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Foeldvari I, Bohn M, Petrushkin H, Angeles Han S, Bangsgaard R, Calzada-Hernández J, Constantin T, de Boer JH, Díaz-Cascajosa J, Edelsten C, Glerup M, Ingels H, Kramer S, Miserocchi E, Nordal E, Saurenmann RK, Simonini G, Solebo AL, Titz J, Anton J. A practical approach to uveitis screening in children with juvenile idiopathic arthritis. Br J Ophthalmol 2024:bjo-2023-324406. [PMID: 38575198 DOI: 10.1136/bjo-2023-324406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA)-associated uveitis typically presents as a silent chronic anterior uveitis and can lead to blindness. Adherence to current screening guidelines is hampered by complex protocols which rely on the knowledge of specific JIA characteristics. The Multinational Interdisciplinary Working Group for Uveitis in Childhood identified the need to simplify screening to enable local eye care professionals (ECPs), who carry the main burden, to screen children with JIA appropriately and with confidence. METHODS A consensus meeting took place in January 2023 in Barcelona, Spain, with an expert panel of 10 paediatric rheumatologists and 5 ophthalmologists with expertise in paediatric uveitis. A summary of the current evidence for JIA screening was presented. A nominal group technique was used to reach consensus. RESULTS The need for a practical but safe approach that allows early uveitis detection was identified by the panel. Three screening recommendations were proposed and approved by the voting members. They represent a standardised approach to JIA screening taking into account the patient's age at the onset of JIA to determine the screening interval until adulthood. CONCLUSION By removing the need for the knowledge of JIA categories, antinuclear antibody positivity or treatment status, the recommendations can be more easily implemented by local ECP, where limited information is available. It would improve the standard of care on the local level significantly. The proposed protocol is less tailored to the individual than the 'gold standard' ones it references and does not aim to substitute those where they are being used with confidence.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | - Marcela Bohn
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- West Hertfordshire Teaching Hospitals NHS Foundation Trust, London, UK
| | - Harry Petrushkin
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Regitze Bangsgaard
- Department of Ophthalmology, Copenhagen University Hospital Glostrup/Rigshospitalet, Copenhagen, Denmark
| | | | | | - Joke H de Boer
- Ophthalmology, F.C. Donders Institute, Utrecht, The Netherlands
| | | | | | - Mia Glerup
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Helene Ingels
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | | | | | - Ellen Nordal
- Department of Paediatrics, UiT The Arctic University of Norway, Tromso, Norway
| | - Rotraud K Saurenmann
- Department of Paediatrics, Kantonsspital Winterthur, Winterthur, Switzerland
- Department of Rheumatology, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Ameenat Lola Solebo
- MRC Centre of Epidemiology of Child Health, Institute of Child Health University College London, London, UK
| | - Jan Titz
- Patients Representative, Hamburg, Germany
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Tarsia M, Vitale A, Gaggiano C, Sota J, Maselli A, Bellantonio C, Guerriero S, Dammacco R, La Torre F, Ragab G, Hegazy MT, Fonollosa A, Paroli MP, Del Giudice E, Maggio MC, Cattalini M, Fotis L, Conti G, Mauro A, Civino A, Diomeda F, de-la-Torre A, Cifuentes-González C, Tharwat S, Hernández-Rodríguez J, Gómez-Caverzaschi V, Pelegrín L, Babu K, Gupta V, Minoia F, Ruscitti P, Costi S, Breda L, La Bella S, Conforti A, Mazzei MA, Carreño E, Amin RH, Grosso S, Frediani B, Tosi GM, Balistreri A, Cantarini L, Fabiani C. Effectiveness and Safety of Biosimilars in Pediatric Non-infectious Uveitis: Real-Life Data from the International AIDA Network Uveitis Registry. Ophthalmol Ther 2024; 13:761-774. [PMID: 38206518 PMCID: PMC10853125 DOI: 10.1007/s40123-023-00863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/23/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Since many biological drug patents have expired, biosimilar agents (BIOs) have been developed; however, there are still some reservations in their use, especially in childhood. The aim of the current study is to evaluate the efficacy and safety of tumor necrosis factor (TNF) inhibitors BIOs as treatment for pediatric non-infectious uveitis (NIU). METHODS Data from pediatric patients with NIU treated with TNF inhibitors BIOs were drawn from the international AutoInflammatory Disease Alliance (AIDA) registries dedicated to uveitis and Behçet's disease. The effectiveness and safety of BIOs were assessed in terms of frequency of relapses, risk for developing ocular flares, best-corrected visual acuity (BCVA), glucocorticoids (GCs)-sparing effect, drug survival, frequency of ocular complications, and adverse drug event (AE). RESULTS Forty-seven patients (77 affected eyes) were enrolled. The BIOs employed were adalimumab (ADA) (89.4%), etanercept (ETA) (5.3%), and infliximab (IFX) (5.3%). The number of relapses 12 months prior to BIOs and at last follow-up was 282.14 and 52.43 per 100 patients/year. The relative risk of developing ocular flares before BIOs introduction compared to the period following the start of BIOs was 4.49 (95% confidence interval [CI] 3.38-5.98, p = 0.004). The number needed to treat (NNT) for ocular flares was 3.53. Median BCVA was maintained during the whole BIOs treatment (p = 0.92). A significant GCs-sparing effect was observed throughout the treatment period (p = 0.002). The estimated drug retention rate (DRR) at 12-, 24-, and 36-month follow-up were 92.7, 83.3, and 70.8%, respectively. The risk rate for developing structural ocular complications was 89.9/100 patients/year before starting BIOs and 12.7/100 patients/year during BIOs treatment, with a risk ratio of new ocular complications without BIOs of 7.1 (CI 3.4-14.9, p = 0.0003). Three minor AEs were reported. CONCLUSIONS TNF inhibitors BIOs are effective in reducing the number of ocular uveitis relapses, preserving visual acuity, allowing a significant GCs-sparing effect, and preventing structural ocular complications. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05200715.
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Affiliation(s)
- Maria Tarsia
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Carla Gaggiano
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Jurgen Sota
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Anna Maselli
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Chiara Bellantonio
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Silvana Guerriero
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Rosanna Dammacco
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Francesco La Torre
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, 70126, Bari, Italy
| | - Gaafar Ragab
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Mohamed Tharwat Hegazy
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
| | - Maria Pia Paroli
- Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Emanuela Del Giudice
- Pediatric Rheumatology Unit, Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Maria Cristina Maggio
- University Department PROMISE "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Lampros Fotis
- Third Department of Paediatrics, National and Kapodistrian University of Athens, General University Hospital "Attikon", Athens, Greece
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit with Dialysis, Department of Human Pathology in Adulthood and Childhood "G. Barresi", AOU Policlinic "G. Martino", Messina University, Messina, Italy
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121, Milan, Italy
| | - Adele Civino
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Federico Diomeda
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Cifuentes-González
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, Dakahlia Governorate, Egypt
| | - José Hernández-Rodríguez
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Pelegrín
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Kalpana Babu
- Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bengaluru, Karnataka, India
| | - Vishali Gupta
- Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Francesca Minoia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, PO Box 67100, L'Aquila, Italy
| | | | - Luciana Breda
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | - Saverio La Bella
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | | | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, 53100, Siena, Italy
| | - Ester Carreño
- Department of Ophthalmology, Hospital Universitario Rey Juan Carlos, Madrid, Spain
- Department of Ophthalmology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rana Hussein Amin
- Opthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Salvatore Grosso
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Gian Marco Tosi
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Alberto Balistreri
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy.
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Sharon Y, Goren L, Barayev E, Neumann R, Chu DS, Kramer M. Recurrent and chronic anterior uveitis: Long-term outcome and treatment strategies. Indian J Ophthalmol 2024; 72:S248-S253. [PMID: 38146973 DOI: 10.4103/ijo.ijo_1042_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/10/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE To study the long-term clinical outcome and treatment strategies of recurrent and chronic non-infectious anterior uveitis. METHODS Multicenter study of anterior uveitis patients from 2001 to 2022. Outcome measures included ocular complications, medical and surgical therapies, and visual acuity measured at the beginning of follow-up and at 1, 2, and 5 years thereafter. RESULTS In total, 76 patients were included, with a mean follow-up of 6.8 years. Idiopathic anterior uveitis was the most common etiology (56%). Immunomodulatory agents (IMAs) were used in almost half of the cohort. Early initiation of IMAs was associated with a lower risk of developing glaucoma ( P = 0.019). Mean best corrected visual acuity (BCVA) improved after 5 years in both groups. Early use of immunomodulation was correlated with a better visual outcome at 2 years ( P = 0.024). CONCLUSION Chronic and recurrent anterior uveitis were associated with greater risk than expected for ocular complications, surgeries, and vision impairment. Early initiation of immunomodulation should be strongly considered to improve clinical course and outcome.
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Affiliation(s)
- Yael Sharon
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Goren
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
| | - Edward Barayev
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
| | - Ron Neumann
- Maccabi Health Care Services, Tel Aviv, Israel
| | - David S Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, New Jersey, USA
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Michal Kramer
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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van Meerwijk C, Kuiper J, van Straalen J, Ayuso VK, Wennink R, Haasnoot AM, Kouwenberg C, de Boer J. Uveitis Associated with Juvenile Idiopathic Arthritis. Ocul Immunol Inflamm 2023; 31:1906-1914. [PMID: 37966463 DOI: 10.1080/09273948.2023.2278060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/27/2023] [Indexed: 11/16/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common cause of uveitis in children. While symptoms are usually mild, persistent eye inflammation could lead to severe complications and impaired vision. It is essential that JIA patients at risk are diagnosed with uveitis early, receive adequate treatment, and avoid developing complications, such as cataract, glaucoma, and amblyopia. The purpose of this mini-review is to summarize the screening strategies and clinical management for JIA-associated uveitis (JIA-U) as well as the current state of molecular markers linked to this condition. Because glaucoma is one of the most common causes of visual loss in JIA-U, special focus will be put on this serious complication. We conclude by describing the current evidence regarding the long-standing question of whether chronic anterior uveitis without arthritis may be the same disease entity as JIA-U.
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Affiliation(s)
- Charlotte van Meerwijk
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jonas Kuiper
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joeri van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Viera Kalinina Ayuso
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roos Wennink
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Anne-Mieke Haasnoot
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carlijn Kouwenberg
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joke de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Huard J, Mihailescu SD, Muraine M, Raymond S, Grall Lerosey M, Gueudry J. Effectiveness and Safety of Weekly Adalimumab for Non-Infectious Chronic Anterior Uveitis in Children. Ocul Immunol Inflamm 2023; 31:2039-2049. [PMID: 37972236 DOI: 10.1080/09273948.2023.2279682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Non-infectious chronic anterior uveitis (CAU) remains a therapeutic challenge. The purpose of this study was to analyze the effectiveness and safety of weekly dosing of adalimumab in children with non-infectious refractory CAU. Methods: Demographic and clinical data of children followed by non-infectious CAU treated with adalimumab were retrospectively reviewed. RESULTS Of the 42 children with CAU, 27/42 (64.3%) were treated with adalimumab. Escalation to weekly dosing of adalimumab was necessary for 11/27 children (40.7%). After 3 and 6 months, 7/11 children (63.6%) met the composite endpoint of inflammation control improvement. Children requiring weekly adalimumab had initially more severe uveitis: anterior chamber cells (p = 0.02), aqueous flare (p = 0.02), and presence of macular edema (p = 0.007). No children had serious systemic side effects. CONCLUSION Weekly adalimumab in children with refractory CAU appears to be an effective and safe treatment for inflammation control and corticosteroid sparing, and an alternative before biologic switching. Controlled studies are needed.
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Affiliation(s)
- Justine Huard
- Department of Ophthalmology, CHU ROUEN, Rouen, France
| | - Sorina-Dana Mihailescu
- Innovation, Clinical Research and Educational Unit (CIRCE), Eure-Seine Hospital, Evreux, France
| | - Marc Muraine
- Department of Ophthalmology, CHU ROUEN, Rouen, France
| | | | | | - Julie Gueudry
- Department of Ophthalmology, CHU ROUEN, Rouen, France
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Kouwenberg CV, Blom LA, Vellinga SC, Bozkir I, de Boer JH, Ayuso VKK. The Role of the Retinal Nerve Fiber Layer Thickness on OCT in the Evaluation of Papillitis in Childhood Uveitis. Am J Ophthalmol 2023; 254:62-68. [PMID: 37149246 DOI: 10.1016/j.ajo.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/12/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE To investigate the diagnostic value of using retinal nerve fiber layer thickness measured on optical coherence tomography (OCT-RNFL) to diagnose papillitis in pediatric uveitis. DESIGN Retrospective cohort study. METHODS Demographic and clinical data were collected retrospectively for 257 children with uveitis (with 455 affected eyes). Receiver operating characteristic (ROC) analysis was performed to compare fluorescein angiography (FA, the diagnostic gold standard for papillitis) to OCT-RNFL in a subgroup of 93 patients. An ideal cut-off value for OCT-RNFL was then determined by calculating the highest Youden index. Finally, a multivariate analysis was applied to the clinical ophthalmological data. RESULTS Based on a subset of 93 patients who underwent both OCT-RNFL and FA, the ideal cut-off OCT-RNFL for diagnosing papillitis was >130 µm, with 79% sensitivity and 85% specificity. Among the entire cohort, the prevalence of OCT-RNFL >130 µm was 19% (27/141), 72% (26/36), and 45% (36/80) in patients with anterior uveitis, intermediate uveitis, and panuveitis, respectively. Our multivariate analysis of the clinical data revealed that OCT-RNFL >130 µm was associated with a higher prevalence of cystoid macular edema, active uveitis, and optic disc swelling on fundoscopy, with odds ratios of 5.3, 4.3, and 13.7, respectively (all P < .001). CONCLUSIONS OCT-RNFL can be a useful noninvasive additional imaging tool for diagnosing papillitis in pediatric uveitis with relatively high sensitivity and specificity. OCT-RNFL was >130 µm in approximately one-third of all children with uveitis and was particularly prevalent in cases of intermediate uveitis and panuveitis.
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Affiliation(s)
- Carlyn V Kouwenberg
- From the Department of Ophthalmology (C.V.K., L.A.B., I.B., J.H.dB., V.K.-K.A), University Medical Center Utrecht, Utrecht, Netherlands.
| | - Laurens A Blom
- Faculty of Medicine (L.A.B., S.E.V.), Utrecht University, Utrecht, Netherlands
| | - Suzanne C Vellinga
- Faculty of Medicine (L.A.B., S.E.V.), Utrecht University, Utrecht, Netherlands
| | - Irem Bozkir
- From the Department of Ophthalmology (C.V.K., L.A.B., I.B., J.H.dB., V.K.-K.A), University Medical Center Utrecht, Utrecht, Netherlands
| | - Joke H de Boer
- From the Department of Ophthalmology (C.V.K., L.A.B., I.B., J.H.dB., V.K.-K.A), University Medical Center Utrecht, Utrecht, Netherlands
| | - Viera Koopman-Kalinina Ayuso
- From the Department of Ophthalmology (C.V.K., L.A.B., I.B., J.H.dB., V.K.-K.A), University Medical Center Utrecht, Utrecht, Netherlands
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Siiskonen M, Hirn I, Pesälä R, Ohtonen P, Hautala N. Encouraging visual outcomes in children with idiopathic and JIA associated uveitis: a population-based study. Pediatr Rheumatol Online J 2023; 21:56. [PMID: 37322490 DOI: 10.1186/s12969-023-00841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/04/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Pediatric uveitis is typically asymptomatic and may become chronic affecting ocular structures and vision. We evaluated visual outcomes, clinical features, medication, and uveitis activity in children with either idiopathic uveitis (idio-U) or juvenile idiopathic arthritis associated uveitis (JIA-U). METHODS A longitudinal, population-based cohort study of children with uveitis in 2008-2017. The data included parameters for age, gender, age at diagnosis, laterality, chronicity, anatomical distribution, etiology, systemic association, uveitis activity, medication, and visual outcomes. RESULTS A total of 119 patients aged < 16 years with uveitis were included. Uveitis was idio-U in 23% and associated with JIA in 77% of cases. 37% of the patients in the idio-U group and 65% in the JIA-U were girls (p = 0.014). The mean age at first uveitis was 10.0 (SD 3.4) years in idio-U and 5.5 (SD 3.3) years in JIA-U (p < 0.001). Anterior location of uveitis was noted in 74% in idio-U and 99% in JIA-U (p < 0.001). Mostly, uveitis was chronic (59% in idio-U and 75% in JIA-U) and bilateral (56% in idio-U and 64% in JIA-U). Topical corticosteroids were initially used by 89% and 100%, systemic corticosteroids by 30% and 27% in some extent during the follow-up, disease-modifying antirheumatic drugs (DMARDs) by 33% and 85% (p < 0.001) of the patients in idio-U and JIA-U, respectively. Biologic disease-modifying antirheumatic drugs (bDMARDs) were more common in JIA-U (55% vs. 15% in idio-U, respectively, p < 0.001). Most patients had normal visual acuity (Snellen > 0.8, [6/7.5]) in the affected eye and bilaterally in 85% idio-U and 70% JIA-U. Only 5 patients (4%) had visual impairment in one, but none in both eyes. Uveitis activity by SUN classification was 0 + in 81% and 72%, 0.5 + in 19% and 25%, and 1 + in 0% and 3% in the idio-U and JIA-U, respectively. CONCLUSIONS Children with uveitis have good visual acuity and a low rate for visual impairment. In addition, modern treatment with DMARDs and bDMARDs seems to save vision.
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Affiliation(s)
- Mira Siiskonen
- Department of Ophthalmology, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Iida Hirn
- Research Unit of Clinical Medicine, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Roosa Pesälä
- Research Unit of Clinical Medicine, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- The Research Unit of Surgery, Anesthesia and Intensive care, Oulu University Hospital and University of Oulu, Oulu, Finland
- Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Nina Hautala
- Department of Ophthalmology, Oulu University Hospital, Oulu, Finland.
- Research Unit of Clinical Medicine, Oulu, Finland.
- Medical Research Center, University of Oulu, Oulu, Finland.
- Research Unit of Clinical Medicine and MRC Oulu, Department of Ophthalmology, University of Oulu, Oulu University Hospital, Oulu, P.O.Box 21, 90029 OYS, Finland.
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8
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Triggianese P, Fatica M, Caso F, Costa L, D'Antonio A, Tasso M, Greco E, Conigliaro P, Bergamini A, Fabiani C, Cantarini L, Chimenti MS. Rheumatologist's Perspective on Non-Infectious Uveitis: Patterns from Tertiary Referral Rheumatologic Clinics in Italy. Int J Mol Sci 2023; 24:ijms24119690. [PMID: 37298638 DOI: 10.3390/ijms24119690] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Non-infectious uveitis (NIU) can be an early or even the first extra-articular manifestation of systemic rheumatic diseases, or the first one; thus, rheumatologists are often involved in the diagnostic and therapeutic assessment of NIU. We evaluated 130 patients with a diagnosis of NIU who were admitted to two Italian rheumatologic clinics (Tor Vergata University Hospital in Rome, and Federico II University in Naples) from January 2018 to December 2021. Anterior uveitis (AU) occurred in 75.4% of patients, followed by posterior uveitis (PU, 21.5%); acute (54.6%) and recurrent (35.4%) NIU were more documented than chronic NIU (10%), and a bilateral involvement was observed in 38.7% of cases. Half of NIU cases were associated with spondyloarthritis (SpA); the remaining were affected by Behçet disease (BD)-related uveitis (13.9%) and idiopathic NIU (9.2%). HLA-B27+ patients (34.8%) had a higher prevalence of anterior and unilateral NIU (p = 0.005) with acute course (p = 0.04) than HLA-B27- patients. On the contrary, HLA-B51+ patients (19.6%) had mostly PU and bilateral NIU (p < 0.0001) and recurrent course (p = 0.04) than HLA-B51- patients. At the first rheumatologic referral, 117 patients (90%) received systemic treatments. Findings from this study demonstrate that rheumatologic referral has a pivotal role in the diagnostic work-up of NIU and may dramatically influence NIU-treatment strategies.
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Affiliation(s)
- Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Mauro Fatica
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesco Caso
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Luisa Costa
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Arianna D'Antonio
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Marco Tasso
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Elisabetta Greco
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Paola Conigliaro
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Alberto Bergamini
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behcet's Disease Clinic, University of Siena, 53100 Siena, Italy
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
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9
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Heiligenhaus A, Klotsche J, Minden K. Authors reply to the 'Response to "Similarities in clinical course and outcome between juvenile idiopathic arthritis (JIA)-associated and ANA-positive idiopathic anterior uveitis: data from a population-based nationwide study in Germany"'. Arthritis Res Ther 2023; 25:52. [PMID: 36991432 PMCID: PMC10053479 DOI: 10.1186/s13075-023-03017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/31/2023] Open
Affiliation(s)
- Arnd Heiligenhaus
- Department of Ophthalmology at St. Franziskus Hospital, Muenster, Hohenzollernring 74, 48145, Muenster, Germany.
- University of Duisburg-Essen, Duisburg, Germany.
| | - Jens Klotsche
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
- Epidemiology and Health Economics, Charité - University Medicine Berlin, Institute for Social Medicine, Berlin, Germany
| | - Kirsten Minden
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
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10
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Yalçındağ FN, Köse HC, Temel E. Comparative study of laser flare photometry versus slit-lamp cell measurement in pediatric chronic non-infectious anterior uveitis. Eur J Ophthalmol 2023; 33:382-390. [PMID: 35708177 DOI: 10.1177/11206721221107303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the role of laser flare photometry (LFP) for monitoring the course of intraocular inflammation in children with chronic anterior uveitis. METHODS Seventy-six eyes of 43 children with non-infectious chronic anterior uveitis were reviewed retrospectively. RESULTS The median follow-up was 48.6 ± 23.1 months. Patients on immunosuppressive treatment at last follow-up, showed significantly higher flare values than patients who discontinued treatment (20.47 ± 15.49 vs. 6.33 ± 4.87 p < 0.001). The higher LFP values were correlated with the duration of immunosuppressive treatment, total duration of topical corticosteroid use and the risk for development of ocular complications at all follow-ups (all p < 0.001). No significant correlation was found between the AC cell grades and the duration of immunosuppressive treatment, topical corticosteroid use and the prevalence of complications. CONCLUSION LFP measurements have a predictive value of monitoring the course of uveitis and the occurrence of ocular complications, and it should be considered as a primary modality to monitor intraocular inflammation in children with chronic anterior uveitis.
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Affiliation(s)
- F Nilüfer Yalçındağ
- 63990Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Helin Ceren Köse
- 63990Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Emine Temel
- 63990Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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11
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Tappeiner C, Heiligenhaus A. The Value of Laser Flare Photometry as a Monitoring Tool for Uveitis. Klin Monbl Augenheilkd 2022; 240:662-668. [PMID: 36257601 DOI: 10.1055/a-1962-7422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Laser flare (LF) photometry (P) is used to quantify the protein concentration in the aqueous humor, and therefore assess the blood-aqueous humor barrier. LFP is more reliable than the clinical assessment of the Tyndall effect, and is thus especially useful in the follow-up of uveitis patients. In active uveitis, LFP correlates well with the anterior chamber cell grading. Various studies have shown that high LF values are associated with an increased risk of uveitic complications, such as macular edema, glaucoma, and posterior synechiae. LFP can also be used to assess the response to anti-inflammatory treatments as well as the optimal timing and selection of the surgical technique for intraocular surgeries.
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Affiliation(s)
- Christoph Tappeiner
- Augenklinik, Pallas Klinik, Olten, Schweiz.,Klinik für Augenheilkunde, Universitätsklinikum Duisburg-Essen, Essen, Deutschland.,Universität Bern, Schweiz
| | - Arnd Heiligenhaus
- Augenabteilung, St. Franziskus Hospital, Münster, Deutschland.,Universität Duisburg-Essen, Essen, Deutschland
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12
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Miraldi Utz V, Angeles-Han ST, Mwase N, Cassedy A, Hennard T, Lovell DJ, Lopper S, Brunner HI, Dosunmu EO, Grom AA, Henrickson M, Huggins JL, Sisk RA, Ting TV, Kaufman AH. Alternative Biologic Therapy in Children Failing Conventional TNFα Inhibitors for Refractory, Noninfectious, Chronic Anterior Uveitis. Am J Ophthalmol 2022; 244:183-195. [PMID: 35863492 DOI: 10.1016/j.ajo.2022.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE A significant number of children with noninfectious, chronic anterior uveitis (CAU) fail to respond to conventional therapy; however, successful alternative biologic treatments (ABT) have not been well described. This study aims to review the clinical and treatment characteristics of children with CAU who require ABT. DESIGN Retrospective, nonrandomized clinical study. METHODS Setting: Tertiary center. STUDY POPULATION Children with noninfectious CAU. OBSERVATION PROCEDURES Clinical characteristics, uveitis course, complications, and treatment were compared among patients treated with methotrexate (MTX) monotherapy, conventional TNFα inhibitors (cTNFi), and ABT for >3 months. MAIN OUTCOME MEASURE Success of ABT (abatacept, tocilizumab, and/or golimumab) in children failing conventional treatment. RESULTS Of the 52 children with CAU, 75% had juvenile idiopathic arthritis. CAU was controlled in 15 children receiving MTX monotherapy, 28 receiving cTNFi, and 9 receiving ABT (n = 1, abatacept; n = 3, tocilizumab; n = 5, golimumab). Patients in the ABT group had a greater number of total ocular complications per person before ABT than those in the control groups (3.4 vs 0.7 [MTX], P < .001, and 1.5 [cTNFi], P < .001, respectively). In all 9 children on ABT, treatment led to control of CAU and topical glucocorticoids tapered to ≤2 drops/d with no new ocular complications. CONCLUSIONS In this study, alternative biologics (abatacept, golimumab, and tocilizumab) were useful for treating CAU in children who fail MTX and cTNFi therapy. Patients who were controlled on ABT had more disease activity, ocular complications, and anti-cTNFi neutralizing antibodies (before ABT) than those managed with conventional therapy. Larger studies are required to confirm these findings.
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Affiliation(s)
- Virginia Miraldi Utz
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Sheila T Angeles-Han
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.).
| | - Najima Mwase
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Amy Cassedy
- University of Cincinnati, and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (A.C.)
| | - Theresa Hennard
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Sarah Lopper
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Eniolami O Dosunmu
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Alexei A Grom
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Michael Henrickson
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Jennifer L Huggins
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Robert A Sisk
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
| | - Tracy V Ting
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Adam H Kaufman
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
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13
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Wennink RA, Kalinina Ayuso V, Pameijer EM, Dekkers CC, Bozkir I, de Boer JH. Improved clinical outcomes in patients with juvenile idiopathic arthritis associated uveitis in the last decade. Acta Ophthalmol 2022; 100:781-787. [PMID: 35076174 PMCID: PMC9786763 DOI: 10.1111/aos.15097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/24/2021] [Accepted: 12/29/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE The purpose of the study was to analyse the development of ocular complications and visual prognosis in juvenile idiopathic arthritis associated uveitis (JIA-uveitis) compared to the previous decade in the light of new treatment guidelines. METHODS In this retrospective cohort, 143 patients with JIA-uveitis were stratified into two cohorts based on the year of diagnosis of uveitis, <2010 (n = 61) and ≥2010 (n = 82). Development of ocular complications and visual outcomes were analysed by univariate and multivariate methods. Treatment with systemic corticosteroids and immunomodifying medication (IMT) were documented. RESULTS In total, 109 and 133 affected eyes, respectively, for cohort 1 (<2010) and cohort 2 (≥2010) were included for analysis. In the multivariate analysis with correction for paired eyes, patients in cohort 1 were at higher risk for cataract surgery (p = 0.03) and secondary glaucoma (p = 5.15 × 10-3 ). Also, the number of eyes that were legally blind and visually impaired at 5 years of follow-up was significantly higher in cohort 1 (7% versus 2% and 8% versus 0%, p = 0.01 respectively). The number of patients that started IMT was significantly higher in cohort 2 (57% versus 98%, p = 2.17 × 10-6 ). In cohort 2, both methotrexate and anti-TNF-α therapy were prescribed earlier in the disease course (1.41 versus 0.05 years, p = 8.31 × 10-6 and 6.07 versus 1.84 years, p = 5.14 × 10-5 respectively). CONCLUSIONS The prognosis of JIA-uveitis has improved during the last decade. There is a reduction in the number of cataract surgeries and secondary glaucoma and fewer patients lose their vision parallel with earlier access to tertiary care and earlier introduction of IMT.
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Affiliation(s)
- Roos A.W. Wennink
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Viera Kalinina Ayuso
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Els M. Pameijer
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Coco C. Dekkers
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Irem Bozkir
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Joke H. de Boer
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
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14
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Halim MS, Hasanreisoglu M, Onghanseng N, Tran ANT, Hassan M, Yilmaz M, Segawa A, Gurelik G, Afridi R, Ormaechea MS, Uludag G, Kesim C, Nguyen NV, Bae JH, Park JH, Do DV, Ibrahim MA, Sepah YJ, Nguyen QD. Correlation of Clinical Aqueous Flare Grading to Semi-Automated Flare Measurements Using Laser Flare Photometry. Ocul Immunol Inflamm 2022; 30:1906-1912. [PMID: 35081012 PMCID: PMC10863987 DOI: 10.1080/09273948.2021.1971723] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/11/2021] [Accepted: 08/18/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE To compare laser flare photometry (LFP) measurements of aqueous flare with Standardization of Uveitis Nomenclature (SUN) and modified SUN grading. METHODS In this prospective study with multicenter design, uveitis patients were classified according to SUN and modified SUN grading scales. LFP was performed with Kowa FM-700 flaremeter. Mean LFP values were compared with SUN and MSUN scores. RESULTS The study included 475 LFP measurements, of which 216, 48, 150, 31, 28 and 2 had 0, 0.5+, 1+, 1.5+, 2+ and 3+ flare, respectively. LFP values were significantly different between each two consecutive steps for both clinical gradings (all P < .05). Cut-off values for modified SUN grading steps were defined as 5.7, 9.7, 15.7 and 43.2 for 0/0.5+, 0.5+/ 1+, 1+/1.5+ and 1.5/2+ borders of clinical flare, respectively. CONCLUSIONS LFP proves to be an objective measurement in analyzing aqueous flare comparable to both SUN and MSUN clinical grading systems.
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Affiliation(s)
- Muhammad Sohail Halim
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Ophthalmology, Ocular Imaging Research and Reading Center, Sunnyvale, California, USA
| | - Murat Hasanreisoglu
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Department of Ophthalmology, Gazi University, School of Medicine, Ankara, Turkey
- Department of Ophthalmology, Koc University Medical School, Istanbul, Turkey
- KUTTAM, Koç University Research Center for Translational Medicine, Koç University, Istanbul, Turkey
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Anh N T Tran
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Mervenur Yilmaz
- Department of Ophthalmology, Gazi University, School of Medicine, Ankara, Turkey
| | - Asadu Segawa
- Department of Ophthalmology, Gazi University, School of Medicine, Ankara, Turkey
| | - Gokhan Gurelik
- Department of Ophthalmology, Gazi University, School of Medicine, Ankara, Turkey
| | - Rubbia Afridi
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Maria Soledad Ormaechea
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Department of Ophthalmology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Cem Kesim
- Department of Ophthalmology, Koc University Medical School, Istanbul, Turkey
| | - Nam V Nguyen
- Ophthalmology, Ocular Imaging Research and Reading Center, Sunnyvale, California, USA
| | - Jeong Hun Bae
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Jung Huynh Park
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Mohamed A Ibrahim
- Ophthalmology, Ocular Imaging Research and Reading Center, Sunnyvale, California, USA
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
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15
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Tsui E, Chen JL, Jackson NJ, Leyva O, Rasheed H, Baghdasaryan E, Fung SS, McCurdy DK, Sadda SR, Holland GN. Quantification of Anterior Chamber Cells in Children with Uveitis Using Anterior Segment Optical Coherence Tomography. Am J Ophthalmol 2022; 241:254-261. [PMID: 35609675 DOI: 10.1016/j.ajo.2022.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate the feasibility of anterior segment optical coherence tomography (AS-OCT) for measuring anterior chamber (AC) cells in children with uveitis and to compare different AS-OCT acquisition modes. DESIGN Validity and reliability analysis. METHODS We enrolled children younger than 18 years of age who had uveitis involving the anterior segment and children without eye disease as controls. All underwent clinical grading of AC cells. AC images of each eye were obtained using the Optovue Avanti RTVue XR AS-OCT. Two acquisition modes were used: a single cross-sectional line scan and an 8-line radial scan in an asterisk pattern. Two independent, masked graders counted cells manually on AS-OCT images. Rater agreement was assessed using intraclass correlation (ICC). RESULTS Included were 30 children (59 eyes) with uveitis (median age 13.0 years, range 3-17 years) and 20 control children (40 eyes, median age 10.5 years, range 4-17 years). The number of eyes assigned each clinical grade of cells were as follows: none, 32 (54%); 0.5+, 12 (20.3%); 1+, 5 (8.5%); 2+, 8 (13.6%); 3+, 2 (3.4%). ICC of graders for line and radial scan protocols were 0.87 and 0.90. There was no significant difference between acquisition modes for pooled grader results (95% confidence interval [CI] for difference: -0.04 to 0.14). ICC of cell counts between line and radial scan protocols was 0.85 (95% CI: 0.69-0.90). No control eyes had cells on AS-OCT images. CONCLUSIONS Quantification of AC cell in children with uveitis is feasible with AS-OCT and has excellent reliability between different graders and acquisition modes.
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16
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Kouwenberg CV, Wennink RA, Shahabi M, Bozkir I, Ayuso VKK, de Boer JH. Clinical course and outcome in pediatric idiopathic chronic anterior uveitis. Am J Ophthalmol 2022; 241:198-205. [PMID: 35513031 DOI: 10.1016/j.ajo.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/25/2022] [Accepted: 04/20/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To examine the clinical course and outcome in children with idiopathic chronic anterior uveitis (iCAU) and compare the results with age-matched children with juvenile idiopathic arthritis-associated uveitis (JIA-U). DESIGN Retrospective cohort study. METHODS Data regarding ocular complications, visual acuity, and systemic treatment were retrospectively collected for two patient groups that were matched regarding age and year of uveitis diagnosis. Outcome was evaluated using survival analysis. RESULTS The iCAU and JIA-U groups included 48 patients with 83 affected eyes and 48 patients with 73 affected eyes, respectively. Multivariate analyses showed that iCAU was associated with a higher prevalence of posterior synechiae (adjusted hazard rate [aHR]: 3.63; P < 0.001) and cataract surgery (aHR: 2.90; P = 0.006). Baseline visual acuity was worse in the iCAU group compared to the JIA-U group (20/25 vs. 20/20, respectively; P < 0.001), but improved in the iCAU group after 5 years (20/20 vs. 20/20, respectively; P = 0.052). At the 5-year follow-up, the younger children with iCAU (≤8 years of age at diagnosis) had a higher prevalence of posterior synechiae (aHR: 2.56; P = 0.007), secondary glaucoma (aHR: 16.0; P = 0.020), and cataract surgery (aHR: 4.79; P = 0.004) compared to older children with iCAU (≥9 years at diagnosis). CONCLUSIONS Vision-threatening ocular complications are more common in children with iCAU compared to children with JIA-U, particularly in cases in which the onset of uveitis occurred at ≤8 years of age. However, the long-term vision of these children can be improved with adequate treatment.
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Juvenile Idiopathic Arthritis-associated Uveitis: Diagnosis, Management, Sequelae. Int Ophthalmol Clin 2022; 62:143-154. [PMID: 34965232 DOI: 10.1097/iio.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Zhao NO, Crowell EL. Epidemiology and Long-term Sequelae of Pediatric Uveitis. Int Ophthalmol Clin 2022; 62:131-142. [PMID: 34965231 DOI: 10.1097/iio.0000000000000393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Abstract
Childhood noninfectious uveitis leads to sight-threatening complications. Idiopathic chronic anterior uveitis and juvenile idiopathic arthritis-associated uveitis are most common. Inflammation arises from an immune response against antigens within the eye. Ophthalmic work-up evaluates anatomic involvement, disease activity, ocular complications, and disease course. Local and/or systemic glucocorticoids are initial treatment, but not as long-term sole therapy to avoid glucocorticoids-induced toxicity or persistent ocular inflammation. Children with recurrent, refractory, or severe disease require systemic immunosuppression with methotrexate and/or anti-tumor necrosis factor monoclonal antibody medications (adalimumab, infliximab). Goals of early detection and treatment are to optimize vision in childhood uveitis.
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Affiliation(s)
- Margaret H Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University, Emory Eye Center, 1365 Clifton Road, Clinic Building B, Atlanta, GA 30326, USA
| | - Jacob J Fondriest
- Department of Internal Medicine, Summa Health System, Internal Medicine Center, 55 Arch Street, Suite 1B, Akron, OH 44304, USA; Rush Eye Center, 1725 West Harrison Street, Suite 945, Chicago, IL 60612, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Division of Ophthalmology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
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20
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Cooper AM, Flanagan ER, Ronis T, Goldberg B, Sherman AK, Smith C, Holland GN. Knowledge about juvenile idiopathic arthritis-associated uveitis: more frequent reminders are associated with higher patient and family uveitis knowledge. Pediatr Rheumatol Online J 2021; 19:149. [PMID: 34600529 PMCID: PMC8487555 DOI: 10.1186/s12969-021-00639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic anterior uveitis is a sight-threatening complication of juvenile idiopathic arthritis (JIA) and a primary contributor to long-term morbidity in people with JIA. Levels of knowledge about uveitis among JIA patients and their parents are unknown. A survey of JIA patients and parents was conducted to assess knowledge about uveitis complications and recommended screening. METHODS A survey was developed consisting of six demographic questions, six arthritis/uveitis history questions, and nine uveitis knowledge questions. The survey was administered to JIA patients age 14 and older and parents of patients with JIA at three pediatric rheumatology practices and online through the Patients, Advocates, and Rheumatology Teams Network for Research and Service (PARTNERS) network. ANOVA, chi-square and Fisher's exact tests were used to look for relationships between survey questions and demographic variables. RESULTS Thirty-three patients and 111 parents completed the survey. Overall, 17.4% reported a history of uveitis, and 89.6% had heard of uveitis. The mean composite knowledge score was 6.46 ± 2.6 out of 9. Patients and parents with a history of uveitis had higher composite knowledge scores than their counterparts without a uveitis history (p = 0.01 and p < 0.01, respectively). Parents whose rheumatologist reminded them about eye exams at every visit had higher knowledge of the risk of blindness (p = 0.04), the risk for uveitis when arthritis is controlled (p = 0.02), the need for ongoing eye exams when off of medications (p = 0.01), and had a higher overall score (p = 0.02) than those who were reminded at some visits or not at all. CONCLUSIONS JIA patients and parents report variable levels of knowledge regarding uveitis complications and recommended screening. Frequent discussion between the rheumatology provider and family about uveitis screening is associated with higher uveitis knowledge. Incorporating detailed and frequent education about uveitis into rheumatology clinic appointments may improve early uveitis detection and visual outcomes.
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Affiliation(s)
- Ashley M. Cooper
- grid.239559.10000 0004 0415 5050Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 USA ,grid.266756.60000 0001 2179 926XUniversity of Missouri Kansas City School of Medicine, Kansas City, MO USA
| | - Elaine R. Flanagan
- grid.189967.80000 0001 0941 6502Emory University School of Medicine, Atlanta, GA USA
| | - Tova Ronis
- grid.239560.b0000 0004 0482 1586Children’s National Hospital and George Washington University, Washington, DC USA
| | - Baruch Goldberg
- grid.189967.80000 0001 0941 6502Emory University School of Medicine, Atlanta, GA USA
| | - Ashley K. Sherman
- grid.239559.10000 0004 0415 5050Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 USA
| | - Chelsey Smith
- grid.239559.10000 0004 0415 5050Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 USA
| | - Gary N. Holland
- grid.19006.3e0000 0000 9632 6718UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA USA
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21
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Lazăr C, Spîrchez M, Ştefan M, Predeţeanu D, Nicoară S, Crişan M, Man O. Diagnosis and treatment of uveitis associated with juvenile idiopathic arthritis. Med Pharm Rep 2021; 94:S28-S32. [PMID: 34527905 DOI: 10.15386/mpr-2224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in pediatric population, with uveitis as the most common and severe extra-articular manifestation. Eye damage (bilateral in 70-80% of cases) is usually anterior, chronic and asymptomatic. Young age, female gender, oligoarticular form and ANA positivity are risk factors for chronic anterior uveitis (CAU). Acute anterior uveitis (AAU) frequently occurs in HLA-B27 positive boys with enthesitis-related arthritis. The onset is on average 1.8 years after the onset of JIA, but it may also precede the articular manifestations. Ophthalmological screening for JIA is recommended every 3 or 6-12 months depending on the combination of risk factors for associated uveitis. The major purpose of the treatment is to minimize the loss of visual acuity. The treatment is topical (corticosteroids, cycloplegics) and systemic (short-term glucocorticoids, methotreexate, biological drugs). Biological therapy (indicated if previous treatments are ineffective) is using anti-TNF drugs as first choice (most studies are indicating sup erior efficiency for Adalimumab). Usually AAU is treated promptly and no systemic treatment is needed. In some cases the evolution of CAU can lead to severe complications (synechiaes, cataract, glaucoma, even blindness). Interdisciplinary approach involving the pediatric rheumatologist and ophthalmologist is essential for correct monitoring of this disease.
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Affiliation(s)
- Călin Lazăr
- Department of Pediatrics Clinic I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Mihaela Spîrchez
- Department of Pediatrics Clinic II, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics Clinic II, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | | | - Denisa Predeţeanu
- Rheumatology Clinic, "Sfânta Maria" Clinical Hospital, Bucharest, Romania
| | - Simona Nicoară
- Department of Ophthalmology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mirela Crişan
- Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Oana Man
- Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
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22
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Molimard J, Pajot C, Olle P, Belot A, Quartier P, Uettwiller F, Couret C, Coste V, Costet C, Bodaghi B, Dureau P, Bailhache M, Pillet P. Immunomodulatory treatment and surgical management of idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children: a French survey practice. Pediatr Rheumatol Online J 2021; 19:139. [PMID: 34479590 PMCID: PMC8414774 DOI: 10.1186/s12969-021-00626-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgeries for idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children are complex because of the high risk of inflammatory postoperative complications. There is no consensus about treatment adaptation during the perioperative period. The objectives of this study are to report the therapeutic changes made in France and to determine whether maintaining or stopping immunosuppressive therapies is associated with an increased risk of surgical site infection or an increased risk of uveitis or arthritis flare-up. METHODS We conducted a retrospective cohort study between January 1, 2006 and December 31, 2018 in six large University Hospitals in France. Inclusion criteria were chronic idiopathic uveitis or chronic uveitis associated with juvenile idiopathic arthritis under immunosuppressive therapies at the time of the surgical procedure, operated before the age of 16. Data on perioperative treatments, inflammatory relapses and post-operative infections were collected. RESULTS A total of 76 surgeries (42% cataract surgeries, 30% glaucoma surgeries and 16% posterior capsule opacification surgeries) were performed on 37 children. Adaptation protocols were different in the six hospitals. Immunosuppressive therapies were discontinued in five cases (7%) before surgery. All the children in the discontinuation group had an inflammatory relapse within 3 months after surgery compared to only 25% in the other group. There were no postoperative infections. CONCLUSIONS The results of this study show varying practices between centres. The benefit-risk balance seems to favour maintaining immunosuppressive therapies during surgery. Further studies are needed to determine the optimal perioperative treatments required to limit post-operative inflammatory relapses.
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Affiliation(s)
- Julie Molimard
- Pediatric diseases and Rheumatology, CHU Bordeaux, Bordeaux, France.
| | - Christine Pajot
- grid.411175.70000 0001 1457 2980Department of Pediatric Nephrology, Internal Medicine and Hypertension, CHU Toulouse, Toulouse, France
| | - Priscille Olle
- grid.414282.90000 0004 0639 4960Department of Ophtalmology, Hôpital Purpan, CHU Toulouse, Toulouse, France
| | - Alexandre Belot
- grid.413852.90000 0001 2163 3825Department of Pediatric Nephrology, Rheumatology, Dermatology, Reference centre for Rheumatic, AutoImmune and Systemic diseases in children (RAISE), Hôpital Femme Mère Enfant, CHU Lyon, Lyon, France
| | - Pierre Quartier
- grid.412134.10000 0004 0593 9113Paediatric Hematology-Immunology and Rheumatology Department, Reference centre for Rheumatic, AutoImmune and Systemic diseases in children (RAISE), Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Florence Uettwiller
- grid.411167.40000 0004 1765 1600Department of Allergology and Clinical Immunology, Hôpital Clocheville, CHRU de Tours, Tours, France
| | - Chloé Couret
- grid.277151.70000 0004 0472 0371Department of Ophtalmology, Hôtel-Dieu, CHU Nantes, Nantes, France
| | - Valentine Coste
- grid.42399.350000 0004 0593 7118Department of Ophtalmology, CHU Bordeaux, Bordeaux, France
| | - Camille Costet
- grid.42399.350000 0004 0593 7118Department of Ophtalmology, CHU Bordeaux, Bordeaux, France
| | - Bahram Bodaghi
- grid.411439.a0000 0001 2150 9058Department of Ophtalmology, Hopital Pitié-Salpêtrière, APHP, Paris, France
| | - Pascal Dureau
- grid.417888.a0000 0001 2177 525XPediatric Ophthalmology Department, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Marion Bailhache
- grid.42399.350000 0004 0593 7118Department of Pediatric emergencies, CHU Bordeaux, Bordeaux, France
| | - Pascal Pillet
- grid.42399.350000 0004 0593 7118Pediatric diseases and Rheumatology, CHU Bordeaux, Bordeaux, France
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23
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Classification Criteria for Juvenile Idiopathic Arthritis-Associated Chronic Anterior Uveitis. Am J Ophthalmol 2021; 228:192-197. [PMID: 33845021 PMCID: PMC8594759 DOI: 10.1016/j.ajo.2021.03.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine classification criteria for juvenile idiopathic arthritis (JIA)-associated chronic anterior uveitis (CAU). DESIGN Machine learning of cases with JIA CAU and 8 other anterior uveitides. METHODS Cases of anterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the anterior uveitides. The resulting criteria were evaluated on the validation set. RESULTS One thousand eighty-three cases of anterior uveitides, including 202 cases of JIA CAU, were evaluated by machine learning. The overall accuracy for anterior uveitides was 97.5% in the training set and 96.7% in the validation set (95% confidence interval 92.4, 98.6). Key criteria for JIA CAU included (1) chronic anterior uveitis (or, if newly diagnosed, insidious onset) and (2) JIA, except for the systemic, rheumatoid factor-positive polyarthritis, and enthesitis-related arthritis variants. The misclassification rates for JIA CAU were 2.4% in the training set and 0% in the validation set. CONCLUSIONS The criteria for JIA CAU had a low misclassification rate and seemed to perform well enough for use in clinical and translational research.
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24
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van Straalen JW, Giancane G, Amazrhar Y, Tzaribachev N, Lazar C, Uziel Y, Telcharova-Mihaylovska A, Len CA, Miniaci A, Boteanu AL, Filocamo G, Mastri MV, Arkachaisri T, Magnolia MG, Hoppenreijs E, de Roock S, Wulffraat NM, Ruperto N, Swart JF. A clinical prediction model for estimating the risk of developing uveitis in patients with juvenile idiopathic arthritis. Rheumatology (Oxford) 2021; 60:2896-2905. [PMID: 33274366 PMCID: PMC8213427 DOI: 10.1093/rheumatology/keaa733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/02/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To build a prediction model for uveitis in children with JIA for use in current clinical practice. METHODS Data from the international observational Pharmachild registry were used. Adjusted risk factors as well as predictors for JIA-associated uveitis (JIA-U) were determined using multivariable logistic regression models. The prediction model was selected based on the Akaike information criterion. Bootstrap resampling was used to adjust the final prediction model for optimism. RESULTS JIA-U occurred in 1102 of 5529 JIA patients (19.9%). The majority of patients that developed JIA-U were female (74.1%), ANA positive (66.0%) and had oligoarthritis (59.9%). JIA-U was rarely seen in patients with systemic arthritis (0.5%) and RF positive polyarthritis (0.2%). Independent risk factors for JIA-U were ANA positivity [odds ratio (OR): 1.88 (95% CI: 1.54, 2.30)] and HLA-B27 positivity [OR: 1.48 (95% CI: 1.12, 1.95)] while older age at JIA onset was an independent protective factor [OR: 0.84 (9%% CI: 0.81, 0.87)]. On multivariable analysis, the combination of age at JIA onset [OR: 0.84 (95% CI: 0.82, 0.86)], JIA category and ANA positivity [OR: 2.02 (95% CI: 1.73, 2.36)] had the highest discriminative power among the prediction models considered (optimism-adjusted area under the receiver operating characteristic curve = 0.75). CONCLUSION We developed an easy to read model for individual patients with JIA to inform patients/parents on the probability of developing uveitis.
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Affiliation(s)
- Joeri W van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Yasmine Amazrhar
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | | | - Calin Lazar
- Pediatrics, Spitalul Clinic de Urgenta pentru Copii, Cluj-Napoca, Romania
| | - Yosef Uziel
- Department of Pediatrics, Pediatric Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Claudio A Len
- Pediatrics Department, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Angela Miniaci
- Salute della Donna, del Bambino e dell’Adolescente-Padiglione 16 Ambulatorio di reumatologia, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy
| | - Alina L Boteanu
- Pediatric Rheumatology Unit, University Hospital Ramón y Cajal, Madrid, Spain
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariel V Mastri
- Unidad de Reumatologia, Hospital Sor Maria Ludovica, La Plata, Argentina
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Maria G Magnolia
- Paediatrics, Santa Maria della Stella Hospital, Ciconia, Orvieto (TR), Italy
| | - Esther Hoppenreijs
- Pediatric Rheumatology, Radboud University Medical Center/Sint Maartenskliniek, Nijmegen, Netherlands
| | - Sytze de Roock
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
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25
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Brill D, Papaliodis G. Uveitis Specialists Harnessing Disruptive Technology during the COVID-19 Pandemic and Beyond. Semin Ophthalmol 2021; 36:296-303. [PMID: 33755525 DOI: 10.1080/08820538.2021.1896753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Spurred by the coronavirus disease pandemic and shortage of eye care providers, telemedicine is transforming the way ophthalmologists care for their patients. Video conferencing, ophthalmic imaging, hybrid visits, intraocular inflammation quantification, and portable technology are evolving areas that may allow more uveitis patients to be evaluated via telemedicine. Despite these promising disruptive technologies, there remain significant technological limitations, legal barriers, variable insurance coverage for virtual visits, and lack of clinical trials for uveitis specialists to embrace telemedicine.
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Affiliation(s)
- Daniel Brill
- Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - George Papaliodis
- Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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26
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Li Y, Mao X, Tang X, Mao H. Efficacy and Safety of Anti-TNFα Therapy for Uveitis Associated with Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analysis. Rheumatol Ther 2021; 8:711-727. [PMID: 33721267 PMCID: PMC8217376 DOI: 10.1007/s40744-021-00296-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/13/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction To investigate the efficacy and safety of anti-TNFα therapy in patients with juvenile idiopathic arthritis associated uveitis (JIA-U). Methods Embase, PubMed, Cochrane Library, and Web of Science were systematically searched for studies reporting anti-TNFα treatment in patients with JIA-U. The primary outcome was the control of intraocular inflammation (CII). The pooled proportion of CII was assessed by the random-effects method when I2 > 50%, otherwise, by the fixed-effect method. This study was registered with PROSPERO (CRD42020161749). Results Three randomized clinical trials (RCTs), twelve case series, three retrospective cohort studies, and three case reports were identified. A total of 399 patients were receiving anti-TNFα therapy, of which 201 patients were treated with adalimumab (ADA), 139 with infliximab (IFX), 36 with etanercept (ETA), 20 with golimumab (GLM), and 3 with certolizumab pegol (CZP). The pooled proportions of CII on observational studies were 82% (95% CI 63–96%) in patients receiving ADA, 56% (95% CI 30–80%) in IFX, 38% (95% CI 8–73%) in ETA and 65% (95% CI 42–86%) in GLM, respectively. All three patients treated with CZP reached improved activity. ADA therapy led to a significantly higher proportion of CII compared to IFX therapy (χ2 = 26.24, P < 0.001), or to ETA therapy (χ2 = 13.43, P < 0.001); but no statistical difference was observed between IFX and ETA (χ2 = 0.13, P = 0.71). As to safety, most reported adverse events were tolerable and two cohort studies consistently showed that ADA was safer than IFX. Conclusions The existing evidence suggests that ADA is better than IFX regarding efficacy and safety. The effectiveness of IFX is higher than ETA with no statistical difference. GLM and CZP may be proxies for ADA but the evidence is limited. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00296-x.
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Affiliation(s)
- Yulu Li
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaolan Mao
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huawei Mao
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
- Department of Immunology, National Center for Children's Health, Beijing Children's Hospital of Capital Medical University, Beijing, China.
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27
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Angeles-Han ST, Yeh S. Ophthalmology perspectives on the management of juvenile idiopathic arthritis-associated uveitis: Eyeing the need for global, multidisciplinary collaborations. Clin Exp Ophthalmol 2021; 49:12-14. [PMID: 33559366 DOI: 10.1111/ceo.13901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Ophthalmology, Cincinnati Children's Hospital Medical Center and Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Steven Yeh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
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28
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Smith JR, Matthews JM, Conrad D, Hall AJ, Niederer RL, Singh-Grewal D, Tay-Kearney ML, Wells JM, Zagora SL, McCluskey PJ. Recommendations for the management of childhood juvenile idiopathic arthritis-type chronic anterior uveitis. Clin Exp Ophthalmol 2021; 49:38-45. [PMID: 33426782 DOI: 10.1111/ceo.13856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 12/28/2022]
Abstract
IMPORTANCE Australian- and New Zealand-based, uveitis-specialized ophthalmologists have produced recommendations for the management of juvenile idiopathic arthritis (JIA)-type chronic anterior uveitis. BACKGROUND Historically, the visual prognosis of JIA-type chronic anterior uveitis has been poor. New medical advances are likely to improve outcomes, but recently published guidelines are tailored for ophthalmic care in Europe and the United States. DESIGN This work involved a consensus survey and a panel meeting. PARTICIPANTS The Australian and New Zealand JIA-Uveitis Working Group (29 ophthalmologists) participated in the work. METHODS The Delphi technique was used to achieve consensus. MAIN OUTCOME MEASURES This work yielded consensus statements. RESULTS The Working Group achieved consensus around 18 statements related to clinical evaluation, use of topical and regional corticosteroids, use of systemic corticosteroid and non-corticosteroid immunomodulatory drugs, and management of secondary cataract and glaucoma in childhood JIA-type uveitis. CONCLUSIONS AND RELEVANCE Recommendations of the Australian and New Zealand JIA-Uveitis Working Group provide current and regionally applicable advice for managing chronic anterior uveitis in children with JIA.
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Affiliation(s)
- Justine R Smith
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Janet M Matthews
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Diana Conrad
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Anthony J Hall
- Department of Ophthalmology, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael L Niederer
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Davinder Singh-Grewal
- Department of Rheumatology, The Sydney Children's Hospital, Sydney, New South Wales, Australia.,University of NSW School of Women and Children's Health, Sydney, New South Wales, Australia.,University of Sydney Discipline of Child & Adolescent Health, Sydney, New South Wales, Australia
| | - Mei-Ling Tay-Kearney
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Jane M Wells
- Ophthalmology Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Sophia L Zagora
- Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Peter J McCluskey
- Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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29
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Liebling EJ, Faig W, Chang JC, Mendoza E, Moore N, Ledesma Vicioso N, Lerman MA. The temporal relationship between juvenile idiopathic arthritis disease activity and uveitis activity. Arthritis Care Res (Hoboken) 2020; 74:349-354. [PMID: 33044800 DOI: 10.1002/acr.24483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine whether there is a temporal association between arthritis and uveitis activity among children with juvenile idiopathic arthritis-associated uveitis (JIA-U). METHODS Uveitis and arthritis data from JIA-U patients ≤21 years were collected from 7/2013-12/2019 at a tertiary care center. Arthritis activity was assessed at each rheumatology visit, and the primary outcome was the presence of active uveitis at ophthalmologic exams within 45 days of the rheumatology visit. Repeated measures logistic regression was used to evaluate the temporal association between any uveitis activity within 45 days of arthritis activity. Models were adjusted for demographic, disease, and treatment-related factors. RESULTS Ninety eight patients were included; 81 (82%) female, 67 (69%) anti-nuclear antibody positive, 59 (60%) oligoarticular and 13 (13%) enthesitis related arthritis (ERA) subtypes. There were 1229 rheumatology visits with a median of 13 visits per patient (interquartile range 7 - 18). Concordance between arthritis and uveitis activity was observed 73% (694/947) of the time. There was an independent temporal association between uveitis and arthritis activity, odds ratio (OR) 2.47 [95% confidence interval 1.72, 3.54; p<0.01], adjusted for demographic and disease characteristics. Use of combination biologic and non-biologic disease modifying anti-rheumatic drugs, female sex, HLA-B27 positivity, ERA and polyarticular (RF-) subtypes were associated with decreased odds of active uveitis at any time point. CONCLUSION In patients with JIA-U, there is a significant temporal association between arthritis and uveitis disease activity. These novel results suggest that an arthritis flare should prompt an expedited referral to the ophthalmologist.
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Affiliation(s)
- Emily J Liebling
- The Children's Hospital of Philadelphia, Division of Rheumatology, Philadelphia, PA, USA
| | - Walter Faig
- The Children's Hospital of Philadelphia, Research Institute, Philadelphia, PA, USA
| | - Joyce C Chang
- The Children's Hospital of Philadelphia, Division of Rheumatology, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Mendoza
- The Children's Hospital of Philadelphia, Division of Rheumatology, Philadelphia, PA, USA
| | - Nicholas Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Melissa A Lerman
- The Children's Hospital of Philadelphia, Division of Rheumatology, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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30
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Ramanan AV, Dick AD, Jones AP, Hughes DA, McKay A, Rosala-Hallas A, Williamson PR, Hardwick B, Hickey H, Rainford N, Hickey G, Kolamunnage-Dona R, Culeddu G, Plumpton C, Wood E, Compeyrot-Lacassagne S, Woo P, Edelsten C, Beresford MW. Adalimumab in combination with methotrexate for refractory uveitis associated with juvenile idiopathic arthritis: a RCT. Health Technol Assess 2020; 23:1-140. [PMID: 31033434 DOI: 10.3310/hta23150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Children with juvenile idiopathic arthritis (JIA) are at risk of uveitis. The role of adalimumab (Humira®; AbbVie Inc., Ludwigshafen, Germany) in the management of uveitis in children needs to be determined. OBJECTIVE To compare the efficacy, safety and cost-effectiveness of adalimumab in combination with methotrexate (MTX) versus placebo with MTX alone, with regard to controlling disease activity in refractory uveitis associated with JIA. DESIGN This was a randomised (applying a ratio of 2 : 1 in favour of adalimumab), double-blind, placebo-controlled, multicentre parallel-group trial with an integrated economic evaluation. A central web-based system used computer-generated tables to allocate treatments. A cost-utility analysis based on visual acuity was conducted and a 10-year extrapolation by Markov modelling was also carried out. SETTING The setting was tertiary care centres throughout the UK. PARTICIPANTS Patients aged 2-18 years inclusive, with persistently active JIA-associated uveitis (despite optimised MTX treatment for at least 12 weeks). INTERVENTIONS All participants received a stable dose of MTX and either adalimumab (20 mg/0.8 ml for patients weighing < 30 kg or 40 mg/0.8 ml for patients weighing ≥ 30 kg by subcutaneous injection every 2 weeks based on body weight) or a placebo (0.8 ml as appropriate according to body weight by subcutaneous injection every 2 weeks) for up to 18 months. A follow-up appointment was arranged at 6 months. MAIN OUTCOME MEASURES Primary outcome - time to treatment failure [multicomponent score as defined by set criteria based on the Standardisation of Uveitis Nomenclature (SUN) criteria]. Economic outcome - incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the NHS in England and Personal Social Services providers. Full details of secondary outcomes are provided in the study protocol. RESULTS A total of 90 participants were randomised (adalimumab, n = 60; placebo, n = 30). There were 14 (23%) treatment failures in the adalimumab group and 17 (57%) in the placebo group. The analysis of the data from the double-blind phase of the trial showed that the hazard risk (HR) of treatment failure was significantly reduced, by 75%, for participants in the adalimumab group (HR 0.25, 95% confidence interval 0.12 to 0.51; p < 0.0001 from log-rank test). The cost-effectiveness of adalimumab plus MTX was £129,025 per QALY gained. Adalimumab-treated participants had a much higher incidence of adverse and serious adverse events. CONCLUSIONS Adalimumab in combination with MTX is safe and effective in the management of JIA-associated uveitis. However, the likelihood of cost-effectiveness is < 1% at the £30,000-per-QALY threshold. FUTURE WORK A clinical trial is required to define the most effective time to stop therapy. Prognostic biomarkers of early and complete response should also be identified. TRIAL REGISTRATION Current Controlled Trials ISRCTN10065623 and European Clinical Trials Database number 2010-021141-41. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 15. See the NIHR Journals Library website for further project information. This trial was also funded by Arthritis Research UK (grant reference number 19612). Two strengths of adalimumab (20 mg/0.8 ml and 40 mg/0.8 ml) and a matching placebo were manufactured by AbbVie Inc. (the Marketing Authorisation holder) and supplied in bulk to the contracted distributor (Sharp Clinical Services, Crickhowell, UK) for distribution to trial centres.
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Affiliation(s)
- Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Dick
- Bristol Eye Hospital, Bristol, UK.,School of Clinical Sciences, University of Bristol, Bristol, UK.,University College London Institute of Ophthalmology and National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, UK
| | - Ashley P Jones
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Andrew McKay
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anna Rosala-Hallas
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Paula R Williamson
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Ben Hardwick
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Helen Hickey
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Graeme Hickey
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Giovanna Culeddu
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Eifiona Wood
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | | | | | | | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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31
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Orès R, Terrada C, Errera MH, Thorne JE, Doukhan R, Cassoux N, Penaud B, LeHoang P, Quartier PM, Bodaghi B. Laser Flare Photometry: A Useful Tool for Monitoring Patients with Juvenile Idiopathic Arthritis-associated Uveitis. Ocul Immunol Inflamm 2020; 30:118-128. [PMID: 32835572 DOI: 10.1080/09273948.2020.1792511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE We evaluated laser flare photometry (LFP) values in patients with juvenile idiopathic arthritis (JIA)-associated uveitis. METHODS Retrospective study. A decrease of the LFP value between baseline visit and 1 month after anti-inflammatory treatment intensification allowed us to define two groups of patients: group 1 (decreased LFP value ≥50%) and group 2 (<50%). We evaluated the prevalence of vision-threatening complications in both groups. RESULTS Fifty-four patients (87 eyes) were followed for 9.9 ± 5 years. Group 1 eyes (n = 54) had significantly fewer ocular complications than group 2 eyes (n = 33) at both 5 years visit (p = .03) and final visit (p = .047). At the final visit, group 2 eyes had significantly more band keratopathy, trabeculectomy, cataract surgery, glaucoma and papille edema. Group 1 eyes kept a better visual acuity (p < .0001). CONCLUSION The decrease of LFP values ≥50% of the initial value 1 month after treatment intensification is a good early prognostic factor.
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Affiliation(s)
- Raphaëlle Orès
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France.,Department of Ophthalmology, Quinze-Vingts National Eye Hospital, DHU View Restore, INSERM-DHOS CIC, Sorbonne Universités, UPMC Paris VI University, Paris, France
| | - Céline Terrada
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France.,Sorbonne University, UPMC University Paris 06, Paris, France
| | - Marie-Hélène Errera
- Department of Ophthalmology, Quinze-Vingts National Eye Hospital, DHU View Restore, INSERM-DHOS CIC, Sorbonne Universités, UPMC Paris VI University, Paris, France.,Sorbonne University, UPMC University Paris 06, Paris, France
| | - Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raphaël Doukhan
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France
| | - Nathalie Cassoux
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France.,Sorbonne University, UPMC University Paris 06, Paris, France.,Department of Ophthalmology, Curie Institute, Paris, France
| | - Benjamin Penaud
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France
| | - Phuc LeHoang
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France.,Sorbonne University, UPMC University Paris 06, Paris, France
| | - Pierre Marie Quartier
- Imagine Institute, Paris Descartes University, Paris, France.,Necker Hospital for Sick Children, Pediatric Hematology-Immunology and Rheumatology Unit, AP-HP, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, La Pitié-Salpétrière Hospital, DHU View Restore, Paris, France.,Sorbonne University, UPMC University Paris 06, Paris, France
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32
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Heiligenhaus A, Klotsche J, Niewerth M, Horneff G, Ganser G, Haas JP, Minden K. Similarities in clinical course and outcome between juvenile idiopathic arthritis (JIA)-associated and ANA-positive idiopathic anterior uveitis: data from a population-based nationwide study in Germany. Arthritis Res Ther 2020. [PMID: 32293540 DOI: 10.1186/s13075-020-2166-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND To analyze whether ANA-positive idiopathic anterior uveitis differs from JIA-associated uveitis concerning clinical course, response to treatment, and disease outcome. METHODS Prospective study of the National Paediatric Rheumatological Database (NPRD) including its uveitis add-on module from the years 2002 to 2016. Cross-sectional data from the years 2002 to 2016 were analyzed. Patients with JIA-associated uveitis and with ANA-positive idiopathic anterior uveitis were included and the disease manifestation investigated in terms of uveitis characteristics and disease course. RESULTS Of the total cohort of 34,458 patients enrolled in the NPRD, including 3551 patients with uveitis, those with detailed uveitis documentation were taken into account: 62 ANA-positive patients with idiopathic anterior uveitis (group 1), 688 patients with initial uveitis diagnosis after JIA onset (group 2), and 61 JIA patients with initial uveitis diagnosis before arthritis onset (group 3). Anterior uveitis was documented in 100%, 94%, and 80% of patients and with insidious onset of uveitis flare in 50%, 70.9%, and 56.1% each in groups 1, 2, and 3, respectively. Use of topical or systemic corticosteroids and conventional synthetic or biological DMARDs did not significantly differ between the patient groups, either at the initial or the 2-year follow-up (2-FU) visits (mean 2 years, each p > 0.05). At 2-FU, uveitis inactivity was achieved in 64.7%, 55.8%, and 61.5% of patients in groups 1, 2, and 3 (p > 0.05). Uveitis-related complications were more frequent at the initial visit and at 2-FU in groups 1 and 3, as compared to group 2. CONCLUSIONS ANA-positive idiopathic uveitis and JIA-associated uveitis do not significantly differ concerning clinical course of uveitis, treatment, and response to corticosteroids and DMARDs.
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Affiliation(s)
- Arnd Heiligenhaus
- Department of Ophthalmology at St. Franziskus Hospital, Muenster, Hohenzollernring 74, 48145, Muenster, Germany.
- University of Duisburg-Essen, Duisburg, Germany.
| | - Jens Klotsche
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
- Charité - University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Martina Niewerth
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin GmbH, Sankt Augustin, Germany
- Department of Pediatric and Adolescent Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Gerd Ganser
- Sankt Josef-Stift Sendenhorst, Sendenhorst, Germany
| | - Johannes-Peter Haas
- German Centre for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Kirsten Minden
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
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33
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Heiligenhaus A, Klotsche J, Niewerth M, Horneff G, Ganser G, Haas JP, Minden K. Similarities in clinical course and outcome between juvenile idiopathic arthritis (JIA)-associated and ANA-positive idiopathic anterior uveitis: data from a population-based nationwide study in Germany. Arthritis Res Ther 2020; 22:81. [PMID: 32293540 PMCID: PMC7161187 DOI: 10.1186/s13075-020-02166-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/27/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To analyze whether ANA-positive idiopathic anterior uveitis differs from JIA-associated uveitis concerning clinical course, response to treatment, and disease outcome. METHODS Prospective study of the National Paediatric Rheumatological Database (NPRD) including its uveitis add-on module from the years 2002 to 2016. Cross-sectional data from the years 2002 to 2016 were analyzed. Patients with JIA-associated uveitis and with ANA-positive idiopathic anterior uveitis were included and the disease manifestation investigated in terms of uveitis characteristics and disease course. RESULTS Of the total cohort of 34,458 patients enrolled in the NPRD, including 3551 patients with uveitis, those with detailed uveitis documentation were taken into account: 62 ANA-positive patients with idiopathic anterior uveitis (group 1), 688 patients with initial uveitis diagnosis after JIA onset (group 2), and 61 JIA patients with initial uveitis diagnosis before arthritis onset (group 3). Anterior uveitis was documented in 100%, 94%, and 80% of patients and with insidious onset of uveitis flare in 50%, 70.9%, and 56.1% each in groups 1, 2, and 3, respectively. Use of topical or systemic corticosteroids and conventional synthetic or biological DMARDs did not significantly differ between the patient groups, either at the initial or the 2-year follow-up (2-FU) visits (mean 2 years, each p > 0.05). At 2-FU, uveitis inactivity was achieved in 64.7%, 55.8%, and 61.5% of patients in groups 1, 2, and 3 (p > 0.05). Uveitis-related complications were more frequent at the initial visit and at 2-FU in groups 1 and 3, as compared to group 2. CONCLUSIONS ANA-positive idiopathic uveitis and JIA-associated uveitis do not significantly differ concerning clinical course of uveitis, treatment, and response to corticosteroids and DMARDs.
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Affiliation(s)
- Arnd Heiligenhaus
- Department of Ophthalmology at St. Franziskus Hospital, Muenster, Hohenzollernring 74, 48145, Muenster, Germany. .,University of Duisburg-Essen, Duisburg, Germany.
| | - Jens Klotsche
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany.,Charité - University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Martina Niewerth
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin GmbH, Sankt Augustin, Germany.,Department of Pediatric and Adolescent Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Gerd Ganser
- Sankt Josef-Stift Sendenhorst, Sendenhorst, Germany
| | - Johannes-Peter Haas
- German Centre for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Kirsten Minden
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
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34
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Rodriguez-Smith J, Yeh S, Angeles-Han S. Improving quick and accurate diagnosis of childhood JIA-uveitis from a pediatric rheumatology perspective. EXPERT REVIEW OF OPHTHALMOLOGY 2020; 15:101-109. [PMID: 32313548 PMCID: PMC7170263 DOI: 10.1080/17469899.2020.1739521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/04/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease associated with uveitis. JIA-associated uveitis (JIA-U) is typically asymptomatic, chronic, and can lead to sight-threatening complications. This review will provide approaches to improve the diagnosis and outcomes of children with JIA-U. AREAS COVERED We will provide updates on risk factors for uveitis onset and ocular complications, improvements in the ophthalmic screening schedule for uveitis detection, and potential strategies to advance the diagnosis and monitoring of JIA-U using advanced ophthalmic imaging and diagnostic equipment and laboratory biomarkers. EXPERT OPINION There is a lack of high-quality research in JIA-U and few randomized controlled trials, underscoring the urgent need for further studies in this population. Early uveitis diagnosis combined with timely and appropriate treatment can improve visual outcomes. Improved knowledge of uveitis pathogenesis, risk factors for uveitis onset, measurement of uveitis outcomes, and optimal treatment are crucial.
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Affiliation(s)
- Jackeline Rodriguez-Smith
- Cincinnati Children's Hospital Medical Center, Division of Rheumatology, 3333 Burnett Avenue, Cincinnati, Ohio 45229-3026, United States
| | - Steven Yeh
- Emory Eye Center, Department of Ophthalmology, Atlanta, Georgia 30322-1013, United States
| | - Sheila Angeles-Han
- Cincinnati Children's Hospital Medical Center, Division of Rheumatology, 3333 Burnett Avenue, Cincinnati, Ohio 45229-3026, United States
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35
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Schnabel A, Unger E, Brück N, Berner R, Range U, Holl-Wieden A, Morbach H, Leszczynska A, Bau V, Hedrich CM. High-dose intravenous methylprednisolone in juvenile non-infectious uveitis: A retrospective analysis. Clin Immunol 2019; 211:108327. [PMID: 31863906 DOI: 10.1016/j.clim.2019.108327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/24/2022]
Abstract
Non-infectious uveitis is associated with visual impairment and blindness. Non-biologic treatment for non-infectious uveitis is not based on strong evidence. A retrospective chart review was conducted to investigate treatment response to high-dose intravenous methylprednisolone (IVMP) in children with non-infectious uveitis. Fifty-six patients (93 eyes affected) were included. In 29% uveitis was associated with juvenile idiopathic arthritis. Uveitis predominately affected the anterior segment, was bilateral and recurrent. Complications were common and included visual loss, synechiae, cataract and/or retinal lesions. Patients received up to 5 IVMP at monthly intervals. Visual acuity improved at 3 and 6 months. Anterior chamber cells, synechiae, keratic precipitates, papillary and/or macular edema improved at 3 months. Children treated with ≥3 IVMP (vs 1 IVMP) experienced trends towards fewer relapses, fewer cataracts and less frequently required treatment with biologic agents. High-dose IVMP induce rapid improvement in children with non-infectious uveitis. Prospective randomized trials are required to confirm results.
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Affiliation(s)
- Anja Schnabel
- Pediatric Rheumatology, Department of Pediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany.
| | - Elisabeth Unger
- Pediatric Rheumatology, Department of Pediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Normi Brück
- Pediatric Rheumatology, Department of Pediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Reinhard Berner
- Pediatric Rheumatology, Department of Pediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ursula Range
- Institute for Medical Informatics and Biometry, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Annette Holl-Wieden
- Pediatric Rheumatology, Department of Pediatrics, University of Würzburg, Würzburg, Germany
| | - Henner Morbach
- Pediatric Rheumatology, Department of Pediatrics, University of Würzburg, Würzburg, Germany
| | - Anna Leszczynska
- Department of Ophthalmology, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Viktoria Bau
- Department of Ophthalmology, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Christian M Hedrich
- Pediatric Rheumatology, Department of Pediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany; Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom.
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36
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Miraldi Utz V, Bulas S, Lopper S, Fenchel M, Sa T, Mehta M, Ash D, Lovell DJ, Kaufman AH. Effectiveness of long-term infliximab use and impact of treatment adherence on disease control in refractory, non-infectious pediatric uveitis. Pediatr Rheumatol Online J 2019; 17:79. [PMID: 31783768 PMCID: PMC6884783 DOI: 10.1186/s12969-019-0383-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Refractory non-infectious uveitis is a serious condition that leads to ocular complications and vision loss and requires effective systemic treatment to control disease. The effectiveness of long-term infliximab [IFX] in refractory non-infectious childhood uveitis and the impact of treatment adherence on disease control were evaluated. METHODS Retrospective, single-center study between December 2002 and April 2016 of 27 children with refractory non-infectious uveitis [17 with juvenile idiopathic arthritis, JIA] treated with long-term IFX [9+ months]. Disease activity was assessed prior to and while on IFX using the Standardization of Uveitis Nomenclature [SUN]. Number of visits per year with active uveitis was analyzed by repeated measures logistic regression analysis from 2 years prior to IFX initiation or from onset of uveitis until most recent visit on IFX. Incomplete treatment adherence was assessed for each visit and defined as any deviance in corticosteroid use, prescribed infusion frequency, and/or follow-up examination frequency. RESULTS Primary outcomes were sustained uveitic and systemic disease control prior to and during IFX treatment and the impact of incomplete adherence on uveitic disease control while on IFX. Secondary outcomes included corticosteroid and glaucoma medication requirement, ocular complications and need for surgical intervention. Mean age at IFX initiation was 10.4 ± 4.5 years; initial mean dose was 6.6 ± 2.2 mg/kg [and given at weeks 0, 2, 4 and q4 weeks thereafter for 93%]. Median duration on IFX was 35 [range 9-128] months. Prior to IFX, 14/27 patients had failed adalimumab ± methotrexate [MTX]; 21/27 failed MTX. IFX led to uveitis control in 89% and arthritis control in 76% (13/17). The odds ratio of having controlled disease after IFX was 4.1 (2.6, 6.4) compared to pre-treatment visits. Topical corticosteroids and glaucoma medications were statistically decreased (p = 0.007 right eye [OD], 0.003 left eye [OS] and p = 0.001 OD, p = 0.028 OS respectively). Incomplete adherence to treatment showed 10.3 times greater odds (7.1, 15.0) of having disease activity than full adherence. CONCLUSIONS This study adds significantly to the IFX literature by documenting outstanding uveitis control with long-term IFX treatment in non-infectious pediatric uveitis patients. Higher dosage and shorter interval were utilized without adverse effects. Importantly, this is the first study, to our knowledge, to document the significant impact of treatment adherence on uveitis control.
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Affiliation(s)
- Virginia Miraldi Utz
- Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
| | - Sabrina Bulas
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA
| | - Sarah Lopper
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA
| | - Matthew Fenchel
- 0000 0000 9025 8099grid.239573.9Department of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Ting Sa
- 0000 0000 9025 8099grid.239573.9Department of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Mitul Mehta
- 0000 0001 0668 7243grid.266093.8Gavin Herbert Eye Institute, University of California, Irvine, CA USA
| | - Daniel Ash
- 0000 0004 1936 7822grid.170205.1Department of Medicine, University of Chicago, Chicago, IL USA
| | - Daniel J. Lovell
- 0000 0000 9025 8099grid.239573.9Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Adam H. Kaufman
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA ,grid.418609.2Cincinnati Eye Institute, Cincinnati, OH USA
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Kim L, Li A, Angeles-Han S, Yeh S, Shantha J. Update on the management of uveitis in children: an overview for the clinician. EXPERT REVIEW OF OPHTHALMOLOGY 2019; 14:211-218. [PMID: 32831897 PMCID: PMC7437956 DOI: 10.1080/17469899.2019.1663731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/02/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pediatric uveitis comprises a range of ocular inflammatory diseases that may lead to vision impairment, often due to ocular complications from the disease itself or side effects of therapies. The impact on vision, visual functioning, and vision-related quality-of-life over the lifetime horizon can be substantial, underscoring the importance of appropriate ophthalmic evaluation, diagnostic testing and treatment. This review focuses on the anatomic classification, laboratory diagnosis, associated systemic diseases, and management of pediatric uveitis. AREAS COVERED A review of the literature was performed to synthesize our current understanding of the anatomic classification of pediatric uveitis, disease epidemiology, associated systemic diseases, and management principles. We also review important corticosteroid-sparing strategies including non-biologic and biologic agents such as the anti-tumor necrosis factor (TNF)-alpha family of medications, given their key role in the treatment of pediatric uveitis, particularly juvenile idiopathic arthritis (JIA). Recent advances in the assessment of vision-related quality-of-life using the Effects of Youngsters' Eyesight on Quality of Life (EYE-Q) instrument are discussed. EXPERT OPINION Pediatric uveitis can lead to long-term vision impairment if not appropriately screened and treated. JIA is the most common systemic disease associated with uveitis, is typically asymptomatic, and thus requires rigorous screening to detect uveitis and avoid secondary ocular complications. While topical and systemic corticosteroids are useful for the acute treatment of uveitis, the disease chronicity of many pediatric uveitis syndromes including JIA, often warrants early escalation of therapy to immunosuppressive medications including methotrexate (MTX) and anti-TNF-alpha inhibitors. Future directions include an improved understanding of risk factors for uveitis and better metrics to evaluate the impact of disease on vision-related quality-of-life of pediatric uveitis patients.
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Affiliation(s)
- Lucas Kim
- Mercer University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alexa Li
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sheila Angeles-Han
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jessica Shantha
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
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Mastrangelo G, Foeldvari I, Anton J, Simonini G. Defining outcome measures in juvenile idiopathic arthritis associated uveitis by a systematic review analysis: do we need a consensus? Pediatr Rheumatol Online J 2019; 17:40. [PMID: 31296236 PMCID: PMC6625008 DOI: 10.1186/s12969-019-0330-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/17/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis associated Uveitis (JIA-U) represents its most frequent extra-articular manifestation and the main cause of childhood uveitis in in developed countries. The broad variety of outcome measures utilized makes the comparison of the disease course, risk for complications, impairment in visual function, and responses to treatment quite difficult. Our aim was to summarize evidence regarding the current availability of outcome measures in JIA-U. METHODS A systematic review between January 2000 and December 2018 was performed to identify studies investigating outcome measures used in JIA-U. RESULTS The initial search identified 8254 articles of which 89 were potentially eligible. After the full text revision, a total of 27 studies, including 2 RCTs, were included. Among these studies 12 outcome measures for JIA-U use have been identified (grade of cells in the AC, grade of flare in the AC, VA, amblyopia, structural complications, use and sparing of oral corticosteroids and immunosuppressive drugs, surgery requirement, biomarkers, bilateral disease, JIA persistence, quality of life assessments, uveitis subtype). As regards primary outcome measures, 44% among studies included one or more variables related to disease activity (i.e. grade of flare, grade of cells); 56% included visual function performance (i.e. visual acuity); 68% (17/25) included one or more variables of disease-associated tissue damage or complications (i.e. cataract, amblyopia); 24% included disease features (i.e. bilateral disease; uveitis subtype); 44% included laboratory features (i.e. biomarkers); 8% included JIA features (i.e. persistence of disease); 12% included quality of life (i.e. EYE-Q); 44% included management (i.e. use and sparing of oral corticosteroids and other immunosuppressive drugs; surgery requirement). CONCLUSIONS Our systematic review surveys the heterogeneity around outcome measures related to JIA-U in children, even in RCTs. It does not provide the solution to overcome the heterogeneity in uveitis studies, but it does provide an estimate of the scale of the problems and provides data to inform this important debate; highlighting the requirement to obtain a new consensus regarding a common approach to identify suitable and efficient outcome measures in JIA-U.
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Affiliation(s)
- Greta Mastrangelo
- Rheumatology Unit, Anna Meyer Children's Hospital, Pediatric Section-NEUROFARBA Department, University of Florence, Florence, Italy.
| | - Ivan Foeldvari
- 0000 0004 0581 2913grid.491620.8Centre for Pediatric and Adolescence Rheumatology, An der Schön Klinik, Hamburg, Eilbek Germany
| | - Jordi Anton
- 0000 0001 0663 8628grid.411160.3Pediatric Rheumatology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Gabriele Simonini
- 0000 0004 1757 2304grid.8404.8Rheumatology Unit, Anna Meyer Children’s Hospital, Pediatric Section-NEUROFARBA Department, University of Florence, Florence, Italy
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Varnier GC, Ciurtin C. Paediatric and adolescent rheumatic diseases: measures of disease activity. Br J Hosp Med (Lond) 2019; 80:338-342. [PMID: 31180784 DOI: 10.12968/hmed.2019.80.6.338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Juvenile idiopathic arthritis, juvenile systemic lupus erythematosus and juvenile dermatomyositis are rare, chronic, multi-systemic rheumatic disorders that can be associated with significant morbidity, not only during childhood, but lifelong. Dedicated disease activity and damage assessment tools are essential to guide clinical management and perform multicentre clinical trials to ensure the best possible care and outcome for children with rheumatic diseases using an evidence-based, treat-to-target approach. This article summarizes the outcome measures most commonly used in paediatric rheumatology.
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Affiliation(s)
- Giulia C Varnier
- Clinical Research Fellow in Adolescent Rheumatology, Department of Rheumatology, University London College, London WC1E 6BT
| | - Coziana Ciurtin
- Consultant in Adolescent and Adult Rheumatology, Department of Rheumatology, University London College Hospital NHS Trust, London
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Solebo AL, Rahi JS, Dick AD, Ramanan AV, Ashworth J, Edelsten C. Areas of agreement in the management of childhood non-infectious chronic anterior uveitis in the UK. Br J Ophthalmol 2019; 104:11-16. [PMID: 31048286 DOI: 10.1136/bjophthalmol-2018-313789] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS There is a paucity of high-level evidence to support the management of childhood uveitis, particularly for those children without juvenile idiopathic arthritis uveitis (JIA). We undertook a modified Delphi consensus exercise to identify agreement in the management of chronic anterior uveitis (CAU), the most common manifestation of childhood disease. METHODS A four-round, two-panel process was undertaken between June and December 2017. Paediatric uveitis specialists identified through multiple sources, including a multicentre network (the Paediatric Ocular Inflammation Group), were invited to participate. They were asked whether they agreed with items derived from existing guidelines on the management of JIA-U when extrapolated to the population of all children with CAU. Consensus was defined as agreement greater than or equal to 75% of respondents. RESULTS 26 of the 38 (68%) invited specialists participated with the exercise, and response rates were 100% for rounds one to three, and 92% for round four. Consensus was reached on 23 of the 44 items. Items for which consensus was not reached included management at presentation, use of systemic and periocular steroids for children with severe disease and the role of conventional steroid sparing immunosuppressants beyond methotrexate. CONCLUSION The areas of management uncertainty at the level of the group, as indicated by absence of consensus, reflect the areas where the evidence base is particularly poor. Our findings identify the key areas for the future research needed to ensure better outcomes for this blinding childhood ocular inflammatory disorders.
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Affiliation(s)
- Ameenat Lola Solebo
- Lifecourse Epidemiology and Biostatistics Section, Population, Policy and Practice Programme, Great Ormond Street Institute of Child Health University College London, London, UK .,NIHR Biomedical Research Centre at Moorfields Eye Hospital and Institute of Ophthalmology, University College London, London, UK.,Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Great Ormond Street Hospital and Institute of Child Heath, UniversityCollege London, London, UK
| | - Jugnoo S Rahi
- Lifecourse Epidemiology and Biostatistics Section, Population, Policy and Practice Programme, Great Ormond Street Institute of Child Health University College London, London, UK.,NIHR Biomedical Research Centre at Moorfields Eye Hospital and Institute of Ophthalmology, University College London, London, UK.,Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Great Ormond Street Hospital and Institute of Child Heath, UniversityCollege London, London, UK
| | - Andrew D Dick
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and Institute of Ophthalmology, University College London, London, UK.,Ophthalmology Department, University of Bristol, Bristol, UK
| | - Athimalaipet V Ramanan
- Bristol Medical School Translational Health Sciences, University of Bristol, Bristol, UK
| | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Trust, Manchester, UK
| | - Clive Edelsten
- Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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41
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Angeles-Han ST, Ringold S, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Holland GN, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Sen HN, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis. Arthritis Care Res (Hoboken) 2019; 71:703-716. [PMID: 31021540 DOI: 10.1002/acr.23871] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop recommendations for the screening, monitoring, and treatment of uveitis in children with juvenile idiopathic arthritis (JIA). METHODS Pediatric rheumatologists, ophthalmologists with expertise in uveitis, patient representatives, and methodologists generated key clinical questions to be addressed by this guideline. This was followed by a systematic literature review and rating of the available evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A group consensus process was used to compose the final recommendations and grade their strength as conditional or strong. RESULTS Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion. Regular ophthalmic screening of children with JIA is recommended because of the risk of uveitis, and the frequency of screening should be based on individual risk factors. Regular ophthalmic monitoring of children with uveitis is recommended, and intervals should be based on ocular examination findings and treatment regimen. Ophthalmic monitoring recommendations were strong primarily because of concerns of vision-threatening complications of uveitis with infrequent monitoring. Topical glucocorticoids should be used as initial treatment to achieve control of inflammation. Methotrexate and the monoclonal antibody tumor necrosis factor inhibitors adalimumab and infliximab are recommended when systemic treatment is needed for the management of uveitis. The timely addition of nonbiologic and biologic drugs is recommended to maintain uveitis control in children who are at continued risk of vision loss. CONCLUSION This guideline provides direction for clinicians and patients/parents making decisions on the screening, monitoring, and management of children with JIA and uveitis, using GRADE methodology and informed by a consensus process with input from rheumatology and ophthalmology experts, current literature, and patient/parent preferences and values.
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Affiliation(s)
- Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gary N Holland
- UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - H Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Rayfel Schneider
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Angeles-Han ST, Ringold S, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Holland GN, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Sen HN, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis. Arthritis Rheumatol 2019; 71:864-877. [PMID: 31021511 DOI: 10.1002/art.40885] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop recommendations for the screening, monitoring, and treatment of uveitis in children with juvenile idiopathic arthritis (JIA). METHODS Pediatric rheumatologists, ophthalmologists with expertise in uveitis, patient representatives, and methodologists generated key clinical questions to be addressed by this guideline. This was followed by a systematic literature review and rating of the available evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A group consensus process was used to compose the final recommendations and grade their strength as conditional or strong. RESULTS Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion. Regular ophthalmic screening of children with JIA is recommended because of the risk of uveitis, and the frequency of screening should be based on individual risk factors. Regular ophthalmic monitoring of children with uveitis is recommended, and intervals should be based on ocular examination findings and treatment regimen. Ophthalmic monitoring recommendations were strong primarily because of concerns of vision-threatening complications of uveitis with infrequent monitoring. Topical glucocorticoids should be used as initial treatment to achieve control of inflammation. Methotrexate and the monoclonal antibody tumor necrosis factor inhibitors adalimumab and infliximab are recommended when systemic treatment is needed for the management of uveitis. The timely addition of nonbiologic and biologic drugs is recommended to maintain uveitis control in children who are at continued risk of vision loss. CONCLUSION This guideline provides direction for clinicians and patients/parents making decisions on the screening, monitoring, and management of children with JIA and uveitis, using GRADE methodology and informed by a consensus process with input from rheumatology and ophthalmology experts, current literature, and patient/parent preferences and values.
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Affiliation(s)
- Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gary N Holland
- UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - H Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Rayfel Schneider
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Yasumura J, Yashiro M, Okamoto N, Shabana K, Umebayashi H, Iwata N, Okura Y, Kubota T, Shimizu M, Tomiita M, Nakagishi Y, Nishimura K, Hara R, Mizuta M, Yasumi T, Yamaide F, Wakiguchi H, Kobayashi M, Mori M. Clinical features and characteristics of uveitis associated with juvenile idiopathic arthritis in Japan: first report of the pediatric rheumatology association of Japan (PRAJ). Pediatr Rheumatol Online J 2019; 17:15. [PMID: 30975163 PMCID: PMC6460824 DOI: 10.1186/s12969-019-0318-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/01/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although there are many reports on Juvenile Idiopathic arthritis-associated uveitis (JIA-U) from various countries, especially from Europe and North America, there are few reports from Asia. Our aim was to investigate the epidemiology, characteristics and predictors of JIA-U in Japan. METHODS Data were retrospectively collected on 726 patients with JIA from medical records as of April 2016 at 15 medical centers specialized in pediatric rheumatic diseases. Of these, patients with uveitis were further investigated for the specific characteristics of this manifestation. RESULTS The prevalence of uveitis was 6.1% in the 726 JIA patients examined. Incidence of uveitis was significantly higher in patients with an earlier arthritis onset (2.6-vs.-5.8 years, P < 0.0001), oligoarthritis (16.1%-vs.-1.6%, P < 0.001), or anti-nuclear antibodies. On the contrary, it was significantly less common in patients with rheumatoid factor or anti-cyclic citrullinated peptide antibodies. A history of using methotrexate (MTX), infliximab or adalimumab was also associated with uveitis occurrence. The median age at uveitis diagnosis was 5 years, and the median time from arthritis onset to uveitis diagnosis was 2 years. The occurrence of anterior and bilateral uveitis was 79.3 and 53.7%, respectively. There were no symptoms at uveitis diagnosis in 58.5% of cases. Complications arising between the time of uveitis diagnosis and the last observation increased from 31.7 to 56.1%; in particular, cataract was increased 3-fold. While no patients lost their vision, 61.9% did not recover normal vision (≥ 1.0), and in many cases active uveitis persisted, especially in males. In addition to steroid eye drops (97.6%) and MTX (15.4%), biological agents were used for treating the uveitis in 41.5% of patients. CONCLUSIONS The epidemiology, characteristics and predictors of JIA-U in Japan are described here for the first time. Although the prevalence of JIA-U in Japan is lower than in predominantly Caucasian cohorts, as reported from North America and Europe, the epidemiology, characteristics and predictors were found to be similar.
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Affiliation(s)
- Junko Yasumura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Masato Yashiro
- 0000 0004 0631 9477grid.412342.2Department of Pediatrics, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | - Nami Okamoto
- 0000 0001 2109 9431grid.444883.7Department of Pediatrics, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, 569-8686 Japan
| | - Kosuke Shabana
- 0000 0001 2109 9431grid.444883.7Department of Pediatrics, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, 569-8686 Japan
| | - Hiroaki Umebayashi
- 0000 0004 0471 4457grid.415988.9Department of General Pediatrics, Miyagi Children’s Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126 Japan
| | - Naomi Iwata
- Department of Immunology and Infectious Diseases, Aichi Children’s Health and Medical Center, 7-426 Morioka-cho, Obu, Aichi, 474-8710 Japan
| | - Yuka Okura
- Department of Pediatrics, KKR Sapporo Medical Center, 6-3-40 Hiragishi 1-jo, Toyohira-ku, Sapporo, 062-0931 Japan
| | - Tomohiro Kubota
- 0000 0004 0377 8088grid.474800.fDepartment of Pediatrics, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, 890-0075 Japan
| | - Masaki Shimizu
- 0000 0001 2308 3329grid.9707.9Department of Pediatrics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641 Japan
| | - Minako Tomiita
- 0000 0004 0632 2959grid.411321.4Department of Allergy and Rheumatology, Chiba Children’s Hospital, 579-1 Heta-cho, Midori-ku, Chiba, 266-0007 Japan
| | - Yasuo Nakagishi
- grid.415413.6Department of Pediatric Rheumatology, Hyogo Prefectural Kobe Children’s Hospital, 1-6-7 Minatojimaminami-machi, Chuo-ku, Kobe, 650-0047 Japan
| | - Kenichi Nishimura
- 0000 0001 1033 6139grid.268441.dDepartment of Pediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan
| | - Ryoki Hara
- 0000 0001 1033 6139grid.268441.dDepartment of Pediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan
| | - Mao Mizuta
- 0000 0001 2308 3329grid.9707.9Department of Pediatrics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641 Japan
| | - Takahiro Yasumi
- 0000 0004 0372 2033grid.258799.8Department of Pediatrics, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan
| | - Fumiya Yamaide
- 0000 0004 0370 1101grid.136304.3Department of Pediatrics, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670 Japan
| | - Hiroyuki Wakiguchi
- 0000 0001 0660 7960grid.268397.1Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, 755-8505 Japan
| | - Masao Kobayashi
- 0000 0000 8711 3200grid.257022.0Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Masaaki Mori
- 0000 0001 1014 9130grid.265073.5Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
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Angeles-Han ST, Lo MS, Henderson LA, Lerman MA, Abramson L, Cooper AM, Parsa MF, Zemel LS, Ronis T, Beukelman T, Cox E, Sen HN, Holland GN, Brunner HI, Lasky A, Rabinovich CE. Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans for Juvenile Idiopathic Arthritis-Associated and Idiopathic Chronic Anterior Uveitis. Arthritis Care Res (Hoboken) 2019; 71:482-491. [PMID: 29806733 PMCID: PMC6261704 DOI: 10.1002/acr.23610] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 05/22/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Systemic immunosuppressive treatment of pediatric chronic anterior uveitis (CAU), both juvenile idiopathic arthritis-associated and idiopathic anterior uveitis, varies, making it difficult to identify best treatments. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) for CAU for the purpose of reducing practice variability and allowing future comparison of treatments using comparative effectiveness analysis techniques. METHODS A core group of pediatric rheumatologists, ophthalmologists with uveitis expertise, and a lay advisor comprised the CARRA uveitis workgroup that performed a literature review on pharmacologic treatments, held teleconferences, and developed a case-based survey administered to the CARRA membership to delineate treatment practices. We held 3 face-to-face consensus meetings using nominal group technique to develop CTPs. RESULTS The survey identified areas of treatment practice variability. We developed 2 CTPs for the treatment of CAU, case definitions, and monitoring parameters. The first CTP is directed at children who are naive to steroid-sparing medication, and the second at children initiating biologic therapy, with options for methotrexate, adalimumab, and infliximab. We defined a core data set and outcome measures, with data collection at 3 and 6 months after therapy initiation. The CARRA membership voted to accept the CTPs with a >95% approval (n = 233). CONCLUSION Using consensus methodology, 2 standardized CTPs were developed for systemic immunosuppressive treatment of CAU. These CTPs are not meant as treatment guidelines, but are designed for further pragmatic research within the CARRA research network. Use of these CTPs in a prospective comparison effectiveness study should improve outcomes by identifying best practice options.
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Affiliation(s)
- Sheila T. Angeles-Han
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Leslie Abramson
- Vermont Children’s Hospital at University of Vermont Medical Center, Burlington, VT
| | | | | | | | - Tova Ronis
- Children’s National Health System, Washington, DC
| | | | | | - H. Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Gary N. Holland
- UCLA Stein Eye Institute and David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Hermine I. Brunner
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Andrew Lasky
- Randall Children’s Hospital at Legacy Emmanuel, Portland, OR
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Accorinti M, Okada AA, Smith JR, Gilardi M. Epidemiology of Macular Edema in Uveitis. Ocul Immunol Inflamm 2019; 27:169-180. [DOI: 10.1080/09273948.2019.1576910] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Massimo Accorinti
- Department of Ophthalmology, Sapienza University of Rome, Rome, Italy
| | - Annabelle A. Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
| | - Justine R. Smith
- Flinders University College of Medicine & Public Health, Adelaide, Australia
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Timing of infliximab and adalimumab initiation despite methotrexate in children with chronic non-infectious anterior uveitis. Eye (Lond) 2018; 33:629-639. [PMID: 30487588 DOI: 10.1038/s41433-018-0283-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/24/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Methotrexate (MTX) is standard treatment in pediatric chronic anterior uveitis (CAU). Addition of tumor necrosis factor-α inhibitors (TNFi) is often needed. We describe the timing and risk factors for TNFi use in children with CAU on MTX. METHODS In this retrospective study, we reviewed 51 records, and 46 met inclusion criteria. Primary outcome was the addition of TNFi due to active CAU per Standardization of Uveitis Nomenclature criteria. Time to TNFi and factors associated with their addition were assessed using survival analysis models. RESULTS Of 46 children treated with MTX for uveitis (36 juvenile idiopathic arthritis-associated uveitis, 10 idiopathic CAU), 72% had ocular complications. MTX was started a median of 5.0 months, and TNFi 43 months from uveitis diagnosis. Kaplan-Meier estimates suggest that cumulatively, 12% (95% CI: 4-23%) start TNFi within 6 months of MTX, 21% (12-37%) within 1 year, and 39% (24-54%) within 2 years. On Cox Proportional Hazard regression analysis, children with idiopathic CAU required TNFi earlier in their uveitis course (at 3 months (Hazard Ratio 6.06; 95% confidence interval (1.25-29.41))). Females appeared less likely to require TNFi early. Children treated in 2012 and later were more likely to receive TNFi earlier than those treated before 2012. CONCLUSION Little is known about optimal time to initiate treatment or factors associated with the need to add TNFi in children on MTX. Children with idiopathic CAU and males required TNFi earlier in their course. Factors associated with these potential risk factors for TNFi warrant further investigation.
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Angeles-Han ST, Yeh S, Patel P, Duong D, Jenkins K, Rouster-Stevens KA, Altaye M, Fall N, Thornton S, Prahalad S, Holland GN. Discovery of tear biomarkers in children with chronic non-infectious anterior uveitis: a pilot study. J Ophthalmic Inflamm Infect 2018; 8:17. [PMID: 30327966 PMCID: PMC6191408 DOI: 10.1186/s12348-018-0156-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Biomarkers in easily obtained specimens that accurately predict uveitis in children with juvenile idiopathic arthritis (JIA) are needed. Aqueous humor has been studied for biomarkers, but is not routinely available. We evaluated tears from children with chronic anterior uveitis (CAU) for biomarkers reported in aqueous humor. In this pilot study, we used Schirmer strips to collect tears from seven children (nine eyes); three children had JIA- associated uveitis (JIA-U) and four had idiopathic disease (I-CAU). Liquid chromatography-tandem mass spectrometry was used to identify and quantify tear proteins. The Mann-Whitney U test identified differential tear protein expression between children with JIA-U and those with I-CAU. RESULTS S100A9, LAP3, TTR, MIF, sCD14, S100A8, and SAA1 were detected in tears of all children; the same cytokines have been reported in aqueous humor of children with JIA-U. Tears from children with JIA-U had higher expression of proteins associated with inflammatory arthritis (SEMA3G, TIMP1, HEXB, ERN1, and SAA1) than tears from those with I-CAU. In addition, we found higher expression of sCD14, S100A8, and SAA1, but lower expression of S100A9, LAP3, TTR, and MIF, in tears from children with JIA-U compared to tears from those with I-CAU. CONCLUSIONS Tears contain similar cytokine profiles to aqueous humor in children with CAU and may be a clinically useful source of disease biomarkers. Tears from children with JIA-U also contain cytokines associated with inflammatory arthritis; furthermore, differential expression of other tear proteins as well may provide clues to intrinsic differences between JIA-U and I-CAU, despite their similar clinical phenotypes.
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Affiliation(s)
- Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4010, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
| | - Steven Yeh
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, 1365 Clifton Rd B, Atlanta, GA, 30322, USA
| | - Purnima Patel
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, 1365 Clifton Rd B, Atlanta, GA, 30322, USA
| | - Duc Duong
- Emory Integrated Proteomics Core, Emory University, 1510 Clifton Rd, Atlanta, GA, 30322, USA
| | - Kirsten Jenkins
- Childrens Healthcare of Atlanta, Emory Children's Center, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - Kelly A Rouster-Stevens
- Childrens Healthcare of Atlanta, Emory Children's Center, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mekibib Altaye
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 5041, Cincinnati, OH, 45229, USA
| | - Ndate Fall
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4010, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Sherry Thornton
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4010, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Sampath Prahalad
- Childrens Healthcare of Atlanta, Emory Children's Center, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Gary N Holland
- UCLA Stein Eye Institute and David Geffen School of Medicine at University of California, 100 Stein Plaza, Los Angeles, CA, 90095-7000, USA
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Batu ED. Glucocorticoid treatment in juvenile idiopathic arthritis. Rheumatol Int 2018; 39:13-27. [PMID: 30276425 DOI: 10.1007/s00296-018-4168-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/26/2018] [Indexed: 01/17/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of joints in childhood. Glucocorticoids are being used in JIA treatment effectively for decades. Although systemic glucocorticoid use decreased with the introduction of biologic drugs, intraarticular glucocorticoid injections (IAGI) with nonsteroidal anti-inflammatory drugs and non-biologic disease modifying anti-rheumatic drugs (DMARDs) still remain the primary treatment in JIA, especially in oligoarticular subcategory. Systemic glucocorticoids are used mainly for severe JIA-associated complications such as macrophage activation syndrome (MAS), myocarditis, pericarditis, pleuritis, peritonitis, and severe anemia; as bridging therapy while waiting for the full therapeutic effect of DMARDs; and in certain occasions for patients with severe refractory uveitis. Since glucocorticoid administration is associated with many adverse events, it is important to use glucocorticoids in an optimum way balancing the risks and benefits. The aim of this review is to summarize the current knowledge on glucocorticoid treatment in JIA. A comprehensive literature search was conducted utilizing the Cochrane Library and MEDLINE/PubMed databases. The main topics include mechanism of action, dose, duration, adverse events, vaccination during glucocorticoid treatment, the place of glucocorticoids in JIA treatment guidelines and consensus treatment plans, glucocorticoid use in JIA-associated uveitis, MAS, and IAGI. Data from the literature provide guidance on how to use glucocorticoids in JIA treatment especially for IAGI and systemic use in systemic JIA and MAS. However, there is lack of evidence and need for prospective randomized studies in most parts including the indications in different JIA subcategories, optimum dose/route of administration/duration of treatment, and tapering strategies.
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Affiliation(s)
- Ezgi Deniz Batu
- Department of Pediatrics, Division of Rheumatology, Ankara Training and Research Hospital, University of Health Sciences, Ankara, 06100, Turkey.
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Chronic Anterior Uveitis in Children: Psychosocial Challenges for Patients and Their Families. Am J Ophthalmol 2018; 191:xvi-xxiv. [PMID: 29601821 DOI: 10.1016/j.ajo.2018.03.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/18/2018] [Accepted: 03/20/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe issues of concern to children with chronic anterior uveitis; to consider the psychological impact of chronic anterior uveitis on children's lives; and to understand the effect of a child's chronic illness on other family members. DESIGN Expert commentary. METHODS Author experiences were supplemented by a review of pertinent medical literature and by consideration of content from semi-structured, separate patient and parent interviews. RESULTS Vision loss and the fear of blindness are not the only stressors for children with chronic anterior uveitis and their families; of additional concern are the burdens of examinations and treatment regimens, as well as drug toxicities. Children with chronic anterior uveitis experience medical, academic, interpersonal, psychological, and developmental challenges. The impact of disease extends to other members of a patient's family as well; parents experience challenges in similar domains. Problems with adherence to medical regimens are common. Both the disease and its treatment affect quality of life, and can interfere with successful management of disease and transition to autonomy in adulthood, as reported for other chronic conditions. Coping processes vary greatly between different families. CONCLUSIONS Eye examinations and the rigors of long-term treatment often influence the psychosocial health of patients and families; physicians who are aware of these issues can help patients and families cope with chronic illness and may improve outcomes. Further psychosocial research to understand the experiences of children dealing with chronic anterior uveitis is warranted; this commentary can serve as a foundation for development of age- and disease-specific research questions.
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Abstract
Pediatric uveitis differs from adult-onset uveitis and is a topic of special interest because of its diagnostic and therapeutic challenges. Children with uveitis are often asymptomatic and the uveitis is often chronic, persistent, recurrent, and resistant to conventional treatment. Anterior uveitis is the most common type of uveitis in children; the prevalence of intermediate, posterior, and panuveitis varies geographically and among ethnic groups. Regarding etiology, most cases of pediatric uveitis are idiopathic but can be due to systemic inflammatory disorders, infections, or a manifestation of masquerade syndrome. Ocular complications include cataracts, hypotony or glaucoma, band keratopathy, synechiae formation, macular edema, optic disc edema, choroidal neovascular membranes, and retinal detachment. These complications are often severe, leading to irreversible structural damage and significant visual disability due to delayed presentation and diagnosis, persistent chronic inflammation from suboptimal treatment, topical and systemic corticosteroid dependence, and delayed initiation of systemic disease‒modifying agents. Treatment for noninfectious uveitis is a stepwise approach starting with corticosteroids. Immunomodulatory therapy should be initiated in cases where quiescence cannot be achieved without steroid dependence. Patients should be monitored regularly for complications of uveitis along with systemic and ocular adverse effects from treatments. The goals are to achieve steroid-free durable remission, to reduce the risk of sight-threatening complications from the uncontrolled ocular inflammation, and to avoid the impact of lifelong burden of visual loss on the child and their family. Multidisciplinary management will ensure holistic care of affected children and improve the support for their families.
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Affiliation(s)
| | - Jessy Choi
- Department of Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield Children NHS Foundation Trust, Sheffield, United Kingdom
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre, Singapore
- Singapore Eye Research Institute, Singapore
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore
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