Uveitis, Anterior, Childhood Treatment & Management

  • Author: R Christopher Walton, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: May 2, 2012
 

Medical Care

  • JIA-related uveitis: In these children, the ultimate goal of treatment is to eliminate all anterior chamber cells if possible.
    • Initial therapy typically includes topical and systemic corticosteroids. Children treated with topical corticosteroids have an increased risk of developing cataracts, especially those treated more than 3 times daily.[14] Short-acting cycloplegic agents often are prescribed to prevent posterior synechiae.
    • In many patients, corticosteroids alone are not sufficient to control the inflammation, and immunomodulatory therapy will be necessary. Long-term oral methotrexate is often an effective steroid-sparing therapy. Children treated with methotrexate for at least 3 years prior to discontinuation may have a longer relapse-free interval.[15] Cyclosporine, azathioprine, and mycophenolate mofetil have also been useful steroid-sparing therapies.[16, 17]
    • Biologic response modifiers may be useful for children with persistent inflammation despite standard immunomodulator therapy. Among these agents, etanercept may be less effective in the treatment of uveitis.[18, 19, 20, 21]
  • HLA-B27 associated uveitis: The severity of uveitis in these conditions ranges widely, necessitating individualized and, in some cases, ongoing care. Milder cases are treated with topical corticosteroids while moderately severe cases are treated with more intensive topical steroid treatment with the addition of cycloplegics. Treatment with sub-Tenon corticosteroids may also be useful for severe flares and/or cystoid macular edema. In recalcitrant cases, immunomodulatory therapy may be necessary to control the inflammation.
  • 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. When anterior disease predominates, treatment with topical corticosteroids and cycloplegics usually will suffice. However, severe refractory cases may require systemic immunomodulatory therapy.
  • 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.
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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 placement is still somewhat controversial; however, intensive medical therapy to control inflammation is essential for patients receiving intraocular lenses.[22]

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.

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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
  • Nephrologist
  • Cardiologist
  • Gastroenterologist
  • Neurologist
  • Oncologist
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Contributor Information and Disclosures
Author

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerhard W Cibis, MD  Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Ophthalmological Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians and Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Other; Topcon Medical Lasers Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Peter H Spiegel, MD, to the development and writing of this article.

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