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Juvenile Idiopathic Arthritis (JIA)


History of Present Illness

“My rheumatologist asked me to have an eye examination.” A 6-year-old girl with a recent diagnosis of juvenile idiopathic arthritis (JIA) is referred to an ophthalmologist for a routine eye examination. The child has no complaints, and the parents have not noticed any problem with her vision or eyes. She was diagnosed with JIA at 4 years of age, and previous eye examinations every 3 months have been normal. Her joint symptoms have been controlled with oral methotrexate (15 mg/m 2 ) weekly ( Fig. 10.1 ).

Exam
OD OS
Visual acuity 20/20 20/40
Intraocular pressure (IOP) (mm Hg) 12 10
Sclera/conjunctiva Clear, no injection Clear, no injection
Cornea Clear with nongranulomatous (NG) keratic precipitates (KPs) in Arlt triangle Clear with NG KPs in Arlt triangle
Anterior chamber (AC) 1+ flare, 1+ cell 1+ flare, 3+ cell
Iris Round pupil Intermittent posterior synechiae (see Fig. 10.1 )
Lens Clear Clear
Vitreous cavity Clear 2+ vitreous cells
Retina/optic nerve Normal Swollen optic nerve head with normal retina

Fig. 10.1, Posterior synechiae and focal capsular fibrosis resulting from metaplastic changes in iris epithelium, OS.

Questions to Ask

  • Has her vision changed in either eye since seeing her ophthalmologist?

  • What diagnostic tests has she had to confirm her diagnosis of JIA?

  • Has anyone in her family had a viral infection like herpesvirus, measles, or mumps?

  • Does she have a skin rash?

  • Has she been hospitalized for any serious infections, or has she been exposed to anyone with a serious infection like tuberculosis (TB)?

Her vision has not changed before seeing her eye doctor until recently. She had several blood tests to establish a diagnosis of JIA, but the family does not know the exact results. No one in the family has had a recent viral infection, and the patient does not have a skin rash and has not been hospitalized for a serious infection.

Assessment

  • Anterior uveitis both eyes (OU), with optic disc edema and cystoid macular edema (CME) left eye (OS)

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