Ocular concerns in juvenile rheumatoid arthritis

[Uveitis in juvenile idiopathic arthritis]

Anterior uveitis usually occurs in the context of juvenile idiopathic arthritis in about 10% of patients. Frequency is dependent on JIA subtype. Uveitis is most commonly found in patients with extended oligoarthritis (up to 25%) and early-age onset of arthritis. As the uveitis is usually without externally recognisable signs and often leads to ocular complications, all JIA patients should undergo regular ophthalmological examinations to ensure the promptest possible diagnosis and therapy. About 25% of uveitis patients have a complicated clinical course and require systemic immunosuppression. Immunosuppressive therapy should be started as early as possible if the dosage of topical glucocorticoids is not less than 3 drops per day and systemic glucocorticoid therapy is not less than 0.1 mg / kg body weight after 12 weeks. Methotrexate is commonly started as a first line immunosuppressive therapy. In the case of treatment failure, additional therapy can consist of combination therapy with cyclosporine A and biologicals. The main therapeutic goal is to achieve remission. Management of the typical vision-threatening complications such as cataract, glaucoma, ocular hypotension, and macular edema is particularly challenging.

Visual Outcomes in Children with Juvenile Idiopathic Arthritis–Associated Uveitis

PURPOSE

To analyze visual outcomes in children affected by juvenile idiopathic arthritis (JIA)-associated uveitis.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Eighty-nine children with JIA-associated uveitis.

METHODS

Charts of children with JIA-associated uveitis were reviewed.

MAIN OUTCOME MEASURE

Change in patients' visual acuities (VAs).

RESULTS

Of 269 children with uveitic syndromes referred, 89 (33%) had JIA-associated uveitis. The process was bilateral in 76 children. Seventy-three patients were female, and 84% of patients were Caucasian. Mean age of onset of uveitis was 5.7 years. Mean follow-up was 2.96 years. Antinuclear antibody positivity was detected in 56 patients, 44 of them female. Patients with JIA-associated uveitis developed numerous complications in the course of their disease: of 165 affected eyes, 105 (64%) developed cataracts, 33 (20%) developed increased intraocular pressure, and 76 (46%) developed band keratopathy; posterior synechiae were present in 96 (58%). Of 89 children, 73% were treated with immunomodulators, 40% were treated with nonsteroidal antiinflammatory agents alone or in combination with immunomodulators, and 21% were treated with topical and/or systemic steroids. Of 65 children who required immunomodulation, only one chemotherapeutic agent was used in 30, two agents in 21, and > or =3 in 14. Visual acuities of 65 children (122 eyes) were documented and compared at standard intervals. By mixed-models linear regression, improvement in VA of 0.03 logarithm of the minimum angle of resolution units per year was not found to be statistically significant (standard error, 0.02, P = 0.089).

CONCLUSIONS

Juvenile idiopathic arthritis-associated uveitis is a sight-threatening disease. However, much of the children's vision can be preserved if patients are treated appropriately.

Recent advances in uveitis of juvenile idiopathic arthritis

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

The Decreasing Prevalence of Uveitis Associated with Juvenile Rheumatoid Arthritis

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

Ocular vasculitis

Systemic vasculitis can affect practically any structure in or around the eye. Although the ocular presentations of vasculitic disease are highly variable and may be quite subtle, it is important for physicians to understand some of the basic concepts, critical findings, and potential significance of ocular signs and symptoms. In addition to preserving sight, awareness of specific ocular syndromes may afford a critical clue to undiagnosed or newly active systemic vasculitis. A brief discussion of the most common ocular syndromes seen in systemic vascular disease is presented, with special attention given to the signs that may be appreciated by non-ophthalmologists. Recent concepts of ocular immunologic therapy are also reviewed, especially as they relate to the use of systemic immunomodulating drugs, because care of these patients often requires close cooperation between ophthalmologists, primary care physicians, and rheumatologists.