Eye Problems Associated with Juvenile Arthritis

Many parents are understandably alarmed to learn that their child has been diagnosed with "arthritis." Yet to add to their concern, parents are also told that children with juvenile forms of arthritis may develop significant eye problems. A few common questions include:

1) How commonly do children with arthritis develop eye problem?
2) What types of problems can develop?
3) Can my child's vision become affected?

Yes, unfortunately, children with juvenile arthritis may develop significant ocular problems, usually beginning with a process called "uveitis" or "iritis", a medical term for inflammation involving the blood vessel layer of the eye. This blood vessel layer lies immediately below the white part of the eye known as the sclera and includes the pigmented or "colored" part of the eye known as the iris (the structure in the front of the eye that makes an eye appear blue or brown). This inflammation is not an infection, but is an immunologic process (related to the immune system) of unknown origin.

Iritis is a common cause of a "red eye" or " pink eye" and can occur from many causes. However, iritis that occurs in juvenile arthritis is usually not associated with a red or pink eye. Unfortunately, iritis can occur without the patients or the parents having any awareness of inflamniation occurring in the eye. Significant iritis continuing for months without treatment can result in damage to the eye, such as cataracts (cloudiness of the lens) and/or glaucoma (increase in the pressure of the eye) that can damage the nerve (optic nerve) that carries visual information to the brain. Visual loss can be permanent, especially if the iritis is not detected early.

The only way to diagnose "Iritis" early in the disease before damage to the eye has occurred is to have an evaluation by an ophthalmologist who will use a "slit lamp microscope" to see an enlarged image of the front of the eye. With the help of a slit lamp an ophthalmologist (medical eye doctor or Eye MD) can diagnose iritis and prescribe treatment that is in most cases able to prevent damage eye and to your child's vision.

Treatment usually involves eye drops containing steroids that reduce the inflammation in the eye and prevent damage to the eye. Occasionally, stronger medications may be needed to treat iritis, but usually steroids are sufficient.

What are the chances that my child with juvenile arthritis will develop iritis and require treatment? First of all, most of the time that significant eye problems will develop in children with arthritis, some eye problem is found at the first eye exam after diagnosis of juvenile arthritis. That is, the vast majority of children who develop significant eye problems in juvenile arthritis have some eye problem that can be detected by an ophthalmologist (Eye MD) present when first diagnosed with juvenile arthritis. Children whose eyes are normal initially have the greatest risk of developing iritis in the first two years after the onset of arthritis, although iritis can occasionally occur as many as 20 years after the onset of arthritis. The severity of the joint disease does not parallel the eye disease. That is, while a child's joints may have improved significantly, the risk of eye disease is still present.

Overall, 10 to 20% of children with juvenile arthritis will have iritis of some form at some point. Even if iritis develops, the great majority of patients require only treatment with topical steroids. Children with normal eyes who develop iritis after the onset of arthritis have a 1 in 20 chance of visual loss. Most children with serious eye problems will have some eye abnormality (often seen only through a slit lamp exam by an eye doctor) after diagnosis of arthritis.

Children with some forms of arthritis have a higher risk of eye problems than others. Children with four or fewer joints involved at the onset of arthritis, have a higher risk of developing iritis. If a blood test called ANA (anti-nuclear antibody) is positive, the risk is higher still. This form of arthritis usually occurs in young girls. Children with four (or fewer) joints involved and a positive ANA need to be seen by an ophthalmologist (Eye MD) every two to three months for the first two years after diagnosis of juvenile arthritis. Children with other forms of arthritis are seen every three to six months the first two years. After two years from the onset of arthritis, most children should be seen every four to six months; after five years, yearly exams are recommended.

Children who present with high fever at the first sign of juvenile arthritis (systemic JRA) have almost no risk of developing iritis. Boys with a form of arthritis affecting the hip and low back pain and have positive blood test for HLA-B27 are at risk of developing iritis with a red eye. All other forms of arthritis will not develop a red eye when iritis develops.

One's rheumatologist will refer the child to an ophthalmologist for evaluation if juvenile arthritis has been diagnosed. It is very important to keep regular appointments with the ophthalmologist, especially for the first two years after diagnosis of arthritis. Most children with significant eye problems will have some detectable eye abnormality on initial eye exam. Parents must continue to have their children's eyes examined regularly as iritis occasionally occurs even several years after diagnosis of juvenile arthritis. Fortunately, even if eye problems develop, they can almost always be treated to prevent visual loss.