Juvenile rheumatoid arthritis often affects different body parts and organs, including the eyes; and it is estimated that that 12 percent of children with pauciarticular JRA go blind as the result of low grade chronic inflammation in the eyes, known as iridocyclitis (ee-ree-doh-see-klee-tees) or uveitis (yu-ve-i-tis). Yet, children under the proper care of ophthalmologists, doctors who specialize in eye illnesses, usually retain their eyesight.

JRA and Uveitis

Uveitis, not related to the degree of inflammation in the joints, is a complication of JRA. The eye condition most often occurs in children who have only one or a few joints inflamed, while10 to 20 percent of children with pauciarticular JRA get it. The uveitis may begin in one or both eyes before the arthritis is diagnosed. If, after six to 12 months, the illness affects only one eye, it is unusual for the other eye to be affected.

Because uveitis may initially occur without obvious signs or symptoms, you and your child may not be aware of its presence. In fact, about half of the children with uveitis will not initially have symptoms of the illness. And by the time the uveitis is discovered, the child may have irreversible vision loss. 

It is, therefore, important that all children diagnosed with JRA have their eyes checked regularly by ophthalmologists, even if the eyes are not red or painful.

Diagnosis and treatment

An ophthalmologist will give your child a complete medical eye evaluation, and will see the inflammation, using a special microscope called a slit lamp. This simple, painless procedure counts the inflammation cells in the fluids of the eyes. Cell count helps to tell the doctor how severe the illness is. The best doctor to diagnose this condition is an ophthalmologist with advanced training in uveitis and ocular immunology.

Treatment includes eye drops and medications given in a shot or by mouth. Medications include corticosteroids; methotrexate and cyclosporine A.  Nonsteroidal anti-inflammatory drugs (NSAIDS) may also control the severity of the disease.

In Europe, Japan, and Canada, laser treatment is often the first line of therapy. In the U.S., use of laser has lagged, even though prospective, multi-centered, peer-reviewed studies, since the early '90s, have shown laser to be at least as effective as topical medications in controlling intraocular pressure and preserving visual field.

Eye Illnesses

Please understand that tolerating low grade uveitis can – over a period of four to eight years – lead to conditions known as maculopathy, with macular edema, macular cysts, epiretinal membrane, optic neuropathy and cyclitic membranes. Yet, some ophthalmologists, concerned that corticosteroids will lead to side effects, including cataracts and glaucoma, tolerate low grade eye inflammation, leading to these illnesses. Yet, proper use of medications for eye illnesses will not lead to these side effects.

Definitions

Cataract: an opacity that develops in the crystalline lens of the eye or in its envelope. The most effective   and common treatment is to surgically remove the cloudy lens.

Glaucoma: a group of diseases of the optic nerve involving loss of retinal ganglion cells in a characteristic pattern of optic neuropathy. Pharmaceuticals and surgery are currently the mainstays of glaucoma treatment.

Corneal degeneration: an inflammatory or more seriously, infective condition of the cornea, involving disruption of the epithelial layer with involvement of the corneal stroma. Corneal ulcers are extremely painful due to nerve exposure, and can cause tearing, squinting, and vision loss. Proper diagnosis is essential for optimal treatment. Supplementation with Vitamin A by oral or intramuscular route is often given. Drugs that are usually contraindicated in corneal ulcers are corticosteroids and anesthetics.

Recommended screening schedule for eye disease

SType                                    Subtype                                Recommendations

Pauciarticular JRA              ANA- positive                        Before age 7: Every 3 to  4 months                                          



                                                ANA–negative                      Age 7 and older: Every 6 months

                                                         

                                                All ages                                  Every 6 months                                  

Polyarticular JRA                 ANA-positive                         Before age7: Every 3 to 4 months

                                                                                              

                                                                                    Age 7 and older: Every 6  months

                                                          

                                                ANA-negative                       All ages: Every 6 months

                                                                         

Systemic JRA                                                                       All ages: Every 12 months