Uveitis, Juvenile Idiopathic Arthritis Clinical Presentation

  • Author: Manolette R Roque, MD, MBA; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Sep 28, 2010
 

History

Always complete a thorough history of new patients. The ocular immunology and uveitis survey form, developed by Dr. C Stephen Foster, provides a complete checklist (present illness, past medical history, family history, and review of systems) and may assist the physician in the history. The patient questionnaire may be downloaded from the Massachusetts Eye and Ear Infirmary Immunology and Uveitis Service.

  • Chief complaint and history of present illness
    • Many patients are referred first by a pediatrician or rheumatologist and often are asymptomatic. Typically, patients have no pain or photophobia and the eye appears white.
    • Asymptomatic patients may recall previous insignificant symptoms that may be useful in determining the duration of the ocular disease. Therefore, ask specific questions regarding past ocular history, such as previous episodes of pink eye or conjunctivitis, blurry vision, ocular pain, or abnormal pupil size/shape.
  • Past medical history
    • Crucial to establish chronicity and to determine the subtype of JIA
    • Age at onset
    • Specific joints involved and number of joints
    • Other systemic manifestations are as follows:
      • Fever, rash, lymphadenopathy, fatigue, weight loss, hepatosplenomegaly, pericardial effusion, pleural effusion
      • Anemia
      • Growth retardation, delay of secondary sexual characteristics
      • Chronic low back pain, diarrhea, psoriasis
    • Current systemic medications for JIA
  • Past ocular history
    • Previous episodes and treatment
    • Previous surgeries
    • Previous complications
      • Cataract
      • Glaucoma
      • Band keratopathy
      • Cystoid macular edema (CME)
  • Review of systems
    • 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
    • Musculoskeletal - Muscle or joint pain, arthritis, back pain, limitation of motion
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Physical

Ocular manifestations

Perform a complete ophthalmic examination.

  • Vision - Best-corrected visual acuity, including near acuity
  • Anterior uveitis
    • Cells and flare; chronic flare (very common)
    • Nongranulomatous uveitis (>90%)
    • Bilateral (70-80%)
    • Iridocyclitis in approximately 90% of patients; rarely panuveitis or vitritis
    • Chronic smoldering or recurrent disease in greater than 90%; rarely acute monophasic course (< 5%)
  • Conjunctiva and sclera - Most patients have no conjunctival injection even during acute exacerbations.
  • Cornea
    • Band keratopathy (shown in the image below) - Corneal degeneration that derives its name from the distinctive appearance of calcium deposition in a band across the central cornea Juvenile idiopathic arthritis uveitis. Band keratoJuvenile idiopathic arthritis uveitis. Band keratopathy. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
    • Keratic precipitates - Small-medium, rarely mutton fat
  • Iris - Posterior synechiae; pupillary membrane; rarely may develop Koeppe nodules
  • Pupil examination
  • Lens - Posterior subcapsular cataracts
  • Posterior uveitis
    • Dilated fundus examination - Vitritis, CME, hypotony maculopathy
    • Anterior vitreous (anterior vitreous cells not uncommon)
  • Others - Intraocular pressure, secondary glaucoma (open angle or pupillary block), hypotony

Articular manifestations

  • Assessment must consist of a quick evaluation of the skin and joints (warmth, redness, effusion, and deformity). Identify the particular joint and number involved.
  • The ophthalmologist evaluating the patient may perform this; however, the pediatrician or rheumatologist is expected to execute a complete musculoskeletal examination.
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Causes

The cause of uveitis and arthritis in JIA remains unknown. Akin to many other autoimmune diseases, the target antigen is unidentified. Associated factors may include the possibility of infectious triggers, a genetic predisposition, an autoimmune response, psychological stress, female sex, and hormone interaction.[11, 9]

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Contributor Information and Disclosures
Author

Manolette R Roque, MD, MBA  President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic; Senior Eye Surgeon, Precise Eye Laser Center

Manolette R Roque, MD, MBA is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD  Full Partner, Ophthalmic Consultants Philippines Co; Ophthalmology Consultant, Eye Republic Ophthalmology Clinic; Visiting Ophthalmologist, QC Eye Center and Asian Hospital and Medical Center

Barbara L Roque, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Philippine Academy of Ophthalmology, and Philippine Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Elisabetta Miserocchi, MD  Fellow in Immunology and Uveitis Service, Department of Ophthalmology, Harvard Medical School

Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO  Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

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.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

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.

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.

References

  1. Nguyen QD, Foster CS. Saving the vision of children with juvenile rheumatoid arthritis-associated uveitis. JAMA. Oct 7 1998;280(13):1133-4. [Medline].

  2. Päivönsalo-Hietanen T, Tuominen J, Saari KM. Uveitis in children: population-based study in Finland. Acta Ophthalmol Scand. Feb 2000;78(1):84-8. [Medline].

  3. Boone MI, Moore TL, Cruz OA. Screening for uveitis in juvenile rheumatoid arthritis. J Pediatr Ophthalmol Strabismus. Jan-Feb 1998;35(1):41-3. [Medline].

  4. Kotaniemi K, Kaipiainen-Seppanen O, Savolainen A, et al. A population-based study on uveitis in juvenile rheumatoid arthritis. Clin Exp Rheumatol. Jan-Feb 1999;17(1):119-22. [Medline].

  5. Malleson P. Prevalence and outcome of uveitis in a regional cohort of patients with juvenile rheumatoid arthritis. J Rheumatol. Jun 1998;25(6):1242. [Medline].

  6. Kesen MR, Setlur V, Goldstein DA. Juvenile idiopathic arthritis-related uveitis. Int Ophthalmol Clin. Summer 2008;48(3):21-38. [Medline].

  7. Wright T, Cron RQ. Pediatric rheumatology for the adult rheumatologist II: uveitis in juvenile idiopathic arthritis. J Clin Rheumatol. Aug 2007;13(4):205-10. [Medline].

  8. Kanski JJ. Anterior uveitis in juvenile rheumatoid arthritis. Arch Ophthalmol. Oct 1977;95(10):1794-7. [Medline].

  9. Gallagher KT, Bernstein B. Juvenile rheumatoid arthritis. Curr Opin Rheumatol. Sep 1999;11(5):372-6. [Medline].

  10. Kotaniemi K. Late onset uveitis in juvenile-type chronic polyarthritis controlled with prednisolone, cyclosporin A and methotrexate. Clin Exp Rheumatol. Jul-Aug 1998;16(4):469-71. [Medline].

  11. Donn RP, Farhan AJ, Barrett JH, et al. Absence of association between interleukin 1 alpha and oligoarticular juvenile chronic arthritis in UK patients. Rheumatology (Oxford). Feb 1999;38(2):171-5. [Medline].

  12. Reininga JK, Los LI, Wulffraat NM, et al. The evaluation of uveitis in juvenile idiopathic arthritis (JIA) patients: are current ophthalmologic screening guidelines adequate?. Clin Exp Rheumatol. Mar-Apr 2008;26(2):367-72. [Medline].

  13. Yen JH, Tsai WC, Tsai JJ, et al. HLA-DMA and HLA-DMB genotyping in patients with rheumatic diseases. Kaohsiung J Med Sci. May 1999;15(5):263-7. [Medline].

  14. Cassidy JT. Medical management of children with juvenile rheumatoid arthritis. Drugs. Nov 1999;58(5):831-50. [Medline].

  15. Ceisler EJ, Foster CS. Juvenile rheumatoid arthritis and uveitis: minimizing the blinding complications. Int Ophthalmol Clin. Winter 1996;36(1):91-107. [Medline].

  16. Hemady RK, Baer JC, Foster CS. Immunosuppressive drugs in the management of progressive, corticosteroid-resistant uveitis associated with juvenile rheumatoid arthritis. Int Ophthalmol Clin. Winter 1992;32(1):241-52. [Medline].

  17. Yu EN, Meniconi ME, Tufail F, et al. Outcomes of treatment with immunomodulatory therapy in patients with corticosteroid-resistant juvenile idiopathic arthritis-associated chronic iridocyclitis. Ocul Immunol Inflamm. Sep-Oct 2005;13(5):353-60. [Medline].

  18. Kilmartin DJ, Forrester JV, Dick AD. Cyclosporin A therapy in refractory non-infectious childhood uveitis. Br J Ophthalmol. Jul 1998;82(7):737-42. [Medline].

  19. Okada AA. Immunomodulatory therapy for ocular inflammatory disease: a basic manual and review of the literature. Ocul Immunol Inflamm. Sep-Oct 2005;13(5):335-51. [Medline].

  20. Shetty AK, Zganjar BE, Ellis GS Jr, et al. Low-dose methotrexate in the treatment of severe juvenile rheumatoid arthritis and sarcoid iritis. J Pediatr Ophthalmol Strabismus. May-Jun 1999;36(3):125-8. [Medline].

  21. Singer NG, McCune WJ. Update on immunosuppressive therapy. Curr Opin Rheumatol. May 1998;10(3):169-73. [Medline].

  22. Weiss AH, Wallace CA, Sherry DD. Methotrexate for resistant chronic uveitis in children with juvenile rheumatoid arthritis. J Pediatr. Aug 1998;133(2):266-8. [Medline].

  23. Imrie FR, Dick AD. Biologics in the treatment of uveitis. Curr Opin Ophthalmol. Nov 2007;18(6):481-6. [Medline].

  24. Tynjala P, Kotaniemi K, Lindahl P, et al. Adalimumab in juvenile idiopathic arthritis-associated chronic anterior uveitis. Rheumatology (Oxford). Mar 2008;47(3):339-44. [Medline].

  25. Heiligenhaus A, Mingels A, Heinz C, et al. Methotrexate for uveitis associated with juvenile idiopathic arthritis: value and requirement for additional anti-inflammatory medication. Eur J Ophthalmol. Sep-Oct 2007;17(5):743-8. [Medline].

  26. Ilowite NT. Update on biologics in juvenile idiopathic arthritis. Curr Opin Rheumatol. Sep 2008;20(5):613-8. [Medline].

  27. BenEzra D, Cohen E. Cataract surgery in children with chronic uveitis. Ophthalmology. Jul 2000;107(7):1255-60. [Medline].

  28. Holland GN. Intraocular lens implantation in patients with juvenile rheumatoid arthritis-associated uveitis: an unresolved management issue. Am J Ophthalmol. Aug 1996;122(2):255-7. [Medline].

  29. Acevedo S, Quinones K, Rao V, et al. Cataract surgery in children with juvenile idiopathic arthritis associated uveitis. Int Ophthalmol Clin. Spring 2008;48(2):1-7. [Medline].

  30. Sijssens KM, Los LI, Rothova A, Schellekens PA, van de Does P, Stilma JS. Long-term ocular complications in aphakic versus pseudophakic eyes of children with juvenile idiopathic arthritis-associated uveitis. Br J Ophthalmol. Sep 2010;94(9):1145-9. [Medline].

  31. Dana MR, Merayo-Lloves J, Schaumberg DA, et al. Visual outcomes prognosticators in juvenile rheumatoid arthritis-associated uveitis. Ophthalmology. Feb 1997;104(2):236-44. [Medline].

  32. Fox GM, Flynn HW Jr, Davis JL, et al. Causes of reduced visual acuity on long-term follow-up after cataract extraction in patients with uveitis and juvenile rheumatoid arthritis. Am J Ophthalmol. Dec 15 1992;114(6):708-14. [Medline].

  33. Ozdal PC, Vianna RN, Deschênes J. Visual outcome of juvenile rheumatoid arthritis-associated uveitis in adults. Ocul Immunol Inflamm. Feb 2005;13(1):33-8. [Medline].

  34. Gray T, Kanski J, Lightman S. Steroid responsive disc neovascularisation in uveitis associated with juvenile chronic arthritis. Br J Ophthalmol. Mar 1998;82(3):327-8. [Medline].

  35. Ducos de Lahitte G, Terrada C, Tran TH, et al. Maculopathy in uveitis of juvenile idiopathic arthritis: an optical coherence tomography study. Br J Ophthalmol. Jan 2008;92(1):64-9. [Medline].

  36. Wolf MD, Lichter PR, Ragsdale CG. Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology. Oct 1987;94(10):1242-8. [Medline].

  37. Aggarwal A, Misra RN. Juvenile rheumatoid arthritis in India--rarity of antinuclear antibody and uveitis. Indian J Pediatr. May-Jun 1996;63(3):301-4. [Medline].

  38. Akinci A, Cakar N, Uncu N, et al. Keratoconjunctivitis sicca in juvenile rheumatoid arthritis. Cornea. Sep 2007;26(8):941-4. [Medline].

  39. Baldassano VF Jr. Ocular manifestations of rheumatic diseases. Curr Opin Ophthalmol. Dec 1998;9(6):85-8. [Medline].

  40. Dollfus H. Eye involvement in children's rheumatic diseases. Baillieres Clin Rheumatol. May 1998;12(2):309-28. [Medline].

  41. Singh S, Salaria M, Kumar L, et al. Clinico-immunological profile of juvenile rheumatoid arthritis at Chandigarh. Indian Pediatr. May 1999;36(5):449-54. [Medline].

 
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Acute anterior uveitis with hypopyon in a child. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Band keratopathy. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Pseudophakia with posterior chamber intraocular lens with anterior membrane and posterior capsular opacification with cyclitic membrane formation. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Use of Grieshaber iris hooks to create and maintain a large enough pupil for adequate visualization during membranectomy and pars plana vitrectomy in a pseudophakic child. The intraocular lens was clear after the anterior lenticular membrane was peeled off. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
 
 
 
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