A Melbourne study found reassuring visual outcomes despite gaps in surveillance, prompting changes to local screening protocols.
Australian researchers have called for improved adherence to uveitis screening guidelines in children with juvenile idiopathic arthritis after finding that fewer than one-third of patients received recommended eye assessments during their first year after diagnosis.
The retrospective study, conducted at Melbourne’s Royal Children’s Hospital, found that while screening adherence was suboptimal, visual outcomes were generally reassuring, with no children experiencing significant visual impairment in their better-seeing eye.
The findings, published in Clinical Rheumatology, suggest that simplifying screening protocols and ensuring children receive timely baseline assessments may deliver greater benefits than universally increasing screening frequency.
“To our knowledge, this is the first published comprehensive dataset describing JIA-U screening practice and outcomes in Australia,” the researchers wrote.
Researchers led by Dr William Renton examined the records of 107 children newly diagnosed with juvenile idiopathic arthritis (JIA) between September 2021 and December 2023, with an average follow-up of 3.5 years.
Of these, 88 children (82.2%) had at least one documented ophthalmological assessment, including all 32 patients classified as high risk for developing uveitis.
However, adherence to recommended screening intervals varied considerably according to risk, the researchers said.
Among high-risk patients, 65.6% received appropriate screening during the first year after JIA diagnosis, compared with just 19.4% of intermediate-risk patients. None of the six low-risk patients received screening consistent with local guidelines.
The researchers identified uveitis in 15 children (14%), including two diagnosed before their JIA diagnosis, seven within the first year and six more than a year afterwards.
Three children (20%) had ocular complications at the time of uveitis diagnosis, including synechiae and vitreous haze, but none had significant visual impairment attributable to uveitis. Only one patient had high-grade ocular inflammation at diagnosis.
By the final follow-up, 10 of the 15 children with uveitis (66.7%) had developed at least one ocular complication.
These included synechiae and raised intraocular pressure in six patients each, cataracts and band keratopathy in three patients each, and other inflammatory complications.
Two children required surgery, including one cataract extraction with intraocular lens insertion and one trabeculectomy.
Despite these complications, none had significant visual impairment in their better-seeing eye at the final assessment. Two patients had moderate visual impairment in their worse eye due to cataracts.
The researchers said the findings were broadly consistent with contemporary international studies, although some complication rates were higher.
A recent meta-analysis reported a pooled JIA-associated uveitis incidence of 12.7% over three to five years, compared with 14% in the Melbourne cohort. The Australian patients also had higher rates of synechiae (40% versus 23%) and ocular hypertension (40% versus 10%) than those reported in the meta-analysis.
However, the absence of severe visual impairment was encouraging, particularly given previous systematic reviews reporting severe impairment in approximately 16.6% of patients with longer-term follow-up.
The researchers said the results raised important questions about the value of increasing screening frequency for all children with JIA.
“More frequent screening could intuitively lead to earlier uveitis detection and improved outcomes,” they wrote.
“This however must be balanced against the significant burden of screening.”
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They noted that eye examinations could be uncomfortable for children, require time away from school and work for families, and place considerable demands on healthcare resources.
Importantly, the researchers did not identify any patients with ocular complications or abnormal visual acuity for whom more frequent screening during the first year would have improved outcomes.
Instead, they highlighted the importance of early baseline assessments, noting that more than one-third of children with uveitis were diagnosed at their first eye examination.
The findings have already informed changes to the hospital’s local screening protocol.
Under the revised approach, the maximum recommended time to an initial uveitis screening assessment has been reduced from six weeks to four weeks.
The updated protocol also introduces specific follow-up intervals rather than ranges, simplifies risk assessment criteria and recommends shared care between ophthalmologists and community optometrists for low-risk patients without a history of uveitis.
Antinuclear antibody status has been removed from the risk assessment criteria because results may not be available at the time of JIA diagnosis, potentially delaying screening recommendations.
The researchers said they expected the revised protocol to reduce the overall number of eye examinations through less frequent reviews for low-risk patients, while improving the timeliness and consistency of screening.
They also recommended that all patients receive written referrals specifying their JIA diagnosis and an appropriate screening schedule, regardless of their perceived uveitis risk.
The researchers acknowledged several limitations, including the retrospective, single-centre design, relatively small sample, and missing clinical data.
They also cautioned that inadequate screening among some low- and intermediate-risk patients meant cases of uveitis may have gone undetected.
Changes in clinical practice since the study period, including the establishment of a dedicated uveitis clinic and improved access to biologic therapies, may also influence future outcomes, they said.
Nevertheless, the researchers said the findings provided important Australian evidence to inform screening practices and reduce the risk of preventable vision loss.
“Regular review of adherence to recommended uveitis screening schedules should be embedded within routine care for children and young people with JIA,” they concluded.
