Editorial
Association between smoking and uveitis
Asociación entre tabaco y uveítis
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Temblador Barba, J. Benítez-del-Castillo Sánchez, A.H. Rodríguez Súarez, A. Michán" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Temblador Barba" "email" => array:1 [ 0 => "irenetembladorbarba@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Benítez-del-Castillo Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A.H." "apellidos" => "Rodríguez Súarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Michán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asociación entre tabaco y uveítis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Smoking is a major preventable cause of disease, disability and premature death. Smoking is known to be associated with a variety of diseases, including respiratory, cardiovascular, gastrointestinal, neurological and ocular diseases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among the latter, smoking has been shown to be a risk factor for cataracts, age-related macular degeneration, thyroid ophthalmopathy, ischemic optic neuropathy and open-angle glaucoma.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In addition, several studies have been published linking smoking to uveitis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Smoking is associated with worse reduced vision and bilateral inflammation at presentation in ocular inflammatory diseases and increased risk of recurrence.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> As uveitis is an inflammatory disease resulting from an alteration of the immune system, it is feasible that smoking may contribute to its pathogenesis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In one published study, a history of smoking was found to be significantly associated with all anatomical subtypes of uveitis and infectious uveitis. The association was stronger in patients with intermediate uveitis and panuveitis with cystoid macular edema (CME) compared to those without CME.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This finding on the development and progression of CME was previously described several years ago,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and in addition a particularly strong association between smoking and infectious uveitis is also suggested in this study.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The reason for this is not yet fully understood. The authors suggest that the pro-inflammatory components of tobacco smoke could facilitate the access of micro-organisms to intraocular tissue and also enhance the response of inflammatory cells to the damaging agent.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Despite demonstrating a strong link between smoking and uveitis, it is not proven that smoking causes or aggravates uveitis, although both scenarios are biologically plausible.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Apart from the association between smoking and all anatomical subtypes of uveitis, several studies have found a correlation between smoking and CME in patients with intermediate uveitis and panuveitis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> and that this association is also dose-dependent.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The exact mechanism by which smoking may cause macular edema is also unknown. Damage to ocular tissues occurs via ischemic and/or oxidative pathways. The detrimental effects of smoking on the vascular endothelium are widely known, and it is also known that the retinal vasculature responds abnormally to hyperoxia in smokers. Endothelial dysfunction appears to be one of the first pathological effects of smoking, and it may be that this damage leads to increased permeability of retinal blood vessels, resulting in the development of macular edema.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Age is a potential confounding variable, as younger patients are less likely to have a history of smoking, although this is changing in current times. However, after controlling for this potentially confounding variable in research papers, smoking remained a statistically significant risk factor for CME.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Similarly, it appears that uveitis manifests at an earlier age in smokers than in non-smokers, and that smoking would be associated with the degree of uveitis activity. This increases both the need for corticosteroid treatment and the incidence of cataracts and macular edema,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in addition to the fact that smoking is implicated as a possible cause of poor response to treatment.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It has also been reported that the relationship between smoking and uveitis is evident in both current and former smokers.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We would like to highlight the hypothesis that smoking not only plays a role in the development of uveitis, but may also contribute to the severity of inflammation, giving rise to complications such as CME.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although the available scientific literature is limited and more well-designed studies with larger patient samples are needed to address this issue, all studies point to the importance of recommending that patients with uveitis quit, or at least reduce, smoking.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The history of the discovery of the cigarette-lung cancer link: evidentiary traditions, corporate denial, global toll" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.N. 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