Management Of Uveitis Research Articles

Primary Ocular Toxoplasmosis Presenting to Uveitis Services in a Non-endemic Setting.

PurposeThis study sought to describe the different clinical features and presentations of primary ocular toxoplasmosis in a setting not demonstrating an outbreak of disease.MethodsThis was a retrospective review of patients presenting to uveitis management services in Auckland and Hamilton, New Zealand between 2003 to 2018 with uveitis and positive toxoplasmosis immunoglobulin M serology.ResultsWe identified 16 patients with primary acquired toxoplasmosis infection and ocular involvement. The mean age was 53 years. Systemic symptoms were reported in 56% (9 / 16). Visual acuity was reduced to 20 / 30 or less in 50% of patients (8 / 16). A single focus of retinitis without a pigmented scar was the salient clinical feature in 69% (11 / 16). Optic nerve inflammation was the sole clinical finding in 19% (3 / 16). Bilateral arterial vasculitis was the sole clinical finding in 13% (2 / 16). A delay in the diagnosis of toxoplasmosis of more than two weeks occurred in 38% (6 / 16) due to an initial alternative diagnosis. Antibiotic therapy was prescribed in all cases. Vision was maintained or improved in 69% (11 / 16) at the most recent follow-up visit (15 months to 10 years). Relapse occurred in 69% (11 / 16), typically within four years from the initial presentation.ConclusionsPrimary ocular toxoplasmosis presenting in adulthood is a relatively uncommon cause of posterior uveitis in New Zealand. This condition should be considered in any patient presenting with retinitis or optic nerve inflammation without a retinochoroidal scar. This disease tends to relapse; thus, close follow-up is required.

Ocular Spot Fluorometer Equipped With a Lock-In Amplifier for Measurement of Aqueous Flare.

PurposeTo evaluate a custom-made ocular fluorometer for detection of intensity of light scatter (ILS) from the anterior chamber (A/C) as an objective measure of aqueous flare.MethodsThe fluorometer, equipped with a lock-in amplifier, was employed in the scatter mode to detect ILS from A/C. Measurements were performed with two illumination slit widths of 0.5 and 0.25 mm. The axial resolution at these slit widths were 80 and 200 μm, respectively. Healthy and pseudophakic eyes, with grade 0 Standardization of Uveitis Nomenclature (SUN) score, were employed as control subjects. ILS was also recorded in a cohort of patients who had undergone phacoemulsification and showed grades 1+ or 2+ on postoperative days 1 and 4.ResultsThe inter- and intraobserver variabilities in the measurement of ILS were not significant. In cataract patients, ILS was significantly higher on postoperative day 1 relative to healthy eyes. By day 4, ILS decreased significantly and was only marginally different from ILS in quiet pseudophakic eyes or healthy eyes. Eyes with higher SUN scores showed proportionately increased ILS. The receiver-operator characteristic analysis indicated no advantage in using the smaller slit width in discriminating ILS at different SUN scores although it provided higher axial resolution.ConclusionsThe lock-in–based spot fluorometer is reliable for measurement of ILS with high precision and accuracy.The measured ILS correlates linearly with SUN scores and can be used to provide a higher granularity for recording aqueous flare.Translational RelevanceThe instrument can be used in the clinical management of uveitis and drug development toward uveitis.

Clinical practice guidance for juvenile idiopathic arthritis (JIA) 2018

Juvenile idiopathic arthritis (JIA) is the most common disease in pediatric rheumatism. There is no specific symptom or examination finding for JIA, and the diagnosis is made by exclusion and differentiation. Because non-pediatric rheumatologists are sometimes involved in medical care, ‘proposal for JIA guidance on diagnosis and treatment for primary care pediatricians and non-pediatric rheumatologists’ was first published in 2007. In these 10 years, a number of new findings on pathophysiology and treatment of JIA have been published; therefore, we propose this guidance of 2018th edition aiming at updating and standardization of JIA medical care in Japan. This edition included the management of uveitis, macrophage activation syndrome, infectious diseases before and during treatment. Moreover, details of biologics are also described. Although this guidance is tailored to adaptation of examinations and drugs, we do not purpose to limit the physicians' discretion in clinical practice. This guidance should be viewed as recommendations and be individualized according to the condition of the patient. We hope that medical care for JIA will advance and more patients will get benefit based on this guidance. Then, further revisions are needed due to changes in future conditions.

Cost-Effectiveness Analysis of Adalimumab for the Treatment of Uveitis Associated with Juvenile Idiopathic Arthritis

To investigate the cost effectiveness of adalimumab in combination with methotrexate, compared with methotrexate alone, for the management of uveitis associated with juvenile idiopathic arthritis (JIA). A cost-utility analysis based on a clinical trial and decision analytic model. Children and adolescents 2 to 18 years of age with persistently active uveitis associated with JIA, despite optimized methotrexate treatment for at least 12 weeks. The SYCAMORE (Randomised controlled trial of the clinical effectiveness, SafetY and Cost effectiveness of Adalimumab in combination with MethOtRExate for the treatment of juvenile idiopathic arthritis associated uveitis) trial (identifier, ISRCTN10065623) of methotrexate (up to 25 mg weekly) with or without fortnightly administered adalimumab (20 or 40 mg, according to body weight) provided data on resource use (based on patient self-report and electronic records) and health utilities (from the Health Utilities Index questionnaire). Surgical event rates and long-term outcomes were based on data from a 10-year longitudinal cohort. A Markov model was used to extrapolate the effects of treatment based on visual impairment. Medical costs to the National Health Service in the United Kingdom, utility of defined health states, quality-adjusted life-years (QALYs), and incremental cost per QALY. Adalimumab in combination with methotrexate resulted in additional costs of £39 316, with a 0.30 QALY gain compared with methotrexate alone, resulting in an incremental cost-effectiveness ratio of £129 025 per QALY gained. The probability of cost effectiveness at a threshold of £30 000 per QALY was less than 1%. Based on a threshold analysis, a price reduction of 84% would be necessary for adalimumab to be cost effective. Adalimumab is clinically effective in uveitis associated with JIA; however, its cost effectiveness is not demonstrated compared with methotrexate alone in the United Kingdom setting.

Infectious uveitis: an Asian perspective.

Several intraocular infections can present with protean manifestations posing major diagnostic and management challenges. Infections such as tuberculosis, dengue and chikungunya fever have continued to remain major endemic diseases that are associated with uveitis in the Asia Pacific region. These entities often require a high index of clinical suspicion and laboratory analysis including assays of ocular fluids and/or tissues for confirmation of the diagnosis. Infectious uveitis caused by tuberculosis, dengue and chikungunya can present with characteristic clinical features and imaging findings on ancillary investigations; that may provide clue to the early diagnosis. Use of modern imaging modalities such as enhanced-depth imaging optical coherence tomography, optical coherence tomography angiography and ultra-wide field fundus photography greatly aid in the evaluation of these conditions. In the current review, we have discussed the epidemiology, clinical phenotypes, imaging characteristics, diagnosis and management of uveitis caused by tuberculosis, dengue and chikungunya.

Glycosylation-enhanced biocompatibility of the supramolecular hydrogel of an anti-inflammatory drug for topical suppression of inflammation

Intravitreal/periocular injection of triamcinolone acetonide (TA) suspension is a common uveitis treatment, but it displays a high risk for serious side effects (e.g., high intraocular pressure, retinal toxicity). We report here an intravitreally injectable thermosensitive glycosylated TA (TA-SA-Glu) hydrogel, formed by covalently conjugating glucosamine (Glu) with succinate TA (TA-SA), for treating uveitis. The TA-SA-Glu hydrogelator forms a supramolecular hydrogel spontaneously in aqueous solution with a minimal gelation concentration of 0.25 wt%. Structural analysis revealed that hydrogen bonds assisted by hydrophobic interaction resulted in self-assembled nanofibers. Rheology analysis demonstrated that this TA-SA-Glu hydrogel exhibited a typical thixotropic property. Sustained release of both TA-SA-Glu and TA from the hydrogel occurred throughout the 3-day in vitro release study. The obtained TA-SA-Glu hardly caused cytotoxicity against ARPE-19 and RAW264.7 cells after 24 h of incubation at drug concentration up to 600 μM. In particular, TA-SA-Glu exhibited a comparable anti-inflammatory efficacy to TA in terms of inhibiting the production of nitric oxide, tumor necrosis factor-α, and interleukin-6 in activated RAW264.7 macrophages. Following a single intravitreal injection, 69 nmol TA-SA-Glu hydrogel caused minimal apparent retinal toxicity, whereas the TA suspension displayed significant effects in terms of localized retinal toxicity. A single intravitreal injection of TA-SA-Glu hydrogel was more effective in controlling inflammatory response than that of the TA suspension treatment, particularly in down-regulating the pro-inflammatory Th1 and Th17 effector responses for treating experimental autoimmune uveitis. This study strongly indicates that supramolecular TA-SA-Glu hydrogels may represent a new option for posterior uveitis management. Statement of SignificanceIntravitreal/periocular injection of triamcinolone acetonide (TA) suspension is a common uveitis treatment, but suffers a high risk for serious side effects (e.g., high intraocular pressure, retinal toxicity). We generated an injectable glycosylated triamcinolone acetonide hydrogelator (TA-SA-Glu) hydrogel for treating uveitis. Following a single intravitreal injection, the proposed TA-SA-Glu hydrogel hardly caused apparent retinal toxicity at a dosage of 69 nmol per eye. Furthermore, TA-SA-Glu hydrogel was more effective in controlling non-infectious uveitis over than a TA suspension, particularly in terms of down-regulating the pro-inflammatory Th1 and Th17 effector responses for treating experimental autoimmune uveitis (EAU). This study strongly indicates that TA-SA-Glu supramolecular hydrogels may represent a new option for the management of various intraocular inflammations.

I006 Rheumatologist perspective: management of uveitis and inflamatory eye diseases

i006 Rheumatologist perspective: management of uveitis and inflamatory eye diseases

I004 Management of uveitis in adults: working together with rheumatologists

i004 Management of uveitis in adults: working together with rheumatologists

Pars Plana Vitrectomy for the Treatment of Uveitis

To review and summarize evidence in the medical literature regarding the use of pars plana vitrectomy in the management of uveitis. Systematic literature review. A systematic literature search was conducted for relevant articles on pars plana vitrectomy for the management of uveitis. Results from the studies were compiled and analyzed. Thirty-four articles, published from 2005 through 2014, were included in the final data analysis. Thirty-two manuscripts were from retrospective case series and 2 manuscripts were from randomized pilot studies. The median Scottish Intercollegiate Guidelines Network level of evidence grade was 3 and the median Oxford Center for Evidence-based Medicine level of evidence grade was 4. Fewer than 50% of the articles in the current study applied Standardization of Uveitis Nomenclature (SUN) criteria in regard to reporting the anatomic location of uveitis, fewer than 25% of studies applied SUN criteria in regard to the reporting of anterior chamber cells before and after PPV, fewer than 10% of studies applied SUN criteria to the grading of anterior chamber flare before and after PPV, and fewer than 10% of studies applied standardized criteria to the grading of vitreous haze after PPV. Overall, 627 patients and 708 total eyes undergoing PPV for uveitis were included. The average reported age of all patients was 43.4 years. The median duration of uveitis prior to PPV reported in the studies was 36.1months (range 4-198months). The median follow-up after PPV reported in the studies was 18.9months (range 2-114months). Vision was reported for 519 eyes and was improved in 356 eyes (69%), unchanged in 95 eyes (18%), and worse in 68 eyes (13%) following PPV. Preoperatively, 157 of 300 (52%) eyes in these studies had documented cystoid macular edema compared to 112 of 300 (37%) postoperatively. Median use of oral corticosteroids improved from 48% preoperatively to 12% postoperatively among the reporting studies. Median use of other immunosuppressive medications decreased from 56% preoperatively to 36% postoperatively among the reporting studies. Although nearly all studies continue to report favorable outcomes of PPV in the management of uveitis, the quality of data remains limited by a lack of application of standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative

BackgroundIn 2012, a European initiative called Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for...

Management of Uveitis in Spondyloarthropathy: Current Trends.

Spondyloarthritis is a chronic inflammatory disease predominantly affecting joints of the axial skeleton. However, as many as 50% of patients with this disease may have extra-articular manifestations, which include uveitis; psoriasis; inflammatory bowel disease such as Crohn disease or ulcerative colitis; cardiovascular manifestations in the form of conduction abnormalities, atherosclerosis, or valvular heart disease; pulmonary involvement; and rarely renal involvement. Uveitis occurs in 25% to 40% of patients with spondyloarthritis. Management of uveitis is crucial to prevent morbidity caused by vision loss and secondary complications. Treatment ranges from local therapies to systemic drugs and varies depending on the severity and response to treatment. Categories of medical treatment include nonsteroidal anti-inflammatory agents, corticosteroids, and steroid-sparing agents. Biologic therapies such as antitumor necrosis factor agents act early in the disease process and have revolutionized the field of rheumatology, including management of uveitis. This review will focus on the management of ophthalmic manifestations in spondyloarthropathies.

Ultra-widefield angiography in the diagnosis and management of uveitis

PURPOSE:The aim of this study is to evaluate the clinical use of ultra-widefield angiography (UWFA) in uveitis.MATERIALS AND METHODS:We showed the UWFA and traditional 55° fluorescein angiography (FA) of four cases with Eales' disease, idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome, Behçet's disease, and idiopathic panuveitis in a tertiary medical center. Comparison of UWFA with traditional 55°FA in the diagnosis and management of uveitis and review of the literature is also presented.RESULTS:Ultra-widefield FA revealed far-peripheral vascular imaging. This information would not have been easily obtained from traditional FA. With more information of the peripheral retina, it may facilitate appropriate diagnosis and monitoring, and the management may be revised.CONCLUSION:University of Western Australia played an important role to confirm the diagnosis of uveitis and to determine the corresponding treatment.

Intravitreal therapeutic agents in noninfectious uveitic macular edema.

The management of uveitis is challenging for most treating ophthalmologists. The treatment of uveitis often requires the use of high dose of systemic corticosteroid and immunosuppressive agents, which are almost always associated with potential side effects. Intravitreal medications have become a popular mode of drug administration in uveitis patients as they provide high volume of drug to the target tissues, eliminating the risk of systemic toxicity. There has been tremendous development in the intravitreal therapeutics over the last few years. With the advent of sustained-release technique, increasing patient compliance, biodegradable nature of the implant, and introduction of newer agents with better safety profile, the intravitreal medications have become more popular in recent years. This review presents evidence in the scientific literature supporting the use of intravitreal medications for the management of uveitis and its complications.

Diagnóstico y tratamiento inicial de la uveítis por médicos no oftalmólogos

Objetivos: Describir los principales signos y síntomas, así como el tratamiento inicial de un paciente con diagnóstico de uveítis con el propósito de evitar retardo en la remisión y el inicio del manejo oportuno de esta patología. Métodos: Se realizó una revisión sistemática de la literatura en la cual se identificaron los principales signos y síntomas que deben ser tenidos en cuenta para sospechar el diagnóstico de uveítis y su tratamiento indicado. Se llevó a cabo una búsqueda en PubMed durante el periodo del 2010-2015, se eligieron 439 artículos, los cuales fueron sometidos a dos procesos de filtrado manual, eligiendo por un grupo de investigadores los resúmenes que respondieran nuestra pregunta de investigación. Posteriormente un grupo de oftalmólogos expertos y médicos con experiencia en oftalmología realizaron una segunda revisión. Resultados: Posterior al primer proceso de filtrado se obtuvieron 73 artículos que se sometieron a un segundo proceso de selección donde se obtuvieron 30 artículos. De la selección final de artículos: seis fueron estudiosobservacionales o ensayos clínicos; los artículos restantes fueron revisiones de la literatura. Los estudios observacionales y ensayos clínicos aleatorizados se evaluaron con la herramienta GRADE siendo la mayoría de evidencia alta. Se hizo una revisión de los treinta artículos seleccionados, por parte de nuestros investigadores, dando como resultado recomendaciones para el diagnósticoy tratamiento de la uveítis para el personal médico no oftalmólogo. Conclusiones: Existen un conjunto de signos y síntomas que pueden hacer sospechar al médico no oftalmólogo el diagnóstico de uveítis. Ante un paciente que presenta dolor ocular asociado a disminución de la agudezavisual, fotofobia, ojo rojo sin secreción conjuntival, miosis pupilar, depósitos retroquératicos y hallazgos al fondo de ojo como vitreitis o coriorretinitis se debe sospechar una uveítis. El manejo precoz de la uveítis anterior no infecciosa puede ser instaurado por el médico no oftalmólogo con corticoides tópicos, sin embargo, en caso de uveítis intermedia y posterior es importante remitiral oftalmólogo cuanto antes. Proponemos un algoritmo para ayudar al diagnóstico de la uveítis y recomendaciones para su manejo inicial.

Failure to Integrate Quantitative Measurement Methods of Ocular Inflammation Hampers Clinical Practice and Trials on New Therapies for Posterior Uveitis.

Uveitis is one of the fields in ophthalmology where a tremendous evolution took place in the past 25 years. Not only did we gain access to more efficient, more targeted, and better tolerated therapies, but also in parallel precise and quantitative measurement methods developed allowing the clinician to evaluate these therapies and adjust therapeutic intervention with a high degree of precision. Objective and quantitative measurement of the global level of intraocular inflammation became possible for most inflammatory diseases with direct or spill-over anterior chamber inflammation, thanks to laser flare photometry. The amount of retinal inflammation could be quantified by using fluorescein angiography to score retinal angiographic signs. Indocyanine green angiography gave imaging insight into the hitherto inaccessible choroidal compartment, rendering possible the quantification of choroiditis by scoring indocyanine green angiographic signs. Optical coherence tomography has enabled measurement and objective monitoring of retinal and choroidal thickness. This multimodal quantitative appraisal of intraocular inflammation represents an exquisite security in monitoring uveitis. What is enigmatic, however, is the slow pace with which these improvements are integrated in some areas. What is even more difficult to understand is the fact that clinical trials to assess new therapeutic agents still mostly rely on subjective parameters such as clinical evaluation of vitreous haze as a main endpoint; whereas a whole array of precise, quantitative, and objective modalities are available for the design of clinical studies. The scope of this work was to review the quantitative investigations that improved the management of uveitis in the past 2-3 decades.

The application of ultra-wide-field angiography in the evaluation and management of patients with posterior, and panuveitis

Objective: To evaluate the clinical application of ultra-wide-field fluorescein angiography in posterior and panuveitis patients. Methods: It's a prospective, observational case series study. A total of 82 eyes of 42 patients conformed to the research criteria of posterior and panuveitis. Clinical examinations, conventional fluorescein angiography and ultra-wide-field fluorescein angiograms were performed for each patient. The main outcome was the detection of peripheral retinal changes by ultra-wide-field fluorescein angiography, and how these changes influenced the evaluation and management of the disease. Results: There were 22 male and 20 female in the 42 patients. The mean age of the patients was (43±21) years. Twelve eyes (6 patients) were diagnosed as posterior uveitis, and 70 eyes (36 patients) as panuveitis. Clinical examinations and conventional fluorescein angiography detected active inflammation in 30 eyes (37%), while ultra-wide-field fluorescein angiography identified active inflammation in 48 eyes (59%). In these 18 additional eyes (22%) with active inflammation found by ultra-wide-field fluorescein angiography, non-perfusion area was observed in 4 eyes (5%) and neovascularization was observed in 1 eye (1%). By means of ultra-wide-field fluorescein angiography, a larger area of peripheral vessel leakage showed in 10 eyes (12%) which judged as active inflammation by conventional fluorescein angiography. Additional angiographic changes showed in 46%(21/45) of the eyes with clear etiology, while only in 19%(7/37) of the eyes without clear etiology. According to these findings, treatment strategies adjusted for 12 patients. Conclusions: Ultra-wide-field fluorescein angiography detected more peripheral retinal vascular pathology than conventional fluorescein angiography. The changes found in the periphery were important in the management of uveitis. (Chin J Ophthalmol, 2016, 52: 924-928).

A Review of the Course and Treatment of Non-Infectious Uveitis during Pregnancy

ABSTRACTInflammatory conditions such as autoimmune uveitis often occur in women of childbearing age. During pregnancy, women may experience exacerbations of their disease in the first trimester. In the later stages of pregnancy, however, the uveitis tends to remain less active. The management of uveitis during pregnancy is a challenging task, forcing the physician to re-evaluate the patient’s current therapy and offer alternative options that pose the least risk to the patient and fetus. This article will review treatments widely used for uveitis, including corticosteroid therapy, anti-metabolites, calcineurin inhibitors, and biologic therapy. It will evaluate the use of these medications in pregnancy and the postpartum state.

A national survey of Canadian ophthalmologists to determine awareness of published guidelines for the management of uveitis.

BackgroundThe objectives of this study are to assess Canadian ophthalmologists’ awareness of established uveitis treatment guidelines and clinical management of uveitis and to assess the frequency of government applications for immunomodulatory therapy (IMT) and identify primary prescribers.A 25-item questionnaire was sent to 759 practicing Canadian ophthalmologists. Six questions assessed demographics including the year of residency completion, training by uveitis specialists during residency, and fellowship training. Five questions assessed application of guidelines to clinical scenarios, and 12 questions assessed referral patterns and success of obtaining coverage for IMT.ResultsOf 144 respondents, 12 (8.3 %) were uveitis specialists; 45.1 % of respondents had uveitis training during residency by a uveitis specialist. Sixty-one percent reported awareness of management guidelines. Recent graduates (2001–2012) referred patients to uveitis specialists (55.3 %) less frequently than earlier graduates. Recent graduates also managed uveitis patients more frequently with corticosteroid injections (15.6 %) than those who graduated before 1980 (9.75 %). The majority (93.6 %) of respondents submitted less than six IMT funding applications for provincial drug coverage yearly, and 5.5 % reported prescribing IMT themselves, rather than referring to other specialists.ConclusionsAlthough greater than half of respondents reported awareness of uveitis treatment guidelines, Canadian ophthalmologists’ awareness of uveitis treatment guidelines and application of the guidelines to patient care could be improved. Few applications are made for IMT, and the majority of applications are sent by non-ophthalmologists. This suggests the need for further education of ophthalmologist about uveitis treatment guidelines and for more ophthalmologists trained to manage uveitis with IMT.Electronic supplementary materialThe online version of this article (doi:10.1186/s12348-016-0102-3) contains supplementary material, which is available to authorized users.

The Use of Cyclosporine A in Rheumatology: a 2016 Comprehensive Review.

Cyclosporine A, an inhibitor of calcineurin, exerts an immunomodulator action interfering with T cell activation. Even though novel therapeutic tools have emerged, CyA still represents a suitable option in several clinical rheumatology settings. This is the case of refractory nephritis and cytopenias associated with systemic lupus erythematosus. Furthermore, CyA is a valued therapeutic tool in the management of uveitis and thrombophlebitis in course of Behçet's disease. Topical CyA has been proven to be beneficial in the dry eye of Sjogren's syndrome, whereas oral treatment with CyA can be considered for the severe complications of adult onset Still's disease. CyA provides a therapeutic option in psoriatic arthritis, being rather effective in skin disease. CyA is currently regarded as a second-line option for patients with inflammatory myopathies refractory to standard regimen. CyA is used even in paediatric rheumatology, in particular in the management of juvenile dermatomyositis and macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Importantly, CyA has been shown to suppress the replication of HCV, and it can thus be safely prescribed to those patients with chronic hepatitis C. Noteworthy, CyA can be administered throughout the gestation course. Surely, caution should be paid to CyA safety profile, in particular to its nephrotoxicity. Even though most evidence comes from small and uncontrolled studies with few randomised controlled trials, CyA should be still regarded as a valid therapeutic tool in 2016 rheumatology.

Specialty Practice and Cost Considerations in the Management of Uveitis Associated With Juvenile Idiopathic Arthritis.

To evaluate whether cost, prior insurance authorization concerns, and subspecialty practice influence therapeutic decisions in the treatment of uveitis associated with juvenile idiopathic arthritis. A total of 2,965 pediatric ophthalmologists, uveitis specialists, retina specialists, and rheumatologists across the United States were surveyed via e-mail regarding their choice in long-term therapy for a hypothetical patient with uveitis associated with juvenile idiopathic arthritis. Outcomes of interest were differences in therapy choice based on cost/prior authorization and specialty practice. There were significant differences in the use of methotrexate and biologics among specialists, both with and without consideration for cost and prior authorization. Physicians in four different specialties who treat uveitis associated with juvenile idiopathic arthritis agree on methotrexate as a first-line treatment choice and a biologic immunosuppressive medication as a second choice, but there are significant differences between the specialties in their use of these medications. Cost and insurance considerations did not affect therapy selection. [J Pediatr Ophthalmol Strabismus. 2016;53(4):246-251.].