Treatment Of Pediatric Uveitis Research Articles

Non-infectious uveitis referred forpediatric rheumatologic assessment andmanagement: A Portuguese retrospective study.

Pediatric uveitis poses challenges in diagnosis and treatment due to asymptomatic or oligosymptomatic presentations and high rates of intraocular complications. This study aimed to characterize clinical manifestations and treatment approaches of pediatric uveitis patients in a northern Portuguese tertiary hospital. A retrospective study was conducted involving 41 patients diagnosed with uveitis between 2006 and 2021. All individuals identified by the Opthalmology department were referred to Pediatric Rheumatology outpatient clinic. Demographic, clinical, treatment, and intraocular complications data were collected. Of the patients, 78% had anterior uveitis, 17% had panuveitis, and 5% had intermediate uveitis. Uveitis associated with juvenile idiopathic arthritis (JIA) was the most common cause (43.9%), predominantly in the oligoarticular, anti-nuclear antibody-positive subgroup. Complications were identified in 80.5% of the patients. Uveitis associated with JIA was diagnosed earlier [5.0 years (3.0-10.5) vs. 9.0 years (5.5-14.0), P = .036], more frequently in asymptomatic patients (71% vs. 23%, P = .010), had a more insidious installation (71% vs. 17%, P = .004), and required more tumor necrosis factor (TNF) inhibitor treatment (70% vs. 39%, P = .027). The high rates of intraocular complications and systemic pathology association highlight the need for a combined approach of ophthalmology and pediatric rheumatology in the diagnosis and treatment of pediatric uveitis.

The effect of anti-tumor necrosis factor alpha agents on the outcome in pediatric uveitis of diverse etiologies.

This study aimed to report the clinical outcome of children with uveitis treated with anti-tumor necrosis factor alpha (TNF-α) agents. This included a retrospective cohort study. Children with uveitis treated with infliximab or adalimumab in 2008-2014 at five dedicated uveitis clinics were identified by database search. Their medical records were reviewed for demographic data, clinical presentation, ocular complications, and visual outcome. Systemic side effects and the steroid-sparing effect of treatment were documented. The cohort included 24 patients (43 eyes) of whom 14 received infliximab and 10 received adalimumab after failing conventional immunosuppression therapy. Mean age was 9.3 ± 4.0years. The most common diagnosis was juvenile idiopathic arthritis-related uveitis (n = 10), followed by Behçet's disease (n = 4), sarcoidosis (n = 1), and ankylosing spondylitis (n = 1); eight had idiopathic uveitis. Ocular manifestations included panuveitis in 20 eyes (46.5%), chronic anterior uveitis in 19 (44.2%), and intermediate uveitis in 4 (9.3%). The duration of biologic treatment ranged from 6 to 72months. During the 12months prior to biologic treatment, while on conventional immunosuppressive therapy, mean visual acuity deteriorated from 0.22 to 0.45 logMAR, with a trend of recovery to 0.25 at 3months after initiation of biologic treatment, remaining stable thereafter. A full corticosteroid-sparing effect was demonstrated in 16 of the 19 patients (84.2%) for whom data were available. Treatment was well tolerated. Treatment of pediatric uveitis with anti-TNF-α agents may improve outcome while providing steroid-sparing effect, when conventional immunosuppression fails. The role of anti-TNF-α agents as first-line treatment should be further investigated in controlled prospective clinical trials.

Treatment of pediatric uveitis with adalimumab: the MERSI experience

To evaluate adalimumab therapy in children with uveitis. The electronic health records of pediatric patients diagnosed with uveitis and treated with adalimumab therapy were reviewed retrospectively. Demographic information, site and degree of intraocular inflammation, visual acuity, underlying systemic disorders, duration of therapy, side effects, and ability to obtain steroid-free remission were recorded. A total of 17 patients were included, 16 patients with anterior uveitis and 1 with panuveitis; 14 patients had bilateral disease. Juvenile idiopathic arthritis had been diagnosed in 14 patients, sarcoidosis in 1 patient, and idiopathic etiology in 2 patients. Of the 17 patients, 13 (about 77%) achieved steroid-free remission, and 4 did not. Six patients flared after discontinuation of adalimumab, with evidence of inflammation noted 3-7months later. Adalimumab therapy was of 12-64months' duration (mean, 36months). At the time of initiation, 14 patients were using other agents concomitantly with adalimumab; 3 patients were on adalimumab monotherapy. At 1year's follow-up, 12 patients were using combination therapy, and 3 patients were on adalimumab monotherapy: 11 patients had no evidence of inflammation. Side effects included pain at site of injection in 3 patients, anemia in 1 patient, and depression in 1 patient. In our study cohort, adalimumab was effective in inducing steroid-free remission. It was well tolerated, especially in combination with other immunomodulatory agents. The dosing and the interval can be adjusted to further improve inflammation control.

Dexamethasone intravitreal implant (Ozurdex) for the treatment of pediatric uveitis

To report our experience using Ozurdex (Allergan, Irvine, CA), a biodegradable intravitreal implant containing of 0.7 mg of dexamethasone approved for use in adults with noninfectious uveitis in adults, in the treatment of pediatric uveitis. The medical records of consecutive patients with noninfectious posterior uveitis who were unresponsive to standard treatment and subsequently received the Ozurdex implant from March 2011 to March 2013 were retrospectively reviewed. A total of 14 eyes of 11 patients (mean age, 10.1 years; range 4-12) received 22 Ozurdex implants during the study period. Of the 11 patients, 7 had idiopathic intermediate or posterior uveitis, 1 had sympathetic ophthalmia, 2 had juvenile idiopathic arthritis, and 1 had sarcoidosis. All patients were uncontrolled with standard treatment, including topical or sub-Tenon's or systemic corticosteriods and/or immune-modulation. Visual acuity improved after Ozurdex implant in 5 of 8 patients (63%). Intraocular inflammation was controlled or improved after 17 of 22 of implants (12 eyes [77%]). The frequency of topical corticosteroids was decreased and/or discontinued after 18 of 22 implants (12 eyes [82%]). Complications included implant migration into the anterior chamber (4 aphakic eyes), increased intraocular pressure (5 eyes), and progression of a preexisting cataract (1 eye). The uveitis reoccurred in 57% of eyes at 4.3 months (2-7 months) after injection. The Ozurdex implant in combination with systemic immunomodulatory therapy resulted in improved visual acuity, control of intraocular inflammation, and a decrease in corticosteroid use. In the majority of eyes the uveitis reoccurred around 4 months after injection. The adverse events in our study are similar to those identified in adult studies.

Dexamethasone intravitreal implant (Ozurdex) in the treatment of pediatric uveitis

The dexamethasone (Ozurdex) implant (Allergan Inc, Irvine, CA) is an implantable biodegradable polymer containing of 0.7 mg of dexamethasone. It is approved for the treatment of non-infectious uveitis in adults. To our knowledge its use in the treatment of pediatric uveitis has not been reported. A retrospective chart review of all pediatric patients at our institution with noninfectious posterior uveitis unresponsive to standard treatment that received the Ozurdex implant. Thirteen eyes of 10 patients (mean age 9.5 years range 4-12 years) underwent one to three Ozurdex implants (total 18 implants) in 2011-2012. Seven patients (10 eyes) had idiopathic intermediate or posterior uveitis. The remaining 3 patients had sympathetic ophthalmia, juvenile idiopathic arthritis and sarcoidosis. All patients were uncontrolled with standard treatments including topical corticosteroids, subtenon’s corticosteriod injections and systemic corticosteroid and/or immune-modulation. Improvement was noted initially in all patients. Initial implantation allowed for reduction of topical treatment in 8/13 eyes. Four eyes (31%) underwent 2 or 3 implantations for recurrent inflammation. Complications included implant migration into the anterior chamber in aphakic eyes (5 implants), increased IOP (>10 mm Hg from baseline)3 eyes, and progression of a preexisting cataract (1 eye). The Ozurdex implant should be considered in pediatric patients with refractory uveitis. The adverse events identified in our study are similar to those identified in adult studies. The dexamethasone intravitreal implant can be used safely and effectively in the pediatric population as an adjunctive treatment for intraocular inflammation in noninfectious intermediate and posterior uveitis.

Use of tumor necrosis factor inhibitors in uveitis

Use of tumor necrosis factor-alpha blocking agents to treat chronic pediatric uveitis is becoming recognized as an important therapeutic modality. This review summarizes the rationale for this use, highlighting new studies of these agents in pediatric uveitis. The majority of patients with pediatric uveitis either have idiopathic uveitis or uveitis associated with juvenile idiopathic arthritis. Ophthalmologic morbidity among these children is common. Most studies evaluating tumor necrosis factor-alpha blockade in pediatric uveitis are retrospective case series, with attendant limitations that are inherent to any retrospective study. Study of uveitis has been hampered by lack of standardization of disease and outcome measures, which has been addressed by uveitis experts with publication of consensus measures. Data to date suggest that tumor necrosis factor-alpha blockade is efficacious in refractory uveitis. Agents with direct tumor necrosis factor-alpha membrane receptor binding activity may be the most efficacious. There remain many unanswered questions in the treatment of pediatric uveitis, including optimal dosing regimen and long-term efficacy. Tumor necrosis factor-alpha blocking agents play an important role in the treatment of chronic pediatric uveitis. Prospective comparative studies are needed so that we may better understand this role.