Managing posterior uveitis in children a must

November 15, 2008
Ron Rajecki

The adequate management of posterior uveitis in children is difficult but imperative. Many treatment options exist, but to determine the best one for patients, it may be best to divide them into two groups at least initially: those with unilateral disease and those with bilateral disease. Treatment decisions then will follow, based on the severity of the disease.

Key Points

Hong Kong-Posterior uveitis can be difficult to manage in children, but managing it adequately is a must, said Susan Lightman, MD, PhD, FRCP, FRCOphth, at the World Ophthalmology Congress.

She suggested dividing patients into two groups: those with unilateral disease, who often can be treated with periocular or intraocular steroids; and those with bilateral disease, who may need oral steroids plus other immunosuppressive agents to aid disease control when necessary.

According to Dr. Lightman, in these instances, the steroid may need to be combined with cyclosporine (Neoral, Novartis Pharmaceuticals), azathioprine (Azasan, Salix Pharmaceuticals; Imuran, GlaxoSmithKline), mycophenolate (CellCept, Roche; Myfortic, Novartis Pharmaceuticals), methotrexate (Trexall, Barr Pharmaceuticals; Rheumatrex, Lederle Laboratories), or one of the anti-tumor necrosis factor drugs such as infliximab (Remicade, Centocor Pharmaceuticals), etanercept (Enbrel, Immunex), or adalimumab (Humira, Abbott Laboratories).

Although some practitioners might consider using agents such as cyclophosphamide (Cytoxan, Bristol-Myers Squibb) or chlorambucil (Leukeran, GlaxoSmithKline), Dr. Lightman advised doing so with caution.

"We have to be very wary using these [agents] for sight-threatening but not life-threatening disorders in children, as these drugs could have potential risks for the child in the future," she said.

In children with vitritis or mild cystoid macular edema (CME), especially in one eye, Dr. Lightman recommended a periocular steroid such as 20 to 40 mg of depomedrone/triamcinolone. The peak effect of this therapy will occur around 6 weeks, the effects can last for more than 3 months, and the therapy can be repeated. The downsides: it often requires general anesthesia to administer, especially in younger children, and it can cause a rise in IOP.

For children with severe vitritis and CME with significant visual loss, Dr. Lightman advised stepping up the therapy to intraocular steroids, which she said work much more quickly than periocular steroids. She recommended 2 to 4 mg of triamcinolone; 2 mg for patients aged fewer than 5 years, 4 mg for patients aged more than 5 years.

The effects of intraocular steroids generally last 3 to 3.5 months but can last longer.

"The lasting effects may be because you're reducing the volume of the edema, and the patient's own eye is keeping the situation under control," she said.

Intraocular steroids do carry a higher risk of IOP rise than periocular steroids, Dr. Lightman said, so be sure to monitor IOP closely and treat when necessary.

Also, be aware that even if intraocular steroids do the job of reducing and controlling edema, they may reach a point where they have done all they can do for a patient.

"Obviously, you aim to reduce the CME with your treatment, but in some cases, the retina has become abnormal from the prolonged edema, and improvement in visual acuity does not occur," she said. "In this situation, the patient is not going to benefit from further treatment."

In bilateral or severe unilateral disease, oral steroids may be necessary to control the inflammation.

"When using oral steroids, there may be social side effects as well as systemic side effects," Dr. Lightman said. "Steroids can cause 'moon face' and hirsutism, and children can be cruel to each other."

She recommended administering one-half the adult dose in children aged fewer than 12 years and using prednisone 2.5 mg/day during periods of growth, supplemented by local steroids (intraocular or periocular) when required.

If the inflammation remains unchecked even with high-dose steroids, it's time to consider the second-line agents, such as methotrexate, cyclosporine, azathioprine, and mycophenolate, she said.

"Mycophenolate is currently our second-line drug of choice, as it is very effective and well tolerated," Dr. Lightman said. "Others may prefer methotrexate or one of the other agents."

She said that steroid ophthalmic implants may be a promising therapy in the future for children aged more than 13 years.

"Current fluocinolone implants can control the disease for more than 2 years without relapses, but experience to date is very limited in children, and a child may require multiple implant exchanges with time-the effect of this is currently unknown," Dr. Lightman concluded. She said she is awaiting the results of the ongoing Multicenter Uveitis Steroid Treatment Trial for more information about the use of the fluocinolone implants in children.