Journal Reading

Visual loss in Uveitis of Childhood

dr. Nirwan Arief

Source :
Boer JD, Wulffraat N, Rothova A
Br.J.Ophthalmol 2003;87:879-884

Ophthalmology Department
Sriwijaya University/Mohammad Hoesin Hospital Palembang
2007
Introduction
Uveitis is potentially blinding disorder and accounts
for 10 -15% of all cases of total blindness in US

Legal blindness in at least one eye developed in 22

% of all uveitis patients and about 23% of all with
required intraocular surgery

In children younger than 7 years the risk of

amblyopia must be considered
 Introduction..

The results of surgical procedures for the various

complications of uveitis in children are often
discouraging

The aim of this study was to investigate the

manifestations and severity of uveitis in children and
to identify the risk and specific causes of blindness
in this population
Patients and methods
Included 123 consecutive patients with active uveitis

The onset uveitis before the age 16 years, the average

follow up was 3 years

Retrospective analysis of medical records of all

patients

The uveitis chronic if the duration of active ocular

inflammation 3 months
 Patients and methods.
Depending on the severity of the disease and clinical
presentation , patients underwent a uveitis screening protocol

HLA-B27 typing was performed in patients with anterior or

panuveitis (n=34)

JIA was defined as arthritis starting before age of 16 years

with duration 3 months and the patients had no otherwise
identifiable cause for their uveitis
 Patients and methods.
The clinical diagnosis of the ocular toxoplasmosis was based
on the criteria creamy-white focal retinal lession eventually
combined with hyperpigmented retinochoroidal scars in either
eye

In the visual outcome analysis, only eyes with visual loss due
to uveitis were included

Excluded were two patients with blindness due to other cause

Lebers hereditary optic neuropathy
Optic nerve hypoplasia
 Results
The patients series consisted of 69 girls(56%) and 54 boys(44%),
the mean age of onset of uveitis was 8 years with a range of 2-15
years, the median age 7 years

Uveitis anterior in 44 patients (36%), intermediate in 30 (24%),

posterior in 23 (19%) and panuveitis in 26 (21%)

Uveitis chronic in 102/123 patients, bilateral in 88/123 resulting

in 211 affected eyes
 Unexpected diagnosis of multiple sclerosis was made in a 14
years old boy

Antinuclear antibodies were positive in 27 of the 70 (39%)

HLA-B27 was positive in 3/34 (9%) patients

ACE was elevated in 19/64 (30%) patients tested, of which one

had biopsy confirmed sarcoidosis
 Elevated serum ACE levels(22-31 U/l) were
observed in
Anterior uveitis of unknown origin (n=6)
Fuchs heterochromic cyclitis (n=1)
Intermediate uveitis (n=5),
Posterior uveitis of unknown origin (n=2)
Panuveitis (n=3)
Tubulointerstitial nephritis and uveitis (TINU syndrome
n=1)
 Aqueous humour analysis revealed a specific
diagnosis in 5/29(17%) patients tested

Active intraocular antibody production against varicella

zoster virus (2/6 patients with anterior uveitis)

Toxoplasma gondii 3/6 cases with posterior uveitis tested

 35 patients (28%) underwent surgery for
complications of uveitis

In total , 75 operations were performed with a

maximum of six operations per patients

Cataract surgery was the most commonly

performed in 34 eyes of 23 patients
Discussion

This study point : uveitis of children serious and potentially

blinding disease

The high complication rate of 76%

The principal causes of visual loss in uveitis of children were

clearly distinct from adult population

The macular scars , which constituted a major cause of

blindness in childhood uveitis, were predominantly caused by
ocular toxoplasmosis
 Discussion
Kanski et al reported that one third of the glaucomatous eyes in
JIA ended with no light perception

Cystoid macular oedema complicated uveitis less frequently in

children(17%) compared with adults(26%)

Various disease associated with uveitis in childhood may

strongly resemble JIA
 Discussion.
In our series, infectious uveitis was noted at least
13% of children

Aqueous humour analyses specifically for

toxoplasmosis or herpes viruses was beneficial in
diagnosing intraocular infections

Although positive serological results might be more

informative in young children than in adults, positive
antibodies are not discriminatory for intraocular
infection
 Discussion.
Rare causes of uveitis included masquerade syndrome
in a 6 year old girl who appeared to have
retinoblastoma

The value of the positive ANA is very useful in

suspicious diagnosis of JIA

Kimura first reported positive ANA in uveitis in young

girls without JIA and also in our series
 Discussion

The new therapeutic strategies , such as the use of MTX, were

reported to improve the control of intraocular inflammation and
have beneficial visual results especially in JIA associated cases

Compared to other anti-inflammatory medications, MTX was

well tolerated in childhood and has no cataractogenic or eye
pressure elevating properties
 Our study points out that
Uveitis of childhood is a potentially blinding disease
associated with a complication rate of 76% and surgical
intervention in 28%

Blind eyes developed in 19% of patients and macular

scars and secondary glaucoma were the major causes of
visual loss

Early diagnosis, timely recognition, or prevention of

complications with new treatment strategies will
hopefully improve the visual prognosis of children uveitis
Critical Appraisal

Are the aim clearly stated ? Yes

To investigate the manifestations and
severity of uveitis in children and to
identify the risk and specific causes of
blindness in this population
 Critical Appraisal.
Was the sample size justified ? Yes
A total 123 consecutive patients examined with
active uveitis and the onset of ocular disease
before the a age of 16 years

Are the statistical methods described ? Yes

Retrospective study
 Critical Appraisal.
Was the assigment of patients to treatments
randomized ?
Yes

Was the assigment of patients to treatments

randomized ?
Yes

Were the groups similar at the start of the trial ?

Yes
 Critical Appraisal
Did untoward events occur during the study ?
Yes

Were side effects reported?

Yes
Can the results be applied to patients in my care?
Yes
Were all the clinically Important outcomes
considered?
Yes
The left eye of our patient with arrows indicating the band keratopathy
found at initial review.
Smaller arrows show areas of the iris adherent to the lens (posterior
synechiae).
Toxoplasma macrogamets in small intestinal cells of cat, Photo

from Dubey,J.P An Atlas of Protozoan Parasites in Animal Tissues,1988