Study recommends vigilant eye screenings in JIA

The clear message to pediatricians from a recent prospective study looking at new onset uveitis risk in juvenile idiopathic arthritis (JIA) is to encourage patients and families to get the recommended eye exams, even when patients don’t have ocular or joint symptoms.¹

Juvenile idiopathic arthritis is the most common pediatric rheumatic disease and uveitis is one of its most frequent and potentially devastating extra-articular manifestations with complications that can compromise eyesight,¹ according to the article’s senior author Karen N. Watanabe Duffy, MD, FRCPC, a rheumatologist in the Division of Rheumatology, Department of Pediatrics, at the Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada.

“JIA-uveitis is most often asymptomatic, and those who are at highest risk for uveitis are younger children who are diagnosed with JIA before the age of 7 years and those with a positive antinuclear antibody (ANA). Children with JIA should have screening eye examinations for at least 5 years after JIA diagnosis,” Watanabe Duffy, who is also an associate professor of Pediatrics at the University of Ottawa, writes in an e-mail to Contemporary Pediatrics.

JIA and uveitis

The prevalence of JIA is about 1 to 4 for every 1000 children,1 and when JIA-associated uveitis does occur in these patients, more than half will develop vision-threatening complications.²

Early detection and vigilant screening are essential to reduce ocular complications, including blindness, Watanabe Duffy writes.

Key points from the study

Watanabe Duffy and colleagues studied data from the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) inception cohort, including 1183 patients enrolled within 6 months of their JIA diagnosis. The researchers report 87 of those patients, who were followed for up to 5 years, developed new-onset uveitis post-enrollment.

The researchers found the incidence of new-onset uveitis was 2.8% each year in the first 5 years after diagnosis. Whereas the annual incidence fell slightly from the first through fifth year post-JIA diagnosis, incidence was still 2.1% in the fifth year.

Notably, JIA subtype and female sex were not independent predictors for JIA-related uveitis. Rather, being aged younger than 7 years at JIA diagnosis and having positive ANA were independent predictors, according to the paper published in Arthritis Care and Research.¹

“This article is the first to demonstrate the yearly incidence of uveitis, highlighting the importance of vigilance in screening. [It’s] important to note, although we concentrate on the younger patient, the oldest patient was 18.⁴ years at uveitis diagnosis. So, although less likely, uveitis can still appear in older children,” according to AnneMarie C. Brescia, MD, FAAP, FACR, chief of Pediatric Rheumatology at Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware. Brescia is not an author on the paper.

What pediatricians need to know

Although pediatric rheumatologists make it a point to encourage JIA patients to get recommended ophthalmology screenings, it’s often not enough to get families and patients to comply, according to Sheila T. Angeles-Han, MD, MSC, associate professor of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Families might not understand the urgency of going for regular screenings when their children don’t have symptoms and aren’t suffering. The demand on families can be substantial, says Han, whose research focus is in uveitis associated with JIA, but she is not an author of the paper featured here.

“Children who are at highest risk for uveitis need regular ophthalmology screening every 3 months for several years. [Because] they often have no symptoms, the best way to screen is through a slit-lamp examination. The frequent visits can be a burden for families, but that’s the only way to detect eye inflammation unless the child has developed eye complications. By then, the damage from uveitis has occurred. You want to detect the uveitis before you get complications,” Han says. “[Because] these children are regularly seen by their pediatricians with whom they have a close relationship, I think it’s important that pediatricians emphasize the importance of screening, as well.”

For how often those visits should occur according to risk, pediatricians can refer to “Ophthalmologic examinations in children with juvenile rheumatoid arthritis” published in 2006 in Pediatrics.³ They can also refer to the “Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative,” in an open access paper published August 2018 in the Annals of the Rheumatic Diseases.⁴

“Ongoing monitoring by the pediatrician is crucial to ensure that patients undergo eye examinations on a recommended and ongoing basis according to contemporary and audited screening protocols,” Watanabe Duffy writes.⁴

Han says pediatricians should note that JIA patients need the screenings even when their arthritis is inactive or well controlled.

“Some patients think that because their arthritis is well controlled, they don’t need to continue with their eye screenings with ophthalmology, but the arthritis and uveitis activity don’t parallel each other. You can have arthritis that’s in remission or inactive and still develop the uveitis,” Han says.

Pediatricians should also note that ophthalmologists might treat JIA-associated uveitis with systemic immunosuppressive medicines when topical medicines are insufficient or result in adverse effects, such as glaucoma or cataracts, according to Brescia.

“Kids with JIA who are not on immunosuppressive medications can get all the vaccines. Kids with JIA on systemic immunosuppressive medicines should not get the live virus vaccines,” Brescia writes in an e-mail to Contemporary Pediatrics.

Uveitis risk and JIA treatment

Medications used to treat arthritis, including methotrexate and some of the tumor necrosis factor (TNF) inhibitors, are also used to treat uveitis, according to Han. Research is showing that being on these medications for JIA may change whether a child will develop uveitis, she says.

However, children with JIA who are in the process of tapering and stopping systemic immunosuppressive therapy after a period of remission are at risk for developing new-onset uveitis, according to Duffy.

“It is recommended that those who discontinue such treatment should have screening eye examinations every 3 months for 1 year,” Watanabe Duffy writes.⁴

The researchers note that a limitation of the study was that it was only for 5 years.

“It would be important to determine what the risk is after that 5-year period,” Han says.