Juvenile rheumatoid arthritis and glaucoma

Juvenile rheumatoid arthritis is a common cause of uveitis in children, which often develop an increase in intraocular pressure and glaucoma.

Depending on the number of affected joints and the presence of systemic manifestations during the first 3 months from the onset of the disease, 3 subtypes of juvenile rheumatoid arthritis with different risks of uveitis develop. Juvenile rheumatoid arthritis with systemic manifestation, or Still's disease, is an acute systemic disease manifested by skin rash, fever, polyarthritis, hepatosplenomegaly, leukocytosis and polyserositis; usually found in boys under the age of 4 years. Girls are more likely to develop oligo-, spiocarticular (less than 5 joints) and polyarticular (affected by 5 or more joints) forms of juvenile rheumatoid arthritis, in which systemic manifestations are absent.

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Epidemiology of juvenile rheumatoid arthritis

The incidence of uveitis in juvenile rheumatoid arthritis ranges from 2 to 21%. With Still's disease, or juvenile rheumatoid arthritis with a systemic manifestation, uveitis usually does not develop. Anterior uveitis is more common in patients with a spiocarticular form (19-29%) than in patients with a polyarticular (2-5%) form of juvenile rheumatoid arthritis. Children with a spiocarticular or monoarticular form of joint manifestation account for more than 90% of patients suffering from uveitis associated with juvenile rheumatoid arthritis. Secondary glaucoma develops in approximately 14-22% of patients suffering from chronic anterior uveitis associated with juvenile rheumatoid arthritis.

[10], [11], [12], [13], [14], [15], [16], [17], [18]

What causes juvenile rheumatoid arthritis?

Increased intraocular pressure and the development of glaucoma in patients suffering from juvenile rheumatoid arthritis are most often the result of a synechial closure of the angle of the anterior chamber of the eye. In chronic inflammation of the trabecular network, open-angle glaucoma can develop, and with prolonged local treatment with glucocorticoids, steroid-induced glaucoma.

Symptoms of juvenile rheumatoid arthritis

In 90% of patients suffering from juvenile rheumatoid arthritis, uveitis develops after arthritis. Due to the fact that anterior uveitis with juvenile rheumatoid arthritis of mild course is asymptomatic and rarely causes reddening of the eye, the disease can not be detected for a long time until visual acuity, cataract or pupillary deformation are seen. Almost in all cases uveitis with juvenile rheumatoid arthritis is bilateral.

Course of the disease

Associated with juvenile rheumatoid arthritis, uveitis is a hard-to-treat chronic disease. In patients with juvenile rheumatoid arthritis, there is no direct relationship between eye damage and joint damage. The longer the duration of the disease, the higher the risk of secondary complications, for example, ribbon-like keratopathy, cataracts and glaucoma. Previously, an unfavorable prognosis in children with inflammatory glaucoma improved somewhat due to the development of more effective surgical technologies.

Ophthalmological examination

Almost 50% of children with anterior uveitis are diagnosed with ribbon-like keratopathy, which is probably due to the chronic course of the disease. Anterior uveitis in patients suffering from juvenile rheumatoid arthritis is overwhelmingly non-granulomatous. However, in rare cases, sebaceous precipitates are detected on the cornea and Koeppe nodules. Precipitates are usually located in the lower half of the cornea. Patients often identify signs that can lead to the development of glaucoma: miosis due to the presence of posterior synechia or pupillary membranes, iris bombardment and peripheral synechiae. Approximately 1/3 of patients develop anterior and posterior subcapsular cataracts. When examining the posterior segment of the eye of patients suffering from juvenile rheumatoid arthritis, it is possible to identify papillitis and cystic macular edema, which can lead to a decrease in visual acuity.

Diagnosis of juvenile rheumatoid arthritis

Differential diagnosis of chronic anterior uveitis in children is performed with sarcoidosis, parsplanitis, HLA B27-associated diseases and idiopathic anterior uveitis.

Laboratory research

Almost 80% of patients with anterior uveitis in juvenile rheumatoid arthritis have antinuclear antibodies and no rheumatoid factor.

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Treatment of juvenile rheumatoid arthritis

Primary treatment of intraocular inflammation in patients with juvenile rheumatoid arthritis includes the use of local glucocorticoids and cycloplegic drugs to prevent the formation of synechia. Often, for the treatment of anterior uveitis, a periocular or systemic administration of glucocorticoids is necessary. Apply also non-steroidal anti-inflammatory drugs inside. To treat ocular or joint manifestations of juvenile rheumatoid arthritis, methotrexate is used in the form of monotherapy or in combination with other immunosuppressors (prednisolone or cyclosporine). The effectiveness of new biological preparations, etanercept (enbrel) and infliximab (remicade), with respect to joint damage in juvenile rheumatoid arthritis has been proved. Currently, studies of the effectiveness of these drugs with uveitis are under way.

With increasing intraocular pressure, juvenile rheumatoid arthritis is treated with antiglaucoma drugs. The effectiveness of drug therapy in patients suffering from juvenile rheumatoid arthritis is initially 50%, but for a long time only 30% of patients have medication control. To eliminate the pupillary block in the presence of posterior synechia, laser iridotomy or surgical iridectomy may be required. If the drug is ineffective, surgical treatment is necessary. To improve the results of surgical intervention, the operation should be performed when monitoring intraocular inflammation for at least 3 months. Children with juvenile rheumatoid arthritis undergo trabeculectomy and tubular drainage implantation. Better results of trabeculectomy with antimetabolites were noted. Trabekulodialysis in a small group of patients suffering from juvenile rheumatoid arthritis has contributed to an effective reduction in intraocular pressure up to 2 years.