Cataract surgery in children with juvenile idiopathic arthritis associated uveitis

Uveitis in Children and Adolescents

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.

Cataract Surgery with or without Intraocular Lens Implantation in Pediatric Uveitis: A Systematic Review with Meta-Analyses

PURPOSE

To systematically review the results of comparative studies of modern cataract surgery in pediatric uveitis with or without intraocular lens (IOL) implantation and to perform comparative meta-analyses to compare visual acuity outcomes and complication rates.

METHODS

On 12 November 2020, we systematically searched the Cochrane Central, PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, and all affiliated databases of the Web of Science. Two authors independently reviewed studies and extracted data. Studies were reviewed qualitatively in text and quantitatively with meta-analyses. Outcome measures were preoperative and postoperative best-corrected visual acuity (BCVA), inflammation control, and rates of postoperative complications.

RESULTS

Ten studies of 288 eyes were eligible for review of which the majority were eyes with juvenile idiopathic arthritis-associated uveitis. Summary estimates revealed that the BCVA was better in pseudophakic eyes vs. aphakic eyes (1-year postoperative: -0.23 logMAR, 95% CI: -0.43 to -0.03 logMAR, P=0.027; 5-year postoperative: -0.35 logMAR, 95% CI: -0.51 to -0.18 logMAR, P=0.000036). Pseudophakic eyes had more visual axis opacification (OR 6.76, 95% CI: 2.73 to 16.8, P=0.000036) and less hypotony (OR 0.19, 95% CI: 0.04 to 0.95, P=0.044).

CONCLUSIONS

In modern era cataract surgery on eyes with pediatric uveitis with IOL implantation leads to satisfactory and superior visual outcomes and no differences in complication rates apart from an increased prevalence of visual axis opacification and a decreased prevalence of hypotony when compared to aphakia. However, limitations of the retrospective design and the presence of selection bias necessitate a careful interpretation.

Monitoring and Treatment of Juvenile Idiopathic Arthritis-associated Uveitis: Brazilian Evidence-based Practice Guidelines

Purpose: To present a national guideline for ophthalmologic care and surveillance of juvenile idiopathic arthritis-associated uveitis (JIA-uveitis).Methods: Review article based on medical literature and the experience of an Expert Committee composed of members of the Brazilian Society of Pediatric Ophthalmology/Brazilian Council of Ophthalmology and the Brazilian Society of Pediatrics/Brazilian Society of Rheumatology. Studies with a high level of evidence were selected by searching the PubMed/Medline database. The final document was approved by the experts.Results: The main recommendations are that children/adolescents with JIA should undergo screening according to their risk factors. Ophthalmological checkups should also consider ocular inflammation and therapy. Topical glucocorticoids should be the first line of therapy, with systemic glucocorticoids acting as bridge treatments in severe uveitis. Methotrexate should be the first-line systemic therapy and anti-tumor necrosis factor (anti-TNF alpha) the second for uncontrolled uveitis.Conclusions: This evidence-based guideline for JIA-uveitis will be useful for both ophthalmology and rheumatology practice.

[Cataract surgery in children with non-infectious uveitis: Review of current practices in France]

PURPOSE

To evaluate the medical-surgical management of cataract surgery in children with chronic uveitis in various French pediatric ophthalmology centers.

MATERIALS AND METHODS

Two-part study: first, a descriptive observational segment on the evaluation of French practices. A questionnaire was sent to the various pediatric ophthalmologists in France. A second retrospective chart review, including children with non-infectious chronic uveitis who had cataract surgery in the pediatric ophthalmology department of Bordeaux University Hospital from 2008 to 2017.

RESULTS

Twenty-one ophthalmologists responded to the questionnaire. Only 23.8% systematically initiated immunosuppressive drugs (aside from corticosteroids) before surgery. A total of 88.2% prescribed oral corticosteroid treatment preoperatively. Eleven surgeons administered intravenous corticosteroid boluses during the surgery, and primary lens implantation is the most common method used in 95.2%. A total of 76.2% initiated oral steroid therapy after surgery. Postoperatively, all surgeons started local therapy with high-dose corticosteroids. At one year, 100% achieved improvement of visual acuity greater than or equal to 2 lines. On our service, 10 eyes (7 children) underwent cataract surgery. Seven were treated with systemic immunosuppressive drugs (aside from corticosteroids) and 80% of cases received oral corticosteroid therapy a few days before surgery. An intravenous corticosteroid bolus was administered preoperatively in 8 cases, and primary lens implantation was performed in 100% of cases. Postoperatively, 5 children received oral corticosteroid treatment. All were treated with local high dose steroids. At one year, the mean best-corrected visual acuity was 0.18 LogMar (0-0.7, SD: 0.25).

CONCLUSION

When performed with an aggressive anti-inflammatory protocol, cataract surgery leads to a good visual outcome in selected children with chronic uveitis.

Cataract Surgery with Primary Lens Implantation in Children with Chronic Uveitis

PURPOSE

To evaluate the evolution of chronic uveitis in children undergoing cataract surgery with primary intraocular lens (IOL) implantation.

METHODS

Twelve children with chronic uveitis underwent cataract surgery with primary posterior chamber intraocular lens (IOL) implantation.

RESULTS

Fourteen eyes were implanted with a foldable hydrophobic acrylic IOL. The mean follow-up was 35.39 months (8.72-69.57). The mean BCDVA before surgery and at the end of follow-up was 1.11 (0.40-2.30; SD: 0.57) and 0.48 (0-3; SD: 0.77; p=0.007) respectively. The mean oral corticosteroids dosage after surgery and at the end of follow-up was 0.80 mg/kg/day (SD: 0.37) and 0.17 mg/kg/day (SD: 0.24; p=0.001) respectively. All patients except one were treated with methotrexate. Four patients (5 eyes) were additionally treated with anti-tumor necrosis factor agent.

CONCLUSIONS

Cataract surgery with primary posterior chamber hydrophobic IOL implantation is possible and leads to a good visual recovery in cases of pediatric chronic uveitis. This surgery requires aggressive anti-inflammatory management with immunosuppressive drugs to control inflammation and reduce the corticosteroids dosage.

Outcomes of cataract surgery in patients with uveitis: a systematic review and meta-analysis

PURPOSE

To critically assess the evidence base regarding outcomes following cataract surgery in uveitic cases.

DESIGN

Systematic evidence-based review and meta-analysis.

METHODS

A comprehensive search query was performed on MEDLINE, EMBASE, CINHAL, and CENTRAL databases. Relevant publications were identified by reviewing query results and reference list searches.

RESULTS

A total of 89 articles met eligibility criteria. Among uveitic eyes with quiet or mostly quiet uveitis before cataract surgery, 20/40 visual acuity or better (≥20/40) was achieved in 68% following phacoemulsification, 72% following extracapsular cataract extraction, and 40% following pars plana lensectomy. More eyes undergoing cataract surgery with intraocular lens (IOL) implantation than eyes left aphakic achieved ≥20/40 postoperatively (71% vs 52%). Eyes receiving acrylic IOLs or heparin-surface-modified (HSM) polymethylmethacrylate had better visual outcomes than those receiving non-HSM polymethylmethacrylate or silicone IOLs. Active uveitis at the time of cataract surgery was associated with worse visual outcomes. Compared with other uveitis cases, the proportion achieving 20/40 or better post cataract surgery was better for Fuchs heterochromic cyclitis cases and worse for uveitis related to Behçet disease, Vogt-Koyanagi-Harada disease, or sympathetic ophthalmia, and also posterior uveitis in general.

CONCLUSION

Cataract surgery in eyes with uveitis resulted in normal range levels of visual acuity in most cases. The review suggests that preoperative control of uveitis, use of an acrylic or HSM IOL, and a diagnosis of Fuchs heterochromic cyclitis were associated with better outcomes. Posterior-involving uveitides tended to do worse, likely because of vision-limiting complications of uveitis. Average results may not be applicable to specific clinical scenarios.

Cataract management in juvenile idiopathic arthritis: simultaneous versus secondary intraocular lens implantation

PURPOSE

To compare primary versus secondary intraocular lens (IOL) implantation after cataract removal in patients with juvenile idiopathic arthritis (JIA).

METHODS

Retrospective interventional study. Data were obtained for 40 children (40 eyes) with JIA-associated uveitis operated on for cataract before the age of 16 years between January 1998 and January 2005.

RESULTS

Twenty-one patients underwent primary IOL implantation at a mean age of 13.1 ± 2.6 (9-16) years. Mean follow-up was 48.2 ± 5.4 (35-64) months. Nineteen patients underwent cataract removal at a mean age 12.3 ± 2.0 (9-16) years and secondary IOL implantation 13.6 ± 0.3 (11-16) months later. Mean follow-up was 47.2 ± 6.5 (32-64) months. BCVA difference between the two groups was significant at 24-month visit only (p = 0.001). Incidence of secondary glaucoma was significantly lower in the group that underwent secondary IOL implantation (p = 0.01).

CONCLUSION

Secondary IOL implantation after cataract removal in children with JIA-related uveitis provided a significantly lower incidence of secondary glaucoma.

Prevention and management of cataracts in children with juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA)-associated uveitis can be associated with vision-compromising complications such as cataracts, glaucoma, synechiae, and band keratopathy. Of these, cataracts are one of the most common sequelae of JIA-associated uveitis and can result in significant visual disability. Risk factors for cataracts include posterior synechiae and longstanding ocular inflammation. Prevention of cataract development is crucial through appropriate control of uveitis. However, not all preventive measures are successful, and further management consisting of medical and surgical techniques is often necessary. Various factors should be taken into consideration when deciding on cataract management, including timing of surgery and placement of an intraocular lens. Continued partnership between pediatric rheumatologists and pediatric ophthalmologists can help ensure favorable visual outcomes.

Juvenile idiopathic arthritis-associated uveitis

PURPOSE OF REVIEW

To describe recent evidence from the literature pertaining to juvenile idiopathic arthritis (JIA)-associated uveitis.

RECENT FINDINGS

Uveitis is most common in extended oligoarticular JIA. A significant number of patients already have ocular complications at time of diagnosis of uveitis. Risk factors for complications include either abnormally high or low intraocular pressure, posterior synechiae, male sex, temporal proximity to diagnosis of arthritis and topical corticosteroid use. Use of immunosuppressive agents significantly reduces ocular complications. Aggressive perioperative control of intraocular inflammation is necessary for successful cataract surgery with lens implantation. Controlled clinical trials are under way to assess the efficacy of biologic agents in JIA-associated uveitis. Long-term safety, however, is still unknown.

SUMMARY

JIA-associated uveitis carries significant ocular morbidity that lasts well into adulthood. Treatment with immunosuppressive agents can reduce the risk of ocular complications. Biologic agents hold promise in the treatment of JIA-associated uveitis, but require long-term data to assess their safety.

Cataract surgery in the setting of uveitis

PURPOSE OF REVIEW

To describe recent evidence from the literature concerning optimal treatment of cataract in patients with concomitant uveitis.

RECENT FINDINGS

Optimal treatment of cataract in the setting of uveitis requires optimal management of uveitis, including appropriate diagnostic workup and scrupulous attention to preoperative preparation, intraoperative technique, and postoperative management. Recent literature suggests high rates of recurrence of certain forms of uveitis (such as ocular toxoplasmosis) after surgery, suggesting that perioperative prophylaxis may be warranted. Placement of intraocular lenses in the setting of certain forms of uveitis, such as juvenile idiopathic arthritis-associated uveitis, remains controversial. Although excellent outcomes can be achieved with many types of intraocular lenses, several recent studies have suggested that the incidence of postoperative complications may be lower in patients receiving acrylic intraocular lenses compared with other materials. Recent long-term outcome studies in cohorts of uveitis patients undergoing cataract surgery suggest very good outcomes in the majority of patients.

SUMMARY

Provided the unique challenges of cataract surgery in the setting of uveitis are recognized and appropriately addressed, excellent visual outcomes can be achieved in most patients.