Perspective
Special considerations in the evaluation and management of uveitis in children

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Abstract

Purpose

To review issues related to the diagnosis, examination, and treatment of children with uveitis that are important for ophthalmologists.

Design

Literature review.

Methods

A review was made of pertinent reports from the medical literature, with commentary based on the authors’ experiences and on discussions at an international workshop.

Results

There are differences between children and adults in the differential diagnosis and manifestations of uveitis that should be considered during evaluation. There may be a higher risk of some ocular complications such as uveitic glaucoma, and the presence of other unique complications, such as amblyopia, in young patients during follow-up. With regard to treatment, children with uveitis may have unique dosing requirements and drug-associated risks such as growth retardation with systemic corticosteroids that must be considered. Examination and treatment may also be more difficult with children because of problems with patient cooperation.

Conclusions

There are unique patient care issues associated with uveitis in children that must be considered by care providers. Attention to these issues will improve the well-being of this patient population.

Section snippets

Patient populations

Children with uveitis actually represent a heterogeneous group of patients. Issues of importance vary with the age of the patient; among other factors, stages of growth and development, metabolism, cooperation, and exposures vary greatly between birth and adulthood. Subpopulations include neonates and infants; young children, during the period of risk for amblyopia; older children; and adolescents.

Examination may be difficult in very young patients, and in some cases, examination under

Differential diagnosis

As with adults, there are many causes of childhood uveitis, and a differential diagnosis depends on the region of the eye involved and the characteristics of disease. The distribution of cases between anatomic categories of disease (anterior, intermediate, posterior, and panuveitis) in children varies with age1, 3 and varies between reported series, in part because of a different spectrum of diseases seen in different geographic areas. Cunningham4 found that posterior uveitis was slightly more

Complications of disease

It is generally believed that children with uveitis are at greater risk than adults for development of complications,4 although there is no definitive proof of that. The higher prevalence of complications among children with uveitis may be attributable to longer delays before diagnosis and treatment or to the spectrum of diseases seen in children. Complications include band keratopathy, secondary glaucoma, posterior synechiae, secondary cataract formation, inflammatory membranes, macular edema,

Therapy

Traditionally, corticosteroids have been the mainstay of treatment for noninfectious forms of uveitis. In recent years, there has been a trend to earlier and more aggressive use of immunomodulatory agents for adults and children to treat noninfectious forms of uveitis, both to prevent development of complications and to avoid local and systemic side effects of corticosteroids. The more traditional approach of waiting until vision drops or complications develop before beginning immunomodulatory

Monitoring and compliance

Monitoring of disease and treatment effects is especially important in children with uveitis, who may not report changes in vision, as would an adult. Particular attention should be paid to visual acuity of children at risk for amblyopia. As with adults, periodic examinations should be performed to assess levels of inflammation (anterior chamber cells and flare; vitreous humor cells and haze), signs of uncontrolled inflammation (keratic precipitates; iris nodules), the presence of

Summary

The evaluation and management of children with uveitis is based on the same principles that apply to adults, with the caveat that there are additional special considerations when dealing with children. Examination and treatment are more challenging in young patients, and coordination of care with pediatricians experienced in the management of inflammatory diseases is important.14 Substantial progress has been made in this field over the past several decades, but even recent surveys demonstrate

Acknowledgements

Additional participants in the workshop “Evaluation and Management of Inflammatory Eye Disease in Children” included: Emmett T. Cunningham, Jr., MD, PhD, MPH (New York, NY), Janet L. Davis, MD (Miami, FL), Joseph L. Demer, MD, PhD (Los Angeles, CA), Sean P. Donahue, MD, PhD (Nashville, TN), Clive Edelsten, MRCP, FRCOphth (London, England), C. Stephen Foster, MD (Boston, MA), Lynn K. Gordon, MD, PhD (Los Angeles, CA), Elizabeth M. Graham, FRCP, DO, FRCOphth (London, England), Sherwin J.

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    InternetAdvance publication at ajo.com March 24, 2003.

    Doctor Holland was supported in part by Research to Prevent Blindness, Inc, New York, New York, the Skirball Foundation, Los Angeles, California, and the David May II Endowed Professorship, and is a recipient of a Research to Prevent Blindness Physician-Scientist Award.

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