Favourable outcome after cataract surgery with IOL implantation in uveitis associated with juvenile idiopathic arthritis

Outcomes of cataract surgery in children who present with cataract at uveitis diagnosis

PURPOSE

To describe the clinical and demographic characteristics of patients presenting with cataract at uveitis diagnosis treated at a single institution between 2005 and 2019 and to analyze postoperative outcomes following cataract surgery.

METHODS

We retrospectively reviewed the medical records of children (<18 years of age) diagnosed with cataract at their initial uveitis presentation who subsequently underwent cataract extraction. Outcome measures were best-corrected visual acuity, number of uveitis flare-ups (cells ≥1+), and postoperative complications.

RESULTS

A total of 14 children (17 eyes) were included. Mean patient age was 7.2 ± 3.9 years. Methotrexate was initiated preoperatively in 11 patients; adalimumab, in 3. Primary intraocular lens was implanted in 4 eyes. Best-corrected visual acuity improved from a mean of 0.90 ± 0.40 logMAR preoperatively to 0.50 ± 0.35 logMAR at 1 year and 0.57 ± 0.40 logMAR at mean of 6.3 ± 3.4 years postoperatively. Four eyes (24%) had a single episode of uveitis flare-up during the first postoperative year. Macular and/or disk edema was discovered in 6 eyes following cataract removal. Only 3 eyes (18%) had ocular hypertension in the first year, but glaucoma developed in subsequent years in 7 eyes (41%), 5 of which required surgery.

CONCLUSIONS

In our study cohort, surgery for preexisting cataract at uveitis diagnosis resulted in improved visual acuity. Postoperative uveitis flare-ups were relatively uncommon, occurring in 4 of 17 eyes. Glaucoma was the main long-term complication.

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.

Occurrence and Risk Factors for Macular Edema in Patients with Juvenile Idiopathic Arthritis-Associated Uveitis

Purpose: To analyze occurrence and risk factors for macular edema (ME) in juvenile idiopathic arthritis-associated uveitis (JIA-U). Methods: Retrospective analysis of patients with JIA-U at a tertiary referral uveitis center between 2000 and 2019. Epidemiological data and clinical findings before ME onset were evaluated. Results: Out of 245 patients, ME developed in 41 (18%) of the 228 JIA-U patients for whom data documentation was complete during the follow-up (mean 4.0 ± 3.8 years). Risk factors (univariable logistic regression analysis) at baseline for subsequent ME onset included older age at initial documentation at institution (hazard ratio, HR 1.19, p < 0.0001), longer duration of uveitis at initial documentation (HR 1.17, p < 0.0001), worse best-corrected visual acuity (BCVA; HR 2.49, p < 0.0001), lower intraocular pressure (IOP; HR 0.88, p < 0.01), band keratopathy (HR 2.29, p < 0.01), posterior synechiae (HR 2.55, p < 0.01), epiretinal membrane formation (HR 6.19, p < 0.0001), optic disc swelling (HR 2.81, p < 0.01), and cataract (HR 4.24, p < 0.0001). Older age at initial documentation at institution (HR 1.55, p < 0.001), worse BCVA (HR 28.56, p < 0.001), and higher laser-flare photometry (LFM) values (HR 1.003, p = 0.01) were independent risk factors for ME manifestation. Patients with ME revealed significant changes in BCVA, LFM, and IOP and new optic disc swelling at 6 and 3 months before ME onset compared to timepoint of ME occurrence (p < 0.05, each). Conclusion: ME is a common complication of JIA-U. Demographic risk factors and courses of IOP, BCVA, and LFM may indicate patients at risk for ME onset.

Immunomodulatory treatment and surgical management of idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children: a French survey practice

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.

Results 5 to 10 years after cataract surgery with primary IOL implantation in juvenile idiopathic arthritis-related uveitis

PURPOSE

To evaluate the results of cataract extraction with primary intraocular lens (IOL) implantation in patients with juvenile idiopathic arthritis (JIA) and uveitis-related cataract.

SETTING

Department of Ophthalmology, Helsinki University Hospital, Finland.

DESIGN

Retrospective case series.

METHODS

All consecutive patients younger than 20 years with JIA-uveitis-related cataract undergoing cataract extraction with primary IOL implantation in 1 or both eyes at the Department of Ophthalmology, Helsinki University Hospital, Finland, from February 2000 to April 2012 were included. Twenty eligible patients with 26 operated eyes were identified; 14 were girls and 6 were boys. All patients had a follow-up of 5 years and 13 patients (16 eyes [65%]) reached 10 years of follow-up.

RESULTS

Twenty-six eyes of 20 patients were studied. Preoperative median corrected distance visual acuity (CDVA) was 0.05 in decimal notation. Median CDVA was 1.0 at 5 years and 0.9 at 10 years of follow-up. Two eyes did not reach CDVA 0.5 with the operation, and in 2 eyes, CDVA decreased below 0.5 over the period of 3 to 5 years after the operation. Active uveitis during 3 and 12 months preoperatively was a risk indicator for postoperative CDVA <0.5 at 5 years (P = .005 and P = .007, respectively).

CONCLUSIONS

Cataract extraction with primary IOL implantation provides long-standing good visual acuity for young patients with well-controlled JIA-related uveitis.

Cataract Surgery with Intraocular Lens Implantation in Juvenile Idiopathic Arthritis-Associated Uveitis: Outcomes in the Era of Biological Therapy

This study compared the outcomes of cataract surgery with intraocular lens (IOL) implantation in patients with juvenile idiopathic arthritis (JIA)-associated chronic anterior uveitis treated with antimetabolite drugs and systemic corticosteroids (Non-Biological Group) versus patients treated with antimetabolites and biological drugs (Biological Group). A cohort of patients with cataract in JIA-associated uveitis undergoing phacoemulsification with IOL implantation was retrospectively evaluated. The main outcome was a change in corrected distance visual acuity (CDVA) in the two groups. Ocular and systemic complications were also recorded. The data were collected preoperatively and at 1, 12, and 48 months after surgery. Thirty-two eyes of 24 children were included: 10 eyes in the Non-Biological Group and 22 eyes in the Biological Group. The mean CDVA improved from 1.19 ± 0.72 logMAR preoperatively to 0.98 ± 0.97 logMAR at 48 months (p = 0.45) in the Non-Biological Group and from 1.55 ± 0.91 logMAR preoperatively to 0.57 ± 0.83 logMAR at 48 months (p = 0.001) in the Biological Group. The postoperative complications, including synechiae, cyclitic membrane, IOL explantation, glaucoma, and macular edema, were not statistically different between the two groups. An immunosuppressive treatment with biological drugs can improve the visual outcome after cataract surgery in patients with JIA-associated uveitis, but it does not significantly reduce postoperative ocular complications.

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.

[Results of surgical treatment of complicated uveal cataract]

PURPOSE

A retrospective analysis of the results of surgical treatment of complicated uveal cataracts of different origin.

MATERIAL AND METHODS

The study analyzed the results of surgical treatment of uveal cataract in 30 patients (34 eyes) who were divided into three groups by uveitis etiology. The first group included 11 patients with spondyloarthritis associated with the HLA-B27 antigen; the second group included 10 patients with juvenile chronic arthritis and spondyloarthritis, negative for HLA-B27 antigen; the third group consisted of 9 patients with other systemic autoimmune diseases and uveitis of unknown etiology, also negative for the HLA-B27 antigen. The average age of the patients was 35.8±2.6; 30.8±3.8 and 34.0±2.3 years, respectively. Four patients (6 eyes) with juvenile chronic arthritis and severe ribbon-like corneal degeneration underwent standard intracapsular cataract cryoextraction with subsequent spectacle correction of aphakia. In other cases, ultrasound phacoemulsification with implantation of an intraocular lens (IOL) was used as a surgical aid.

RESULTS

Regardless of the surgery technique and the cause of uveal cataract, a statistically significant decrease in the number of exacerbations per year (p<0.0001) and an increase in best corrected visual acuity (BCVA) were noted after its removal. In the long-term follow-up (2-24 months), 9 patients experienced persistent decompensation of the IOP level, which required various types of antiglaucoma surgery.

CONCLUSION

Surgical treatment of uveal cataracts of various etiologies with adequate pre- and postoperative therapy provides an improvement in visual acuity and a reduction in the frequency of inflammation recurrence. Considering the high likelihood of IOP decompensation in the long-term postoperative period, IOP control should be given attention in such cases.

Childhood Uveitis

Childhood uveitis is an ophthalmological challenge, since on the one hand it often remains asymptomatic and difficult to detect, and on the other hand it often has a chronic course and is associated with a high risk of complications threatening the vision. The most important risk factors for childhood uveitis are underlying rheumatic diseases; recommendations for ophthalmological monitoring have been developed together with paediatric rheumatologists. Intermediate and posterior uveitis are rare in children. The therapy must effectively control inflammation and at the same time cause only minimal side effects. Since steroids in particular cause side effects frequently, an immunosuppressive therapy must be initiated early in an interdisciplinary cooperation with paediatric rheumatologists and parents with the goal of minimising steroids.

Paediatric cataract in the uveitis setting

BACKGROUND/AIMS

Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis.

METHODS

This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery.

RESULTS

In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2-14 years) with onset of cataract at a mean of 29.3 months later (range 0-66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 (p < 0.05). These patients had significant co-morbidities with concurrent glaucoma, band keratopathy and cystoid macular oedema. Uveitis was quiet for a minimum of 6 months in all cases prior to surgery with augmentation of immunosuppression pre-operatively as well as intra-operative local or intra-venous steroids. Tight post-operative care was necessary as 80% developed further flare-up of uveitis requiring increased immunosuppression and surgical interventions to manage their uveitis.

CONCLUSION

Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

Phacoemulsification in patients with uveitis: long-term outcomes

BACKGROUND

To assess the long-term outcomes of phacoemulsification and intraocular lens (IOL) implantation in eyes with uveitis.

METHODS

One hundred and five eyes of 81 patients, who underwent phacoemulsification and IOL implantation between January 2009 and July 2016, were included in this study. The demographic data, preoperative clinical findings, postoperative outcomes, and intraoperative and postoperative complications were recorded. All collected data and risk factors with regard to visual prognosis were analyzed with the help of the Statistical Package for the Social Sciences version 20.0 software program (IBM Corp., Armonk, NY, USA).

RESULTS

During follow-up (mean: 35.2 ± 22.2 months), corrected distance visual acuity (CDVA) improved in 87.7% of all eyes and reached a level of 0.3 LogMAR or greater in 61.3% of eyes. Postoperative complications included posterior capsule opacification (50.9%), posterior synechiae (21.7%), cystoid macular edema (16%), epiretinal membrane (13.2%), glaucoma (11.3%), increased intraocular pressure (8.5%), and severe inflammation (6.6%). Uveitis recurred in 55.7% of all eyes. The risk for the development of cystoid macular edema was found to be associated with recurrence in the early postoperative period. Low visual acuity risk was 11.1-fold higher with macular scarring (p = 0.001) and 14-fold higher with optic atrophy (p < 0.001), respectively.

CONCLUSIONS

With appropriate management during the pre- and postoperative periods, phacoemulsification and IOL implantation surgery can be safe and effective in eyes with uveitis. However, great caution must be taken to prevent complications both before and after the surgery.

A Cross-Sectional Online Survey Identifies Subspecialty Differences in the Management of Pediatric Cataracts Associated with Uveitis

Introduction

To determine if differences exist between pediatric ophthalmologists and uveitis ophthalmologists in the treatment of pediatric uveitic cataracts and placement of intraocular lenses.

Methods

Uveitis ophthalmologists and pediatric ophthalmologists were surveyed via an online poll regarding their therapeutic management of pediatric uveitic cataract and intraocular lens (IOL) placement.

Results

Sixty-two responses from uveitis ophthalmologists and 47 responses from pediatric ophthalmologists were recorded. According to 79% of all responses, uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation. Pediatric ophthalmologists were more likely to respond that the presence of chronic juvenile idiopathic arthritis-associated iridocyclitis, pars planitis, or recurrent acute anterior uveitis is a contraindication for primary IOL implantation in pediatric cases with full control of intraocular inflammation. There was no consensus within either specialty with regard to the preferred IOL material for lens implantation. Uveitis ophthalmologists were more likely to report the use of intravenous and intravitreal steroids for perioperative treatment. In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists (71%) than pediatric ophthalmologists (50%) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types.

Conclusions

Pediatric ophthalmologists and uveitis ophthalmologists have similar approaches to the management of pediatric uveitic cataract removal and IOL insertion, but several differences remain between these subspecialties. Continued collaboration between the subspecialties would be helpful to better develop consistent criteria to improve patient care.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00245-x) contains supplementary material, which is available to authorized users.

[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.

Safety and efficacy of dexamethasone implant along with phacoemulsification and intraocular lens implantation in children with juvenile idiopathic arthritis associated uveitis

PURPOSE

To assess the safety and efficacy of intraoperative intravitreal dexamethasone implant in patients of juvenile idiopathic arthritis (JIA)-associated uveitis undergoing phacoemulsification with posterior chamber intraocular lens (PCIOL) implantation.

METHODS

Retrospectively, data of patients with JIA-associated uveitis undergoing phacoemulsification with PCIOL implantation with intraoperative dexamethasone implant injection were analyzed. Patients with a minimum follow-up of 6 months were included. Primary outcome measures were ocular inflammation, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and worsening of uveitis.

RESULTS

8 eyes of 6 patients were included. BCVA was significantly improved at 1, 3, and 6 months postoperatively 0.20 ± 0.09, P = 0.008; 0.18 ± 0.11, P = 0.008; and 0.24 ± 0.11, P = 0.01, respectively. No statistical difference noted in mean IOP at various follow-up visits. None developed worsening of uveitis or Cystoid macular edema.

CONCLUSION

Intraoperative intravitreal dexamethasone implant is a safe and effective in preventing and managing the postoperative inflammation in children with JIA-associated uveitic cataract.

Long-term results after primary intraocular lens implantation in children with juvenile idiopathic arthritis-associated uveitis

PURPOSE

To evaluate the long-term outcome after cataract surgery with primary intraocular lens implantation in children with juvenile idiopathic arthritis-associated uveitis.

METHODS

The medical records of all 24 children (34 eyes) with chronic juvenile idiopathic arthritis-associated uveitis who underwent cataract surgery between 1990 and 2013 were reviewed retrospectively. Primary intraocular lens implantation was performed in all patients.

RESULTS

Median age at diagnosis of uveitis in the first eye was 5.3 years (range: 2.7-9.4 years) and median age at the time of cataract surgery in the first eye was 9.7 years (range: 4.1-16.9 years). Postoperative follow-up time ranged from 1 to 23.1 years, with a median of 10.9 years. Best corrected visual acuity at the last follow-up was good (⩾20/40) in 65% of the eyes. Postoperatively, glaucoma developed in 8 eyes (24%), posterior capsular opacification and secondary membrane formation requiring surgery in 15 eyes (44%), macular oedema in 5 eyes (15%) and phthisis in 2 eyes (6%).

CONCLUSION

This study shows a favourable visual outcome in most of the cases. Primary intraocular lens implantation may be considered in juvenile idiopathic arthritis-associated uveitis complicated by cataract in patients with well-controlled inflammation.

Decision-making and management of uveitic cataract

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.

Management of cataract in uveitis patients

PURPOSE OF REVIEW

This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles.

RECENT FINDINGS

All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes.

SUMMARY

Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

Dexamethasone implants in paediatric patients with noninfectious intermediate or posterior uveitis: first prospective exploratory case series

BACKGROUND

To evaluate the efficacy and safety of dexamethasone (DEX) implants in paediatric patients with noninfectious intermediate or posterior uveitis.

METHODS

Prospective single center exploratory case series. Children and adolescents, 6 to 17 years old, with a vitreous haze score of ≥1.5+ or cystoid macular edema (CME) of >300 μm were enrolled. Vitreous haze score at month 2 was chosen as primary endpoint. Best corrected visual acuity (BCVA), central retinal thickness (CRT) and concomitant medication at month 6 were defined as secondary endpoints. Intraocular pressure (IOP) and cataract formation were determined as safety endpoints.

RESULTS

Three out of 6 eligible patients participated in the case series. At month 2, vitreous haze was reduced from a score of 1.5+ to 0.5+ and 0 and BCVA improved by ≥3 lines, ≥4 lines and ≥2 lines of Early Treatment of Diabetic Retinopathy (ETDRS)-letters, respectively. Visual acuity gain was accompanied by a CRT reduction of -186 μm and -83 μm in the first and third patient, in whom CME was the indication for DEX implantation. A reduction of concomitant medication was achieved in 1 patient. IOP increase was seen in all 3 patients, but could be treated sufficiently with primarily IOP lowering medications and without need for glaucoma surgery. Cataract progression did not occur.

CONCLUSIONS

DEX implants led to an improvement in all endpoints, especially BCVA. This study confirms that IOP rises may also occur in the paediatric population and should be monitored and treated appropriately.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials (EudraCT)- nr: 2013-000541-39.

Laser flare-cell photometer: principle and significance in clinical and basic ophthalmology

A slit-lamp examination is an indispensable and essential clinical evaluation method in ophthalmology, but, it is qualitative subjective. To complement its weaknesses in making a quantitative evaluation of flare intensity and number of cells in the aqueous humor in the eye, we invented the laser flare-cell photometer in 1988. The instrument enables a non-invasive quantitative evaluation of flare intensity and number of cells in the aqueous with good accuracy and repeatability as well as maneuverability equal to slit-lamp microscopy. The instrument can elucidate the pathophysiology in the blood-aqueous barrier (BAB) function in a variety of ocular disorders. The accuracy of the instrument makes it possible to investigate not only the pathophysiology of intraocular disorders but also the effects of various drugs and surgical procedures in BAB. The instrument does not only lighten the burden on patients in clinical examinations and study but it also helps minimize the sacrifice of experimental animals and improves the reliability of the results by minimizing inter-individual variations through its good repeatability. Here I shall relate how the instrument has been applied to clinical and basic studies in ophthalmology and what novel knowledge its application contributed to pathophysiology in ophthalmology.

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.

Juvenile idiopathic arthritis-associated uveitis

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

Complicated uveitis in late onset juvenile idiopathic psoriatic arthritis

CASE REPORT

A 6 year-old girl with juvenile psoriatic arthritis (JPsA) and bilateral complicated anterior uveitis developed several ocular complications that required 5 surgical procedures. Despite the aggressive course of ocular inflammation, her visual acuity remained good. Arthritis (main criterion for the diagnosis of JPsA) appeared years after ocular involvement. She showed a good anti-tumour necrosis factor initial response.

DISCUSSION

The definitive diagnosis of JPsA was established years after the onset of symptoms. In addition, the patient maintained a good visual acuity, despite its complicated disease course. Finally, she showed a good clinical response to adalimumab.

Controversies in intraocular lens implantation in pediatric uveitis

Cataract is one of the most common and visually debilitating complications of pediatric uveitis. It develops as a consequence of chronic inflammation and steroid use and is seen most often in juvenile idiopathic arthritis (JIA)-associated uveitis. Cataract extraction with intraocular lens (IOL) insertion has been carried out with a measure of success in non-uveitic pediatric eyes, but in cases of uveitis, multiple factors affect the final outcome. Chronic inflammation and its sequelae such as band keratopathy, posterior synechiae, and cyclitic membranes make surgical intervention more challenging and outcome less certain. Postoperative complications like increased inflammation, glaucoma, posterior capsular opacification, retrolental membranes, and hypotony may compromise the visual outcome. Early refractive correction is imperative in pediatric eyes to prevent amblyopia. The use of contact lenses and intraocular lenses in pediatric uveitic eyes were fraught with complications in the past. Surgical interventions such as vitreo-lensectomy followed by contact lens fitting and small incision cataract surgery followed by different types of intraocular lenses have been utilized, and many reports have been published, albeit in small patient groups. This review analyzes and discusses the existing literature on intraocular lens implantation in cases of pediatric uveitic cataract surgery.

Chronic Non-infectious Uveitis in Patients with Juvenile Idiopathic Arthritis

PURPOSE

To describe clinical findings and analyze treatment evolution of chronic, non-infectious uveitis in patients with juvenile idiopathic arthritis (JIA).

METHODS

A total of 82 patients (147 eyes) with JIA-related uveitis treated for ≥2 months were included (78% females; 79% bilateral uveitis; 74% anterior uveitis). Outcome measures were visual acuity (VA), inflammation control, side-effects, and surgical procedures.

RESULTS

Mean ± SD age at diagnosis was 4.9 ± 3.8 years; mean ± SD follow-up time was 8.7 ± 7.8 years. Mean VA did not significantly change throughout the study. Three (2%) eyes resulted in no light perception (NLP) vision. Thirty (37%) patients underwent 69 procedures. In total, 41 (50%) patients achieved inflammation control. TNF-α inhibitors were significantly associated with inflammation control. Seven (8.5%) patients stopped treatment due to side-effects.

CONCLUSIONS

JIA is a cause of significant ocular morbidity. TNF-α inhibitor use was associated with inflammation control. Prospective, randomized, double blind clinical trials in this regard are warranted.

Uveitis associated with juvenile idiopathic arthritis

Uveitis is a potentially sight-threatening complication of juvenile idiopathic arthritis (JIA). JIA-associated uveitis is recognized to have an autoimmune aetiology characterized by activation of CD4(+) T cells, but the underlying mechanisms might overlap with those of autoinflammatory conditions involving activation of innate immunity. As no animal model recapitulates all the features of JIA-associated uveitis, questions remain regarding its pathogenesis. The most common form of JIA-associated uveitis is chronic anterior uveitis, which is usually asymptomatic initially. Effective screening is, therefore, essential to detect early disease and commence treatment before the development of visually disabling complications, such as cataracts, glaucoma, band keratopathy and cystoid macular oedema. Complications can result from uncontrolled intraocular inflammation as well as from its treatment, particularly prolonged use of high-dose topical corticosteroids. Accumulating evidence supports the early introduction of systemic immunosuppressive drugs, such as methotrexate, as steroid-sparing agents. Prospective randomized controlled trials of TNF inhibitors and other biologic therapies are underway or planned. Future research should aim to identify biomarkers to predict which children are at high risk of developing JIA-associated uveitis or have a poor prognosis. Such biomarkers could help to ensure that patients receive earlier interventions and more-potent therapy, with the ultimate aim of reducing loss of vision and ocular morbidity.

Cataract surgery in children with uveitis: retrospective analysis of intraocular lens implantation with anterior optic capture

PURPOSE

To present experience with cataract extraction in 9 eyes of 7 pediatric patients with chronic uveitis and compare the technique of anterior optic capture in 5 eyes that underwent cataract extraction without optic capture of the intraocular lens (IOL) or were left aphakic.

METHODS

A retrospective review of pediatric patients with chronic uveitis undergoing cataract surgery was performed, examining the preoperative and postoperative visual acuity, immunosuppressive therapy, surgical technique, complications, subsequent procedures, and need for escalation of systemic immunosuppressive therapy. The technique of anterior optic capture is described in detail.

RESULTS

Of the 9 eyes, 5 underwent cataract extraction with IOL placement with the haptics in the capsular bag and optic prolapsed through the anterior capsulorhexis. One eye underwent cataract extraction with IOL implantation in the bag. Three eyes had lensectomy without IOL placement. The eyes with anterior optic capture had no adverse outcomes and uveitis flares were controlled with topical medications and systemic immunosuppressants; the eye with IOL placement without optic capture had recurrent membranes and uveitis flares, necessitating increased systemic immunosuppression. All eyes achieved best-corrected visual acuity of 20/60 or better by 6 months following surgery and 20/30 or better at the most recent follow-up.

CONCLUSIONS

The technique of cataract extraction with IOL placement and anterior prolapse of the optic through the anterior capsulorhexis shows promise to be a safe and viable option for pediatric patients with chronic uveitis treated with systemic immunotherapy.

Clinical management algorithm of uveitis associated with juvenile idiopathic arthritis: interdisciplinary panel consensus

Uveitis associated with juvenile idiopathic arthritis (JIA) typically involves the anterior chamber segment, follows an indolent chronic course, and presents a high rate of uveitic complications and a worse outcome as compared to other aetiologies of uveitis. Disease assessment, treatment, and outcome measures have not been standardized. Collaboration between pediatric rheumatologists and ophthalmologists is critical for effective management and prevention of morbidity, impaired vision, and irreparable visual loss. Although the Standardization of Uveitis Nomenclature Working Group recommendations have been a great advance to help clinicians to improve consistency in grading and reporting data, difficulties arise at the time of deciding the best treatment approach in the individual patient in routine daily practice. For this reason, recommendations for a systematized control and treatment strategies according to clinical characteristics and disease severity in children with JIA-related uveitis were developed by a panel of experts with special interest in uveitis associated with JIA. A clinical management algorithm organized in a stepwise regimen is here presented.

Uveitis in juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common systemic disease causing uveitis in childhood, with a prevalence of 10 per 100 000 persons. JIA often takes a severe inflammatory course, and its complications often endanger vision.

METHODS

This review is based on pertinent articles retrieved by a selective literature search up to 18 August 2014 and on the current interdisciplinary S2k guideline on the diagnostic evaluation and anti-inflammatory treatment of juvenile idiopathic uveitis.

RESULTS

Uveitis arises in roughly 1 in 10 patients with JIA. Regular eye check-ups should be performed starting as soon as JIA is diagnosed. 75-80% of patients are girls; antinuclear antibodies are found in 70-90%. The risk to vision is higher if JIA begins in the preschool years. As for treatment, only a single, small-scale randomized controlled trial (RCT) and a small number of prospective trials have been published to date. Topical corticosteroids should be given as the initial treatment. Systemic immunosuppression is needed if irritation persists despite topical corticosteroids, if new complications arise, or if the topical steroids have to be given in excessively high doses or have unacceptable side effects. If the therapeutic effect remains inadequate, conventional and biological immune modulators can be given as add-on (escalation) therapy. Treatment lowers the risk of uveitis and its complications and thereby improves the prognosis for good visual function.

CONCLUSION

Severely affected patients should be treated in competence centers to optimize their long-term outcome. Multidisciplinary, individualized treatment is needed because of the chronic course of active inflammation and the ensuing high risk of complications that can endanger vision. Future improvements in therapy will be aided by prospective, population-based registries and by basic research on biomarkers for the prediction of disease onset, prognosis, tissue damage, and therapeutic response.

Perioperative pharmacological management in patients with glaucoma

REVIEẂS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery.

PROPOSED PROTOCOLS

In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery.

CONCLUSIONS

this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Solutions in pediatric cataracts

PURPOSE OF REVIEW

Modern pediatric cataract surgical techniques combined with a greater understanding of the natural history of aphakia and pseudophakia have changed the approach to the surgery of pediatric cataracts.

RECENT FINDINGS

Advanced surgical techniques, new pharmacologic options and long-term refractive planning have improved surgical success.

SUMMARY

It is essential that the ophthalmic surgeon who cares for children with cataracts is aware of these issues.

Preoperative cataract surgery use of an intravitreal dexamethasone implant (Ozurdex) in a patient with juvenile idiopathic arthritis and chronic anterior uveitis

We report a 6-year-old boy with anterior uveitis associated with juvenile idiopathic arthritis (JIA) who underwent cataract extraction in his right eye. One month before surgery he received an intravitreal sustained-release dexamethasone implant. During 10 months' follow-up, his uveitis remained quiet. To our knowledge this is the first report using an intravitreal sustained-release dexamethasone implant as a perioperative anti-inflammatory medication.

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.

Surgical outcomes in childhood uveitic glaucoma

PURPOSE

To evaluate surgical outcomes and to describe a strategy for pediatric uveitic glaucoma.

DESIGN

Retrospective case series.

METHODS

The clinical practice of a single surgeon identified 36 patients with juvenile uveitic glaucoma (diagnosed before 18 years of age) who underwent 1 or more intraocular pressure (IOP)-lowering surgical procedures. The first eye operated on was included in the analysis. The main indication for success was IOP of less than 21 mm Hg with controlled inflammation, without further IOP-lowering surgery or devastating complication.

RESULTS

Patients with uveitic glaucoma associated with juvenile idiopathic arthritis (n = 20), idiopathic uveitis (n = 9), other (n = 6) were included. Mean age ± standard deviation at initial glaucoma surgery was 11.1 ± 4.4 years with a follow-up of 5.6 ± 4.8 years (range, 0.2 to 16.4 years). Goniotomy was the initial surgical procedure in 31 (86%) eyes. Fifteen eyes did not require further IOP-lowering surgery. Sixteen eyes had additional IOP-lowering surgery: second goniotomy (n = 9), glaucoma drainage device (n = 6), and trabeculectomy (n = 1). By Kaplan-Meier survival analysis, the first versus the first or second goniotomy were successful at 10 years in 48% (95% confidence interval, 28% to 65%) versus 69% (95% confidence interval, 47% to 84%). Goniotomy failure was noncorrelative with phakic status or presence of preoperative synechiae. Five eyes (14%) had initial glaucoma drainage device implantation because of closed angles. Visual acuity was similar between initial and final examinations (0.37 ± 0.48 logarithm of the minimal angle of resolution units [Snellen 20/47] vs 0.28 ± 0.34 logarithm of the minimal angle of resolution units [Snellen 20/38]). IOP was reduced (33.0 ± 8.0 mm Hg vs 12.6 ± 4.5 mm Hg; P < .0001), as was number of glaucoma medications (3.2 ± 1.1 vs 1.2 ± 1.3; P < .0001). Eyes undergoing cataract removal after successful glaucoma surgery maintained IOP control. Glaucoma was controlled and vision was preserved in 33 (92%) eyes.

CONCLUSIONS

Refractory juvenile uveitic glaucoma was managed successfully by goniosurgery and glaucoma drainage device implantation. Cataract removal can be accomplished successfully, provided IOP and uveitis are well controlled before surgery.

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.