approach to pediatric uveitis - hapos.gr · pdf filemultiple sclerosis inflammatory bowel...
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Approach to Pediatric Uveitis
Paris Tranos PhD,ICO,FRCSOPHTHALMICA –Vitreoretinal & Uveitis Service
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Epidemiology• Uveitis is the 3rd leading cause of
blindness in USA
• 5-10% of uveitis cases involve
children <16 yrs
•3-6 cases per 100.000 children
• Worse prognosis in children
• Importance of annual vision
screening for all children
Edelsten C et al. Visual loss associated with pediatric uveitis in english primary and referral centers. Am J Ophthalmol. 2003 May; 135(5):676-80
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Clinical presentation
Red eye
Lacrimation
Photophobia
Floaters
Loss of vision
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Clinical presentation
ASYMPTOMATIC
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Classification • Anterior-non granulomatous
-granulomatous
• Intermediate
• Posterior- with vasculitis
-without vasculitis
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Differential DiagnosisAnterior non granulomatous uveitis
IdiopathicHLA-B27 associated
Ankylosing SpondylitisReactive arthritisPsoriasisInflammatory bowel disease
Juvenile Idiopathic Arthritis NephritisSystemic lupus erythematosusHerpes Simplex virus Lyme disease LeukemiaDrug-induced
•
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Differential DiagnosisAnterior granulomatous uveitis
SarcoidosisTuberculosis Bechet's disease Multiple Sclerosis Inflammatory bowel diseaseHerpes simplex virus Fungal disease SyphilisWhipple's disease
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Differential DiagnosisIntermediate uveitis
Pars PlanitisJIAMultiple SclerosisLyme disease Cat-scratch diseaseSarcoidosis
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Differential DiagnosisPosterior uveitis/Panuveitis
ToxocariasisTORCH
ToxoplasmosisSyphilis
RubellaCytomegalovirusHSV/VZV
Vogt-Koyanagi Harada SyndromeBechet's diseaseLeukemia TuberculosisInflammatory bowel diseaseSystemic lupus erythematosus
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Diagnostic tests• FBC, Urine analysis, ANA testing, HLA-B27 testing, systemic evaluation
•FBC, Urine analysis, FTA-ABS, ANA, Lyme disease testing, PPD analysis, CXR, sACE, Chest CT*, Gallium*, Audiogram*, Lumbar puncture*,systemic evaluation
• Recurrent
Anterior non
granulomatous
• Anterior
granulomatous
• Intermediate
• Posterior
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Juvenile Idiopathic Arthritis (JIA)
• Arthritis > 6 weeks duration without any other identifiable cause in children <16 years of age
•7 subtypes
•Uveitis more common in oligoarticular(<5 joints involved)
• Risk factors for development of uveitisYoung onsetFemale genderANA +veoligoarticularRF-ve
Tugal-Tutkun I Pediatric uveitis.J Ophthalmic Vis Res. 2011 Oct;6(4):259-69.
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JIA UVEITIS JUVENILE HLA B27
Chronic anterior uveitisband keratopathy
Acute recurrent uveitisMay have hypopyonpositive family historyRF negative
WHITE EYE RED EYE
FrequentUveitis about 20%
uveitis common
RF –ve, HLA B27 -ve,
ANA +ve
HLA B27 +ve
ANA -ve
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Complications• More common compared to adults
• Children with JIA at greater risk
• Presence of complications at
baseline is important risk factor
Edelsten C et al. An evaluation of baseline risk factors predicting severity in juvenile idiopathic arthritis
associated uveitis and other chronic anterior uveitis in early childhood .Br J Ophthalmol. 2002
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Complications• More common compared to adults
• Children with JIA at greater risk
• Presence of complications at
baseline is important risk factor
• The most common include:
- post. Synechiae
- band keratopathy
- cataract
- glaucoma
- CME
- hypotony
Edelsten C et al. An evaluation of baseline risk factors predicting severity in juvenile idiopathic arthritis
associated uveitis and other chronic anterior uveitis in early childhood .Br J Ophthalmol. 2002
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Myths in pediatric uveitis• “The kid will outgrow uveitis”
• “The drops will get him through it”
•“ It is just the eye. Systemic treatment is not
necessary”
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Treatment
Tugal-Tutkun I Pediatric uveitis.J Ophthalmic Vis Res. 2011 Oct;6(4):259-69.
• Treat the cause
• Control the inflammation
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Treatment• Step ladder approach
• Steroids
topical
regional
systemic
• Methotrexate
• Cyclosporin, Mucophenolate
mofetil
• Biologicals (Adalimumab)
Tugal-Tutkun I Pediatric uveitis.J Ophthalmic Vis Res. 2011 Oct;6(4):259-69.
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