eMedicine Specialties > Ophthalmology > Iris & Ciliary Body
Uveitis, Anterior, Childhood: Treatment & Medication
Updated: Jan 5, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- JIA-related uveitis: The mainstay of treatment currently is topical corticosteroids. The goal of treatment is to reduce the anterior chamber inflammation as much as possible. Sometimes brief courses of intensive treatment, with as frequent as hourly instillations, are needed. Some patients require prolonged courses of less frequent instillations to keep the inflammation in check. Short-acting cycloplegic agents often are prescribed to prevent synechiae. Severe or recalcitrant cases may require sub-Tenon corticosteroids or systemic corticosteroids. Long-term oral methotrexate is often an effective adjunct and may be an effective steroid-sparing therapy.
- HLA-B27–associated uveitis: The severity of uveitis in these conditions ranges widely, necessitating individualized and, in some cases, ongoing care. Milder cases related to Crohn disease or ulcerative colitis are treated with topical corticosteroids; more severe cases are treated with more intensive topical steroid treatment with the addition of cycloplegics. Treatment with sub-Tenon corticosteroids and systemic immunosuppressants expressly for the uveitis rarely is required.
- Sarcoidosis-associated uveitis: Keep in mind that the particular tissues involved, the severity of the inflammation, and the degree of visual loss drives treatment decisions in most cases. However, when anterior disease predominates, treatment with topical corticosteroids and cycloplegics usually will suffice.
- Kawasaki disease and uveitis associated with systemic viral illness: Treatment rarely is required in these self-limited conditions; topical steroids may be given in symptomatic cases. More severe cases may be treated with topical corticosteroids and cycloplegics.
- Blau syndrome: Topical corticosteroids are the mainstay of therapy for patients with anterior uveitis. Cycloplegics may be used for patients with photophobia and to prevent posterior synechiae formation. Severe exacerbations may require periocular corticosteroids to control the inflammation. Patients with posterior uveitis require systemic corticosteroids and/or immunosuppressive therapy.
- Juvenile xanthogranuloma: Topical and systemic corticosteroids are often effective in treating this condition.
Surgical Care
Surgery is required to treat the complications of severe or chronic inflammation. For example, in JIA-associated uveitis, cataract often develops and the eye should be quiet for at least 3 months prior to surgery. Perioperative systemic corticosteroids have been advocated to reduce postoperative inflammation. Intraocular lens (IOL) placement carries more risk of subsequent complications compared to leaving the patient aphakic; however, IOLs currently are being placed more often than in the past.
Severe band keratopathy, as seen in JIA, may require treatment with Ca EDTA chelation. Development of glaucoma may require trabeculectomy or placement of a drainage implant.
Consultations
Depending on the patient, one or more of the following pediatric subspecialists may assist in the evaluation and treatment of patients:
- Rheumatologist
- Pulmonologist
- Infectious disease specialist
- Cardiologist
- Gastroenterologist
- Neurologist
- Oncologist
Medication
The primary medications used in treating anterior uveitis in children are corticosteroids, topical cycloplegics, and, in certain cases of JIA-associated uveitis, methotrexate.
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone)
Inhibits phospholipase A and Fc receptor expression, reduces cytokine production, suppresses lymphocyte function, and redistributes circulating leukocytes.
Adult
1 mg/kg/d PO qd
Pediatric
Administer as in adults
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; herpes; fungal infection; severe hypertension; severe diabetes; psychosis; active tuberculosis; peptic ulceration; severe osteoporosis or osteomalacia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Some of the major adverse effects are hyperglycemia, fluid retention, hypertension, osteoporosis, and psychologic disturbances; monitor blood glucose, urinalysis, and blood pressure on a monthly basis; monitor bone density and psychologic assessments every 6-12 mo; prevention of truncal obesity and osteoporosis includes caloric restriction, exercise, sunlight, high-calcium diet, and estrogen replacement
Prednisolone acetate suspension 1% (AK-Pred, Pred Forte)
Potent topical corticosteroid used to treat anterior segment inflammation. Initial dosage is determined by the degree of inflammation.
Adult
Up to 1 gtt q1-2h for severe cases; most moderate-to-mild cases respond to qid dosing; slowly taper dosage after inflammation begins to decrease; rapid taper may result in rebound of inflammation
Pediatric
Administer as in adults
Effects may decrease in patients taking phenytoin, barbiturates, and rifampin
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May activate herpetic keratitis; known to cause cataract formation with long-term use; in prolonged use, withdraw treatment by gradually decreasing frequency of applications
Cycloplegics
Instillation of a long-acting cycloplegic agent can relax ciliary muscle spasm that can cause a deep aching pain and photophobia.
Homatropine 2% and 5% (Isopto Homatropine)
Useful in treating pain from ciliary spasm and decreasing formation of synechiae.
Adult
1 gtt bid/qid
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Toxic anticholinergic systemic adverse effects can occur but are rare when used sparingly; adverse effects are more common in children, especially infants; compressing lacrimal sac by digital pressure for 1-3 min following instillation minimizes systemic absorption
Antimetabolites
Decrease inflammation; corticosteroid-sparing effect.
Methotrexate (Folex, Rheumatrex)
Useful in patients with JIA-associated uveitis, where it may reduce inflammation in patients who do not adequately respond to corticosteroid treatment.
Adult
7.5-15 mg/wk PO divided tid
Pediatric
Administer as in adults
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX; coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase MTX plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity of MTX; may increase plasma levels of thiopurines
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor CBC monthly, and liver and renal function every 1-3 mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occurs; aspirin, NSAIDs, or low-dose corticosteroids may be administered concomitantly with MTX (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)
Immunomodulators
May be useful for uveitis associated with inflammatory bowel disease.
Infliximab (Remicade)
Neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Mix in 250-mL normal saline for infusion over 2 h. Must use with low-protein-binding filter (1.2 µm or less). Several investigational reports have described use in childhood uveitis.
Adult
5 mg/kg IV infusion at 0, 2, and 6 wk as induction regimen, then 5 mg/kg IV q6wk for maintenance
Pediatric
Not established; limited data suggest dosages of 5-10 mg/kg IV as being effective in childhood uveitis
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of infections, including bacterial sepsis, tuberculosis, and invasive fungal and other opportunistic infections; inform patient regarding symptoms of infection and closely monitor for signs and symptoms of infection during and after treatment; test for tuberculosis before and during treatment; may increase lymphoma risk compared to controlled groups
More on Uveitis, Anterior, Childhood |
| Overview: Uveitis, Anterior, Childhood |
| Differential Diagnoses & Workup: Uveitis, Anterior, Childhood |
 Treatment & Medication: Uveitis, Anterior, Childhood |
| Follow-up: Uveitis, Anterior, Childhood |
| References |
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Further Reading
Keywords
anterior uveitis, juvenile idiopathic arthritis, JIA, juvenile rheumatoid arthritis, JRA, ankylosing spondylitis, AS, reactive arthritis, Reiter syndrome, inflammatory bowel disease, IBD, sarcoidosis
