Eye screening for uveitis in paediatric rheumatology patients

What is uveitis?

Uveitis is inflammation inside the eye. It can occur on its own (idiopathic) but also with other inflammatory conditions, such as juvenile idiopathic arthritis (JIA).

Between 10 to 20% of children and young people with JIA develop uveitis. The exact cause of this is unknown, but we know that the immune system mistakes the proteins in the eye for a foreign invader, like a bacteria or virus, and this causes an inflammatory reaction. It is very similar to how the immune system affects the joints in JIA.

Most children who develop uveitis have a mild form of the condition that does not lead to long-term complications, especially if treated early. However, some children will develop more severe eye inflammation. Early and regular eye screening is vital, because uveitis can be difficult to detect. Children often do not notice any problems and there is not always anything to see on the outside of the eye. Screening can detect problems early so that they can be treated and prevent damage to the eye and loss of vision.

Uveitis screening is conducted by an ophthalmologist (specialist eye doctor) or occasionally by a specially trained orthoptist. The screening occurs in a clinic using specialist equipment called a slit lamp. High street opticians are not able to examine the eye in enough detail to screen for uveitis in children.

The eye

Uveitis commonly affects the front part of the eye. This is called anterior uveitis. Up to 20% of children with JIA can develop chronic anterior uveitis which causes very mild symptoms, including slight eye redness and very mild sensitivity to light. Rarely for some children, the middle and back parts of the eye are affected.

Which children with JIA develop uveitis?

There is currently no way of predicting which children with JIA will develop uveitis and all children with a diagnosis of JIA should have uveitis screening. We do know that uveitis is more common in these groups:

• girls
• age under seven years (especially under four years)
• oligoarticular (four or fewer joints affected)
• antinuclear antibody (ANA) positive on blood tests

Uveitis is very uncommon in:

• rheumatoid factor-positive polyarticular (five or more joints affected) JIA
• systemic onset JIA (sJIA)

What does screening involve?

The first eye examination should take place within six weeks of JIA being diagnosed. If your child has symptoms which suggest uveitis is present, then more urgent screening will be arranged. Subsequent eye examinations will be individually arranged.

Screening involves having a standard eye test where your child’s vision will be tested. It also involves a more in-depth look at the eye using a special microscope called a slit lamp which shines the light into the eye and shows up the cells causing inflammation. Sometimes eye drops will be required to enlarge (dilate) the pupils which enables the ophthalmologist to have a better look.

What are the signs and symptoms of uveitis?

• Eye pain
• Red eyes
• Sensitivity to light
• Floaters
• Unequal or change in pupil shape
• Clouding of pupil
• Blurry/cloudy vision
• Headaches

In younger children you should note:

• Abnormal blinking, especially with bright lights
• Eye rubbing
• Visual inattention
• Responding to sounds rather than visual stimulus
• New squint/eyes not moving together

What are the treatments for uveitis?

If your child is found to have uveitis, the treatment will be discussed with you by your ophthalmologist. There are a range of treatments available depending on the severity of uveitis. Treatments include:

• Steroid eye drops: these reduce inflammation in the eye(s).
• Pupil-dilating eye drops: these prevent scarring inside the eye. They can be stingy and blur the vision but are really important.
• Tablets and injections: if the uveitis is not controlled using drops, it is sometimes necessary to use medications that suppress the immune response. The decision to start these medications is usually made jointly with your ophthalmologist and rheumatologist.

What happens if uveitis is left untreated?

If left untreated uveitis can cause serious damage to the eye. The complications include cataracts (cloudy lens), glaucoma (high pressure in the eye) and permanent loss of vision (blindness). This is why screening and attending appointments is really important.

Contact information

• Paediatric rheumatology specialist nurses: 01223 254988 or email the paediatric rheumatology team.
• Paediatric ophthalmology specialist nurses: 01223 596414 or email the paediatric ophthalmology team.
• Clinic 3 (ophthalmology): 01223 256691
• Clinic 6: 01223 216410