution over time.

One of the characteristics of birdshot chorioretinopathy is its association with the HLA-A29 allele, which constitutes the strongest link between a disease and class I HLA allele. The mechanism by which HLA-A29 confers a risk for birdshot chorioretinopathy is a key question that remains unanswered. As with other associations between HLA class I antigens and diseases (HLA-B27 with spondylarthropathies and HLA B51 with Behçet's disease), the physiopathogeny of these links have not been elucidated.

Other factors playing a role in the physiopathogeny of the disease and not linked to the major histocompatibility complex are researched. A few families of patients with birdshot chorioretinopathy have been reported, which could point to additional genetic factors for disease susceptibility but does not rule out an environmental effect.

Hence, the complex physiopathology of birdshot chorioretinopathy could involve the HLA-A29 allele, other unknown genetic factors, as well as environmental factors.

Given the above, we are planning a GWAS (Genome Wide association Study) based on DNA of the cohort patients, which will be performed with the aim to identify other susceptibility genes associated with BCR.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 600
• Est. completion date: December 31, 2030
• Est. primary completion date: December 31, 2030
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

1. Bilateral disease

2. Presence of at least three peripapillary "birdshot lesions" inferior or nasal to the optic disk in one eye

3. Low-grade anterior segment intraocular inflammation (defined as = 1+cells in the anterior chamber)

4. Low grade vitreous inflammatory reaction (defined as = 2+ vitreous haze‡) Supportive findings

1. HLA-A29 positivity 2. Retinal vasculitis 3. Cystoid macular edema

Exclusion Criteria:

1. Keratic precipitates

2. Posterior synechiae

3. Presence of infectious, neoplastic, or other inflammatory diseases that can cause multifocal choroidal lesions

Related Conditions & MeSH terms

• Birdshot Chorioretinopathy
• Chorioretinitis
• Posterior Uveitis
• Uveitis
• Uveitis, Posterior

Intervention

Other:
• Observational study
The goal of the study is purely observational. Treatment decisions will be made by physicians according to the grading of the intraocular inflammation related to birdshot chorioretinopathy and to their consequences on visual function. These treatment decisions will be independent from the observational study.

Locations

Country	Name	City	State
France	Ophtalmopôle, Hôpital Cochin	Paris	Île-de-France

Sponsors (1)

Lead Sponsor	Collaborator
Assistance Publique - Hôpitaux de Paris

Country where clinical trial is conducted

France, 

References & Publications (14)

Bousquet E, Khandelwal N, Séminel M, Mehanna C, Salah S, Eymard P, Bodin Hassani S, Monnet D, Brezin A, Agrawal R. Choroidal Structural Changes in Patients with Birdshot Chorioretinopathy. Ocul Immunol Inflamm. 2021 Feb 17;29(2):346-351. doi: 10.1080/09273948.2019.1681472. Epub 2019 Nov 12. — View Citation

Brézin AP, Monnet D, Cohen JH, Levinson RD. HLA-A29 and birdshot chorioretinopathy. Ocul Immunol Inflamm. 2011 Dec;19(6):397-400. doi: 10.3109/09273948.2011.619295. Review. — View Citation

Cunningham ET, Levinson RD, Denniston AK, Brézin AP, Zierhut M. Birdshot Chorioretinopathy. Ocul Immunol Inflamm. 2017 Oct;25(5):589-593. doi: 10.1080/09273948.2017.1400800. — View Citation

Dastiridou AI, Bousquet E, Kuehlewein L, Tepelus T, Monnet D, Salah S, Brezin A, Sadda SR. Choroidal Imaging with Swept-Source Optical Coherence Tomography in Patients with Birdshot Chorioretinopathy: Choroidal Reflectivity and Thickness. Ophthalmology. 2017 Aug;124(8):1186-1195. doi: 10.1016/j.ophtha.2017.03.047. Epub 2017 Apr 26. — View Citation

Gordon LK, Monnet D, Holland GN, Brézin AP, Yu F, Levinson RD. Longitudinal cohort study of patients with birdshot chorioretinopathy. IV. Visual field results at baseline. Am J Ophthalmol. 2007 Dec;144(6):829-837. Epub 2007 Oct 15. — View Citation

Holland GN, Shah KH, Monnet D, Brezin AP, Yu F, Nusinowitz S, Levinson RD. Longitudinal cohort study of patients with birdshot chorioretinopathy II: color vision at baseline. Am J Ophthalmol. 2006 Dec;142(6):1013-8. Epub 2006 Aug 2. — View Citation

Kappel PJ, Monnet D, Yu F, Brezin AP, Levinson RD, Holland GN. Contrast sensitivity among patients with birdshot chorioretinopathy. Am J Ophthalmol. 2009 Feb;147(2):351-356.e2. doi: 10.1016/j.ajo.2008.08.021. Epub 2008 Oct 29. — View Citation

Levinson RD, Brezin A, Rothova A, Accorinti M, Holland GN. Research criteria for the diagnosis of birdshot chorioretinopathy: results of an international consensus conference. Am J Ophthalmol. 2006 Jan;141(1):185-7. — View Citation

Levinson RD, Du Z, Luo L, Monnet D, Tabary T, Brezin AP, Zhao L, Gjertson DW, Holland GN, Reed EF, Cohen JH, Rajalingam R. Combination of KIR and HLA gene variants augments the risk of developing birdshot chorioretinopathy in HLA-A*29-positive individuals. Genes Immun. 2008 Apr;9(3):249-58. doi: 10.1038/gene.2008.13. Epub 2008 Mar 13. — View Citation

Levinson RD, Monnet D, Yu F, Holland GN, Gutierrez P, Brezin AP. Longitudinal cohort study of patients with birdshot chorioretinopathy. V. Quality of life at baseline. Am J Ophthalmol. 2009 Feb;147(2):346-350.e2. doi: 10.1016/j.ajo.2008.08.011. Epub 2008 Oct 9. — View Citation

Monnet D, Brézin AP, Holland GN, Yu F, Mahr A, Gordon LK, Levinson RD. Longitudinal cohort study of patients with birdshot chorioretinopathy. I. Baseline clinical characteristics. Am J Ophthalmol. 2006 Jan;141(1):135-42. — View Citation

Monnet D, Brézin AP. Birdshot chorioretinopathy. Curr Opin Ophthalmol. 2006 Dec;17(6):545-50. Review. — View Citation

Monnet D, Levinson RD, Holland GN, Haddad L, Yu F, Brézin AP. Longitudinal cohort study of patients with birdshot chorioretinopathy. III. Macular imaging at baseline. Am J Ophthalmol. 2007 Dec;144(6):818-828. Epub 2007 Oct 18. — View Citation

Pagnoux C, Mahr A, Aouba A, Bérezné A, Monnet D, Cohen P, Levinson RD, Brézin AP, Guillevin L. Extraocular manifestations of birdshot chorioretinopathy in 118 French patients. Presse Med. 2010 May;39(5):e97-e102. doi: 10.1016/j.lpm.2009.12.005. Epub 2010 Mar 10. — View Citation

* Note: There are 14 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Best Corrected Visual Acuity (BCVA)	Standard decimal clarity for distance visual acuity. It is expressed from 0 which is minimum & worse value, corresponding to no light perception; to 1.0 (20/20) which is maximum & best value	Through study completion, an average of 1 year
Primary	Visual field testing	Humphrey 30-2 automated threshold perimetry with foveal sensitivity. It is expressed in Mean Deviation from -25 decibels or unachievable which is minimum & worse value, to 0 decibel, which is maximum & best value.	Through study completion, an average of 1 year
Primary	Color vision	Assessed with Desaturated Lanthony 15-Hue Test: an objective technic evaluating sensitivity to color & colour vision deficiency. Test result is categorized as Abnormal for minimum & worse evaluation; and Normal for maximum & best evaluation.	Through study completion, an average of 1 year
Primary	National Eye Institute 25-Item Visual Function Questionnaire	Using a scale from 0 for minimum & worse, to 100 for maximum & best result; this questionnaire measures influence of visual impairment on various dimensions of quality of life such as emotional well-being and social functioning	Through study completion, an average of 1 year
Secondary	Assessment of birdshot spot size	It describes appearance of the birdshot spots as small for minimum or large for maximum.	Through study completion, an average of 1 year
Secondary	Assessment of birdshot spot number	Spots are counted and categorized as <10 for minimum value & >50 for maximum	Through study completion, an average of 1 year
Secondary	Assessment of birdshot spot localization	Spots are categorized as Juxtapapillary, Equator & Diffuse.	Through study completion, an average of 1 year
Secondary	Assessment of birdshot spot pigmentation	Spot pigmentation is analysed and categorized as No pigmentation for minimum & Sever for maximum.	Through study completion, an average of 1 year
Secondary	Assessment of edema	Papillary & macular edema are analysed by Optical Coherence Tomography, using a scale from 0 to 4 respectively for minimum & best, to maximum & worse value.	Through study completion, an average of 1 year
Secondary	Assessment of retinal vasculitis	Arterial & venous vasculitis are analysed by Fluorescein Angiography, using a scale from 0 to 4 respectively for minimum & best, to maximum & worse value.	Through study completion, an average of 1 year