Uveitis associated with juvenile rheumatoid arthritis

Evaluation of Uveitis Induced in Rats by a Type I Collagen Peptide as a Model for Childhood Arthritis-associated Uveitis

Chronic asymptomatic and acute symptomatic anterior uveitis are forms of ocular inflammation associated with juvenile idiopathic arthritis (JIA) Chronic JIA-associated uveitis is characterized by young age of onset, female predilection, oligoarthritis, and antinuclear antibody (ANA) positivity. Acute JIA-associated uveitis predominantly affects older male juveniles who also develop enthesitis. A type I collagen-derived peptide (melanin-associated antigen [MAA]) induces anterior uveitis in rodents. In this study, we evaluated MAA-induced uveitis in rats as a potential model for JIA-uveitis. We characterized MAA-induced uveitis by assessing its relationship to age and sex; tracking the occurrence of arthritis, enthesitis, and ANA positivity; and measuring vitreous fluid inflammatory biomarkers. Juvenile and adult and male and female Lewis rats (Rattus norvegicus) were inoculated with MAA. Slit-lamp biomicroscopy, indirect ophthalmoscopy, and joint examinations were performed 3 times weekly. Rats were euthanized at 4 wk after MAA inoculation, and plasma ANA testing, vitreous inflammatory biomarker assays, and globe histopathology assessments were conducted. Uveitis, arthritis, ANA status, levels of inflammatory biomarkers, histopathology, and joint tomographic images were assessed in relation to age and sex and compared with nonuveitic controls. All MAA-immunized rats developed uveitis characterized by anterior chamber fibrin, iridal vessel dilation, and miosis, and uveal and choroidal lymphocytic infiltration. Levels of the vitreous fluid biomarker CCL5 were higher in uveitic rats compared with control rats. Time to uveitis onset, clinical uveitis scores, and biomarker levels did not differ based on age or sex. None of the MAA-exposed rats had arthritis, enthesitis, or ANA. None of the rats inoculated with MAA that had been treated with matrix metallopeptidase 1 had clinical, histologic, or immunohistochemical evidence of ocular inflammation. In contrast to JIA-associated uveitis in humans, MAA-induced uveitis in rats is not associated with age or sex predilections and MAA is not arthritogenic.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

Long-Term Control of Macular Edema With Adalimumab After Cataract Surgery in a Japanese Child With Juvenile Idiopathic Arthritis: Case Report and Review of 26 Japanese Patients

Juvenile idiopathic arthritis–associated uveitis is rare in the Japanese population. In this article, we report a child whose macular edema was controlled for years after cataract surgery with adalimumab, and reviewed 26 Japanese patients in the literature. In this case report, a 4-year-old boy developed band keratopathy, posterior iris synechiae, and complicated cataract in both eyes. Oral prednisolone prescribed at another hospital was discontinued due to high intraocular pressure in both eyes as a steroid responder. At the age of 5 years, he started oral methotrexate 8 mg weekly for recurrent bilateral iridocyclitis and then underwent lensectomy with core vitrectomy in both eyes. Planned intraocular lens implantation was cancelled at surgery because the anterior vitreous had severe inflammatory opacity with diffuse retinal edema in both eyes. Due to persistent macular edema in both eyes 5 months postoperatively, at the age of 6 years, he began to use adalimumab injection 20 mg every 2 weeks. The macular structure depicted by optical coherence tomography became normal in 2 months. At final visit at the age of 11 years, he had the best-corrected visual acuity of 0.8 in the right eye and 0.4 in the left eye, with adalimumab 40 mg every 2 weeks and methotrexate 8 mg weekly. In conclusion, macular edema persistent despite oral methotrexate after cataract surgery could be controlled for long term by adalimumab in a child with juvenile idiopathic arthritis. In the Japanese literature, only 26 additional cases with juvenile idiopathic arthritis–associated uveitis have been reported so far.

Juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA) is the commonest rheumatic disease in children and JIA-associated uveitis its most frequent extra-articular manifestation. The uveitis is potentially sight-threatening and thus carries a considerable risk of morbidity with associated reduction in quality of life. The commonest form of uveitis seen in association with JIA is chronic anterior uveitis, which is almost always asymptomatic in the initial stages. Therefore, screening for JIA-associated uveitis in at-risk patients is essential. The aim of early detection and treatment is to minimise intraocular inflammation and to avoid complications that lead to visual loss, which can result from both disease activity and medications. The sight-threatening complications of JIA-associated uveitis include cataracts, glaucoma, band keratopathy, and macular oedema. There is increasing evidence for the early introduction of systemic immunosuppressive therapies to reduce topical and systemic use of glucocorticoids. A recently published randomised controlled trial of adalimumab in JIA-associated uveitis now provides convincing evidence for the use of this biologic in patients who fail to respond adequately to methotrexate. Tocilizumab and abatacept are being investigated as alternatives in children inadequately treated with anti-tumour necrosis factor drugs.

Juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with JIA-associated uveitis its most common extra-articular manifestation. JIA-associated uveitis is a potentially sight-threatening condition and thus carries a considerable risk of morbidity. The aetiology of the condition is autoimmune in nature with the predominant involvement of CD4(+) T cells. However, the underlying pathogenic mechanisms remain unclear, particularly regarding interplay between genetic and environmental factors. JIA-associated uveitis comes in several forms, but the most common presentation is of the chronic anterior uveitis type. This condition is usually asymptomatic and thus screening for JIA-associated uveitis in at-risk patients is paramount. Early detection and treatment aims to stop inflammation and prevent the development of complications leading to visual loss, which can occur due to both active disease and burden of disease treatment. Visually disabling complications of JIA-associated uveitis include cataracts, glaucoma, band keratopathy and macular oedema. There is a growing body of evidence for the early introduction of systemic immunosuppressive therapies in order to reduce topical and systemic glucocorticoid use. This includes more traditional treatments, such as methotrexate, as well as newer biological therapies. This review highlights the epidemiology of JIA-associated uveitis, the underlying pathogenesis and how affected patients may present. The current guidelines and criteria for screening, diagnosis and monitoring are discussed along with approaches to management.

Male gender as a risk factor for complications in uveitis associated with juvenile idiopathic arthritis

PURPOSE

To analyze the role of baseline factors in long-term development of ocular complications in uveitis associated with juvenile idiopathic arthritis (JIA).

DESIGN

Retrospective nonrandomized interventional case series.

METHODS

Data of 117 affected eyes (65 patients) with JIA-associated uveitis with a minimum follow-up of 1 year were obtained. Development of complications was analyzed univariately and multivariately in relation to gender, age of onset of uveitis (<7 years or >7 years), and initial manifestation of JIA (as uveitis or as arthritis).

RESULTS

Female-to-male ratio was 3:1 and follow-up for uveitis ranged from 1.1 to 27.5 years (median 7.6 years). Time interval between arthritis and uveitis was shorter in boys (median 0.3 year) than in girls (median 1.0 year) (P < .01). At 5 years of follow-up boys suffered more frequently from cystoid macular edema (CME) (50% vs 4%; P < .01) and papillitis (31% vs 2%; P < .01), and needed more cataract surgery (59% vs 32%; P = .02). At 5 years of follow-up children with initial uveitis had more posterior synechiae, band keratopathy, and CME (all P <or= .02), but less glaucoma (P = .03). In multivariate analysis male gender appeared to be independently associated with cataract surgery (adjusted hazard ratio [HR] = 4.33; P < .01), CME (HR = 4.59; P = .01), and papillitis (HR = 4.10; P = .01). Development of posterior synechiae was independently associated with initial uveitis (HR = 3.21; P < .01).

CONCLUSIONS

Male gender and uveitis as initial manifestation of JIA were independently associated with a complicated course of JIA-associated uveitis. Age of onset of JIA-associated uveitis does not seem to have independent prognostic value for the course of this ocular disorder.

Is musculoskeletal history and examination so different in paediatrics?

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

Visual outcome of juvenile rheumatoid arthritis-associated uveitis in adults

PURPOSE

Juvenile rheumatoid arthritis (JRA) is the systemic disease most frequently associated in childhood uveitis. The disease may cause several ocular complications, visual impairment, and blindness. Recent studies revealed a more favorable ocular prognosis. Our purpose was to analyze the long-term visual outcome of JRA-associated uveitis.

METHODS

Ocular complications and visual outcome in adult patients with JRA-associated uveitis were evaluated. Among 18 patients included in the study, uveitis was bilateral in 12 (66.7%) and unilateral in six (33.3%), for a total of 30 eyes with ocular involvement.

RESULTS

The mean durations of JRA and its associated uveitis were 24.9 and 20.5 years, respectively. All eyes (100%) had at least one ocular complication. The most frequently observed ocular complications were cataract (83.3%), band keratopathy (60%), posterior synechia (46.7%), glaucoma (33.3%), hypotony (16.7%), and macular pathology (13.3%). Final visual acuity was impaired in 40% of the eyes, poor in 20%, and totally lost in 10%. Therefore, 70% of the eyes were either visually handicapped or totally blind. Most eyes underwent at least one surgical procedure. Inflammation was active at last examination in 63.3% of eyes. All patients were still treated topically and with systemic NSAID. Sixty-one percent of the patients were using an immunosuppressive agent.

CONCLUSION

JRA-associated uveitis still has a severe course and blinding potential. Patients suffer from uveitis and its complications even during the adulthood period. However, because our series represents a more severe subset of the disease, the outcome may be poorer than that of some other outcome studies.

Visusmindernde Komplikationen bei Uveitis im Kindesalter

PURPOSE

We analyzed the epidemiologic data and vision-threatening complications in different forms of childhood uveitis.

METHODS

This retrospective study included 187 consecutive patients with onset of uveitis before the age of 16 years classified as anterior (AU), intermediate (IU), posterior (PU), and panuveitis (PanU). We analyzed the epidemiologic data as well as visual acuity, uveitic complications and the conservative and surgical therapy.

RESULTS

Associated disease was observed in 85 of 187 patients. The most common complications in AU patients were cataract, posterior synechiae, band keratopathy and CME. IU was accompanied by dense vitreous opacities, cataract and CME. Macular scars were the most frequent cause for visual loss in PU. PanU was complicated by dense vitreous opacities, cataract, retinal detachment, CME and phthisis bulbi.

CONCLUSIONS

Childhood uveitis is frequently associated with systemic immune-mediated diseases. The diverse uveitis types have different but typical complications.

A randomized, placebo-controlled, double-masked clinical trial of etanercept for the treatment of uveitis associated with juvenile idiopathic arthritis

OBJECTIVE

To investigate the safety and efficacy of etanercept in the treatment of uveitis associated with juvenile idiopathic arthritis (JIA).

METHODS

Children who met the American College of Rheumatology diagnostic criteria for JIA with active uveitis, who had anterior chamber cells of >/=1+ or requiring topical corticosteroid >/=3 times daily, and who were on a stable regimen for arthritis treatment were eligible. Study participants received etanercept (0.4 mg/kg) or placebo administered subcutaneously twice weekly for 6 months. All participants received open-label etanercept for an additional 6 months.

RESULTS

Five patients received placebo and 7 received etanercept. Three of the 7 patients treated with etanercept and 2 of the 5 placebo-treated patients were considered ophthalmic successes (P = 1.0). One patient in each treatment group was considered a treatment failure. Three of the 7 etanercept-treated and 2 of the 5 placebo-treated patients were neither successes nor failures by our definition. There were no serious adverse events for any patient during the entire study period. Reports of minor infections were comparable in each treatment group, 71% for etanercept and 60% for placebo (P = 0.58).

CONCLUSION

In this small pilot study there was no apparent difference in the anterior segment inflammation between patients treated with etanercept and placebo. The stringent criteria used to measure ophthalmic success of treatment and the small patient population limit the implications of our findings.

Recent advances in uveitis of juvenile idiopathic arthritis

Chronic scarring-type uveitis is a frequent extra-articular manifestation of juvenile idiopathic arthritis. It occurs in about 20% of children with this disease, commencing typically within a few years from its onset. The risk of uveitis is greatest in antinuclear antibody-positive girls with early onset oligoarthritis. The classic clinical picture is chronic bilateral anterior uveitis, usually asymptomatic until substantial damage to intraocular structures occurs. In view of the asymptomatic nature of the condition, routine screening of juvenile idiopathic arthritis patients 2-4 times a year is crucial to prevent complications. The treatment consists of topical corticosteroids and mydriatics, in severe cases with immunosuppressive agents, and surgical management of complications. Although the prognosis of uveitis is improving, there are cases refractory to standard regimens. Patients in whom uveitis commences prior to the onset of arthritis present a special problem.

The Decreasing Prevalence of Uveitis Associated with Juvenile Rheumatoid Arthritis

We studied the prevalence and characteristics of chronic uveitis in a population of children diagnosed with juvenile rheumatoid arthritis (JRA). Uveitis is one of the most important, potentially debilitating extra-articular manifestations of JRA and has been observed in as many as 20% of cases. The medical records of 230 patients diagnosed with JRA and treated at a tertiary care hospital ophthalmology clinic between 1992 and 2000 were retrospectively reviewed. Seventeen patients (7.4%) were found to have clinical features of uveitis. There was a preponderance of female patients (16/17) and pauciarticular disease (13/17). Only 12 of 17 were ANA positive. Six had uveitis at diagnosis. Patients who were receiving naproxen had less incidence of uveitis compared with those receiving other nonsteroidal antiinflammatory drugs. Despite a relatively low prevalence of uveitis, complications occurred in about 24% (4/17) of the patients, even with adequate treatment and close monitoring. The prevalence of uveitis in JRA seems to be decreasing and may be secondary to the increased use of naproxen. However, routine ophthalmologic screening should be continued in patients with JRA to avoid potential complications of chronic uveitis.

Uveitis associated with childhood rheumatic diseases

Optimal management of childhood rheumatic diseases requires an appreciation of their multisystem nature. The eye represents an important site of involvement, and inflammation of the uveal tract is a particularly frequent and potentially debilitating extra-articular feature of some childhood rheumatic diseases. Anterior uveitis associated with oligoarticular juvenile idiopathic arthritis is an especially distinctive entity. Other disorders in children, however, can be associated with posterior and intermediate uveal tract inflammation. The potentially debilitating consequences of uveitis associated with childhood rheumatic diseases, the inadequacies of existing therapies, and the immunopathogenic basis for particular forms of uveitis have prompted the use of immunomodulatory therapy, including new biologic agents, to treat childhood uveitis. This review summarizes recent contributions to the literature that help to clarify the spectrum of conditions associated with uveitis in children, consider evidence for immunopathogenic processes associated with uveitis, and address new approaches to therapy.

Juvenile idiopathic arthritis: a clinical overview

The chronic arthritides in childhood remain a poorly understood group of conditions. Their classification has been a source of much confusion over the years with differences in terminology between Europe and North America. A significant step forward in paediatric rheumatology has been the recent development of an internationally agreed classification system which uses the overall term juvenile idiopathic arthritis (JIA). The various subtypes of JIA and their clinical features are described, together with an overview of their differential diagnosis, complications and outcomes. An outline of current management strategies is given and potential future developments highlighted.

Prognosis in Juvenile Arthritis

Juvenile arthritis implies an onset of disease under 16 years with arthritis persisting in one or more joints for at least six weeks, and with the active exclusion of well defined illnesses, such as systemic lupus erythematosus. Prognosis implies the ability to predict outcome. Its accuracy depends on many factors with early recognition and appropriate care being important. However, response to treatment may be variable. In general, those with involvement of a few joints do better than those with systemic disease or seropositive juvenile rheumatoid arthritis both with regard to persistence of disease activity and complications. These include not just joint deformities, but osteoporosis, amyloidosis, alterations in growth with overall failure and local anomalies, chronic iridocyclitis and psychosocial problems. More aggressive therapy was only introduced in the 1990's, so it is important that multicentre studies are properly assessed in the context of the suggested International diagnostic criteria. One hundred years ago, George Fredric Still drew attention to the systemic form of the disease as distinct from pure polyarthritis [1], but it was only in the 1970s, as follow-up proceeded, that the separate identity of variants became clinically evident [2]. At the Park City meeting [3] and at the EULAR meeting in 1977 [4] when three subgroups (notably systemic, polyarthritis and pauci-articular onset) were defined, that subclassification became regularly used. However, since there were no absolute diagnostic tests there had to be exclusions. At that time the most common medications were aspirin and corticosteroids, although a few patients received gold or penicillamine. In their large group Wallace and Levinson (1990) [5] found that at the 10 year follow-up between 31% and 55% still had active disease. Girls appeared to have a five-fold greater risk for persistent activity than boys; disease duration was probably the most important factor influencing disease activity at follow-up as suggested previously [6]. It was not until the 1990's that the more aggressive therapy in the form of methotrexate--which Giannini had shown to be effective when given in appropriate dosage [7]--and sulphasalazine [8] and the long acting local corticosteroid triamcinolone hexatonide became regularly employed [9, 10]. At the ILAR Meeting in 1993 an international task force was set up under the chairmanship of Dr. C. Fink [11] to develop a classification for the idiopathic arthritides in children, defining childhood as up to 16 years of age. Active exclusion of well-recognised disorders such as rheumatic fever or systemic lupus erythematosus, still had to be made. The first proposed types, which are mutually exclusive, are shown in Table 1. A more recent meeting in Durban under the chairmanship of Dr. R. Petty is yet to be published, but considerable advances have been made, particularly in the definition of subgroups.

Eye involvement in children's rheumatic diseases

Rheumatoid paediatric diseases are a leading cause of uveitis in childhood. Juvenile chronic arthritis (JCA), juvenile onset spondyloarthropathies as well as sarcoidosis and other systemic diseases with arthritis may include ocular manifestations that can threaten vision, and especially so in juvenile chronic arthritis. Special risk factors concerning the eye have to be considered for JCA. The diagnosis, detection, follow-up studies and treatment in children may differ significantly from adult rheumatoid diseases because of the young age of the patients and the specific features and signs of ocular involvement. Medical and surgical treatment of such ocular manifestations may be challenging. Special attention to children's ophthalmic complications must be undertaken by paediatricians and ophthalmologists.

Screening for uveitis in juvenile rheumatoid arthritis

BACKGROUND

Uveitis associated with juvenile rheumatoid arthritis (JRA) is an important cause of visual impairment in children. Because uveitis is often asymptomatic in this age group, frequent ophthalmologic screening examinations are recommended. Recent reports have found a decrease in the prevalence and severity of uveitis in JRA when compared to older data.

METHODS

The charts of 52 consecutive patients with JRA seen over a 30-month period were retrospectively reviewed.

RESULTS

Eye examination identified uveitis in five (12%) patients. All patients with uveitis were female, ANA positive, and had pauciarticular-onset arthritis. Three patients had the onset of uveitis before the age of 2. All patients have maintained good visual acuity and have not developed serious sight-threatening ocular complications over the follow-up period.

CONCLUSIONS

Although the prevalence and severity of JRA-associated uveitis may be decreasing, we strongly recommend continued strict adherence to the current screening guidelines.

Prevalence of uveitis in an outpatient juvenile arthritis clinic: onset of uveitis more than a decade after onset of arthritis

PURPOSE

To determine the prevalence and severity of uveitis in an outpatient pediatric arthritis clinic in the midwestern United States during the 1990s.

METHODS

The prevalence and clinical characteristics of uveitis were studied retrospectively for all children diagnosed with arthritis at Shriner's Hospital for Crippled Children and followed by the pediatric rheumatology and ophthalmology units of the St Louis Children's Hospital between 1992 and 1995.

RESULTS

Seven children (9%) developed uveitis in a population of 78 patients with juvenile arthritis. Six of the seven children were female, and all six females had anti-nuclear antibody (ANA)-positive, juvenile rheumatoid arthritis (JRA). The prevalence of anterior uveitis in females with ANA-positive, pauciarticular JRA was 20%, and in polyarticular JRA, 17%. One of the girls with uveitis had combined JRA and sarcoidosis; the boy with uveitis had juvenile spondylitis. Arthritis preceded the onset of uveitis in each child by 1 to 13 years (average, 6.4 years). Progression of the uveitis in three of the children resulted in band keratopathy and cataract, causing significant visual loss in two (i.e., in 29% of the children who developed uveitis).

CONCLUSION

The prevalence and ocular morbidity of uveitis in juvenile arthritis appears to have remained relatively stable over the last 2 decades. Onset of the uveitis in several of the children in our study population occurred more than a decade after the diagnosis of arthritis. Girls with ANA-positive JRA and boys with juvenile spondylitis may need to be followed by periodic slit-lamp examination for longer periods than recommended previously.

Patterns of uveitis as a guide in making rheumatologic and immunologic diagnoses

OBJECTIVE

To describe the patterns of clinical presentation in a series of 407 patients with uveitis and to establish the relationship between these patterns and the final diagnosis.

METHODS

Patients were referred to the Uveitis Clinic of a tertiary hospital from January 1992 to January 1996. All patients received a complete ophthalmologic examination, and a general clinical history was obtained. The current International Uveitis Study Group classification system was used for anatomic classification. To establish the final diagnosis of the most common entities causing uveitis, current diagnostic criteria were used. A discriminant analysis, with diagnostic grouping as the outcome variable and the clinical presentation features as discriminating variables, was performed.

RESULTS

With our classification system, 66.5% of the cases could be correctly classified according to the clinical pattern and morphologic findings. By diagnostic groups, discriminant analysis showed that 75% of patients with Behçet's disease, 77.1% of those with spondylarthropathy (including inflammatory bowel disease), 33.3% of those with sarcoidosis, 97.9% of those with toxoplasmosis, 85.7% of those with Vogt-Koyanagi-Harada syndrome, 100% of those with herpes, and 50.4% of those with idiopathic uveitis were correctly classified. In the miscellaneous group, which included disease entities with fewer than 5 cases, 42.9% were correctly classified.

CONCLUSION

Rheumatologic evaluation of the patient with uveitis can be more cost-effective if the referring ophthalmologist follows the classification system described herein, allowing a tailored approach in which only specific and necessary diagnostic tests are used.

Visual outcomes prognosticators in juvenile rheumatoid arthritis-associated uveitis

PURPOSE

The purpose of the study is to delineate the visual prognosticators in juvenile rheumatoid arthritis-associated uveitis.

METHODS

The records of 43 patients with juvenile rheumatoid arthritis-associated uveitis who were observed for at least 6 months were studied retrospectively. Bivariate and multivariate statistical models were applied to more than 40 parameters to determine the relative odds of visual rehabilitation among patients with each characteristic.

RESULTS

Thirty-seven (86%) patients were females and 6 (14%) males. The mean known age of uveitis onset was 13 years, with females having, on average, 4 years earlier onset of disease compared to males (P = 0.04). Ninety-three percent had chronic, 5% had recurrent, and 2% had an acute monophasic disease course. Of the 76 affected eyes, 93% were nongranulomatous and 97% had iridocyclitis. The mean overall duration of uveitis was 146 months, with females suffering from a significantly longer duration of active disease than did males (P < 0.001). Nineteen (44%) patients underwent cataract extraction, and 16 (37%) underwent vitrectomy. Thirty (70%) of the patients experienced visual improvement with their therapy. When controlling for potential confounders, male sex (P = 0.006), shorter duration of uveitis (P = 0.007), older age at disease onset (P = 0.02), and a shorter delay in presentation to a subspecialist (P = 0.02) were associated significantly with visual acuity improvement. Visual acuity at presentation (P = 0.001), use of systemic nonsteroidal anti-inflammatory drugs (P = 0.01), older age at disease onset (P = 0.02), absence of glaucomatous neuropathy (P = 0.02), and male sex (P = 0.03) were correlated strongly with a final visual acuity outcome of 20/40 or better.

CONCLUSION

Juvenile rheumatoid arthritis-associated uveitis is a serious disease with a guarded visual prognosis. It is hoped that increased awareness of its prognosticators will lead to treatment and referral patterns that have the best chance of minimizing the likelihood of visual impairment in patients with juvenile rheumatoid arthritis.

Juvenile rheumatoid arthritis--clinical manifestations

Chronic inflammatory arthritis in childhood could be due to an obvious cause (e.g. sepsis, rheumatic fever, systemic lupus erythematosus etc.), or it could be idiopathic. After excluding those with obvious cause there still remains a large group of chronic inflammatory arthritis in childhood. This category has been variously called 'juvenile rheumatoid arthritis', 'juvenile arthritis', 'juvenile chronic arthritis', and more recently, 'idiopathic arthritis of childhood', The present article reviews the various classification criteria used for defining this group of disorders with emphasis on the common features as well as the major differences between these criteria. The major classes within this group with their characteristic clinical and laboratory features are also discussed.

Changing patterns in uveitis of childhood

BACKGROUND

Although uveitis is relatively uncommon in children, its diagnosis and management present a distinct clinical challenge for the physician. An improved knowledge of disease patterns and associated morbidity will help in the care of children with uveitis.

METHODS

The authors reviewed the records of 130 patients with onset of uveitis at 16 years of age or younger. The etiology of uveitis, complications encountered, treatment administered, and visual results were analyzed.

RESULTS

Uveitis associated with juvenile rheumatoid arthritis (JRA) was the largest group (41.5%) followed by idiopathic uveitis (21.5%) and pars planitis (15.3%). Twenty-six percent of the eyes had less than 20/200 visual acuity at the time of first referral. Patients with JRA had the highest rate of complications: cataract (71%), glaucoma (30%), band keratopathy (66%), and hypotony (19%). The most frequent complication of pars planitis was maculopathy (55%). Final visual acuity was less than 20/200 in 26% of eyes with JRA, 10.5% with pars planitis, and 14% with idiopathic uveitis.

CONCLUSION

Uveitis beginning in childhood is a serious disease associated with sight-threatening complications. Juvenile rheumatoid arthritis-associated uveitis remains a leading cause of ocular morbidity in patients with childhood uveitis. Increased awareness by pediatricians, rheumatologists, and ophthalmologists of the seriousness of ocular complications of uveitis in childhood may lead to earlier diagnosis and more effective treatment regimens in the future.

Frequency and complications of chronic iridocyclitis in ANA-positive pauciarticular juvenile chronic arthritis

Chronic iridocyclitis (CI) is among the most important extra-articular manifestations of juvenile chronic arthritis (JCA) and is most often observed in young girls with pauciarticular JCA and circulating antinuclear antibodies (ANAs). The frequency of CI found in 39 children with ANA-positive pauciarticular JCA was 56%. None of the patients developed ocular complications during follow-up. We think that this favourable outcome was primarily due to the early diagnosis and to our choice of using atropine as a mydriatic agent and to prolong atropine, after having spaced its administration further apart, up to one year or longer after the remission of ocular manifestations.

Serum antiocular antibodies in patients with juvenile rheumatoid arthritis

Although the uveitis associated with juvenile rheumatoid arthritis (JRA) is presumed to have an autoimmune etiology, its pathogenesis is unknown. We utilized immunohistochemical techniques to detect the presence of serum antibodies directed against ocular tissues in these patients. The staining patterns of serum from patients with JRA, with and without uveitis, were compared with normal controls. Antibodies directed against epitopes in iris and ciliary body basement membranes, lens epithelium and fibers, Bruch's membrane, and iris and retinal blood vessels were observed in the sera of several individuals. These staining patterns were statistically more frequent among the pauciarticular and polyarticular JRA patients, with and without uveitis, than either the systemic JRA or normal populations. These results demonstrate the presence of antiocular antibodies in the sera of JRA patients, with and without uveitis. Whether those nonuveitic JRA patients with antiocular antibodies will develop uveitis is unknown at this time.

Human leukocyte antigen-DRB1*1104 in the chronic iridocyclitis of pauciarticular juvenile rheumatoid arthritis

To determine whether genetic markers for chronic iridocyclitis could be identified, we used both serologic and oligonucleotide dot blot techniques to characterize immunogenetically 164 children with early-onset pauciarticular juvenile rheumatoid arthritis. Seventy-eight children (47.6%) had chronic iridocyclitis and 86 (52.4%) had not had evidence of eye disease during a mean follow-up period after the onset of arthritis of 15.8 years (minimum of 5.5 years). Control subjects were 218 healthy, unrelated individuals. The analysis was limited to alleles known to be associated with an increased or decreased risk of early-onset pauciarticular juvenile rheumatoid arthritis or of chronic iridocyclitis in this form of juvenile rheumatoid arthritis. Only one split of human leukocyte antigen (HLA)-DR5, HLA-DRB1* 1104, showed a statistically significant association with a risk of chronic iridocyclitis (chi-square value = 7.52; p = 0.036 adjusted; odds ratio 3.45); HLA-DQA1* 0501 and HLA-DQB1* 0301, both in linkage disequilibrium with HLA-DRB1* 1104, also were significantly associated with eye disease. Patients with both the DRB1* 1104 and DPB1* 0201 genes had a 7.7-fold increased risk for chronic iridocyclitis compared with that for other patients. The presence of HLA-DRB1* 1104 was about four times as specific, but only about one third as sensitive, as antinuclear antibodies in identifying patients at risk for eye disease. Although all children with early-onset pauciarticular juvenile rheumatoid arthritis should undergo periodic slit-lamp examinations, those with the HLA class II gene DRB1* 1104 are at particularly high risk for eye disease, and we recommend that they be monitored carefully for its evolution.

Preschool sarcoidosis masquerading as juvenile rheumatoid arthritis: two case reports and a review of the literature

Preschool sarcoidosis is characterized by the triad of skin, joint, and eye disease without pulmonary involvement. Arthritis and uveitis are also frequently seen together in juvenile rheumatoid arthritis. We report two patients with preschool sarcoidosis, both of whom were initially diagnosed and treated as having juvenile rheumatoid arthritis. Skin biopsy is an important early diagnostic procedure to differentiate the conditions. The uveitis in both diseases can have serious sequelae.

Identification of antihistone antibodies in subsets of juvenile chronic arthritis

Antihistone antibodies (AHAs) as measured by an enzyme linked immunosorbent assay (ELISA) were detected in the sera of 58 (48%) of 121 unselected patients with juvenile chronic arthritis (JCA). AHAs were found in 28 (93%) of 30 patients with JCA with uveitis but in only 30 (33%) of 91 patients with JCA without uveitis. AHA positivity was unrelated to the type of joint involvement, disease activity, and drug regimen. When the AHA positive group was divided into 28 patients with JCA with uveitis and 30 patients with JCA without uveitis a distinct response pattern of AHA was detected in each group. Anti-H3 dominated in the JCA/uveitis group, whereas a more heterogeneous AHA pattern was shown in the group without uveitis. The results indicate that subtyping for AHA reactivity may define patients who are highly susceptible for the development of anterior uveitis.

Advanced drug therapy for juvenile rheumatoid arthritis

Childhood rheumatic diseases are frequently chronic, painful, and potentially debilitating. They may adversely affect growth and development, compromise future quality of life, and contribute added stress to the patient and family. Awareness of these consequences provides a stimulus to develop more effective therapeutic regimens. There is optimism that new therapeutic strategies will result in the more widespread and earlier use of drugs, including those discussed, that may substantially impede or arrest the underlying disease.