Risk Factors for Loss of Visual Acuity among Patients with Uveitis Associated with Juvenile Idiopathic Arthritis: The Systemic Immunosuppressive Therapy for Eye Diseases Study

Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ophthalmology (Impact Factor: 6.17). 01/2013; 120(1). DOI: 10.1016/j.ophtha.2012.07.052
Source: PubMed

ABSTRACT PURPOSE: To describe the incidence of and risk factors for visual acuity (VA) loss and ocular complications in patients with juvenile idiopathic arthritis (JIA)-associated uveitis. DESIGN: Multicenter retrospective cohort study. PARTICIPANTS: A total of 327 patients (596 affected eyes) with JIA-associated uveitis managed at 5 tertiary uveitis clinics in the United States. METHODS: Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) cohort study. Demographic and clinical characteristics were obtained for every eye of every patient at every visit via medical record review by trained expert reviewers. MAIN OUTCOME MEASURES: Loss of VA to 20/50 or to 20/200 or worse thresholds and the development of ocular complications. RESULTS: At presentation, 240 eyes (40.3%) had a VA of ≤20/50, 144 eyes (24.2%) had a VA of ≤20/200, and 359 eyes (60.2%) had at least 1 ocular complication. The incidences of VA loss to the ≤20/50 and ≤20/200 thresholds were 0.18 and 0.09 per eye-year (EY), respectively; the incidence of developing at least 1 new ocular complication over follow-up was 0.15/EY (95% confidence interval [CI], 0.13-0.17). However, among eyes with uveitis that had no complications at presentation, the rate of developing at least 1 ocular complication during follow-up was lower (0.04/EY; 95% CI, 0.02-0.06). Posterior synechiae, active uveitis, and prior intraocular surgery were statistically significantly associated with VA to the ≤20/50 and ≤20/200 thresholds both at presentation and during follow-up. Increasing (time-updated) anterior chamber cell grade was associated with increased rates of visual loss in a dose-dependent fashion. Use of immunosuppressive drugs was associated with a reduced risk of visual loss, particularly for the ≤20/50 outcome (hazard ratio, 0.40; 95% CI, 0.21-0.75; P<0.01). CONCLUSIONS: Ocular complications and vision loss were common in our cohort. Increasing uveitis activity was associated with increased risk of vision loss, and use of immunosuppressive drugs was associated with reduced risk of vision loss, suggesting that control of inflammation and use of immunosuppression may be critical aspects in improving the outcomes of patients with JIA-related uveitis. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Juvenile idiopathic arthritis (JIA) is one of the most common rheumatic diseases in childhood with a prevalence of 4 in 1,000 children. Anterior uveitis is a well-known threatening comorbid condition of JIA and affects around 10 % of the patients depending on JIA subtype. A large proportion of children with JIA develop uveitis in the first year of disease and 73 to 90 % after 4 years. Uveitis can progress into adulthood and usually occurs as 'white uveitis', while in the JIA related to the enthesitis subtype that is symptomatic. Current studies reinforced the previous observations that early age of JIA onset, oligoarticular subtype and ANA reactivity are the main risk factors for the development of uveitis. Factors associated to worse prognosis are as follows: findings of 1+ or more vitreous cells at presentation and initial visual acuity of 20/200 or worse. The Standardization of Uveitis Nomenclature (SUN) Group took the first step to define outcome measures for uveitis, but it was established for adults. The Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC) proposed outcome measures for JIA-associated uveitis incorporating the SUN criteria in 2011. The current suggested management recommends to start early a steroid-sparing effective immunomodulatory systemic treatment. Methylprednisolone intravenous pulse therapy, rituximab, tocilizumab and abatacept are promising agents. Because JIA-associated uveitis is a potentially threatening comorbidity, it is important to recognize and treat it early to prevent any visual damage that could impair visual acuity.
    Clinical Reviews in Allergy & Immunology 08/2014; DOI:10.1007/s12016-014-8436-9 · 4.73 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE: To analyze inflammatory parameters as possible predictors for the development of uveitis in juvenile idiopathic arthritis (JIA) patients. Further, to analyze the predictive value of demographic and clinical factors at the onset of arthritis. DESIGN: Retrospective cohort study. METHODS: In 358 children with oligoarthritis and rheumatoid factor-negative polyarthritis, erythrocyte sedimentation rate (ESR), C-reactive protein, leukocyte count, presence of antinuclear antibodies (ANA), presence of human leukocyte antigen (HLA-)B27, age of onset of JIA, and sex were analyzed for their predictive value for the onset of uveitis. RESULTS: One hundred forty-seven patients (41%) were diagnosed with chronic anterior uveitis. Young age of onset, presence of ANA, and elevated ESR appeared to be predictive factors according to univariate analyses (P = .029, P = .007, and P = 5E(-4), respectively). According to multivariate analysis, young age of onset and elevated ESR appeared to be predictive after adjusting for the other relevant factors (P = .004 and P = .001, respectively). A prediction model was developed. CONCLUSIONS: Elevated ESR appears to be a predictor for the occurrence of uveitis in patients with JIA. Since ESR is already routinely tested in patients with recently diagnosed arthritis, its use as a biomarker can easily be implemented in daily practice.
    American Journal of Ophthalmology 11/2014; 159(2). DOI:10.1016/j.ajo.2014.11.007 · 4.02 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Juvenile idiopathic arthritis (JIA) is a clinically heterogeneous group of diseases whose general characteristics is joint involvement in children and adolescents before the age of 16 which persists for a period of 6 weeks and is of non-infectious nature and undefined cause. Most common exta-articular manifestation of JIA is intraocular inflammation in form of bilateral nongranulomatous anterior uveitis. This study consists of 42 patients with JIA (21 with and 21 without ocular manifestations) with females being represented in significantly higher numbers (Z = 6.451, р = 0.039 < 0.05). There was no JIA – associated uveitis in children under the age of 4. No statistically significant difference between age intervals 4 – 6 and 7 – 12 was noted, while the group over the age of 12 had male predominance. Group, which consisted of individuals with no ocular manifestations i.e. the control group, but had JIA also showed that 90.48% were under the age of six. All of the patients in the examined group had ocular manifestations that post-dated joint involvement. There were no children with polyarticular type of the disease as part of the control group of patients. On the other hand, examined group consisted of individuals with a single joint involvement (monoarticular) or systemic type of disease. Majority of patients with monoarticular type of disease were girls. In presence of JIA – associated uveitis there was no noted difference between occurrence of oligoarticular and polyarticular form of disease, whilst antinuclear antibody (ANA) positivity was more common in the group with JIA – associated uveitis (p < 0.5). All of the patients had serofibrinous, bilateral, form of uveitis and 33.33% had disc edema. Severe and moderate forms of uveitis were more frequent and had similar probability (47.62% vs. 52.38%). Initially there were 52.38% of individuals with visual efficiency (VE) greater than 0.5 with no statistically important increase having occurred during the follow-up period. In 61.90% of cases, as result of the disease, there was complicated cataract formation, and one third of patients had macular edema as consequence of the same. Systemic corticosteroid therapy was used as part of the treatment plan in 76.19% of cases. Methotrexate (MTX) was applied in 42.86% of the control group and 47.62% of the examined group. Subtenonial injections of triamcinolone acetonide were used in 9.52% of cases with macular edema.


Available from
May 16, 2014