Clinical Profile of Juvenile Idiopathic Arthritis Associated Uveitis in A ...

UVEA SESSION
715
Clinical Profile of Juvenile Idiopathic Arthritis Associated Uveitis
in A Tertiary Care Eye Centre
Dr. Anushree V. Kaduskar, Dr. Amala Elizabeth George, Dr. S. Sudharshan,
Dr. Jyotirmoy Biswas
(Presenting Author: Dr. Anushree V. Kaduskar)
Juvenile idiopathic arthritis (JIA) is defined as
clinical evidence of chronic arthritis (with a
duration of at least 3 months) of unknown cause
in a child younger than 16 years of age.3
Approximately 6% of all uveitis occur in
children. 1 Uveitis associated with juvenile

716 AIOC 2010 PROCEEDINGS
idiopathic arthritis is the most common cause of
chronic intraocular inflammation among
paediatric population. 2 We describe the clinical
profile, complications, management and visual
outcomes in patients with JIA associated uveitis
in a tertiary eye care centre in India.
Materials and Methods
This is a retrospective study in which we
reviewed the records of 40 patients (80 eyes) who
presented to our uveitis referral centre between
1994 and 2008.Complete eye evaluation was
done on each visit and included a complete
history, visual acuity, cycloplegic refraction, slit
lamp examination intraocular pressure
estimation and dilated fundoscopic examination.
The Standardization of Uveitis Nomenclature
(SUN) Working Group criteria were used to
report clinical data. Results of laboratory
investigations, diagnostic and therapeutic
procedures were analyzed. The systemic
condition of the patient was managed by a
rheumatologist.
Results
Forty patients (80 eyes) with JIA seen at our
hospital between 1994 and 2008 were analyzed in
the study. Age at presentation at the hospital
ranged between 3 to 24 years (mean of 12.27+/-
6.48 years). The male: female ratio was 3:2.Thirty
one patients (77.5%) had bilateral presentation
and seven (17.5%) had unilateral presentation.
There was no ocular involvement in 2 patients at
presentation and on subsequent follow up. The
age of onset of arthritis ranged from 1.5-16 years
(mean of 7.42+/-4.2 years) and the age of onset
of uveitis ranged from 3-24 years (mean of
9.08+/-5.5 years).Onset of arthritis preceded the
onset of uveitis in thirty seven patients (92.5%),
uveitis was the primary manifestation in 1
patient and 2 patients had only arthritis. The
presentation of arthritis was pauciarticular in 32
patients (80%) and polyarticular in 6 patients
(15%). Knee joint was the most commonly
involved joint in 22 patients(55%). Ankle joint
was involved in 9 patients, wrist joint in 5
patients, small joints in 3 patients and elbow joint
in 2 patients. Diminution of vision was the most
common symptom in 56 eyes followed by
redness in 26 eyes. Other presenting symptoms
included pain in 15 eyes, photophobia in 12 eyes
and floaters in 6 eyes. Seven eyes had no
perception of light at presentation. The most
common type of uveitis in our series was chronic
anterior uveitis in 60 eyes (75%) followed by
intermediate uveitis in 10 eyes (12.5%) and
panuveitis in 2 eyes (2.5%). Posterior uveitis was
the presentation in 5 eyes. Acute anterior uveitis
with hypopyon was seen in 1 eye. Band shaped
keratopathy was present in 34 eyes
(42.5%),complicated cataract in 33(41.25%) and
seclusio papillae in 34(42.5%). Other features
seen were aphakia in 3 eyes(3.75%),
pseudophakia in 4 eyes(10%) and iris nodules in
1 eye. Posterior segment features seen were pars
planitis and glaucomatous optic atrophy in 1 eye
each (1.25%), cystoid macular oedema and total
retinal detachment in 2 eyes each(2.5%) and disc
hyperemia in 5 eyes(6.25%). Fundus examination
was normal in 30 eyes.30 patients were
investigated for rheumatoid arthritis (RA) factor
and 3(10%) amongst them tested positive for the
same. Anti nuclear antibodies (ANA) were
positive in 7 patients (26.9%) out of 26 patients
who were tested. All patients were tested for
erythrocyte sedimentation rate (ESR).Sixteen
patients had raised ESR. One young adolescent
male was positive for HLA B 27. Prednisolone
acetate 1% eye drops were used in tapering
dosage and the frequency of application was
based on the severity of anterior chamber
reaction. A combination of topical and oral
steroids was used in 12 patients(30%).Topical,
periocular and oral steroids were used in 8
patients(20%). 2 patients required intravenous
(methyl prednisolone) and intravitreal steroids
each. Oral steroids were used in the dose of

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ethylenediaminetetraacetic acid (EDTA) for BSK
was done in 6 eyes (7.5%).Other procedures
included vitrectomy and belt buckle in 4 eyes
each and trabeculectomy in 1 eye. Five eyes
(6.25%) required YAG laser capsulotomy for
posterior capsular opacification following
intraocular lens implantation. IOL removal with
vitrectomy was done in 4 eyes due to severe post
operative reactivation of uveitis and IOL
intolerance after surgery.11 patients had
recurrence of infection amongst which 3 patients
were not on any medications at the time of
recurrence. Visual acuity at final follow up
showed improvement in 31eyes (38.75%), was
stable in 34 eyes (42.5%) and deteriorated in 15
eyes (18.75%) despite treatment due to
complications of JIA.
Discussion
JIA associated uveitis is reported to occur most
commonly in young girls seropositive for ANA
with pauciarticular-onset arthritis.4,5In our
study, males outnumbered females in contrast to
studies in western population where females
were more commonly affected.2,5Sabri et al
reported JIA uveitis to occur in 61% of patients
who had pauciarticular JIA. Pauciarticular type
of JIA was seen in 80% of our patients. The
reason for increased incidence of pauciarticular
JIA in our series is because patients with ocular
symptomatology are seen by us and
pauciarticular type JIA is most commonly
associated with uveitis.2,7 The mean time from
diagnosis of JIA to diagnosis of uveitis was 1.66
years. Chalom et al9 have reported that a shorter
interval between diagnosis of JIA and uveitis was
a significant risk factor for developing uveitic
complications. The most common type of uveitis
in our series was chronic anterior uveitis as in
1. O’Brien JM,Albert DM,Foster CS.Juvenile
rheumatoid arthritis. In: Albert DM,Jackobiec
FA.eds.Principles and practice of ophthalmology:
Clinical practice. Vol.5. Philadelphia: W.B.Saunders
Co,1994;chap233
2. Kanski JJ.Uveitis in juvenile chronic arthritis:
incidence, clinical features and prognosis. EYE
1988;2:641-5.
3. Petty RE,Southwood TR, Manners P,Baum J,Glass
DN,Goldenberg J,et al.International league of
Associations for Rheumatology classification of
References
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(41.25%) and BSK (42.5%) were the most common
complications noted in our cohort.5We found
ANA positivity in only 7 of the 26 patients tested
for the same. Western studies4 have noted a
higher incidence and the risk of development of
severe disease in females with ANA positivity.
Agarwal et al.10 have however noted the rarity
of ANA positivity in Indian population.
Methotrexate was the most commonly used
immunosuppressant in 19 patients (47.5%) in our
study and showed good results in concordance
with study by Hemady et al.11We found
methotrexate as an effective steroid sparing agent
especially as a long term option. Liver function
tests and blood counts of the patients on
methotrexate have to be monitored periodically
(atleast every month) in association with an
internist. Kanski 1had noted good results after
lensectomy for cataracts in patients with JIA. In
our study, cataract was the most common cause
for which patients underwent surgery. Most of
the patients who underwent lensectomy were
rehabilitated with aphakic correction with
spectacles or contact lenses.
Our study indicates that in India, JIA associated
uveitis commonly presents as pauciarticular type
and is more common in males. Investigations for
RA and ANA are probably not of much help in
diagnosis or prognosis of these patients.
Complications such as BSK and complicated
cataract need prompt treatment for helping
speedy visual recovery. As long-term treatment
options, immunosuppressives are a better choice
than steroids. These patients need to be followed
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development of complications like glaucomatous
optic atrophy and hypotony can occur in such
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