Visusmindernde Komplikationen bei Uveitis im Kindesalter

Understanding the impact of uveitis on health-related quality of life in adolescents

PURPOSE

A reduction in quality of life (QoL) during an active phase of disease has been shown for patients with uveitis of various age groups. Adult uveitis patients were shown to also have reduced QoL-values despite disease being quiescent, but adolescents have not been investigated in this respect.

METHODS

This clinic-based, cross-sectional pilot study assessed the overall health-related quality of life (HRQoL) in adolescents (11-18 years) with a history of inactive uveitis and good visual function. Two independent generic (non-disease-specific) instruments were applied, the Inventory for Assessing the Quality of Life and the German KINDL-R-questionnaire.

RESULTS

Thirty-seven adolescents, 20 females (54%) and 17 males with a mean age of 15 ± 3 years and diagnosis since 5 ± 2 years participated. Subgroups with a reduced HRQoL were those with anterior and intermediate localization of uveitis, bilateral disease, application of immunosuppressive therapy, a short time since diagnosis, and a high number of recurrences.

CONCLUSION

Even despite quiescence of disease and good visual function, certain risk factors may result in a decreased HRQoL in juvenile uveitis patients. Our findings support the need of further evaluation of HRQoL in this patient group, the validation of specific psychometric inventories for this disease and the establishment of interdisciplinary collaboration including psychological counselling.

Trabeculectomy or modified deep sclerectomy in juvenile uveitic glaucoma

Purpose

The purpose of this study is to report the effectiveness of trabeculectomies (TE) and modified deep sclerectomies (mdS) in a group of patients with juvenile uveitic secondary glaucoma.

Methods

This is a retrospective analysis of 16 TE and eight mdS.

Results

Postoperatively, an IOP reduction to 11.6 ± 4.7 mmHg was achieved in the TE group and to 18.5 ± 11.4 mmHg in the mdS group (p = 0.045). In the TE group, 14 patients showed postoperative success, one limited success and another was a failure compared to four successes and four failures in the mdS group (p = 0.041). The mean number of complications was 1.25 ± 1.49 in the TE group and 0.38 ± 0.74 after mdS (p = 0.11). In the mdS group, four patients (50%) needed additional glaucoma surgery compared to one TE patient (p = 0.023).

Conclusion

Both surgical techniques showed a marked reduction of IOP. Trabeculectomy has a higher probability of achieving success and lowering IOP.

Elevated laser flare values correlate with complicated course of anterior uveitis in patients with juvenile idiopathic arthritis

PURPOSE

To evaluate the prognostic value of anterior chamber (AC) laser flare (LF) in uveitis associated with juvenile idiopathic arthritis (JIA).

METHODS

Monocentre, retrospective study of 150 JIA children (girls n = 107, 71.3%) with unilateral or bilateral chronic anterior uveitis (statistical analysis of one eye per patient). LF values (KOWA FM-500), visual acuity, intraocular pressure, glaucoma treatment and uveitis complications were investigated longitudinally.

RESULTS

Patients were followed up for a mean of 8.7 months (range 1-36). High LF values correlated with poor visual acuity (p < 0.0001). Patients with low LF values (LF ≤ 20 photon units per millisecond) less often required glaucoma medication (p = 0.0005) or surgery (p = 0.01) and showed a lower prevalence of cataract, band keratopathy, posterior synechiae, epiretinal membrane, optic disc oedema and glaucoma/ocular hypertension (p < 0.05, each). Baseline LF > 20 photon units per millisecond was a better prognosticator for the development of subsequent complications than baseline AC cells (p = 0.04).

CONCLUSIONS

High LF values in patients with JIA uveitis are associated with poor vision and a higher prevalence of uveitis complications.

Limited value of cyclosporine A for the treatment of patients with uveitis associated with juvenile idiopathic arthritis

AIMS

Juvenile idiopathic arthritis (JIA) is often associated with severe chronic anterior uveitis (CAU), and immunosuppressive therapy may be required. In this study, the value of cyclosporine A (CsA) as monotherapy or as combination therapy for treating uveitis was studied in a large cohort of JIA children.

METHODS

Multicentre retrospective study including 82 JIA children (girls n=60) suffering from unilateral or bilateral (n=55) CAU. The indication for CsA was active uveitis, although patients were on topical or systemic corticosteroids, MTX, or other immunosuppressive drugs.

RESULTS

Inactivity of uveitis during the entire treatment period (mean 3.9 years) was obtained with CsA monotherapy in 6 of 25 (24%) patients, but more often when CsA was combined with the immunosuppressives (35/72 patients; 48.6%, P=0.037), or MTX (18/37 patients, 48.6%, P=0.065), which had already been given. With CsA (mean dosage 2.9 mg/kg), systemic immunosuppressive drugs and steroids could be reduced by >or=50% (n=19) or topical steroids reduced to <or=2 drops/eye/day (n=40) in selected patients. Pre-existing cystoid macular oedema did not resolve under CsA treatment in any of the patients. In nine patients (11%), CsA was discontinued because of systemic hypertension (n=1), elevated creatinine levels (n=3), or other adverse effects (n=5).

CONCLUSIONS

These observations suggest that CsA has limited value as a second-line immunosuppressive drug for the treatment of JIA-associated CAU. The efficacy was better as the combination therapy in patients not responding to other immunosuppressives (eg, MTX) than the systemic monotherapy.

Screening for cystoid macular oedema in children with uveitis using the retinal thickness analyser

PURPOSE

This study aimed to investigate the retinal thickness analyser (RTA) as a means to identify the presence of cystoid macular oedema (CMO) in children with uveitis, whether the course of CMO can be monitored using this method, and whether there is a trend towards a correlation between macular oedema and visual acuity (VA) in children.

METHODS

This prospective, cross-sectional study with observer-blinded analysis included 25 eyes. Standardized testing for best corrected distance VA (d-VA), near (reading) VA (n-VA) and slit-lamp examination were conducted. Using the RTA, a 3 x 3-mm scan of the macula was obtained, which was then used to discern CMO and calculate mean foveal thickness (MFT).

RESULTS

Macular scanning was possible in all children. Cystoid macular oedema was discerned in 10 eyes (40%) and ruled out in 15. In CMO eyes, d-VA was 0.5 Snellen and n-VA was 2 Jaeger; neither result differed significantly from those in eyes without CMO. Mean foveal thickness correlated with n-VA (r = 0.511, p = 0.015), but not with d-VA (r = 0.271, p = 0.191). After 3 months of tailored therapy, CMO was still detectable in six eyes. Changes in d-VA in the CMO and non-CMO groups were 3 +/- 2.1 and 0.8 +/- 1.8 Snellen, respectively; changes in n-VA were 1 +/- 1.4 and 0.1 +/- 0.3 Jaeger, respectively. Changes in MFT were - 244.8 +/- 137.4 microm and - 0.8 +/- 18.1 microm, respectively. A statistically significant correlation was found between the changes in MFT and n-VA (r = 0.629), but not with that in d-VA (r = 0.292).

CONCLUSIONS

We used the RTA to establish the presence or absence of CMO according to measurements of the macular region. Our findings show that CMO is a common complication in children with uveitis and can be present even in cases with good d-VA. Mean foveal thickness as measured with the RTA correlates indirectly with n-VA.

[Current cataract surgery for uveitis in childhood]

Cataract formation is a frequent complication in childhood uveitis. The management of cataracts in childhood uveitis may be particularly difficult. Patient selection is important for successful surgery. Preoperative evaluation is required in order to specify the course and etiology of uveitis. Complete quiescence of the inflammation in required before surgery. The surgical trauma should be minimized. Intraocular lens implantation may be proposed for selected uveitis children and may be considered in well controlled juvenile idiopathic arthritis associated uveitis, e.g. with the use of immunosuppressive drugs or TNF-alpha inhibitors. Postoperatively, the anti-inflammatory medication must be increased and continued for 8-10 weeks.