Pediatric Views

December 2005

Looking pediatric uveitis in the eye

Uveitis is a serious inflammatory eye disease that affects the iris, ciliary body and choroid

Three years ago, when she was 7 years old, Jamie Pelchat was sent home from school with a harmless case of conjunctivitis in her left eye. But a day after visiting her pediatrician, who prescribed antibiotic eye drops, the redness in Jamie's eye worsened, she was extremely sensitive to light, and she was experiencing pain in that eye.

The Pelchats were immediately referred to the Fallon Ophthalmology Clinic in Worcester, Mass. where doctors diagnosed Jamie with uveitis, a serious inflammatory eye disease that only affects one in 20,000 children worldwide.

In people with uveitis, the inside of the eye, specifically the three parts that make up the uvea—the iris, ciliary body and choroid—become inflamed. Left untreated, the inflammation can lead to scarring, cataracts, glaucoma and blindness, so prompt care is critical.

For Jamie, initial treatment consisted of steroid eye drops, which were administered several times a day over the course of three months. Unfortunately, the drops did little to control the inflammation, which soon appeared in her right eye as well.

That's when Jamie was referred to Children's Hospital Boston, where she saw Ophthalmologist-in-Chief David Hunter, MD, PhD. "We are very familiar with childhood uveitis because we see so many cases here," says Dr. Hunter. "It is very serious and difficult to treat, requiring a multidisciplinary approach involving specialists in Ophthalmology and Rheumatology."

While rheumatologists typically treat diseases of the muscles and joints, according to Robert Sundel, MD, director of Children's Rheumatology Program, many rheumatologic conditions can affect the eyes. In fact, juvenile rheumatoid arthritis—an auto-immune disease that affects one out of every 500 children, making it among the most prevalent chronic childhood diseases—is the leading cause of uveitis in children.

For this reason, Drs. Sundel and Hunter frequently work together to diagnose and treat the disease. In Jamie's case, they began working together after her uveitis was diagnosed, and she began to show symptoms of arthritis, including joint pain and swelling in her knees. They initially prescribed methotrexate, a powerful immunosuppressive drug commonly used to treat cancer but also used in arthritis treatment.

When the methotrexate failed to reduce the inflammation, they prescribed infusions of a new medication called infliximab, a drug that is used to treat a variety of diseases, including rheumatoid arthritis. Jamie was one of the first children in the U.S. to be treated with infliximab for uveitis, although it has been successfully used to treat adults.

Since she began taking these medications three years ago, Jamie's symptoms have improved dramatically. During her last three visits with Dr. Hunter, she has shown no signs of inflammation in her eyes, and the inflammation in her joints has improved.

Now 11 years old, Jamie's infusions of infliximab have been cut back from once every four weeks to once every six weeks, and are administered at St. Vincent Hospital in Worcester, which is convenient to her home in Millbury.

In addition, Jamie is still on a mild eye drop that she takes just once a day to prevent recurrence. She visits Dr. Hunter every six to eight weeks, so he can check her vision and examine her eyes for possible inflammation and visits Dr. Sundel every three months.

According to Dr. Hunter, the treatment Jamie is receiving is essential, as many patients with uveitis end up with some permanent eye damage if the condition is not well-controlled when it first develops. "The active inflammation tends to calm down once the patient is out of childhood," says Dr. Hunter. "So the long-term prognosis for children with uveitis is good as long as damage does not occur while inflammation is active."

As such, Dr. Hunter recommends immediate referral to a specialist if uveitis is suspected. Signs to look for include conjunctivitis that doesn't improve within a day or two, light sensitivity and redness that is concentrated around the iris. Also, children with juvenile rheumatoid arthritis should be routinely screened for uveitis.

"Uveitis is a dangerous, rare condition that is challenging to treat," says Dr. Hunter. "But if it's managed properly, you can have very good outcomes."

For more information Children's Hospital Boston's Department of Ophthalmology,
visit www.childrenshospital.org/eyes. To schedule an appointment, call
Boston (617) 355-6401
Lexington (781) 672-2100
Peabody (978) 538-3600
Sandwich (781) 331-4715
Waltham (781) 216-2100
Weymouth (781) 331-4751

Children's Hospital Boston
300 Longwood Avenue | Boston, MA 02115 | 617-355-6000
www.childrenshospital.org