Clinical features and visual outcome of intermediate uveitis in children

Update on the systemic management of noninfectious uveitis in children and adolescents

Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.

Pediatric Pars Planitis: A Review

PURPOSE

To provide an overview of pediatric pars planitis.

METHODS

Narrative literature review.

RESULTS

Pars planitis refers to the idiopathic subset of intermediate uveitis in which there is vitritis along with snowball or snowbank formation occurring in the absence of an associated infection or systemic disease. It is thought to be a T-cell mediated disease with a genetic predisposition. Pars planitis accounts for 5-26.7% of pediatric uveitis cases. Presentation is commonly bilateral but asymmetric, often with insidious onset of floaters and blurred vision. Although pars planitis is known to be a benign form of uveitis in most cases, severe complications secondary to chronic inflammation may arise, with cystoid macular edema being the most common cause of visual morbidity. Mild vitritis in the absence of symptoms, vision loss, or macular edema may be observed. Patients with severe vitritis and/or associated vision-threatening complications require prompt aggressive treatment. A stepladder approach including corticosteroids, immunosuppressive agents, anti‑tumor necrosis factor‑alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis.

CONCLUSION

Timely diagnosis and adequate treatment of pediatric pars planitis and associated complications are crucial in order to improve visual outcomes.

The double-edged sword of inflammation in inherited retinal degenerations: Clinical and preclinical evidence for mechanistically and prognostically impactful but treatable complications

We present retrospective data from our clinical research efforts of the past several years alongside a review of past and current clinical and preclinical data independently by several investigators supporting our clinical evidence for the importance of inflammation in inherited retinal degenerations (IRDs). We show how inflammation is a complicating factor in IRDs but, if recognized and managed, also a great opportunity to mitigate disease severity immediately, improve patient prognosis and quality of life, extend the treatment windows for gene-specific and agnostic therapeutic approaches, mitigate the impact of inflammatory complications on the accurate estimate of vision changes in IRD natural history studies, improve the chances of safer outcomes following cataract surgery, and potentially reduce the likelihood of inflammatory adverse events and augment the efficacy of viral vector-based treatment approaches to IRDs. Manuscript contribution to the field. Inflammation has been suspected to be at play in IRDs since the beginning of the 1900s and became a research focus through the early 1990s but was then largely abandoned in favor of genetic-focused research. Thanks to regained cognizance, better research tools, and a more holistic approach to IRDs, the recent reappraisal of the role of inflammation in IRDs has brought back to the surface its importance. A potential confounder in natural history studies and a limiting factor in clinical trials if not accounted for, inflammation can be managed and often offers an opportunity for immediately improved prognosis and outcomes for IRD patients. We present our retrospective clinical evidence for connections with a measurable secondary autoimmune component that can develop in IRDs and contribute to vision loss but is at least in part treatable. We also present ample lines of evidence from the literature corroborating our clinical observations at the preclinical level.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Long-Term Outcomes of Pediatric Idiopathic Intermediate Uveitis

PURPOSE

To describe the course of childhood-onset intermediate uveitis without associated systemic disease, and investigate determinants of outcomes.

DESIGN

A retrospective clinical cohort study METHODS: This study was conducted in an institutional setting. A total of 125 children (221 eyes) aged 16 years and less participated. Outcomes of interest were visual acuity, severity of inflammation, and the occurrence of sight-threatening complications. Variables examined included age and clinical findings at presentation, treatment, and duration of follow-up. Multivariable analysis was undertaken to investigate potential predictors of outcomes.

RESULTS

The median follow-up duration was 57 months. At presentation, best-corrected visual acuity worse than 20/160 was recorded in 11 (4.4%) eyes and significant vitreous haze (≥2+Standardisation of Uveitis Nomenclature (SUN)) in 35 (14%) eyes. Corticosteroid-sparing agents were used in 41 children (33%), with methotrexate most commonly used (27 children, 21.6%). The most frequent complications were raised intraocular pressure (n = 65; 29.4%), cataract (n = 41; 18.5%), and cystoid macular edema (n = 29; 13.1%). At the last visit, 116 (92.8%) patients achieved best-corrected vision of 20/40 or better with quiescent uveitis. The absence of the use of a steroid-sparing immunomodulatory agent was the strongest predictive factor for the development of new macular edema (odds ratio = 6.3, 95% CI = 2.3-16.9, P < .001) or glaucoma (odds ratio = 6.6, 95% CI = 2.5-17.9, P < .001) over the period of observation.

CONCLUSIONS

The visual outcomes of childhood-onset idiopathic intermediate uveitis are favorable. The frequency of sight-threatening sequelae of inflammation, which confer a lifelong risk of further visual loss, is high. The use of immunomodulatory therapy is associated with a lower risk of developing macular edema and ocular hypertension.

Spectral domain optical coherence tomography findings of patients with pars planitis and risk factors affecting visual acuity

PURPOSE

To evaluate spectral domain optical coherence tomography (SD-OCT) findings of 42 eyes with pars planitis and to identify risk factors affecting visual acuity.

METHODS

Medical records and SD-OCT findings were retrospectively reviewed.

RESULTS

Mean best-corrected visual acuity (BCVA) was 0.248 ± 0.3 on the logMAR scale at baseline. SD-OCT findings included epiretinal membrane (ERM) in 16 (38.1%) eyes, loss of normal foveal contour appearance in 8 (19.0%), ellipsoid zone (EZ) damage in 5 (11.9%), external limiting membrane (ELM) damage in 3 (7.1%), disruption of retinal pigment epithelium (RPE) in 2 (4.8%), and macular atrophy in 1 (2.4%). There was macular edema in 10 (23.8%) eyes [cystoid macular edema (CME) in 8 (19.0%), diffuse macular edema (DME) in 6 (14.3%), and serous retinal detachment in 2 (4.8%)]. The mean central macular thickness (CMT) was 272.1 ± 319.5 μm. Patients were followed up for a mean of 50.6 ± 36.7 months. Mean BCVA was 0.210 ± 0.3 at the final evaluation. SD-OCT findings included ERM in 28 (66.7%) eyes, EZ damage in 6 (14.3%), ELM damage in 3 (7.1%), disruption of RPE in 4 (9.5%), loss of normal foveal contour appearance in 12 (28.6%), and macular atrophy in 2 (4.8%). There was CME and/or DME in 6 (14.3%) eyes. The mean CMT was 238 ± 220.9 μm and was significantly lower than the baseline (p < 0.001). According to multivariate linear regression analysis, the presence of DME, and loss of normal foveal contour appearance at baseline were the independent factors associated with BCVA at the final examination (B = 0.726, p < 0.001; B = 0.766, p < 0.001, respectively).

CONCLUSIONS

DME and loss of normal foveal contour appearance were more likely to have adverse effects on visual acuity.

Implications of pars planitis-associated cystoid macular edema on visual outcome and management in children

PURPOSE

Pars planitis is a commonly observed type of pediatric uveitis. The aim of this study was to evaluate the implications of pars planitis-associated cystoid macular edema (CME) on visual outcome and treatment modalities.

METHODS

A retrospective review of medical records in a single center with academic practice.

RESULTS

Included were 33 children (mean age 8 years, 58 eyes). Eighteen eyes developed CME (31%): in 67% of them, CME was diagnosed at presentation and in 33%, it developed at a mean of 57 months after presentation. Anterior and posterior segment complications were more prevalent in eyes with CME. Papillitis was significantly associated with the development of CME (OR 12.4, 95% CI 2.3 to 65.6, p = 0.003). Patients with CME were 1.7 times more likely to be treated with systemic therapy. By the last follow-up, 50% of patients who never developed CME were without systemic therapy compared with 13% of patients who developed CME (p = 0.034). LogMAR visual acuity improvement between presentation and month 36 was 0.41 for eyes with CME compared with 0.14 for eyes that never developed CME (p = 0.009).

CONCLUSION

Pars planitis-associated CME entailed higher prevalence of ocular complications, more frequent use of immunomodulatory therapy, and a lower rate of remission.

Visual and Clinical Outcome of Macular Edema Complicating Pediatric Noninfectious Uveitis

PURPOSE

To investigate the clinical course and visual outcome of macular edema (ME) in pediatric patients with chronic noninfectious uveitis.

DESIGN

Retrospective case series.

METHODS

The databases of the uveitis clinics of 4 tertiary medical centers in Israel and the UK were searched for all children treated for uveitic ME in the years 2005-2015. Data were collected from the medical records as follows: demographics, diagnosis, visual acuity, clinical and imaging findings, and treatment given specifically for ME. Findings at baseline and at 3, 6, 12, and 24 months were evaluated.

RESULTS

The cohort included 25 children (33 eyes) of mean age 8.5 ± 3.4 years. The most common diagnosis was intermediate uveitis, in 14 children (7 idiopathic, 7 pars planitis). Uveitis was active at ME diagnosis in 28 eyes (84.8%). Median duration of follow-up was 48 months. Median time to resolution of ME was 6 months, with complete resolution in 25 eyes (75.8%) by 24 months. Baseline visual acuity was ≥20/40 in 8 eyes (24.2%), increased to 57.6% at 3 months (P < .0001), and remained stable thereafter. Treatment regimens included corticosteroids (systemically and/or locally), immunosuppression, and biologic therapies. No correlation was found between outcome and either structural characteristics of ME or specific treatment strategy.

CONCLUSIONS

The prognosis of pediatric uveitic ME is favorable despite its chronic course. Larger randomized controlled trials are needed to define differences among treatment regimens.

Disease Remission in Children and Adolescents with Intermediate Uveitis: A Survival Analysis

PURPOSE

To report the incidence rate (IR) of remission in pediatric noninfectious intermediate uveitis (IU).

METHODS

Longitudinal retrospective cohort study, including 19 patients (32 eyes) between 1985 and 2014, followed-up until loss or January 2016. Remission was defined following the Standardization of Uveitis Nomenclature workshop criteria, prolonged remission as a remission spanning 12 months and until the end of follow-up, and relapse as recurrence of inflammatory activity in an eye in remission.

RESULTS

Median follow-up time was 6.3 years. IRs (95% confidence interval) for remission, relapse, and prolonged remission were 18.6 (13.1-26.5), 32.3 (20.6-50.7), and 6.7 (3.8-11.9) episodes per 100 eye-years, respectively. 48% of eyes relapsed in the first year following remission. 25 and 50% of eyes achieved prolonged remission after 5 and 10 years of follow-up, respectively.

CONCLUSIONS

Inflammatory relapses may be frequent in noninfectious IU affecting children and adolescents, appearing early after remission. Also, prolonged remission seems infrequent, being achieved late during follow-up.

Predictors of Long-Term Visual Outcome in Intermediate Uveitis

PURPOSE

To describe factors that predict visual loss and complications in intermediate uveitis.

DESIGN

Cross-sectional study.

PARTICIPANTS

Subjects with intermediate uveitis were identified from a database of 1254 uveitis patients seen in the clinic of a single consultant (S.L.L.) between 2011 and 2013.

METHODS

Information was gathered from the clinical notes of all subjects examined in clinic.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), moderate visual loss (MVL; ≤20/50), severe visual loss (SVL; ≤20/200).

RESULTS

Three hundred and five subjects (550 eyes) were included in the study, comprising 24.3% of subjects seen in clinic. Mean (± standard deviation) age at diagnosis was 40.9±16.9 years, and 64.6% of subjects were female. Median follow-up was 8.2 years (mean, 9.7 years, 5452 eye-years). Systemic diagnosis was made in 36.1% of patients, with sarcoidosis (22.6%) and multiple sclerosis (4.6%) the most frequent systemic associations. Median BCVA was 20/30 (mean logarithm of the minimum angle of resolution [logMAR] 0.26±0.38, n = 550 eyes) at presentation, 20/30 (mean logMAR 0.22±0.42, n = 430) at 5 years, and 20/30 (mean logMAR 0.23±0.46, n = 260) at 10 years. Macular edema was observed in 224 eyes (40.7%) and was associated with idiopathic disease (P = 0.001) and diabetes (P = 0.001). Topical therapy was used in 82.7%, and 34.2% received local injections of corticosteroids. A total of 50.5% required oral steroids and 13.8% required second-line immunosuppression. Subjects with a diagnosis of sarcoidosis were less likely to require a second-line agent (4.3% vs. 16.2%, P = 0.011). On multivariate analysis, visual acuity at referral, retinal pigment epithelial atrophy, and macular scarring were associated with increased risk of MVL; and visual acuity at referral, local therapy, macular scarring, retinal detachment, and hypotony and phthisis were associated with increased risk of SVL.

CONCLUSIONS

Intermediate uveitis has a long disease course with frequent complications and often requires systemic treatment. Despite this, most subjects are still able to achieve good long-term visual outcomes.

Use of Immunosuppressive Medications for Treatment of Pediatric Intermediate Uveitis

PURPOSE

To describe the treatment and outcomes of a cohort of pediatric intermediate uveitis (IU) patients, with a particular focus on the use of immunomodulatory therapy (IMT).

METHODS

The disease course, treatment, and outcomes of 39 pediatric IU patients treated in the Uveitis Clinic at the University of Utah from 1999 to 2012 were reviewed, retrospectively.

RESULTS

Mean age at presentation was 7.7 years (SD 3.1). In total, 95% had bilateral involvement. Out of 77 total eyes involved, the most frequent disease complications were ocular hypertension (0.71 events per person year, PPY), cataracts (events PPY = 0.39), and cystoid macular edema (events PPY = 0.33). A total of 20 patients received IMT; 19/20 were tapered off systemic corticosteroids without a uveitis recurrence; 75% of eyes had inactive disease at final follow-up (mean 37 months).

CONCLUSIONS

The use of IMT, including biologic therapies, may effectively manage disease inflammation and reduce steroid dosages in pediatric IU patients.

Review of Intermediate Uveitis

The purpose of this article is to highlight evidence about the medical and surgical management of intermediate uveitis (IU). Updated understandings of the immunopathology of IU were reviewed in this retrospective literature review. Literature selection for this review was based on the PubMed database (National Library of Medicine) and OVID database (Wolters Kluwer). Articles deemed relevant were selected and highlighted. Intermediate uveitis is most often a benign form of uveitis. Since intermediate uveitis has been described in association with different systemic disorders, the initial diagnostic evaluation should serve to exclude masquerade syndromes and infectious diseases in which immunosuppression may be ineffective or contraindicated. Although the pathogenesis of intermediate uveitis is not fully understood, identification of proinflammatory molecules involved in the IU has contributed to the development and implementation of new therapies. Studies about the use of various immunosuppressants, biological agents and surgical treatment on IU have provided more evidence for managing IU. Nevertheless, corticosteroids remain the mainstay of treatment. The treatment options of intermediate uveitis are evolving, with the development of various immunosuppressants and biological agents. The management of intermediate uveitis should be tailored individually, based on specific causes of the disease and associated complications.

Intermediate uveitis: comparison between childhood-onset and adult-onset disease

PURPOSE

To compare demographic and clinical data, systemic disease association, visual prognosis, and complications found in childhood and adult onset of intermediate uveitis (IU).

METHODS

Retrospective cohort study of 287 patients with IU: 122 (42.5%) children at onset (<16 years), 165 (57.5%) adults. The data were entered on a computer-based standardized data entry form for statistical analysis. Student t test was used regarding differences in means. To assess significance of differences in proportions, we used the χ2 test, but when the population in the subgroup was ≤ 5 patients, we used the Fisher exact test (p<0.05 were deemed to be statistically significant and as reported were not corrected for multiple testing and so should be viewed as nominal).

RESULTS

A total of 61% of childhood-onset cases occurred in boys (44% in the adult group), while adult onset was more common in women (56% vs 39%) (p = 0.004, odds ratio [OR] 2.06). Regardless of the onset age, IU was frequently bilateral and idiopathic. The most frequent complication was cystoid macular edema (27.5%, p = 0.469, OR 0.85), which was also the most frequent cause of visual loss. Optic disc edema was more prevalent in children (15.5% vs 9.2%; p = 0.027, OR 1.81), ocular hypertension in adults (15.6% vs 7.5%, p = 0.007, OR 0.44). A total of 25 patients had non-idiopathic IU. A total of 14 patients had multiple sclerosis.

CONCLUSIONS

Intermediate uveitis was mostly idiopathic and bilateral in both groups. Visual prognosis was good and it was not age-related. Childhood onset was more frequent in boys, adult onset in women. Endocrinal factors could be involved.

Autoimmune retinopathies: a report of 3 cases

PURPOSE

To describe 3 representative cases of autoimmune retinopathy (AIR).

METHODS

Clinical records of patients with a diagnosis of AIR were analyzed for demographic data, clinical findings, ancillary and laboratory tests, and treatment employed.

RESULTS

Three female patients diagnosed with AIR had bilateral reduction of electroretinogram amplitudes and elevation of visual field threshold within the central 30 degrees of the visual field that was disproportionately more severe than the clinical findings of retinal degeneration. The diagnoses were cancer-associated retinopathy, non-neoplastic AIR, and hereditary retinal dystrophy with secondary inflammation. Optic nerve involvement was also present in all cases. The patient with non-neoplastic AIR was successfully treated with systemic corticosteroids and immunomodulatory agents.

CONCLUSION

High index of suspicion is essential for an early diagnosis of AIR. Visual function and electrophysiological tests should be included in the initial workup of patients who present with suggestive clinical signs and symptoms of AIR.

Understanding the impact of uveitis on health-related quality of life in adolescents

PURPOSE

A reduction in quality of life (QoL) during an active phase of disease has been shown for patients with uveitis of various age groups. Adult uveitis patients were shown to also have reduced QoL-values despite disease being quiescent, but adolescents have not been investigated in this respect.

METHODS

This clinic-based, cross-sectional pilot study assessed the overall health-related quality of life (HRQoL) in adolescents (11-18 years) with a history of inactive uveitis and good visual function. Two independent generic (non-disease-specific) instruments were applied, the Inventory for Assessing the Quality of Life and the German KINDL-R-questionnaire.

RESULTS

Thirty-seven adolescents, 20 females (54%) and 17 males with a mean age of 15 ± 3 years and diagnosis since 5 ± 2 years participated. Subgroups with a reduced HRQoL were those with anterior and intermediate localization of uveitis, bilateral disease, application of immunosuppressive therapy, a short time since diagnosis, and a high number of recurrences.

CONCLUSION

Even despite quiescence of disease and good visual function, certain risk factors may result in a decreased HRQoL in juvenile uveitis patients. Our findings support the need of further evaluation of HRQoL in this patient group, the validation of specific psychometric inventories for this disease and the establishment of interdisciplinary collaboration including psychological counselling.

Intermediate uveitis in a pediatric Italian population

PURPOSE

To investigate clinical data, outcome, and treatment of intermediate uveitis in children.

METHODS

Retrospective cohort study, including 116 children affected by intermediate uveitis.

RESULTS

Sixty-two percent of patients were males. Ocular involvement was bilateral in 84%. Mean age at uveitis onset was 10.3 ± 3.6 years and 12.2 ± 7 years at first visit. Ninety-seven percent were classified as having idiopathic uveitis. The incidence of ocular complications during follow-up was 0.131/eye-year. Macular edema or a marked vitreous haze at presentation may be risks factors for incident visual loss. The most frequent causes of visual loss were macular edema (64%) and cataract (21%).

CONCLUSIONS

Most cases are idiopathic (pars planitis); only few children presented associated systemic disease. Macular edema and severe vitritis at presentation are associated with increased risk of visual impairment. Cystoid macular edema is the main cause of visual impairment.

Intermediate uveitis and alopecia areata: is there a relationship? Report of 3 pediatric cases

Three previously healthy children, aged 5, 8, and 15 years, with idiopathic intermediate uveitis (IU) and alopecia areata (AA) are described. These are the first 3 cases of which we are aware with this coexistence. The results of extensive diagnostic evaluations were negative in all 3 cases. AA preceded the diagnosis of bilateral IU in 1 child and followed within several months after IU diagnosis in 2 children. The severity of uveitis ranged from mild to sight-threatening, and hair loss ranged from local lesions in 2 cases to total alopecia in 1 case. Pathogenesis of both diseases is discussed. Theoretically, the coexistence of IU and AA might be based on the similarities in their complex pathogenesis. However, more research is needed to evaluate if the coexistence is based on an association between 2 autoimmune disorders or is a coincidence.

Periocular corticosteroid injection in the management of uveitis in children

PURPOSE

To report the outcome of orbital floor corticosteroid injection (OFCI) in the management of uveitis in children.

METHODS

  A retrospective noncomparative interventional case series. The medical records of 15 consecutive children (19 eyes) with various forms of uveitis treated with OFCI of 40 mg/ml methylprednisolone acetate or a combination of 20 mg/0.5 ml Triamcinolone and 2 mg/0.5 ml dexamethasone were reviewed. Data were collected 6 months postinjection and included details of uveitis, best corrected visual acuity (BCVA), ocular inflammation, systemic therapy required and potential complications of OFCI.

RESULTS

The mean BCVA improvement was 0.18 logarithm of the minimum angle of resolution (p < 0.001), at a mean of 6 weeks (range, 4-20). Fourteen eyes (74%) had significant improvement in inflammation, 4-7 weeks post-OFCI, with a median of 4 weeks. Anterior uveitis was treated effectively in all eyes, vitritis resolved in all but one case and resolution of cystoid macular oedema was achieved in six eyes (55%). Uveitis relapsed in seven eyes (50%) after a median time of 4 months (range, 2-5 months). Four eyes (21%) underwent more than one injection. The dosage of immunosuppressive systemic therapy was reduced or able to be stopped in three patients (50%). Steroid-induced cataract was observed in four eyes (21%), 5 months post-OFCI. One patient developed cushingoid features 6 weeks post his second OFCI.

CONCLUSION

Corticosteroid orbital floor injections resulted in control of active uveitis and visual acuity improvement in most children. However, the effect might be transient and induce cataract formation.

Smoking as a risk factor for cystoid macular edema complicating intermediate uveitis

PURPOSE

To describe risk factors for the presence of cystoid macular edema (CME) among patients presenting with intermediate uveitis.

DESIGN

Cross-sectional study.

METHODS

SETTINGS

Single-center, academic practice.

STUDY POPULATION

Two hundred and eight patients with intermediate uveitis evaluated from July 1, 1984 through September 30, 2006.

PROCEDURES

Clinical and demographic data were entered retrospectively into a database and analyzed.

OUTCOME MEASURES

Presence of CME at presentation to our clinic; risk factors for presenting with CME.

RESULTS

Of the 208 patients, 74% had bilateral intermediate uveitis, yielding 363 affected eyes. Eighty-nine patients (43%) had CME in at least one eye at the time of presentation to our clinic. After controlling for potentially confounding variables including demographics, duration of disease, active intraocular inflammation, history of diabetes mellitus or hypertension, and presence of epiretinal membrane, actively smoking at presentation was associated with a four-fold increased risk of CME at presentation vs never smoking (odds ratio (OR), 3.90; 95% confidence interval (CI), 1.43, 10.66; P = .008). Former smoking also appeared to increase the risk of CME at presentation in the multivariate analysis, but the result was of borderline statistical significance (OR, 1.97; 95% CI, 0.99, 3.94; P = .055). After adjusting for confounding, there was a 4% increased risk of CME at presentation for each cigarette smoked per day (OR, 1.04; 95% CI, 1.01, 1.7; P = .005).

CONCLUSIONS

CME was a common structural ocular complication observed in our cohort. Current smoking was associated with a dose-dependent increased risk of having CME at the time of presentation to our clinic.

Management of chronic pediatric uveitis

PURPOSE OF REVIEW

The diagnosis and management of chronic pediatric uveitis can be particularly challenging, with an estimated 25-33% of childhood uveitis cases resulting in severe, life-long visual disability. This paper reviews the recent literature on the management of chronic pediatric uveitis.

RECENT FINDINGS

This review highlights recent advances in the diagnosis and medical and surgical management of pediatric uveitis. Several systemic diseases associated with chronic uveitis in children are highlighted, including juvenile idiopathic arthritis, sarcoidosis and Behçet's disease. The treatment of primary ocular diseases associated with chronic pediatric uveitis such as intermediate uveitis and Fuchs' heterochromic iridocyclitis is discussed. The management of infectious causes of pediatric uveitis is not covered in this review.

SUMMARY

Knowledge of the ocular complications of chronic pediatric uveitis can help to customize efficacious therapeutic regimens for each patient, maximize the visual potential and minimize complications of these diseases. In addition a close relation should be fostered between pediatricians, pediatric rheumatologists and ophthalmologists to effectively monitor these patients who have multiple medical, surgical and refractive needs. Finally, surgical intervention must be appropriately timed with expert perioperative management of immunosuppressive medications with pediatric concerns in mind.