What is juvenile idiopathic arthritis (JIA) of the eyes?
Although it might not seem possible, a disease that affects the joints can sometimes also affect the eyes.
Children with juvenile idiopathic (meaning of unknown cause) arthritis – or JIA – can develop eye problems either as a result of the disease itself or, rarely, as a side effect of some medicines.
This information will help you learn more about how JIA might affect your child's eyes.
How the eye works
- The eye functions in the same way as the inner workings of a camera. The front of the eye admits light rays through the cornea, the pupil (the middle of the iris that determines how much light enters the eye), and a transparent fluid known as the aqueous humor in the anterior (front) chamber.
- Next, the lens focuses that light through a clear gel-like substance called the vitreous humor, onto the retina. The retina is a thin layer of tissue that makes up the inner lining of the back of the eye.
- The retina works like film in a camera, transforming light into images. It converts the light rays to impulses that travel along the optic nerve to the brain. The brain integrates the images sent from both eyes and interprets them as a single, three-dimensional image, allowing us to perceive depth and distance.
If any of the parts of the eye become damaged, changes in eyesight can occur.
What eye problems might affect children with juvenile idiopathic arthritis (JIA)?
Uveitis is the most common eye problem that can develop in children with JIA. Uveitis is an inflammation of inner parts of the eye. The uvea consists of the iris (the colored portion of the eye), the ciliary body (which produces fluid inside the eye and controls the movement of the lens) and the choroid (which lines the eyeball from the iris all the way around the eye).
Uveitis might also be known as iritis or iridocyclitis, depending on which part of the eye is affected by inflammation.
If the inflammation is not detected and treated early, scarring and vision problems can occur. Glaucoma, cataracts and permanent visual damage (including blindness) are all complications that could result from severe uveitis.
Uveitis can occur up to one year before, at the same time as, or up to 15 years after JIA is diagnosed. It can also occur even when JIA is in remission (the disease is not active).
The severity of the child's joint disease does not determine how serious the uveitis might be. However, eye problems are more common in children with oligoarthritis (less than five joints with arthritis in the first six months of disease). Eye problems are also more likely if your child has a positive blood test for antinuclear antibodies (ANA). They are most likely to occur in female toddlers.
How will I know if my child with juvenile idiopathic arthritis (JIA) is developing eye problems?
Because eye inflammation usually is not painful and the eyes are usually not red ("pink"), most children with JIA who develop eye problems do not have any symptoms.
Rarely, children might complain of light bothering their eyes or blurred vision. Sometimes your child's eyes might look red or cloudy. However, these symptoms usually develop so slowly that permanent eye damage can occur before any visual difficulties are noticed.
In order to detect eye problems and prevent them from causing damage, your child needs frequent eye exams with a pediatric ophthalmologist. An ophthalmologist is a medical doctor who specializes in diagnosing and treating eye diseases. An ophthalmologist is different than an optometrist, who does not prescribe treatment in many states.
What happens during an ophthalmologist appointment?
The eye exam performed by the ophthalmologist is painless and lasts several minutes. Be sure to tell the ophthalmologist about the medicines your child is taking. (Your rheumatologist can tell you the names of the medicines, the dosages, and why they have been prescribed.)
Prior to the eye exam, the ophthalmologist will put drops in your child's eyes (which might burn a little) to make the pupils bigger (dilate). Dilating your child's eyes helps the doctor clearly view the inside of the eyes.
To detect eye inflammation, the ophthalmologist uses a special microscope called a slit lamp. The machine shines a thin beam of light into one eye at a time so the doctor can view the inside of the eyes.
A visual field exam might also be performed to detect vision changes.
What is the role of the rheumatologist?
Rheumatologist become involved in the care of patients with eye disease when the eye disease is difficult to control. Rheumatologist have experience in the diagnosis of autoimmune and inflammatory diseases. They can further evaluate the patient for systemic conditions that can be associated with eye inflammation. They also have extensive knowledge of the immunosuppressive medications that may be used to treat the disease. They can monitor for potential side effects of the medications being used as well. The role of the rheumatologist is important in the care of patients with eye inflammatory disease so regular follow up is necessary.
How can eye problems with juvenile idiopathic arthritis (JIA) be prevented?
Carefully follow your healthcare provider's medicine guidelines and keep all your scheduled appointments with your rheumatologist and ophthalmologist, even if you don't think your child has eye problems or if the JIA is less active.
How often should my child with JIA have eye examinations?
The frequency of your child's eye exams will depend on the type of JIA he or she has, how long your child has had arthritis and what medicines have been prescribed to treat it.
Because uveitis is more common in children with certain types of JIA, such as oligoarthritis, or in polyarthritis with a positive ANA, more frequent eye examinations (every three to four months) might be recommended. Children with polyarthritis (when ANA is negative) require an examination every six months and patients with systemic JIA usually need an ophthalmologist examination every 12 months. Eye exams should continue after your child's arthritis goes into remission because eye inflammation can occur even when JIA is not active.
Ask your rheumatologist and ophthalmologist how often your child's eye exams should be scheduled and follow their recommendations. If eye problems are detected, more frequent examinations will be necessary.
How are eye problems caused by juvenile idiopathic arthritis (JIA) treated?
If eye problems occur, your rheumatologist and ophthalmologist will discuss ways to treat them to prevent permanent eye damage.
If uveitis is diagnosed, different types of eye drops might be prescribed. Eye drops to dilate the eyes may be prescribed in order to keep the pupils open and help prevent scarring.
Steroid drops might be prescribed to reduce swelling and decrease inflammation. However, long-term use of steroid eye drops can have significant side effects such as glaucoma and cataracts.
If eye drops are not effective in decreasing the inflammation, oral steroids (taken by mouth) might be prescribed. Oral or injectable methotrexate is now often used to treat significant eye inflammation so the long-term side effects of steroids can be avoided. In cases of severe uveitis, new "biologic modifying medicines," such as infliximab or adalimumab, may be used.