Eye Complications in Children With Juvenile Arthritis
Eye problems such as uveitis can be a devastating complication of childhood arthritis. Here’s what you need to know to protect your child.
By Kelli Miller and Mary Anne Dunkin
Eye problems can be a devastating complication of childhood arthritis. The same inflammation that causes painful, red, swollen joints can silently strike your child’s eyes. You usually cannot see that your child’s eyes are affected, and a young child may not be able to recognize that they are gradually going blind.
“The eye disease associated with juvenile arthritis can cause serious complications and even blindness, if not detected in time. Unfortunately, there are few [noticeable] symptoms, so it’s really very important for your child to have regular eye exams,” says David Epley, MD, a pediatric ophthalmologist in Kirkland, Wash., and a former president of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).
Below, we discuss some eye problems commonly diagnosed in kids with juvenile arthritis and provide information regarding eye exams and treatment.
Uveitis is a serious complication of juvenile arthritis and the most common non-joint-related complication seen in kids with the disease. It requires immediate medical attention and prompt, early treatment to help prevent vision loss. “Children who are diagnosed with advanced uveitis have a high risk of complications,” says Wendy Smith, MD, an ophthalmologist at the Mayo Clinic in Rochester, Minn.
The term “uveitis” is used to describe inflammation in one or more of the inside structures of the eye, which include:
- Iris - the colored part of the eye that controls the amount of light entering the eye.
- Ciliary body – controls the lens shape, helps the eye focus and makes the liquid that fills the front of the eye.
- Choroid – a layer of blood vessels in the back of the eye.
- Retina – the thin tissue lining the inside of the back of the eye
- Vitreous humor – the clear gel that fills the inside of the back of the eye
The type of uveitis your child has depends on the area or areas of the eye affected:
- Anterior uveitis (including iridocyclitis and iritis): This is the most common form of JA-related uveitis. Inflammation occurs inside the front of the eye (the anterior chamber) or in the iris and/or ciliary body.
- Intermediate uveitis: Inflammation of vitreous humor.
- Posterior uveitis: Inflammation of the retina and/or choroid.
A child with uveitis might not have symptoms such as redness, irritation or light sensitivity. That is why eye exams are so important. There is no way to spot uveitis without one.
“By the time a child with arthritis has obvious signs of eye problems, he or she may have significant damage to the eye and vision loss,” says Dr. Smith.
Complications that can result from JA-related eye inflammation such as uveitis include:
- Band keratopathy: White discoloration of the usually clear cornea.
- Cataracts: Clouding of the lens.
- Glaucoma: Increased eye pressure that damages the optic nerve.
- Macular edema: Build up of fluid in the retina.
- Posterior synechia: Scar tissue between the iris and lens, which can cause the pupil to be oval or irregularly shaped.
- Retinal detachment (very rare): Separation of the retinal from the eye wall.
Girls with JA are more likely than boys to develop uveitis. The risk is also higher in children who are diagnosed with JA before age 4.
“Children with a positive antinuclear antibody (ANA) blood test sblood test are at higher risk of eye disease, as are children with oligoarthritis (one to three involved joints),” says Dr. Epley. Some studies suggest that a positive ANA test may be a more accurate predictor of a child’s eye disease risk than the pattern of joint involvement.
Eye problems caused by JA medications
Certain medications used to treat JA may also lead to eye problems.
- Hydroxychloroquine (Plaquenil): In rare cases, this disease-modifying antirheumatic drug (DMARD) can cause pigment changes in the center part of the eye’s retina, called the macula. This can lead to changes in the sharpness of vision or problems with color vision over time, says Paul Howard, MD, a Phoenix-based rheumatologist who has been treating children with juvenile arthritis (JA) for many years. Special eye monitoring is recommended for all children and adults who take hydroxychloroquine.
- Corticosteroids: Long-term use of high-dose corticosteroids, including prednisone, may lead to glaucoma, which can cause damage to the optic nerve, as well as cataracts, a clouding of the eye’s lens.
Your doctor can help reduce your child’s risk of these side effects by prescribing the smallest dose of medication needed to control the arthritis. Getting regular eye exams and reporting all vision changes and other eye symptoms to your child’s doctor are important.
Eye exam recommendations
Every child with JA should have regular eye exams, even if they do not have any symptoms. Routine eye exams can help prevent many of the eye complications related to JA, including permanent vision loss.
Eye exam recommendations vary and depend on your child’s type of arthritis, the age at which the disease started and his or her blood test results.
The American Academy of Pediatrics recommends eye exams as often as every three months for children with early-onset arthritis and a positive ANA test. Children with systemic JIA should have exams once a year, regardless of ANA results.
Treating arthritis-related eye problems
Children with arthritis-related eye problems should see a pediatric ophthalmologist or an ophthalmologist who specializes in uveitis. The ophthalmologist will work closely with your child’s rheumatologist to monitor your child’s progress and treatment.
Arthritis-related eye problems are highly treatable. First-line treatments often include:
- Steroid eye drops to reduce inflammation
- Medicine to widen the pupils to prevent scarring
Your child’s eye doctor will prescribe the eye drops and monitor how well they work for your child. If those treatments do not work, the eye doctor will consult with your child’s pediatric rheumatologist to determine if your child should take methotrexate (Rheumatrex, Trexall) by mouth or injection (Otrexup).
If methotrexate doesn’t work, your child’s pediatric rheumatologist may prescribe another DMARD such as cyclosporine (Neoral) or mycophenolate mofetil (CellCept) or a biologic response modifier such as infliximab (Remicade). If your child’s arthritis is active, these medications can help control both joint symptoms and the eye disease. These medicines are also used for children who have arthritis-related eye disease without active joint inflammation.