Periocular corticosteroid injection in the management of uveitis in children

The management of adult and paediatric uveitis for rheumatologists

Uveitis encompasses multiple different conditions that are all characterized by intra-ocular inflammation. Uveitis occurs in the context of many different rheumatological conditions and carries a substantial risk to vision. Uveitis can develop both at the early stages of rheumatic diseases, sometimes even preceding other clinical features, and at later stages of disease. Uveitis can also occur as either a direct or an indirect complication of therapies used to treat patients with rheumatic disease. Conversely, patients with uveitis of non-rheumatic aetiology sometimes require immunosuppression, a treatment option that is not readily accessible to ophthalmologists. Thus, collaborative working between rheumatologists and ophthalmologists is critical for optimal management of patients with uveitis. This Review is written with rheumatologists in mind, to assist in the care of patients with uveitis. We collate and summarize the latest evidence and best practice in the diagnosis, management and prognostication of uveitis, including future trends and research priorities.

Management of JIA associated uveitis

Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in childhood, and is associated with uveitis in up to 20-25% of cases. Typically, the uveitis is chronic, asymptomatic, non-granulomatous and anterior. For this reason, screening for uveitis is recommended to identify uveitis early and allow treatment to prevent sight-threatening complications. The management of JIA associated uveitis requires a multidisciplinary approach and a close collaboration between paediatric rheumatologist and ophthalmologist. Starting the appropriate treatment to control uveitis activity and prevent ocular complications is crucial. Current international recommendations advise a step-wise approach, starting with methotrexate and moving on to adalimumab if methotrexate alone is not sufficient to control the disease. If the uveitis remains active despite standard treatment other therapeutic options may be considered including anti-IL6 or other anti-TNF agents such as infliximab, although the evidence for these agents is limited.

Treatment Options in Pediatric Behçet's Disease

Behçet's disease is a rare and poorly understood vasculitis affecting blood vessels of all types and sizes. Uveitis and oral and genital ulcers represent the typical clinical triad. Populations along the ancient trading route connecting the Mediterranean basin with the Middle and Far East are most affected. Up to a quarter of the cases has a pediatric onset, typically around puberty. The aim of the treatment is early intervention to control inflammation, with symptom relief and prevention of relapses, damage, and complications. The heterogeneous clinical presentation often requires a multidisciplinary and tailored approach. Ocular, neurological, gastrointestinal, and vascular involvement is associated with a worse prognosis and needs more aggressive treatments. In young patients with expected prolonged disease, treatment should also focus on preventive measures and lifestyle advice. In recent years, the pharmacological armamentarium has grown progressively, although only a limited number of drugs are currently authorized for pediatric use. Most evidence for these drugs still derives from adult studies and experience; these are prescribed as off-label medications and are only available as adult formulations. Corticosteroids frequently represent the mainstay for the management of the initial acute phases, but their potential serious adverse effects limit their use to short periods. Different conventional disease-modifying anti-rheumatic drugs have long been used. Many other biologic drugs targeting different cytokines such as interleukin-1, interleukin-6, and interleukin-17 and treatments with small molecules including the phosphodiesterase 4 and Janus kinase inhibitors are emerging as novel promising therapeutic agents. In recent years, a growing interest has developed around anti-tumor necrosis factor agents that have often proven to be effective in severe cases, especially in those with a gastrointestinal and ocular involvement.

Local versus Systemic Therapy for Noninfectious Uveitis (NIU)

The mainstay of treatment for noninfectious uveitis (NIU) is immunosuppressant therapy. This may come in a localized form that is administered specifically to the eye or a systemic form that penetrates ocular tissues. Over the last twenty years, both local and systemic treatments have undergone advancements in pharmaceutical development. In this review, we will discuss new therapies and analyze the risks and benefits for all existing NIU therapies. Some of these therapies include topical, intravitreal, periocular, and systemic steroids, as well as systemic antimetabolites, tumor necrosis factor-α inhibitors, T-cell inhibitors, anti-CD 20 agents, interleukin-6 inhibitors, alkylating agents, and intravenous immunoglobulin.

Subtenon Triamcinolone Acetonide Injection with Topical Anesthesia in Pediatric Non-Infectious Uveitis

INTRODUCTION

Subtenon triamcinolone acetonide (Kenalog®; Bristol Myers Squibb) (STA) injections are commonly used in the treatment of adults in an outpatient setting. However, publications on detailing its outpatient use, safety, and efficacy in the pediatric population are scarce.

METHODS

We reviewed STA injections performed in children in the outpatient clinics at two tertiary centers from 2014 to 2020. All children were aged ≤ 18 years and had a diagnosis of non-infectious uveitis. STA injections were done using 0.5 cc (20 mg) triamcinolone injected superotemporally with only topical anesthesia. Data on the efficacy and safety of STA in treating inflammation and compiled data on visual acuity improvement and incidence of ocular complications were evaluated.

RESULTS

Forty-eight eyes in 30 patients were included. The mean age of patients was 13.1 (range 7-18) years. There were no immediate complications observed in all injections performed. At the 3-month follow-up, inflammation had improved in 85.4% of eyes, macular edema had resolved in 77.8% of eyes, and there was significant vision improvement after STA. At 6 months after STA, the incidence of ocular hypertension was 12.5% and no new cataracts had developed.

CONCLUSION

STA injection with topical anesthesia was a well-tolerated, reasonable alternative for short-term treatment of uveitis among this pediatric population.

Paediatric cataract in the uveitis setting

BACKGROUND/AIMS

Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis.

METHODS

This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery.

RESULTS

In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2-14 years) with onset of cataract at a mean of 29.3 months later (range 0-66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 (p < 0.05). These patients had significant co-morbidities with concurrent glaucoma, band keratopathy and cystoid macular oedema. Uveitis was quiet for a minimum of 6 months in all cases prior to surgery with augmentation of immunosuppression pre-operatively as well as intra-operative local or intra-venous steroids. Tight post-operative care was necessary as 80% developed further flare-up of uveitis requiring increased immunosuppression and surgical interventions to manage their uveitis.

CONCLUSION

Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Visual and Clinical Outcome of Macular Edema Complicating Pediatric Noninfectious Uveitis

PURPOSE

To investigate the clinical course and visual outcome of macular edema (ME) in pediatric patients with chronic noninfectious uveitis.

DESIGN

Retrospective case series.

METHODS

The databases of the uveitis clinics of 4 tertiary medical centers in Israel and the UK were searched for all children treated for uveitic ME in the years 2005-2015. Data were collected from the medical records as follows: demographics, diagnosis, visual acuity, clinical and imaging findings, and treatment given specifically for ME. Findings at baseline and at 3, 6, 12, and 24 months were evaluated.

RESULTS

The cohort included 25 children (33 eyes) of mean age 8.5 ± 3.4 years. The most common diagnosis was intermediate uveitis, in 14 children (7 idiopathic, 7 pars planitis). Uveitis was active at ME diagnosis in 28 eyes (84.8%). Median duration of follow-up was 48 months. Median time to resolution of ME was 6 months, with complete resolution in 25 eyes (75.8%) by 24 months. Baseline visual acuity was ≥20/40 in 8 eyes (24.2%), increased to 57.6% at 3 months (P < .0001), and remained stable thereafter. Treatment regimens included corticosteroids (systemically and/or locally), immunosuppression, and biologic therapies. No correlation was found between outcome and either structural characteristics of ME or specific treatment strategy.

CONCLUSIONS

The prognosis of pediatric uveitic ME is favorable despite its chronic course. Larger randomized controlled trials are needed to define differences among treatment regimens.

Risk Factors for the Development of Cataract in Children with Uveitis

PURPOSE

To determine the risk factors for the development of cataract in children with uveitis of any etiology.

DESIGN

Cohort study.

METHODS

Two hundred forty-seven eyes of 140 children with uveitis were evaluated for the development of vision-affecting cataract. Demographic, clinical, and treatment data were collected between the time of presentation and the first instance cataract was recorded or findings at final follow-up. Main outcome measures included the prevalence of cataract and distribution by type of uveitis, incidence of new onset cataract time to cataract development, and risk factors for the development of cataract.

RESULTS

The prevalence of cataract in our cohort was 44.2% and was highest among eyes with panuveitis (77.1%), chronic anterior uveitis (48.3%), and intermediate uveitis (48.0%). The overall incidence of newly diagnosed cataract was 0.09 per eye-year, with an estimated 69% to develop uveitis-related cataract with time. The main factors related with cataract development were the number of uveitis flares per year (hazard ratio [HR] = 3.06 [95% confidence interval {CI}, 2.15-4.35], P < .001), cystoid macular edema (HR = 2.87 [95% CI, 1.41-5.82], P = .004), posterior synechia at presentation (HR = 2.85 [95% CI, 1.53-5.30], P = .001), and use of local injections of corticosteroids (HR = 2.37 [95% CI, 1.18-4.75], P = .02). Treatments with systemic and topical corticosteroids were not significant risk factors.

CONCLUSIONS

In this study, we found that development of cataract is common among pediatric eyes with uveitis and is most strongly related to the extent of inflammation recurrences and ocular complications. We suggest that controlling the inflammation, even using higher doses of systemic and topical corticosteroids, is of importance in preventing ocular complications, such as cataract.

Nuclear cataract as an early predictive factor for recalcitrant juvenile idiopathic arthritis-associated uveitis

PURPOSE

To analyze factors predictive of having treatment-resistant uveitis in patients with juvenile idiopathic arthritis (JIA)-associated uveitis.

METHODS

The medical records of patients diagnosed with JIA-associated uveitis treated at a single tertiary referral center from October 2005 to March 2013 were reviewed retrospectively. The main outcome measures were demographic characteristics, ocular comorbidity, clinical course, treatments, and baseline risk factors associated with poor response to first-line therapies.

RESULTS

A total of 96 patients (175 eyes) were included. Of these, 58 patients (108 eyes) required biologic disease-modifying antirheumatic drugs or alkylating agents for their uveitis during follow-up (recalcitrant group), and 38 patients (67 eyes) did not (nonrecalcitrant group). Eyes of the recalcitrant group tended to have a higher incidence of cataract at baseline (49%; P < 0.0001). In the nonrecalcitrant group, the most frequent complications were cataract (20.9%) and secondary glaucoma (20.9%). The mean number of flares in the recalcitrant group was significantly reduced from 3.7/eye/year prior to cataract surgery to 1.6/eye/year after (P < 0.0001). Nuclear cataract was found to be an independent predictor for a severe course of JIA-associated uveitis. Any other type of cataract, posterior synechiae, male sex, or active uveitis at baseline were not found to be independently associated with recalcitrant uveitis.

CONCLUSIONS

Nuclear cataract at baseline evaluation is a risk factor for poor response to first-line therapies in JIA-associated uveitis patients.

Current Treatment Modalities of JIA-associated Uveitis and its Complications: Literature Review

Uveitis is a common and serious complication of juvenile idiopathic arthritis. Up to 75% of all cases of anterior uveitis in childhood are associated with juvenile idiopathic arthritis. Despite the remarkable progress in early detection and treatment of inflammation, vision-threatening complications of uveitis still occur in almost 60% of patients. Structural complications include band keratopathy, maculopathy (macular edema, macular cysts, and epiretinal membrane), glaucomatous optic neuropathy, and cataracts. The management of complications in juvenile idiopathic arthritis is usually complex and requires early surgical intervention. In this paper, we review the general concepts of common ocular complications seen in patients with JIA-associated uveitis, with special attention to the recent diagnostic and preferred treatment approaches at the Massachusetts Eye Research and Surgery Institution. Received 9 March 2015; revised 30 September 2015; accepted 30 October 2015; published online 14 January 2016.

Outcome of Treating Pediatric Uveitis With Dexamethasone Implants

PURPOSE

To describe the outcome in children of eyes with uveitis following repeated treatment with dexamethasone (Ozurdex) implants.

DESIGN

Retrospective, interventional study.

METHODS

Twenty-two eyes of 16 pediatric patients with uveitis were treated with 35 dexamethasone implants at a tertiary referral center. Following implantations, anatomic and functional outcomes, as well as ocular complications, were noted. Main outcome measures included best-corrected visual acuity, central retinal thickness, number and dosage of systemic immunosuppression drugs, vitreous haze score, and presence of raised intraocular pressure or cataract.

RESULTS

Following the first implantation, average best-corrected visual acuity improved significantly from 0.55 ± 0.08 logMAR to 0.37 ± 0.08 logMAR (P = .024), central retinal thickness decreased by 219 ± 55 μm (P = .01), and the percentage of eyes achieving a vitreous haze score of 0 increased from 41% to 88% (P = .006). The median time to relapse following the first injection was 9 months, with a similar response achieved after each repeat implantation. Children previously requiring systemic immunosuppression at the time of the first implantation were able to stop or significantly reduce the dose and number of drugs. In total there were 4 instances of cataract progression that were not visually significant and did not require surgical treatment and 6 cases of raised IOP, 5 of which were treated pharmacologically with no surgical intervention required and 1 that required revision of a previous filtration surgery. There were no cases of implant migration into the anterior chamber, endophthalmitis, or retinal detachment.

CONCLUSIONS

The use of dexamethasone implants in children results in improved retinal thickness and reduction in ocular inflammation, which can improve vision for several months. Repeat implantations result in continued control of the inflammation, allowing for reduction of systemic immunosuppression with few ocular complications.

Conjunctival necrosis following a subconjunctival injection of triamcinolone acetonide in a child

Conjunctival necrosis is a rare complication following periocular/intraocular triamcinolone acetonide injection and has been reported extensively in adults. We describe a child who developed conjunctival necrosis following subconjunctival injection of triamcinolone acetonide for severe chronic anterior uveitis. Prompt diagnosis and management of this uncommon condition is vital.

Case series and descriptive cohort studies in neurosurgery: the confusion and solution

BACKGROUND

Case series (CS) are well-known designs in contemporary use in neurosurgery but are sometimes used in contexts that are incompatible with their true meaning as defined by epidemiologists. This inconsistent, inappropriate and incorrect use, and mislabeling impairs the appropriate indexing and sorting of evidence.

METHOD

Using PubMed, we systematically identified published articles that had "case series" in the "title" in 15 top-ranked neurosurgical journals from January 2008 to December 2012. The abstracts and/or full articles were scanned to identify those with descriptions of the principal method as being "case series" and then classified as "true case series" or "non-case series" by two independent investigators with 100 % inter-rater agreement.

RESULTS

Sixty-four articles had the label "case series" in their "titles." Based on the definition of "case series" and our appraisal of the articles using Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, 18 articles (28.13 %) were true case series, while 46 (71.87 %) were mislabeled. Thirty-five articles (54.69 %) mistook retrospective (descriptive) cohorts for CS. CS are descriptive with an outcome-based sampling, while "descriptive cohorts" have an exposure-based sampling of patients, followed over time to assess outcome(s). A comparison group is not a defining feature of a cohort study and distinguishes descriptive from analytic cohorts.

CONCLUSION

A distinction between a case report, case series, and descriptive cohorts is absolutely necessary to enable the appropriate indexing, sorting, and application of evidence. Researchers need better training in methods and terminology, and editors and reviewers should scrutinize more carefully manuscripts claiming to be "case series" studies.

Treatment with repeat dexamethasone implants results in long-term disease control in eyes with noninfectious uveitis

PURPOSE

To describe the long-term outcome of eyes with uveitis after repeated treatment with dexamethasone implants (Ozurdex; Allergan, Inc., Irvine, CA).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Thirty-eight eyes of 27 patients with uveitis that were treated with 61 dexamethasone implants.

METHODS

All eyes underwent dexamethasone pellet implantation. Anatomic and functional outcomes, as well as ocular complications, were noted.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), central retinal thickness (CRT), vitreous haze score, and presence of increased intraocular pressure or cataract.

RESULTS

Average follow-up was 17.3 ± 1.8 months after the first implant (median, 13.3 months; range, 3-54.5 months; 54.65 eye-years), with 14 eyes (36.9%) receiving a single implant and 24 eyes (63.1%) receiving multiple implantations. After the first implantation, average BCVA improved significantly from 0.47 ± 0.05 logarithm of the minimum angle of resolution (logMAR) units (Snellen equivalent, 20/60) to 0.27 ± 0.07 logMAR (Snellen equivalent, 20/37; P<0.001); CRT decreased by 263 ± 44.22 μm (P = 0.003), although macular edema persisted in 50% of eyes, and the percentage of eyes achieving a vitreous haze score of 0 increased from 58% to 83% (P = 0.03). The median duration of therapeutic effect after the first injection was 6 months (range, 2-42 months), with a similar response achieved after each repeat implantation. The accumulated effect of repeat dexamethasone implants resulted in a continued improvement in BCVA (R(2) = 0.91; P<0.0001), with significant improvement and stabilization of CRT. After repeated implantations, 2 eyes had progression of posterior subcapsular opacities, although neither required surgery. There were 7 instances of increased intraocular pressure of more than 21 mmHg at a rate of 0.13 per eye-year, all of which responded to pharmacologic treatment.

CONCLUSIONS

The accumulated effect of repeat dexamethasone pellet implantations improves retinal thickness and resolves ocular inflammation, resulting in restoration of ocular function. Ocular complications were minimal, with no eyes requiring surgery for increased ocular pressure or progression of cataract.