Pediatric uveitis can be difficult to recognize, but it’s crucial that eyecare professionals be prepared to diagnose and treat this rare inflammatory condition, as it can permanently damage a child’s sight.
Key challenges are that the disease can be asymptomatic and that specialists are few and far between. This means that general ophthalmologists and optometrists, as well as rheumatologists, must shoulder some of the responsibility for identifying uveitis.
Fortunately, there are standard strategies for following children who are at risk for this tissue-destroying condition or who are living with its symptoms, as well as an investigational approach to diagnostic imaging that will eventually make the process easier and more accessible.
But awareness will remain the most important factor, as practitioners who suspect uveitis, even if they aren’t disease-state experts, can make a vital contribution by referring patients to specialty centers. By working together, doctors across various specialties can better protect our youngest patients from irreversible damage to their sight.
Overview of childhood uveitis
The term “uveitis” encompasses more than 30 types of inflammatory eye disease. While these diseases most often arise in people aged 20 to 50, they can also affect children as young as 2 years—usually as autoimmune conditions restricted to the eye without systemic causes.
Of all uveitis cases, 5 to 10% affect children. In industrialized nations, about 4.3 of every 100,000 children develop the condition.1 Children or adolescents with idiopathic uveitis can develop redness, blurry vision, and light sensitivity if inflammation affects the front of the eye versus floaters, and vision changes when inflammation occurs at the back of the eye.
However, uveitis can be less commonly caused by autoimmune disease (AD) that affects the whole body. The AD most associated with pediatric uveitis is juvenile idiopathic arthritis (JIA), which causes swollen, painful joints but tends to affect the front of the eye until inflammation asymptomatically there becomes very severe. At that point, patients can develop complications that result in vision loss—such as cataracts, band keratopathy, or posterior synechiae.
Despite the low incidence of uveitis in the general population, the lack of symptoms in JIA-associated anterior uveitis demonstrates the need to screen for the disease routinely. As a result, most children with JIA should be screened for uveitis every 3 months so that ocular inflammation can be caught early and treated aggressively.
Facing the challenge of pediatric uveitis diagnosis
Our industry gold standard for detecting and evaluating uveitis is the slit lamp, but a well-rounded investigation, including blood tests and X-rays, along with attention to the patient’s overall clinical history shared by primary care doctors and/or rheumatologists, can contribute to the diagnosis.2
In children, slit lamp examination can sometimes be the most challenging part of the exam, as it’s never easy to convince youngsters to sit still while looking into the instrument’s bright light, and their restlessness can compromise accuracy. As a result, my colleagues and I have conducted studies using optical coherence tomography (OCT) as a potential screening method.
Using OCT to detect pediatric uveitis
Routinely used to diagnose and manage glaucoma, diabetes-related retinopathy, and age-related macular degeneration, this noninvasive strategy for ocular imaging can also be used for cornea tomography, biometry, and anterior segment imaging, including the identification of individual cells floating in the anterior chamber, which appear on images as hyper-reflective foci.
In studies presented at the 2024 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO),3,4,5 my team used Heidelberg Engineering's ANTERION, a multidisciplinary OCT device that rapidly captures swept-source cross sections of the entire anterior chamber. We also applied fully automated image-processing algorithms to detect inflammation earlier or possibly more accurately than is possible with slit lamp examination.
Once validated, we believe this method will provide objective results compared with those gleaned from slit-lamp imaging, which are more subjective. My team remains eager to shed light on this emerging strategy and how it can be used not only in the clinic but also objectively to measure intraocular inflammation in clinical trials.
Treating pediatric uveitis
First-line treatment for uveitis, both in children and adults, typically involves steroid eye drops, sometimes given in conjunction with pupil dilators. By reducing inflammation, these treatments can relax the eye and alleviate pain.
After starting a steroid eye drop, depending on the severity of inflammation, the next step may consist of oral steroids, often paired with a systemic immunosuppressant such as methotrexate or adalimumab.
In addition to treatment for uveitis and separate therapies for any underlying causative conditions, children may need additional topical or surgical intervention if uveitis sparks cataracts, glaucoma, or neovascularization.
Collaboration is key to making a difference
Enhancing awareness and early detection of pediatric uveitis is crucial in preserving the sight of affected children. We can ensure timely diagnosis and intervention by fostering strong collaboration among ophthalmologists, optometrists, rheumatologists, and primary care providers.
This united effort will prevent irreversible vision loss and improve the overall quality of life for our youngest patients. Together, we can make a profound difference in combating this rare, sight-threatening disease and safeguarding the future of children's eye health.
