Uveitis in childhood : Complications and treatment with emphasis on juvenile idiopathic arthritis

Abstract

The aim of this study was to gain more insight into the development of complications in childhood uveitis and to evaluate the treatment options for these mostly sight-threatening conditions with emphasis on juvenile idiopathic arthritis (JIA)-associated uveitis. The second aim was to investigate which cytokines are involved in the pathogenesis of pediatric uveitis by analyzing the presence of immune mediators in the aqueous humor of children suffering from this disease. To pursue the aim of this thesis we performed several retrospective studies and two clinical laboratory investigations (multiplex immunoassay). The conclusion to our investigation in this thesis is that of all children with uveitis, those with JIA are at greatest risk of developing secondary glaucoma. When glaucoma surgery is required, we found that the implantation of an Ahmed glaucoma valve is more successful than trabeculectomy in pseudophakic or aphakic eyes of children with JIA-associated uveitis but in phakic eyes trabeculectomy postpones the need for a glaucoma drainage implant by several years. Our next conclusion is that the presence of posterior synechiae at the time of diagnosis of uveitis is the major cause of the development of cataract and conversely, treatment with methotrexate early in the course of uveitis delays the need for cataract surgery in children with JIA-associated uveitis. If cataract surgery is required, the implantation of an intraocular lens in children with JIA-associated uveitis is not associated with an increased risk of the development of long-term ocular complications such as ocular hypertension, secondary glaucoma, cystoid macular edema and optic disc swelling, but led to a good visual outcome. Finally, we conclude that multiple intraocular cytokines, chemokines and soluble adhesion molecules in the aqueous humor are involved in the pathogenesis of pediatric uveitis. These mediators are present in all different uveitis entities without clear predominance of a Th1- or Th2-associated cytokine profile. Furthermore, higher concentrations of several pro-inflammatory immune mediators are present in the aqueous humor of children and adolescents with uveitis than in adults, with the exception of IL-6