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 responses inside the eye. Inflammation is the body s natural response to tissue damage, germs, or toxins. It produces swelling, redness, and destroys tissues as certain white blood cells rush to the affected part of the body to contain or eliminate the insult.

Anatomy: What is Uveitis? The uvea is the middle layer of the eye and contains much of the eye s blood vessels. The uvea consists of the iris, ciliary body, and choroid: Iris: It defines eye color, secretes nutrients to keep the lens healthy. Ciliary Body: located between the iris and the choroid. It helps the eye focus by controlling the shape of the lens, and provides nutrients to the lens. Choroid: A thin, spongy network of blood vessels, which provides nutrients to the retina.

Uveitis may be caused by: An attack from the body s own immune system (autoimmunity). Infections or tumors occurring within the eye or in other parts of the body. Trauma to the eye.

Uveitis Can last for a short (acute) or a long (chronic) time. Uveitis is specifically described as: Anterior uveitis Intermediate uveitis Posterior uveitis Panuveitis

What is Anterior Uveitis? Anterior uveitis occurs in the front of the eye. It is the most common form of uveitis. Many cases occur in healthy people and may only affect one eye, but some are associated with juvenile idiopathic arthritis, skin, gastrointestinal, lung and infectious diseases

What is Intermediate Uveitis? Intermediate uveitis is commonly seen in young adults. The center of the inflammation often appears in the vitreous. It has been linked to autoimmune disorders including sarcoidosis and multiple sclerosis.

What is Posterior Uveitis? Posterior uveitis is the least common form of uveitis. It primarily occurs in the back of the eye, often involving both the retina and the choroid. It is often called choroiditis or chorioretinitis. There are many infectious and non-infectious causes of posterior uveitis.

What is Pan-Uveitis? Pan-uveitis is a term used when all three major parts of the eye are affected by inflammation. Behcet s disease is one of the most well-known forms of pan-uveitis and it greatly damages the retina.

Symptoms of Uveitis: Uveitis can affect one or both eyes. Symptoms may develop rapidly and can include: Blurred vision Dark, floating spots in the vision (floaters) Eye pain Redness of the eye Sensitivity to light (photophobia) OR- A QUIET WHITE EYE

Juvenile Idiopathic Arthritis: It is easy to miss flare-ups due to the white and quiet presentation of this type of uveitis. Children often do not complain of visual problems, precluding the possibility of early detection. Chronic uveitis characteristically is asymptomatic in children with JIA, but leads to complications including possible blindness. 30-40% of patients with JIA-associated uveitis experience severe loss of vision.

How Does Uveitis Occur? The cause of uveitis and arthritis in JIA remains unknown. The target antigen is unidentified. Associated factors may include the possibility of: a infectious triggers, genetic predisposition, an autoimmune response, psychological stress, and hormone interaction

Complications from Lack of Treatment: Cataracts (40-80%) Band keratopathy (30-80%) Macular edema in chronic cases Vitreous debris (20-30%) Glaucoma (10-30%) Chronic hypotony and phthisis (5-20%)

Differential Diagnosis: Ankylosing Spondylitis Dermatologic Aspects of Behcet Disease Dermatologic Manifestations of Kawasaki Disease Fuchs Heterochromic Uveitis Herpes Simplex in Emergency Medicine Herpes Zoster Inflammatory Bowel Disease Interstitial Keratitis Juvenile Xanthogranuloma Lyme Disease Pediatric Tuberculosis Psoriasis Reactive Arthritis Retinoblastoma Imaging Uveitic Glaucoma Uveitis, Anterior, Childhood Uveitis, Anterior, Nongranulomatous Vogt-Koyanagi-Harada (VKH)Disease

Review of Systems- Important General - Weight loss, fatigue, fever Skin - Rash, nodules, changes in nails Neck - Lymphadenopathy Respiratory - Cough, wheezing Cardiac - Chest pain/discomfort, dyspnea Gastrointestinal - Hepatomegaly, diarrhea, frequent bowel movements Genitourinary - Delayed secondary sexual characteristics, rash Musculoskeletal - Muscle or joint pain, arthritis, back pain, limitation of motion

Management of Uveitis: Step ladder approach: Begin with topical corticosteroids. Most patients would respond to this initial treatment. Severe disease, or chronic inflammation increases the risk for Macular Edema. These patients may be given additional nonsteroidal anti-inflammatory drugs (NSAIDs). Bilateral Uveitis may need systemic corticosteroids.

Side Effects of Steroids: Long-term steroid use may produce side effects such as stomach ulcers, osteoporosis (bone thinning), diabetes, cataracts, glaucoma, cardiovascular disease, weight gain, fluid retention. Usually other agents are started if it appears that patients need steroids for >3 months. Systemic immunomodulatory agents may be useful for patients with limited or no response to systemic corticosteroids or for those who develop unacceptable side effects.

Follow up Recommendations: Patients with JIA-associated uveitis need to be seen by an ophthalmologist regularly, every 3 or 4 months. Need an initial screening examination upon diagnosis of JIA, and the exam be performed within one month after diagnosis of JIA. After the initial screening examination, regular follow-up screenings be maintained based on risk category and classification. Screening every 6-12 months in ANA positive patients with disease onset >6 years of age who have not had uveitis within the first two years of JIA diagnosis. Patient is <6 years of age and the provider has a strong suspicion of JIA, should have a screening for uveitis.

Complications: If left untreated, uveitis may lead to: Glaucoma (increased pressure in the eye); Cataract (clouding of the eye's natural lens); Neovascularization (growth of new, abnormal blood vessels) Damage to the retina, including retinal detachment, damage to the optic nerve or both. These complications may need treatment with eye drops, conventional surgery or laser surgery.

Recommendations: It is recommended that screenings for uveitis be performed by an ophthalmologist experienced in pediatric care. Important to have good communication between the Ophthalmologist and the Rheumatologist.

Uveitis Associated with JIA Uveitis is the most common extra-articular complication of JIA Occurs in 11-30% of children with JIA 16% 12% 4% chronic anterior uveitis 68% acute anterior uveitis recurrent anterior uveitis panuveitis

Acute Anterior Uveitis in JIA Subtypes Acute anterior uveitis is often associated with eye pain, redness, headache or photophobia Most common in HLA B27-positive JIA subsets such as ankylosing spondylitis or arthritis associated with inflammatory bowel disease Often treatable with topical steroids alone

Chronic Anterior Uveitis JIA is the most common systemic cause of chronic anterior uveitis Chronic anterior uveitis develops in: 10-30% of pauciarticular JIA (20-40% of ANA positive pts) <10% of polyarticular JIA Most commonly seen in young ANA positive girls >65% cases are asymptomatic & bilateral, but can be unilateral

Chronic Anterior Uveitis in JIA Chronic anterior uveitis is usually asymptomatic at onset Failure to screen & recognize chronic anterior uveitis may lead to serious complications such as vision loss Visual acuity is best measure of disease activity & damage Screening is best done by an ophthalmologist, not an optometrist Frequency of screening by current guidelines is based on subtype of JIA & ANA status

Increased Risk for Chronic Anterior Uveitis in Pauciarticular JIA Young age at onset of JIA (<3 yr) ANA positivity (especially higher titers?) but alone cannot predict risk of uveitis HLA DRB1*11 haplotype (tissue typing) Female ESR >50 at time of JIA diagnosis

Which Occurs First? Mean time between diagnosis of JIA & uveitis onset is 1.8 yr Time between diagnoses of JIA & anterior uveitis (AU): 65% 0% 5% 30% AU before JIA AU & JIA simultaneously AU after JIA

Timing of Chronic Anterior Uveitis in JIA 75% patients develop chronic uveitis within 1 year after JIA diagnosis 90% by 4 years after diagnosis of JIA 50% overall develop complications in part related to topical steroids: synechiae band keratopathy cystoid macular edema vitritis glaucoma Complications related to severity of uveitis

Definition of Severe versus Mild Chronic Anterior Uveitis Mild: single or recurrent episodes without development of complications or need for systemic immunosuppression (as defined by treating ophthalmologist) Severe: Persistent or >2 episodes in 1 year with either: Development of complications Need for systemic immunosuppression

Typical Complications: Pupil Irregularity from Synechiae

Band Keratopathy

Posterior Synechiae, Cataract and Glaucoma

Risk Factors for Ocular Complications in Chronic Anterior Uveitis Male Young age at uveitis onset (<3 yr) Short time duration (<5 months) between development of JIA & uveitis - main risk predictor Presence of synechiae at initial diagnosis of uveitis

Vision Loss in JIA associated Chronic Anterior Uveitis Reduced visual acuity to 20/50: in 13-26% pts To 20/200: in 5-9% pts Risk may be decreasing due to use of methotrexate for JIA? TNF inhibitors?

Risk Factors for Vision Loss Increased risk with: Bilateral uveitis Long duration of eye disease (>5 yr) Presence of synechiae, band keratopathy Abnormal intraocular pressure (high or low) Persistent >1+ cells & vitreous haze History of intraocular surgery

JIA Uveitis is a Systemic Autoimmune Disease Uveitis is a systemic autoimmune disease not localized to eye and is treated as such Specific autoantibodies & autoreactive T cells not yet defined ANA does not appear to play role in development of uveitis Pro-inflammatory cytokines especially TNFa have pivotal role in pathogenesis of uveitis & JIA IFNg TNFa IL-1 IL-6 IL-18, etc IL-4 IL-10 TGFb IL-1RA, etc

Autoimmunity T&B cell-mediated responses against self eye proteins culminating in uveitis Maybe triggered by environmental factors in genetically susceptible individuals Breakdown of tolerance to SELF is key Involves loss of regulatory T cells, increased autoreactive T & B cells, imbalance between pro-inflammatory & anti-inflammatory cytokines Immune system mistakenly attacks self, damaging healthy cells and organs, causing disease

JIA Uveitis Treatment Topical steroids are often used 1 st, alone or with additional immunomodulation: Frequent or long tem steroid eye drops is associated with increased risks of cataracts & glaucoma Systemic steroids may be needed if uveitis is severe & rapid immunosuppression is needed Start DMARD steroid-sparing agent if uveitis not controlled with steroids or develop complications: Methotrexate (MTX) preferred Mycophenolate Cyclosporine Tacrolimus

Methotrexate MTX (SQ or PO) is mainstay of uveitis treatment However, 15-50% pts will have refractory uveitis despite MTX: 30% never controlled 12-20% relapse within 5 years ON MTX Relapses on MTX may be reduced if: Continue MTX for >3 years Withdraw MTX only after >2 years of inactive uveitis

Our New Therapies: Biologic Response Modifiers MTX-resistant pts need biologic therapy Biologics are recombinant drugs that specifically target: inflammatory cytokines co-stimulatory & adhesion molecules cell populations involved in disease pathogenesis

Cytokine Targets are Protein Messengers that Convey Information Between Cells via Specific Cell-surface Receptors Cell 1 Cell 2 signaling molecules Gene expression Cytokine Response

Cytokines in Pathogenesis of Uveitis \ IL-6, etc \ \ \ \ TNFa blood-eye barrier \ \ \ \ \ \ TNFa & other pro-inflammatory cytokines penetrate blood-eye barrier along with activated T cells causing inflammation in the eye

Benefits of Cytokine Inhibitors Most JIA-associated uveitis patients who fail to respond to MTX respond to a biologic Long-acting TNFa inhibitors are used first: Adalimumab Infliximab Etanercept is not recommended since short-acting TNFa inhibition has not proven efficacious in control of chronic uveitis

Other Biologics in Chronic Uveitis IL-6 inhibitor: Tocilizumab: Maybe helpful in patients who fail MTX & TNF inhibitors Short & long acting IL-1 inhibitors: Anakinra: Not known to be helpful Rilonacept: Not known to be helpful Canakinumab: Not known to be helpful

Non-Cytokine Biologics in Chronic Uveitis B-cell inhibition: Rituximab: Maybe helpful in patients who fail MTX & TNF inhibitors T-cell inhibition: Abatacept: Maybe helpful in patients who fail MTX & TNF inhibitors

How to Taper Biologics? No right way to wean off biologic Wean cautiously & slowly Need eye screens just before biologic is due (if infusion) in order to determine if spacing out infusions is possible close communication between rheumatologist & ophthalmologist is critical