The authors used an aggressive stepladder, steroid-sparing, therapeutic algorithm in the care of patients with iridocyclitis associated with juvenile rheumatoid arthritis (JRA) to preserve vision, limit cataract formation, and improve probability of successful visual rehabilitation when cataract surgery became necessary.
The authors treated 60 patients with JRA-associated iridocyclitis with topical and regional corticosteroids, systemic nonsteroidal anti-inflammatory drugs, systemic steroids, and systemic immunosuppressive chemotherapy to achieve total quiescence of intraocular inflammation. Cataract surgery (phacoemulsification extracapsular cataract extraction) combined with pars plana vitrectomy was performed on those eyes with cataract sufficient to limit visual acuity to 20/200 or less, after maintenance of complete freedom from inflammation for at least 3 months. The incidence of cataract development and the visual outcome of cataract surgery were analyzed in those patients for whom a minimum follow-up of 1 year was available.
Eventually, 10 of the 60 patients required systemic immunosuppressive chemotherapy in the stepladder therapeutic approach to achieve complete abolition of all active inflammation. Of 72 phakic eyes without cataract, significant cataract developed in 13 (18%) while under our care. The average postoperative stable visual acuity in this group was 20/40. Sixteen eyes of 12 additional patients had visually significant cataract at the time of our first evaluation of them. The average postoperative stable visual acuity in this group of patients after cataract surgery was 20/40.
Iridocyclitis associated with JRA is an insidiously blinding disease, with 12% of individuals affected by this problem eventually blinded by the inflammatory consequences to the eye. A therapeutic philosophy of complete intolerance for active inflammation and limited tolerance for chronic steroid use may offer the most realistic hope for the next step in progress to prevent blindness in this patient population. The results of this study suggest that such a therapeutic attitude results in diminished cataract prevalence and decreased prevalence of vision-limiting retinal pathology, with resultant improved visual outcome of the cataract surgery which is eventually needed in a small proportion of the patients.