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Special Considerations: Treatment of Pediatric Uveitis

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Treatment of Non-infectious Uveitis

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Abstract

Pediatric uveitis is a significant cause of ocular morbidity and poses diagnostic and treatment dilemmas to ophthalmologists. The spectrum of clinical presentation, difficulty in examination of children, and lifetime burden of vision loss without adequate treatment are the main challenges in management of pediatric uveitis. While infectious and noninfectious, systemic autoimmune conditions may be associated with pediatric uveitis, juvenile idiopathic arthritis remains the most common associated disease condition. Coordination with pediatric rheumatologists and primary care physicians is important to provide comprehensive, multidisciplinary care. While traditional disease-modifying antirheumatic drugs such as methotrexate remain a mainstay for noninfectious pediatric uveitis to avoid complications of topical ophthalmic corticosteroids, the biologic agents, notably the anti-tumor necrosis factor-alpha inhibitors adalimumab and infliximab, have been increasingly used given their benefit in the control of ocular inflammation. This chapter summarizes the common causes of pediatric uveitis and the management approach to the spectrum of disease entities.

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References

  1. Cunningham ET Jr. Uveitis in children. Ocul Immunol Inflamm. 2000;8:251–61.

    Article  Google Scholar 

  2. Suhler EB, Lloyd MD, Choi D, et al. Incidence and prevalence of uveitis in Veterans Affairs Medical Centers of the Pacific Northwest. Am J Ophthalmol. 2008;146:890–6.

    Article  Google Scholar 

  3. Zierhut M, Michels H, Stubiger N, Besch D, Deuter C, Heiligenhaus A. Uveitis in children. Int Ophthalmol Clin. 2005;45:135–56.

    Article  Google Scholar 

  4. Levy-Clarke GA, Nussenblatt RB, Smith JA. Management of chronic pediatric uveitis. Curr Opin Ophthalmol. 2005;16:281–8.

    Article  Google Scholar 

  5. Malinowski SM, Pulido JS, Folk JC. Long-term visual outcome and complications associated with pars planitis. Ophthalmology. 1993;100:818–24.

    Article  CAS  Google Scholar 

  6. Rosenberg KD, Feuer WJ, Davis JL. Ocular complications of pediatric uveitis. Ophthalmology. 2004;111:2299–306.

    Article  Google Scholar 

  7. Nagpal A, Leigh JF, Acharya NR. Epidemiology of uveitis in children. Int Ophthalmol Clin. 2008;48:1–7.

    Article  Google Scholar 

  8. Deschenes J, Murray PI, Rao NA, Nussenblatt RB. International Uveitis Study G. International Uveitis Study Group (IUSG): clinical classification of uveitis. Ocul Immunol Inflamm. 2008;16:1–2.

    Article  Google Scholar 

  9. Wentworth BA, Freitas-Neto CA, Foster CS. Management of pediatric uveitis. F1000Prime Rep. 2014;6:41.

    Article  Google Scholar 

  10. Michels H, Schuchmann L, Truckenbrodt H, Renz K. Rheumatic iridocyclitis in childhood – differentiation on the basis of clinical and immunological parameters. Klin Padiatr. 1982;194:104–8.

    Article  CAS  Google Scholar 

  11. Thorne JE, Woreta FA, Dunn JP. Risk of cataract development among children with juvenile idiopathic arthritis-related uveitis treated with topical corticosteroids. Ophthalmology. 2010;117:1436–41.

    Article  Google Scholar 

  12. Slabaugh MA, Herlighy E, Ongchin S, van Gelder RN. Efficacy and potential complications of difluprednate use for pediatric uveitis. Am J Ophthalmol. 2012;153:932–8.

    Article  CAS  Google Scholar 

  13. Buchman AL. Side effects of corticosteroid therapy. J Clin Gastroenterol. 2001;33:289–94.

    Article  CAS  Google Scholar 

  14. Sood AB, Angeles-Han ST. An update on the treatment of pediatric chronic non-infectious uveitis. Curr Treatm Opt Rheumatol. 2017;3:1–16.

    Article  Google Scholar 

  15. Smith JA, Mackensen F, Sen HN, et al. Epidemiology and course of disease in childhood uveitis. Ophthalmology. 2009;116:1544–51, 51.e1

    Article  Google Scholar 

  16. Petty RE, Southwood TR, Baum J, et al. Revision of the proposed classification criteria for juvenile idiopathic arthritis: Durban, 1997. J Rheumatol. 1998;25:1991–4.

    CAS  PubMed  Google Scholar 

  17. Chia A, Lee V, Graham EM, Edelsten C. Factors related to severe uveitis at diagnosis in children with juvenile idiopathic arthritis in a screening program. Am J Ophthalmol. 2003;135:757–62.

    Article  Google Scholar 

  18. Wolf MD, Lichter PR, Ragsdale CG. Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology. 1987;94:1242–8.

    Article  CAS  Google Scholar 

  19. Kotaniemi K, Kautiainen H, Karma A, Aho K. Occurrence of uveitis in recently diagnosed juvenile chronic arthritis: a prospective study. Ophthalmology. 2001;108:2071–5.

    Article  CAS  Google Scholar 

  20. Zierhut M, Doycheva D, Biester S, Stubiger N, Kummerle-Deschner J, Deuter C. Therapy of uveitis in children. Int Ophthalmol Clin. 2008;48:131–52.

    Article  Google Scholar 

  21. Armaly MF. Statistical attributes of the steroid hypertensive response in the clinically normal eye. I. The demonstration of three levels of response. Invest Ophthalmol. 1965;4:187–97.

    CAS  PubMed  Google Scholar 

  22. Hawkins MJ, Dick AD, Lee RJ, et al. Managing juvenile idiopathic arthritis-associated uveitis. Surv Ophthalmol. 2016;61:197–210.

    Article  Google Scholar 

  23. Heiligenhaus A, Michels H, Schumacher C, et al. Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int. 2012;32:1121–33.

    Article  CAS  Google Scholar 

  24. Simonini G, Paudyal P, Jones GT, Cimaz R, Macfarlane GJ. Current evidence of methotrexate efficacy in childhood chronic uveitis: a systematic review and meta-analysis approach. Rheumatology (Oxford). 2013;52:825–31.

    Article  CAS  Google Scholar 

  25. Sijssens KM, Rothova A, Van De Vijver DA, Stilma JS, De Boer JH. Risk factors for the development of cataract requiring surgery in uveitis associated with juvenile idiopathic arthritis. Am J Ophthalmol. 2007;144:574–9.

    Article  Google Scholar 

  26. Bou R, Adan A, Borras F, et al. Clinical management algorithm of uveitis associated with juvenile idiopathic arthritis: interdisciplinary panel consensus. Rheumatol Int. 2015;35:777–85.

    Article  Google Scholar 

  27. Amin RM, Miserocchi E, Thorne JE, Hornbeak D, Jabs DA, Zierhut M. Treatment options for juvenile idiopathic arthritis (JIA) associated uveitis. Ocul Immunol Inflamm. 2016;24:81–90.

    Article  CAS  Google Scholar 

  28. Bichler J, Benseler SM, Krumrey-Langkammerer M, Haas JP, Hugle B. Leflunomide is associated with a higher flare rate compared to methotrexate in the treatment of chronic uveitis in juvenile idiopathic arthritis. Scand J Rheumatol. 2015;44:280–3.

    Article  CAS  Google Scholar 

  29. Ramanan AV, Dick AD, Jones AP, et al. Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis. N Engl J Med. 2017;376:1637–46.

    Article  CAS  Google Scholar 

  30. Correll CK, Bullock DR, Cafferty RM, Vehe RK. Safety of weekly adalimumab in the treatment of juvenile idiopathic arthritis and pediatric chronic uveitis. Clin Rheumatol. 2018;37:549–53.

    Article  Google Scholar 

  31. Tambralli A, Beukelman T, Weiser P, Atkinson TP, Cron RQ, Stoll ML. High doses of infliximab in the management of juvenile idiopathic arthritis. J Rheumatol. 2013;40:1749–55.

    Article  CAS  Google Scholar 

  32. Smith JA, Thompson DJ, Whitcup SM, et al. A randomized, placebo-controlled, double-masked clinical trial of etanercept for the treatment of uveitis associated with juvenile idiopathic arthritis. Arthritis Rheum. 2005;53:18–23.

    Article  CAS  Google Scholar 

  33. Calvo-Rio V, Santos-Gomez M, Calvo I, et al. Anti-interleukin-6 receptor tocilizumab for severe juvenile idiopathic arthritis-associated uveitis refractory to anti-tumor necrosis factor therapy: a multicenter study of twenty-five patients. Arthritis Rheumatol. 2017;69:668–75.

    Article  CAS  Google Scholar 

  34. Tappeiner C, Mesquida M, Adan A. Evidence for tocilizumab as a treatment option in refractory uveitis associated with juvenile idiopathic arthritis. J Rheumatol. 2016;43:2183–8.

    Article  CAS  Google Scholar 

  35. Mesquida M, Molins B, Llorenc V, et al. Twenty-four month month follow-up of tocilizumab therapy for refractory uveitis-related macular edema. Retina. 2018;38:1361–70.

    Article  CAS  Google Scholar 

  36. Tappeiner C, Miserocchi E, Bodaghi B, et al. Abatacept in the treatment of severe, longstanding, and refractory uveitis associated with juvenile idiopathic arthritis. J Rheumatol. 2015;42:706–11.

    Article  CAS  Google Scholar 

  37. Adrovic A, Barut K, Sahin S, Kasapcopur O. Juvenile spondyloarthropathies. Curr Rheumatol Rep. 2016;18:55.

    Article  Google Scholar 

  38. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361–8.

    Article  Google Scholar 

  39. Hoover DL, Khan JA, Giangiacomo J. Pediatric ocular sarcoidosis. Surv Ophthalmol. 1986;30:215–28.

    Article  CAS  Google Scholar 

  40. Jasper PL, Denny FW. Sarcoidosis in children. With special emphasis on the natural history and treatment. J Pediatr. 1968;73:499–512.

    Article  CAS  Google Scholar 

  41. Weinreb RN. Diagnosing sarcoidosis by transconjunctival biopsy of the lacrimal gland. Am J Ophthalmol. 1984;97:573–6.

    Article  CAS  Google Scholar 

  42. Rodriguez GE, Shin BC, Abernathy RS, Kendig EL Jr. Serum angiotensin-converting enzyme activity in normal children and in those with sarcoidosis. J Pediatr. 1981;99:68–72.

    Article  CAS  Google Scholar 

  43. Gedalia A, Molina JF, Ellis GS Jr, Galen W, Moore C, Espinoza LR. Low-dose methotrexate therapy for childhood sarcoidosis. J Pediatr. 1997;130:25–9.

    Article  CAS  Google Scholar 

  44. Lopalco G, Fabiani C, Sota J, et al. IL-6 blockade in the management of non-infectious uveitis. Clin Rheumatol. 2017;36:1459–69.

    Article  Google Scholar 

  45. Lu L, Shen M, Jiang D, et al. Blau syndrome with good responses to tocilizumab: a case report and focused literature review. Semin Arthritis Rheum. 2018;47:727–31.

    Article  Google Scholar 

  46. Mackensen F, Smith JR, Rosenbaum JT. Enhanced recognition, treatment, and prognosis of tubulointerstitial nephritis and uveitis syndrome. Ophthalmology. 2007;114:995–9.

    Article  Google Scholar 

  47. Mackensen F, Billing H. Tubulointerstitial nephritis and uveitis syndrome. Curr Opin Ophthalmol. 2009;20:525–31.

    Article  Google Scholar 

  48. Gion N, Stavrou P, Foster CS. Immunomodulatory therapy for chronic tubulointerstitial nephritis-associated uveitis. Am J Ophthalmol. 2000;129:764–8.

    Article  CAS  Google Scholar 

  49. Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature Working G. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140:509–16.

    Article  Google Scholar 

  50. Pederson JE, Kenyon KR, Green WR, Maumenee AE. Pathology of pars planitis. Am J Ophthalmol. 1978;86:762–74.

    Article  CAS  Google Scholar 

  51. Nussenblatt RB, Whitcup SM, Palestine AG. Uveitis: fundamentals and clinical practice. 2nd ed. St. Louis: Mosby; 1996.

    Google Scholar 

  52. Tang WM, Pulido JS, Eckels DD, Han DP, Mieler WF, Pierce K. The association of HLA-DR15 and intermediate uveitis. Am J Ophthalmol. 1997;123:70–5.

    Article  CAS  Google Scholar 

  53. Mikkila HO, Seppala IJ, Viljanen MK, Peltomaa MP, Karma A. The expanding clinical spectrum of ocular lyme borreliosis. Ophthalmology. 2000;107:581–7.

    Article  CAS  Google Scholar 

  54. Karma A, Seppala I, Mikkila H, Kaakkola S, Viljanen M, Tarkkanen A. Diagnosis and clinical characteristics of ocular Lyme borreliosis. Am J Ophthalmol. 1995;119:127–35.

    Article  CAS  Google Scholar 

  55. Rosenbaum JT, Rahn DW. Prevalence of Lyme disease among patients with uveitis. Am J Ophthalmol. 1991;112:462–3.

    Article  CAS  Google Scholar 

  56. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1089–134.

    Article  Google Scholar 

  57. Giles CL. Uveitis in childhood – part III. Posterior. Ann Ophthalmol. 1989;21:23–8.

    CAS  PubMed  Google Scholar 

  58. Nussenblatt RB, Belfort R Jr. Ocular toxoplasmosis. An old disease revisited. JAMA. 1994;271:304–7.

    Article  CAS  Google Scholar 

  59. Wong SY, Remington JS. Toxoplasmosis in pregnancy. Clin Infect Dis. 1994;18:853–61; quiz 62.

    Article  CAS  Google Scholar 

  60. Schantz PM, Glickman LT. Toxocaral visceral larva migrans. N Engl J Med. 1978;298:436–9.

    Article  CAS  Google Scholar 

  61. Schantz PM. Toxocara larva migrans now. Am J Trop Med Hyg. 1989;41:21–34.

    Article  CAS  Google Scholar 

  62. Shields JA, Lerner HA, Felberg NT. Aqueous cytology and enzymes in nematode endophthalmitis. Am J Ophthalmol. 1977;84:319–22.

    Article  CAS  Google Scholar 

  63. Dinning WJ, Gillespie SH, Cooling RJ, Maizels RM. Toxocariasis: a practical approach to management of ocular disease. Eye (Lond). 1988;2(Pt 5):580–2.

    Article  Google Scholar 

  64. Shields JA. Ocular toxocariasis. A review. Surv Ophthalmol. 1984;28:361–81.

    Article  CAS  Google Scholar 

  65. Fitzgerald CR, Rubin ML. Intraocular parasite destroyed by photocoagulation. Arch Ophthalmol. 1974;91:162–4.

    Article  CAS  Google Scholar 

  66. Krause I, Uziel Y, Guedj D, et al. Childhood Behcet’s disease: clinical features and comparison with adult-onset disease. Rheumatology (Oxford). 1999;38:457–62.

    Article  CAS  Google Scholar 

  67. Treudler R, Orfanos CE, Zouboulis CC. Twenty-eight cases of juvenile-onset Adamantiades-Behcet disease in Germany. Dermatology. 1999;199:15–9.

    Article  CAS  Google Scholar 

  68. Kone-Paut I. Behcet’s disease in children, an overview. Pediatr Rheumatol Online J. 2016;14:10.

    Article  Google Scholar 

  69. Soheilian M, Aletaha M, Yazdani S, Dehghan MH, Peyman GA. Management of pediatric Vogt-Koyanagi-Harada (VKH)-associated panuveitis. Ocul Immunol Inflamm. 2006;14:91–8.

    Article  CAS  Google Scholar 

  70. Jeroudi A, Angeles-Han ST, Yeh S. Efficacy of adalimumab for pediatric Vogt-Koyanagi-Harada syndrome. Ophthalmic Surg Lasers Imaging Retina. 2014;45(4):332–4.

    Article  Google Scholar 

  71. Khalifa YM, Bailony MR, Acharya NR. Treatment of pediatric Vogt-Koyanagi-Harada syndrome with infliximab. Ocul Immunol Inflamm. 2010;18(3):218–22.

    Article  CAS  Google Scholar 

  72. Kim JB, Jeroudi A, Angeles-Han ST, et al. Adalimumab for pediatric sympathetic ophthalmia. JAMA Ophthalmol. 2014;132(8):1022–4.

    Article  Google Scholar 

  73. Gupta SR, Phan IT, Suhler EB. Successful treatment of refractory sympathetic ophthalmic in a child with infliximab. Arch Ophthalmol. 2011;129:250–2.

    Article  Google Scholar 

  74. Regulations requiring manufacturers to assess the safety and effectiveness of new drugs and biological products in pediatric patients – FDA. Final rule. Fed Regist 1998;63:66631–66672.

    Google Scholar 

  75. Interlandi E, Leccese P, Olivieri I, Latanza L. Adalimumab for treatment of severe Behçet’s uveitis: a retrospective long-term follow-up study. Clin Exp Rheumatol. 2014;32(4 Suppl 84):S58–62.

    PubMed  Google Scholar 

  76. Calvo-Río V, Blanco R, Beltrán E, et al. Anti-TNF-α therapy in patients with refractory uveitis due to Behçet’s disease: a 1-year follow-up study of 124 patients. Rheumatology (Oxford). 2014;53(12):2223–31.

    Article  Google Scholar 

  77. Vallet H, Seve P, Biard L, et al. Infliximab versus adalimumab in the treatment of refractory inflammatory uveitis: a multicenter study from the French Uveitis Network. Arthritis Rheumatol. 2016;68(6):1522–30.

    Article  CAS  Google Scholar 

  78. Papo M, Bielefeld P, Vallet H, et al. Tocilizumab in severe and refractory non-infectious uveitis. Clin Exp Rheumatol. 2014;32(4 Suppl 84):S75–9.

    PubMed  Google Scholar 

  79. Marrani E, Paganelli V, de Libero C, et al. Long-term efficacy of abatacept in pediatric patients with idiopathic uveitis: a case series. Graefes Arch Clin Exp Ophthalmol. 2015;253(10):1813–6.

    Article  CAS  Google Scholar 

  80. Lin P, Suhler EB, Rosenbaum JT. The future of uveitis treatment. Ophthalmology. 2014;121(1):365–76.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Ophthalmology, Uveitis and Vasculitis Service, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA

    Himanshu K. Banda & Steven Yeh

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  1. Himanshu K. Banda
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Editors and Affiliations

  1. Oregon Health and Science University, Casey Eye Institute, Portland, OR, USA

    Phoebe Lin

  2. Oregon Health and Science University, OHSU-PSU School of Public Health, Portland Veterans Administration Medical Center, Portland, OR, USA

    Eric Suhler

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Banda, H.K., Yeh, S. (2019). Special Considerations: Treatment of Pediatric Uveitis. In: Lin, P., Suhler, E. (eds) Treatment of Non-infectious Uveitis. Springer, Cham. https://doi.org/10.1007/978-3-030-22827-9_15

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  • DOI: https://doi.org/10.1007/978-3-030-22827-9_15

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