Ocular Immunology and Inflammation

ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20

Pattern of Pediatric Uveitis Seen at a Tertiary Referral Center from India Sudha K. Ganesh MD, Aparna Bala MD, J. Biswas MD, Arshee S. Ahmed MD & John H. Kempen MD To cite this article: Sudha K. Ganesh MD, Aparna Bala MD, J. Biswas MD, Arshee S. Ahmed MD & John H. Kempen MD (2015): Pattern of Pediatric Uveitis Seen at a Tertiary Referral Center from India, Ocular Immunology and Inflammation, DOI: 10.3109/09273948.2015.1012298 To link to this article: http://dx.doi.org/10.3109/09273948.2015.1012298

Published online: 14 Jul 2015.

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Date: 12 November 2015, At: 01:21

Ocular Immunology & Inflammation, Early Online, 1–8, 2015 ! Informa Healthcare USA, Inc. ISSN: 0927-3948 print / 1744-5078 online DOI: 10.3109/09273948.2015.1012298

ORIGINAL ARTICLE

Pattern of Pediatric Uveitis Seen at a Tertiary Referral Center from India Sudha K. Ganesh,

MD

1

, Aparna Bala, MD1, J. Biswas, MD1, Arshee S. Ahmed, John H. Kempen, MD2

MD

1

, and

1

Medical Research Foundation, Sankara Nethralaya, Chennai, India and 2Departments of Ophthalmology and Epidemiology & Biostatistics, and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Ocular Immunology and Inflammation

ABSTRACT Aim: To analyze the profile, etiology, complications, medical and surgical management, and visual outcome among pediatric uveitis patients seen at a referral uveitis clinic in India. Design: Retrospective cohort study, tertiary hospital setting. Methods: Records between January 2007 and April 2010 were reviewed for patients with uveitis who were 0–18 years of age. Uveitis diagnosis was based on SUN criteria; complications, medical and surgical management, and visual outcome were evaluated. Results: Among 190 children with uveitis, 64.2% were boys and 112 had unilateral disease. The median age at presentation was 11 years. Ninety-nine (52%) had anterior, 49 (26%) intermediate, 27 (14%) posterior, and 15 (7.9%) panuveitis. Infectious uveitis was present in 44 patients, of which 21 cases (48%) were posterior uveitis. Parasitic, tuberculous, and viral infectious uveitis was encountered. A total of 174 patients were followed over 315.5 person-years (median = 1.35 years). Seventy-seven (40.5%) children had complications related to uveitis. Forty-six out of 77 complications noted were complicated cataracts. Surgical procedures were done in 46.9% (15%/100 person-years). The visual acuity improved by two Snellen lines in the uveitic eyes, following therapy in 120 children, was stable in 40 children, and worsened in 14 children. Follow-up visual acuity was missing for 16 children. Conclusion: A large proportion of pediatric uveitis cases experienced complications of uveitis, mostly prior to presentation for subspecialty management. These often required surgical management, most commonly to clear the visual axis of cataract for visual rehabilitation and to prevent amblyopia. In most cases, tertiary management was associated with visual improvement. The results suggest that subspecialty management can result in improvement of the clinical course of pediatric uveitis. Keywords: Complication, etiology, management, pediatric uveitis

Pediatric uveitis is a challenging condition to diagnose, due to difficulty in examining the child. Treatment of uveitis in children is also difficult because of the implications of immaturity on adherence to therapy, acceptance of injectable therapy, limitations on use of systemic corticosteroids due to effects on growth, and the risk of amblyopia. These considerations limit the use of topical, injectable, and systemic corticosteroids and add an element of urgency to dealing with cataracts.

Uveitis has been reported to account for about 25% of blindness in the developing world1 and is an important cause of vision loss in Western countries.2–5 Children have been reported to account for about 2.2–13.8% of uveitis patients.2 Even though uveitis is less common in children than in adults, children reportedly are at greater risk to develop complications and permanent visual loss.3,4 In a large study, Smith et al.5 found a significant risk of visionthreatening complications in pediatric uveitis.

Received 18 October 2014; revised 16 January 2015; accepted 21 January 2015; published online 10 July 2015 Correspondence: Dr. Sudha K. Ganesh, Medical Research Foundation, Sankara Nethralaya 18, College Road, Chennai 600006, India. E-mail: [email protected]

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In order to address the limited information available regarding the outcomes of pediatric uveitis in general, and particularly in tropical developing country settings, here we report the presenting characteristics, etiologic classification, and clinical course of pediatric patients with uveitis from a relatively large cohort of consecutive children seen at a tertiary referral uveitis center in India.

Ocular Immunology and Inflammation

MATERIALS AND METHODS The uveitis service at Sankara Nethralaya (Chennai, India) is a large subspecialty practice with a team of seven uveitis subspecialist consultants providing consultative and walk-in care for patients with ocular inflammatory diseases. A detailed registry of cases is prospectively maintained. This database was used to identify and include consecutive pediatric uveitis cases between 0 and 18 years of age at presentation seen in our hospital between January 1, 2007, and April 30, 2010, inclusive. Data from records were retrospectively abstracted into a case sheet prepared for the study. Examination and/or treatment under anesthesia had been used for patients unable to cooperate with clinical examination or treatments. All patients had a complete history, visual acuity, ophthalmic examination with refraction, slit-lamp biomicroscopy, applanation tonometry, and indirect ophthalmoscopy. For children between 1 and 4 years of age we used CSM method/preferential looking test (Lea paddles/Cardiff visual acuity) or Lea symbols, HOTV, Snellen charts to assess visual acuity. Data retrieved and analyzed included age at first visit, sex, laterality of uveitis, site of inflammation based on SUN/IUSG criteria,6,7 occurrence of complications, use of medical and surgical therapies, and outcome. Clinical characteristics at presentation and over time, results of etiological workup for associated systemic conditions, and both pharmacological and surgical treatments utilized during follow-up also were recorded. Patients had been managed according to the best medical judgment of the uveitis subspecialist consultant managing the case. The SUN criteria were used to report clinical data such as level of anterior chamber cells.6 Details of associated systemic diseases and relevant laboratory investigations were noted. In cases where the specific etiology could not be identified, the term ‘‘idiopathic uveitis’’ was used. Each child’s workup for potentially associated systemic diseases was based on best medical judgment; specific diagnostic tests were done in selected cases based on the history and examination details. For instance, children with a history of joint pains and presentation with anterior uveitis were evaluated for rheumatologic disorders via rheumatologist consultation; children presenting

with granulomatous anterior uveitis were tested for tuberculosis and sarcoidosis. Diagnoses of ocular toxoplasmosis/toxocariasis were made by clinical examination, typically with serum ELISA for Toxoplasma/Toxocara IgG and IgM antibodies done to support the diagnosis. Consultations with a pediatrician and/or rheumatologist were advocated, especially for children requiring immunosuppression and those suspected to have associated systemic diseases. Treatment for noninfectious uveitis generally followed principles of initial use of high-dose topical and/or systemic corticosteroids for induction of control of active inflammation, with liberal use of corticosteroid-sparing therapy when needed to maintain control of chronic disease without excessive use of corticosteroid.7,8 In cases with infectious uveitis, specific treatment for the infection was used when indicated, supplemented by anti-inflammatory therapy as appropriate. Surgeries were done when indicated per best medical judgment, typically to address complications of inflammation, such as cataract or recalcitrant intraocular pressure elevation, band-shaped keratopathy (BSK), tractional retinal detachments (TRD), and/or rhegmatogenous retinal detachments (RRD).

Statistical Methods All statistical analysis was done using SPSS software (SPSS 2005, SPSS for Windows, Version 14.0, Chicago). Distributions were summarized using proportions, means, or medians as appropriate, and 95% confidence intervals. Survival analysis was conducted, including plotting Kaplan-Meier survival curves to plot the visual outcome in patients who underwent surgery for complications due to uveitis.

RESULTS During the study period, 190 children were diagnosed with uveitis, 122 (64.2%) males and 68 (35.8%) females. The age of patients ranged from 0 to 16 years, with median age at presentation being 11 years. One hundred seventy-four (92%) children were followed over 315.5 person-years (median = 1.35 years). The sex and age distribution was similar across the spectrum of anterior, intermediate, posterior, and panuveitis. However, 68.2% of infectious uveitis patients were males (p value = 0.007950.05). Among the children presenting with anterior, intermediate, posterior, and panuveitis, 30 (30%), 29 (59%), 10 (37%), and 9 (60%) cases had bilateral disease, respectively. Bilateral uveitis was seen commonly in intermediate and panuveitis (p value = 0.0032150.05). About 70% of anterior uveitis was unilateral and 63% of posterior uveitis was unilateral (Table 1). Ocular Immunology & Inflammation

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TABLE 1. Patient demographics: age and laterality. Anterior uveitis n = 99 (52%) Median age, years Males Females Unilateral Bilateral

11 65 34 69 30

(range 1–18) (66%) (34%) (70%) (30%)

Intermediate uveitis n = 49 (26%) 11 32 17 20 29

(range 4–16) (65%) (35%) (41%) (59%)

Posterior uveitis n = 27 (14%) 13 15 12 17 10

(range 6–16) (56%) (44%) (63%) (37%)

Panuveitis n = 15 (8%) 14 10 5 6 9

(range 5–17) (67%) (33%) (40%) (60%)

Total n = 190 122 68 112 78

p Value* 0.128 0.7928

(64%) (36%) (59%) (41%)

0.0032

*One-way ANOVA is used to determine whether any significant difference exists in ages among the diagnoses. The chi-square test for independence is used to find the association between diagnosis and gender and diagnosis and laterality.

TABLE 2. Location and etiology of uveitis.

Ocular Immunology and Inflammation

Causes "Idiopathic" Juvenile idiopathic arthritis Trauma Vogt Koyanagi Harada syndrome Sarcoidosis HLA-B27-associated Fuchs uveitis Tubulointer-stitial nephritis with uveitis Sympathetic ophthalmia Tuberculosis Toxoplasmosis Toxocariasis Cysticercosis Viral uveitis Infectious uveitis

Anterior uveitis n = 99

Intermediate uveitis n = 49

Posterior uveitis n = 27

Panuveitis n = 15

36 (36%) 22 (22%) 20 (20%) — 2 (2%) 2 (2%) 2 (2%) — 2 (2%) 4 (4%) — — 1 (1%) 8 (8%)

27 (55%) 2 (4%) 7 (14%) — 3 (6%) 1 (2%) — 1 (2%) 2 (4%) 5 (10%) — — 1 (2%) —

5 (19%) — — — 1 (4%) — — — — 2 (7%) 8 (30%) 8 (30%)

3 (20%) — — 6 (40%) 2 (13%) — — — — 3 (20%) — —

3 (11%)

1 (7%)

Location and Etiology of Uveitis Anterior uveitis was diagnosed in 99 out of 190 cases (52%). Thirty-six percent of anterior, 55%, of intermediate, 19% of posterior, and 20% of panuveitis cases were ‘‘idiopathic.’’ The most common specific diagnoses in each category were as follows: juvenile idiopathic arthritis (JIA) accounted for 22% of anterior uveitis, parasitic uveitis accounted for 60% of posterior uveitis, and Vogt Koyanagi Harada syndrome (VKH) accounted for 40% of panuveitis. Ocular trauma is common in children. We have included traumatic uveitis in this study, as we did find trauma in children a frequent cause for uveitis in our series. Fourteen percent of cases had either blunt or penetrating trauma and all had severe iridocyclitis in the traumatized eye, documented with moderate to severe anterior chamber inflammation, photophobia, pain, and redness; some even had visual loss. Some children had lens protein-induced uveitis due to dehiscence of anterior lens capsule; these children were managed with corticosteroids and cataract surgery. All 4 children with sympathetic ophthalmitis !

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Total n = 190 71 24 27 6 8 3 2 1 4 14 8 8 2 12 44

(37.4%) (13%) (14%) (3.2%) (4.2%) (1.6%) (1.1%) (0.5%) (2.1%) (7.4%) (4.2%) (4.2%) (1.1%) (6.3%) (23%)

on presentation to our clinic were blind in the traumatized eye; all 4 had ocular inflammation in the sympathizing eye. Two children presented with mild anterior uveitis and 2 had anterior uveitis and cyclitis with disc hyperemia. Overall, 44/190 (23%) patients were diagnosed with infectious uveitis. Among the 44 cases of infectious uveitis, 14 were associated with tuberculosis, 18 cases were parasitic, and 12 were viral infections. Twenty-one (48%) of the infectious uveitis patients presented as posterior uveitis; among the posterior uveitis cases, 21 (78%) out of 27 were infectious (Table 2).

Medical Management Of the 190 children with uveitis, 65 were treated only with topical corticosteroids (CS) and 54 with topical and oral CS; 15 needed periocular CS injections along with topical CS. Forty-five children were started on immunomodulatory therapy along with topical and/ or oral CS. The remaining children did not have active disease at the time of observation and did not receive

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TABLE 3. Treatment modalities.

Ocular Immunology and Inflammation

Anti-inflammatory treatment Topical corticosteroids (CS) only Topical with oral CS Topical with periocular depot CS injection(s) Topical with/without oral CS plus immunosuppressants No treatment (inactive) Additional anti-infectious-specific treatment Anti-tuberculosis therapy with oral CS Anti-viral therapy (acyclovir) with oral CS Anti-toxoplasmosis therapy with oral CS Anti-helminthic therapy with oral CS

these therapies. One child with posterior uveitis and 1 child with intermediate uveitis developed choroidal neovascular membrane (CNVM) and received antiVEGF therapy. The child with posterior uveitis received 1 avastin injection and the child with intermediate uveitis received 4 avastin injections (Table 3). Among the 44 cases of infectious uveitis, 14 were associated with tuberculosis, 18 cases were parasitic, and 12 had viral infections. Specific therapy in the form of anti-tuberculous (anti-TB) therapy along with oral corticosteroids was given for 11 children, who had associated tuberculosis; anti-virals along with oral corticosteroids were given for 11 patients diagnosed with viral uveitis; and treatment for toxoplasmosis was initiated along with corticosteroids in 5 out of 8 children diagnosed with toxoplasmosis. The untreated infectious cases were judged to be in remission and not requiring treatment. In children diagnosed with toxocariasis all 8 received oral corticosteroids. Only 2 patients had cysticercosis. Both cysts were removed in toto surgically. One cyst was in the anterior chamber and was removed by an anterior chamber wash through a paracentesis. The other cyst was in the vitreous cavity and was removed following a vitrectomy. One child with cysticercosis received anti-helminthic therapy with systemic corticosteroids after surgical removal of the ocular cyst, as the child had additional cysts in the orbit and brain (Table 3).

Anterior uveitis n = 99

Intermediate uveitis n = 49

Posterior uveitis n = 27

Pan uveitis n = 15

65 13 2 16 3

0 16 11 20 2

0 16 2 4 5

0 9 0 6 0

4 7

4

2 3 5 1

1 1

Total n = 190 65 54 15 46 10

(34%) (28%) (7.8%) (24%) (5%)

11 11 5 1

Cystoid macular edema (CME) occurred only in 5.5% of uveitis cases and was most common in intermediate uveitis and panuveitis. A total of 99/190 (52%) children had anterior uveitis that is rarely associated with CME. Among the panuveitis cases, 6/15 (40%) had VKH, which again is rarely associated with CME. Among the posterior uveitis cases, 16/27 (59%) were parasitic complications, mostly toxocariasis and toxoplasmosis; some were already healed with scars and others resolved with therapy. This distribution could have reflected in a low incidence of CME of 5.5%. Another possible cause for low incidence of CME could be due to the fact that we did not do OCT to evaluate the macula in children at the time of this study. In the absence of OCT it is possible that the early subtle CME changes were missed and/or these changes may have resolved with therapy. Vitreous hemorrhage occurred in 2.2% of cases, all related to traumatic uveitis. Overall, 11.1% of cases had retinal detachments either in the form of rhegmatogenous detachment (RRD) in traumatic uveitis or tractional retinal detachment (TRD) noted in parasitic uveitis and long-standing intermediate uveitis; exudative retinal detachment (ExRD) was noted in 1 child with Vogt Koyanagi Harada syndrome. Hypotony occurred in 2.2% and choroidalneovascular membrane with subretinal fibrosis occurred in 4.4% of the cases analyzed (Table 4).

Surgical Management Complications Patients were followed over 315.5 person-years (median = 1.35 years). Among the 190 cases, 77 cases (40.5%) were observed to have a total of 90 complications of uveitis, 61 at time of presentation and 16 during the course of follow-up. Cataract was the most common complication noted in our study, occurring at a rate of 44%; most of the cataracts were noted at presentation. Elevated IOP and band-shaped keratopathy (BSK) each were noted in 14.4% of cases.

Surgical procedures, either single or multiple, were done in 55 (28.9%) cases, mostly within the first 2 years of follow-up (see Figure 1). Kaplan-Meier analysis suggested that 44% would require surgery within 5 years. Cataract extraction was the most frequent procedure, performed in 46/55 cases (80%). The decision on the type of cataract extraction was based on clinical judgment. Phacoemulsification with intraocular lens (IOL) implantation with or without filtering procedures was done. In a few cases Ocular Immunology & Inflammation

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TABLE 4. Distribution of complications of uveitis. Intermediate uveitis

Complications (Total = 90)

Anterior uveitis

Cataract Elevated intraocular pressure Band-shaped keratopathy Choroidal neovascular membrane/subretinal fibrosis Cystoid macular edema Vitreous hemorrhage TRD/ /RRD/ExRD

22 7 8 0

12 4 4 1

0 2 (traumatic uveitis) 4 (RRD traumatic uveitis)

3 0 2 (TRD)

Macular hole Hypotony

1 (traumatic uveitis) 1

Posterior uveitis

Panuveitis

0 0 1 0

6 2 0 3

0 0 3 (TRD in toxocariasis) 0 0

0 0

Total (90) 40 (44%) 13 (14%) 13 (14%) 4 (4.4%)

2 0 1 (ExRD in VKH) 0 1

5 (5.5%) 2 (2.2%) 10 (11%) 1 (1.1%) 2 (2.2%)

RRD, rhegmatogenous detachment; TRD, tractional retinal detachment; ExRD, exudative retinal detachment; VKH, Vogt Koyanagi Harada syndrome.

TABLE 5. Surgical management. Anterior uveitis n = 33

Intermediate uveitis n = 11

Posterior uveitis n=4

Panuveitis n=7

Total cases (n = 55)

25 9 1 15 3 (traumatic uveitis) 5

11 7 1 3

4 1

6 2 2 2 1

46 (80%)

Ocular Immunology and Inflammation

Surgical management Cataract surgery PE + IOL alone PE + IOL with trabeculectomy Lensectomy + vit Vitreoretinal surgery BSK removal

3

4 5

PE, phacoemulsification; IOL, intraocular lens; BSK, band-shaped keratopathy.

lensectomy and vitrectomy without intraocular lens were performed. Three cases of traumatic uveitis required vitreoretinal procedures and 5 cases required BSK removal (Table 5).

Visual Acuity Among 190 cases that we studied, visual outcome had improved in 120 (69%) cases, was stable in 40 (23%) cases, and deteriorated despite treatment in 14 (8%). Follow-up visual acuity was missing for 16 children. The visual acuity graph (Figure 2) demonstrates good visual outcome in all types of uveitis except intermediate uveitis, where complications like CME interfered with the outcome. Prognosis was poor in children who had severe uveitis with complications at the time of initial presentation. Prognosis was poor in patients presenting at a younger age, those with a longer duration of uveitis, and those who had longer duration of disease before being referred to a specialist (p value = 0.044450.05)

DISCUSSION Both population- and clinic-based surveys suggest that uveitis is about one-tenth as common in children !

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as in adults.9 Our study demonstrates that there is a high risk of morbidity in association with pediatric uveitis referred to a tertiary center, and that, nevertheless, patients under tertiary management have a reasonably good prognosis. Ayuso et al.10 have reported that male gender is an independent risk factor for poor prognosis in JIAassociated uveitis. In an analysis of pediatric uveitis conducted by Kump et al.11 53.5% were females, and studies by Rosenberg et al.12 and Smith et al.13 have also shown a female preponderance. In our study, 64.2% were males and 35.8% were females, with the proportion of males affected more in all the anatomical types of uveitis. While the sex distribution in our study might have been affected by the referral patterns, if the observation of male predominance truly reflects the situation in South India, the prognosis might accordingly be worse. Another factor that may have contributed to the male predominance in our study could be the high proportion with infectious uveitis, as males were more likely to be exposed to infectious agents through play patterns (68.2% of infectious uveitis were males, p value = 0.007950.05). Rosenberg et al.12 analyzed 148 cases and reported that 71% had bilateral disease; Kump et al.11 report that 74% had bilateral disease. In the study by Smith et al.13 bilateral disease was common in anterior,

S. K. Ganesh et al.

FIGURE 1. Kaplan-Meiyer survival graph for complications managed surgically. Estimated survival at 5 years follow-up 56%.

10.00

Difference in Visual acuity with treatment

Ocular Immunology and Inflammation

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5.00

0.00

-5.00

Anterior uveitis

Posterior uveitis Intermediate uveitis

Panuveitis

diagnosis

FIGURE 2. Visual acuity across the groups. Ocular Immunology & Inflammation

Ocular Immunology and Inflammation

Pediatric Uveitis intermediate, and panuveitis, and unilateral disease was found to be more common in posterior uveitis. Our study did observe the pattern of greater bilaterality in intermediate and panuveitis, and more unilaterality in posterior uveitis, but the majority of anterior uveitis cases were unilateral. Overall, only 41.1% had bilateral disease, perhaps reflecting the higher proportion (23%) of unilateral infectious uveitis, including herpetic anterior uveitis. The most common location of uveitis in our study was anterior uveitis (52.1%) and JIA accounted for 22.2% of anterior uveitis. Kump et al.11 also reported that 33% of their cases were associated with JIA. In 37.4% of our cases, no specific systemic syndrome or named uveitis was detected (‘‘idiopathic’’ uveitis). Idiopathic uveitis was more common in the anterior and intermediate uveitis group. This pattern was similar to previous reports.14,15 Vogt Koyanagi Harada syndrome (VKH) was found to be the commonest cause of panuveitis in our series (40%). The overall incidence of VKH in this pediatric uveitic population was 3%, (95% CI = 0.152–0.648), which was higher when compared to the studies by Kump et al.11 and Rosenberg et al.,12 where the incidence of VKH syndrome was 0.7% of all childhood uveitic cases. VKH may be more common in India, possibly due to genetic or other reasons. Sarcoidosis was associated in 4.2% of cases, whereas previous studies16,17 from other parts of the world report 0.8–3.9% cases of pediatric sarcoid uveitis. On comparing infectious uveitis in our tertiary pediatric uveitic population in India to other parts of the world, our study found that 7.3% cases had tuberculous uveitis. In the study by Kump et al., infectious uveitis constituted only 5% of all cases and there was no child with tuberculous uveitis.11 In the study by Rosenberg et al.12 only 1 out of 148 cases had tuberculous panuveitis. This difference could be explained by the fact that tuberculosis is more prevalent in India than in the developed countries. In our study, 29.6% of cases of posterior uveitis had toxoplasmosis retinochoroiditis. Studies from other parts of the world, on the analysis of specific causes of childhood uveitis, show that the incidence of toxoplasmic retinochoroiditis was between 7.2 and 25.6%.18,19 Studies by Rathinam et al.20,21 in a more rural part of South India found trematode infection was a common cause of pediatric granulomatous anterior uveitis. We did not observe this condition, but parasitic uveitis was observed: 2 (1.1%) children with cysticercosis-associated uveitis and 8 (4.2%) children with toxocariasis. We found 12 (6.3%) children had viral uveitis. The difference in these patterns may reflect differences between the urban and rural situation and/or socioeconomic differences. Complications were noted in 40.5% of cases in this series. Of these complications, cataract was the most common in 44.4% of cases, elevated intraocular !

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pressure in 14.4%. Both of these complications were higher in patients with anterior uveitis, and sometimes in both anterior and intermediate uveitis, than posterior or panuveitis; 26.6% cases had posterior segment complications. Rosenberg et al.12 showed that the incidence of cataract was about 12.5%, glaucoma was reported in 7.9% of cases, and 36.8% cases had retinal complications. Differences may reflect slower referral in this region of the world, and/or differences associated with the different pattern of conditions observed. All the reports in the literature suggest fairly high complication rates, with frequent complications potentially attributable to corticosteroid therapy, suggesting that early use of corticosteroid-sparing therapy likely would be beneficial in appropriate cases. In our study, cataract extraction was the most common surgery done, performed in about 54.5% of all the surgeries. The study by Kump et al.11 also observed that cataract surgery with or without IOL implantation was the most common surgery. In a study done for evaluating the outcome of cataract surgery in children with uveitis,22 it was found that IOL implantation has improved visual outcomes in most patients. Studies on IOL implantation in JIA by Ganesh et al.23 found factors associated with favorable outcome were strict preoperative, and postoperative control of inflammation, absence of amblyopia, and older age of the child. Patients with JIA and uveitis were found to have a greater inflammatory response, leading to poor visual outcome following surgery, and this was better controlled with adjuvant immunosuppressive therapy.23,24 Though our study has the inherent drawbacks of a retrospective study done at a referral tertiary care center, we found prognosis was poor in children who presented at a younger age with longer duration of uveitis and who had delayed referral to a tertiary care center, as was found in other studies.25 This observation may reflect increased severity of disease early in life, and potentially also the impact of amblyopia when media opacities interrupt visual input during development. Risk of amblyopia, poor tolerance to drugs, development of side effects to medication, and poor compliance pose difficulties in medical management in children. Management of uveitis in children does not end with diagnosis and treatment but requires long-term adequate follow-up, which reduces the ocular morbidity and ensures psychosocial well-being of these children. In summary, unilateral presentation was more common among anterior and posterior uveitis cases, whereas bilateral presentation was more typical for intermediate and panuveitis cases. Most cases of uveitis were ‘‘idiopathic’’ and the frequent anatomical location was anterior uveitis, confirming patterns seen elsewhere in the world. Pediatric tuberculous uveitis and infectious uveitis in general were found to be

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more prevalent in our study when compared to studies from western countries. Cataract was the complication most commonly encountered. We observed in this study favorable outcomes, on average, of pediatric uveitis managed at a tertiary care center, whereas a longer time-to-referral was associated with poor outcome, suggesting that such management is valuable. Such management of noninfectious uveitis was with corticosteroids alone or immunomodulatory therapy along with corticosteroids, and for infectious uveitis included specific antituberculous therapy, anti-viral, or anti-toxoplasmosis therapy (except for old ‘‘burned out’’ cases) along with oral corticosteroids. Surgical therapy done by the appropriate subspecialty frequently was required, and had reasonably favorable outcomes. These observations suggest that the pattern of uveitis is not entirely uniform throughout the world, and that prompt subspecialty care of pediatric uveitis is indicated for nontrivial cases.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Dr. Kempen receives funding from Research to Prevent Blindness (New York, New York, USA), and the Mackell Foundation (New York, New York, USA). Statistician Mr. Viswanathan helped analyze the data collected. The authors have no financial interest in any of the materials used in the study.

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Ocular Immunology & Inflammation

Pattern of Pediatric Uveitis Seen at a Tertiary Referral Center from India.

To analyze the profile, etiology, complications, medical and surgical management, and visual outcome among pediatric uveitis patients seen at a referr...
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