Approach to Pediatric Uveitis. Paris Tranos PhD,ICO,FRCS OPHTHALMICA Vitreoretinal & Uveitis Service

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1 Approach to Pediatric Uveitis Paris Tranos PhD,ICO,FRCS OPHTHALMICA Vitreoretinal & Uveitis Service

000 children Worse prognosis in children Importance of annual vision screening for all

2 Epidemiology Uveitis is the 3 rd leading cause of blindness in USA 5-10% of uveitis cases involve children <16 yrs 3-6 cases per 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 May; 135(5):676-80

3 Red eye Lacrimation Photophobia Clinical presentation Floaters Loss of vision

4 Clinical presentation ASYMPTOMATIC

5 Anterior -non granulomatous -granulomatous Classification Intermediate Posterior - with vasculitis -without vasculitis

Inflammatory bowel disease Juvenile Idiopathic Arthritis Nephritis

6 Differential Diagnosis Anterior non granulomatous uveitis Idiopathic HLA-B27 associated Ankylosing Spondylitis Reactive arthritis Psoriasis Inflammatory bowel disease Juvenile Idiopathic Arthritis Nephritis Systemic lupus erythematosus Herpes Simplex virus Lyme disease Leukemia Drug-induced

7 Differential Diagnosis Anterior granulomatous uveitis Sarcoidosis Tuberculosis Bechet's disease Multiple Sclerosis Inflammatory bowel disease Herpes simplex virus Fungal disease Syphilis Whipple's disease

8 Differential Diagnosis Intermediate uveitis Pars Planitis JIA Multiple Sclerosis Lyme disease Cat-scratch disease Sarcoidosis

9 Differential Diagnosis Posterior uveitis/panuveitis Toxocariasis TORCH Toxoplasmosis Syphilis Rubella Cytomegalovirus HSV/VZV Vogt-Koyanagi Harada Syndrome Bechet's disease Leukemia Tuberculosis Inflammatory bowel disease Systemic lupus erythematosus

10 Diagnostic tests Recurrent Anterior non granulomatous Anterior granulomatous Intermediate Posterior 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

oligoarticular (<5 joints involved) Risk factors for development of uveitis Young onset

11 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 uveitis Young onset Female gender ANA +ve oligoarticular RF-ve Tugal-Tutkun I Pediatric uveitis.j Ophthalmic Vis Res Oct;6(4):

HLA B27 Acute recurrent uveitis May have hypopyon positive

12 JIA UVEITIS Chronic anterior uveitis band keratopathy WHITE EYE Frequent Uveitis about 20% RF ve, HLA B27 -ve, ANA +ve JUVENILE HLA B27 Acute recurrent uveitis May have hypopyon positive family history RF negative RED EYE uveitis common HLA B27 +ve ANA -ve

13 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

14 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

15 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

16 Treatment Treat the cause Control the inflammation Tugal-Tutkun I Pediatric uveitis.j Ophthalmic Vis Res Oct;6(4):

17 Step ladder approach Steroids topical regional systemic Methotrexate Treatment Cyclosporin, Mucophenolate mofetil Biologicals (Adalimumab) Tugal-Tutkun I Pediatric uveitis.j Ophthalmic Vis Res Oct;6(4):

Nausheen Khuddus, MD Melissa Elder, MD, PhD

Nausheen Khuddus, MD Melissa Elder, MD, PhD Nausheen Khuddus, MD Pediatric Ophthalmologist and Strabismus Specialist Accent Physicians Gainesville, Florida What Is Uveitis? Uveitis is caused by inflammatory