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.
Similar content being viewed by others
References
Carvounis PE, Herman DC, Cha S, Burke JP (2006) Incidence and outcomes of uveitis in juvenile rheumatoid arthritis, a synthesis of the literature. Graefes Arch Clin Exp Ophthalmol 244:281–290
Sabri K, Saurenmann RK, Silverman ED, Levin AV (2008) Course, complications, and outcome of juvenile arthritis-related uveitis. J AAPOS 12:539–545
Heiligenhaus AI, Niewerth M, Ganser G, Heinz C, Minden K (2007) Prevalence and complications of uveitis in juvenile idiopathic arthritis in a population-based nation-wide study in Germany: suggested modification of the current screening guidelines. Rheumatology (Oxford) 46:1015–1019
De Boer J, Wulffraat N, Rothova A (2003) Visual loss in uveitis of childhood. Br J Ophthalmol 87:879–884
Bou R, Iglesias E, Antón J (2014) Treatment of uveitis in juvenile idiopathic arthritis. Curr Rheumatol Rep 16:437. doi:10.1007/s11926-014-0437-4
Heiligenhaus A, Foeldvari I, Edelsten C, Smith JR, Saurenmann RK, Bodaghi B, de Boer J, Graham E, Anton J, Kotaniemi K, Mackensen F, Minden K, Nielsen S, Rabinovich EC, Ramanan AV, Strand V (2012) Proposed outcome measures for prospective clinical trials in juvenile idiopathic arthritis-associated uveitis: a consensus effort from the multinational interdisciplinary working group for uveitis in childhood. Arthritis Care Res (Hoboken) 64:1365–1372
Cassidy J, Kivlin J, Lindsley C, Nocton J (2006) Ophthalmologic examinations in children with juvenile rheumatoid arthritis. Pediatrics 117:1843–1845
Jabs DA, Nussenblatt RB, Rosenbaum JT (2005) Standardization of uveitis nomenclature for reporting clinical data. Results of the first international workshop. Am J Ophthalmol 140:509–516
Chylack LT Jr, Leske MC, McCarthy D, Khu P, Kashiwagi T, Sperduto R (1989) Lens opacities classification system II (LOCS II). Arch Ophthalmol 107:991–997
Nussenblatt RB, Palestine AG, Chan CC, Roberge F (1985) Standardization of vitreal inflammatory activity in intermediate and posterior uveitis. Ophthalmology 92:467–471
Samudre SS, Lattanzio FA Jr, Williams PB, Sheppard JD Jr (2004) Comparison of topical steroids for acute anterior uveitis. J Ocul Pharmacol Ther 20:533–547
Thorne JE, Woreta FA, Dunn JP, Jabs DA (2010) Risk of cataract development among children with juvenile idiopathic arthritis-related uveitis treated with topical corticosteroids. Ophthalmology 117:1436–1441
Lovasik JV (1986) Pharmacokinetics of topically applied cyclopentolate HCl and tropicamide. Am J Optom Physiol Opt 63:787–803
Foeldvari I, Wierk A (2005) Methotrexate is an effective treatment for chronic uveitis associated with juvenile idiopathic arthritis. J Rheumatol 32:362–365
Heiligenhaus A, Mingels A, Heinz C, Ganser G (2007) Methotrexate for uveitis associated with juvenile idiopathic arthritis: value and requirement for additional anti-inflammatory medication. Eur J Ophthalmol 17:743–748
Heiligenhaus A, Michels H, Schumacher C, Kopp I, Neudorf U, Niehues T, Baus H, Becker M, Bertram B, Dannecker G, Deuter C, Foeldvari I, Frosch M, Ganser G, Gaubitz M, Gerdes G, Horneff G, Illhardt A, Mackensen F, Minden K, Pleyer U, Schneider M, Wagner N, Zierhut M (2012) Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int 32:1121–1133
Ferrante P, Ramsey A, Bunce C, Lightman S (2004) Clinical trial to compare efficacy and side-effects of injection of posterior sub-Tenon triamcinolone versus orbital floor methylprednisolone in the management of posterior uveitis. Clin Exp Ophthalmol 32:563–568
Zannin ME, Birolo C, Gerloni VM, Miserocchi E, Pontikaki I, Paroli MP, Bracaglia C, Shardlow A, Parentin F, Cimaz R, Simonini G, Falcini F, Corona F, Viola S, De Marco R, Breda L, La Torre F, Vittadello F, Martini G, Zulian F (2013) Safety and efficacy of infliximab and adalimumab for refractory uveitis in juvenile idiopathic arthritis: 1-year followup data from the Italian Registry. J Rheumatol 40:74–79
Kotaniemi K, Säilä H, Kautiainen H (2011) Long-term efficacy of adalimumab in the treatment of uveitis associated with juvenile idiopathic arthritis. Clin Ophthalmol 5:1425–1429
Díaz-Llopis M, Salom D, Garcia-de-Vicuña C, Cordero-Coma M, Ortega G, Ortego N, Suarez-de-Figueroa M, Rio-Pardo MJ, Fernandez-Cid C, Fonollosa A, Blanco R, Garcia-Aparicio AM, Benitez-Del-Castillo JM, Olea JL, Arevalo JF (2012) Treatment of refractory uveitis with adalimumab: a prospective multicenter study of 131 patients. Ophthalmology 119:1575–1578
García-De-Vicuña C, Díaz-Llopis M, Salom D, Bou R, Díaz-Cascajosa J, Cordero-Coma M, Ortega G, Ortego-Centeno N, Suarez-De-Figueroa M, Cruz-Martínez J, Fonollosa A, Blanco R, García-Aparicio ÁM, Benítez-Del-Castillo JM, Antón J (2013) Usefulness of adalimumab in the treatment of refractory uveitis associated with juvenile idiopathic arthritis. Mediators Inflamm. doi:10.1155/2013/560632
Mok CC, van der Kleij D, Wolbink GJ (2013) Drug levels, anti-drug antibodies, and clinical efficacy of the anti-TNFα biologics in rheumatic diseases. Clin Rheumatol 32:1429–1435
Murias S, Alcobendas R, Pascual-Salcedo D, Remesal A, Peralta J, Merino R (2014) Anti-adalimumab antibodies in paediatric rheumatology patients: a pilot experience. Rheumatology (Oxford) 53:2124–2126
Tambralli A, Beukelman T, Weiser P, Atkinson TP, Cron RQ, Stoll ML (2013) High doses of infliximab in the management of juvenile idiopathic arthritis. J Rheumatol 40:1749–1755
Suhler EB, Smith JR, Giles TR, Lauer AK, Wertheim MS, Kurz DE, Kurz PA, Lim L, Mackensen F, Pickard TD, Rosenbaum JT (2009) Infliximab therapy for refractory uveitis: 2-year results of a prospective trial. Arch Ophthalmol 127:819–822
Richards JC, Tay-Kearney ML, Murray K, Manners P (2005) Infliximab for juvenile idiopathic arthritis-associated uveitis. Clin Exp Ophthalmol 33:461–468
Tynjälä P, Lindahl P, Honkanen V, Lahdenne P, Kotaniemi K (2007) Infliximab and etanercept in the treatment of chronic uveitis associated with refractory juvenile idiopathic arthritis. Ann Rheum Dis 66:548–550
Zulian F, Balzarin M, Falcini F, Martini G, Alessio M, Cimaz R, Cimino L, Zannin ME (2010) Abatacept for severe anti-tumor necrosis factor alpha refractory juvenile idiopathic arthritis-related uveitis. Arthritis Care Res (Hoboken) 62:821–825
Tappeiner C, Heinz C, Ganser G, Heiligenhaus A (2012) Is tocilizumab an effective option for treatment of refractory uveitis associated with juvenile idiopathic arthritis? J Rheumatol 39:1294–1295
Adán A, Mesquida M, Llorenç V, Espinosa G, Molins B, Hernández MV, Pelegrín L (2013) Tocilizumab treatment for refractory uveitis-related cystoid macular edema. Graefes Arch Clin Exp Ophthalmol 251:2627–2632
Heiligenhaus A, Miserocchi E, Heinz C, Gerloni V, Kotaniemi K (2011) Treatment of severe uveitis associated with juvenile idiopathic arthritis with anti-CD20 monoclonal antibody (rituximab). Rheumatology (Oxford) 50:1390–1394
William M, Faez S, Papaliodis GN, Lobo AM (2012) Golimumab for the treatment of refractory juvenile idiopathic arthritis-associated uveitis. J Ophthalmic Inflamm Infect 2:231–233. doi:10.1007/s12348-012-0081-y
Heiligenhaus A (2006) When should intraocular lenses be implanted in patients with juvenile idiopathic arthritis-associated iridocyclitis? Ophthalmic Res 38:316–317
Grajewski RS, Zurek-Imhoff B, Roesel M, Heinz C, Heiligenhaus A (2012) Favourable outcome after cataract surgery with IOL implantation in uveitis associated with juvenile idiopathic arthritis. Acta Ophthalmol 90:657–662
Adán A, Gris O, Pelegrín L, Torras J, Corretger X (2009) Explantation of intraocular lenses in children with juvenile idioapathic arthritis-associated uveítis. J Cataract Refract Surg 35:603–605
Bohnsack BL, Freedman SF (2013) Surgical outcomes in childhood uveitic glaucoma. Am J Ophthalmol 155:134–142
Kotaniemi K, Sihto-Kauppi K (2007) Occurrence and management of ocular hypertension and secondary glaucoma in juvenile idiopathic arthritis-associated uveitis: an observational series of 104 patients. Clin Ophthalmol 1:455–459
Najjar DM, Cohen EJ, Rapuano CJ, Laibson PR (2004) EDTA chelation for calcific band keratopathy: results and long-term follow-up. Am J Ophthalmol 137:1056–1064
Mackensen F, Heinz C, Becker MD, Heiligenhaus A (2008) Intravitreal bevacizumab (avastin) as a treatment for refractory macular edema in patients with uveitis: a pilot study. Retina 28:41–45
Cervantes-Castañeda RA, Giuliari GP, Gallagher MJ, Yilmaz T, MacDonell RE, Quinones K, Foster CS (2009) Intravitreal bevacizumab in refractory uveitic macular edema: one-year follow-up. Eur J Ophthalmol 19:622–629
Adán A, Pelegrín L, Rey A, Llorenç V, Mesquida M, Molins B, Ríos J, Keller J (2013) Dexamethasone intravitreal implant for treatment of uveitic persistent cystoid macular edema in vitrectomized patients. Retina 33:1435–1440
Yu EN, Paredes I, Foster CS (2007) Surgery for hypotony in patients with juvenile idiopathic arthritis-associated uveitis. Ocul Immunol Inflamm 15:11–17
Acknowledgments
The authors thank Marta Pulido, MD, for editing the manuscript and editorial assistance.
Conflict of interest
RB declares that she has received speakers’ bureau fees from Novartis and Abbvie, and travel and expense payments from Abbvie, Pfizer and Novartis. JA. declares that his institution has received a PI grant from Pfizer and that he has received speakers’ bureau fees from Pfizer, Roche, and GEBRO, and speakers’ bureau fees and travel and expense payments from Abbvie. All other authors declare that they do not have competing interests. Meetings to reach consensus were funded by Abbvie through an unrestricted grant.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bou, R., Adán, A., Borrás, F. et al. Clinical management algorithm of uveitis associated with juvenile idiopathic arthritis: interdisciplinary panel consensus. Rheumatol Int 35, 777–785 (2015). https://doi.org/10.1007/s00296-015-3231-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00296-015-3231-3