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

Abstract

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.

Juvenile idiopathic arthritis-associated uveitis

“…This requires effective communication between paediatric rheumatologists and ophthalmologists which may be helped by organisation of multi-disciplinary clinics. The aim of treatment is to achieve 0 cells in the anterior chamber (SUN AC cell grade 0) in both eyes [39]. Practical management protocols have recently been published both by our group in Bristol, UK [40] and an interdisciplinary panel from Spain [39].…”

“…The aim of treatment is to achieve 0 cells in the anterior chamber (SUN AC cell grade 0) in both eyes [39]. Practical management protocols have recently been published both by our group in Bristol, UK [40] and an interdisciplinary panel from Spain [39]. A modified algorithm based on consensus guidelines [39][40][41] is provided in Fig.…”

“…It is indicated after 12 weeks of topical treatment if there is no improvement to AC cell grade ≤ 0.5+, or sooner if > 2 drops daily are required, if there is worsening inflammation or if ocular complications develop [39,41]. A systematic review and meta-analysis identified 9 eligible studies of methotrexate in non-infectious uveitis including 135 patients of [38]].…”

“…Efficacy was seen in most patients although only small numbers have been reported. The duration of maintenance therapy on biologic agents is not certain although consensus recommendations suggest continuing treatment for 24 months of inactive disease [39]. One retrospective cohort study (n = 50, 44 % with JIA) has reported on uveitis reactivation after stopping infliximab (n = 45) or adalimumab (n = 5) [64].…”

Outcome of Juvenile Idiopathic Arthritis Associated Uveitis in Two Disease Subtypes

“…3 Uveitis is an important extraarticular manifestation of JIA present in 10 to 30% of patients. 4 Chronic course, bilateral onset, and recurrent episodes are characteristics of childhood uveitis. Unfortunately, due to young age, uveitis may be asymptomatic or unrecognized.…”