Clinical outcomes in paediatric tubulointerstitial nephritis and uveitis syndrome (TINU).

PURPOSE: To evaluate the clinical presentation, course, and outcomes of uveitis in paediatric patients with tubulointerstitial nephritis and uveitis syndrome (TINU). METHODS: Multicentric Retrospective Cohort Study 110 patients ≤21 years of age diagnosed with TINU from 10 sites across the United States and Canada. Clinical diagnosis of TINU required uveitis diagnosed by an ophthalmologist, elevated serum creatinine (SCr) and elevated urine ß2-microglobulin (ß2M) or abnormal urinalysis. Renal biopsy and systemic illness were not mandatory. Univariate and multivariate analysis was performed to analyse risk factors and treatment modalities. RESULTS: Median age was 13 years (Range (5.9-18.4); 52% male); median follow-up, 1.6 years (IQR 0.98-4.02). Uveitis was symptomatic in 90%, with bilateral anterior uveitis in 94%. Ninety-two (84%) patients required immunomodulatory treatment (IMT). Methotrexate (n = 44) and mycophenolate mofetil (n = 39) were the first agents after oral corticosteroids. 45% required addition of biologic agents (Adalimumab [n = 33], Infliximab [n = 8]). Younger age (p = 0.018), male sex (p = 0.011), and higher uveitis grade at presentation (p = 0.031) were associated with greater IMT ( ≥ 2) requirement. 53% had uveitis recurrence compared to 16% with nephritis recurrence. At the most recent visit, nephritis was controlled in 90%, while uveitis in 74%. Four (4%) patients required glaucoma surgery. Nine (8%) patients had renal complications. CONCLUSIONS: Most patients with TINU require steroid-sparing IMT for control of uveitis, with nearly half requiring addition of biologic agents. Urinalysis, urine ß2M and SCr testing should be considered in children presenting with uveitis, especially when the disease is bilateral and anterior.

Earlier use of systemic immunosuppression is associated with fewer ophthalmic surgeries in paediatric non-infectious uveitis.

BACKGROUND/AIMS: There is a paucity of large trials investigating the effect of management strategies for paediatric non-infectious uveitis on complications requiring surgery. The purpose of our study is to investigate whether earlier initiation of systemic immunosuppression in paediatric non-infectious uveitis is associated with fewer ophthalmic surgeries. METHODS: A retrospective review was conducted on 48 children with non-infectious uveitis assessed in 1998-2013. Patients were divided into uveitis diagnosed before December 2008 (group 1) and after January 2009 (group 2). Duration from uveitis onset to methotrexate initiation (U-MTX) and biological addition (U-Biologic) were reviewed. Follow-up visits with topical corticosteroids >3 times daily and active uveitis (≥1+ cells) during 3.5 years were documented. The main outcome measure was the need for ≥1 ophthalmic surgery at 3.5 years. RESULTS: In group 1, 69.5% of patients required ≥1 ophthalmic surgery at 3.5 years versus 26.9% in group 2 (p=0.005). U-MTX was 28.9±11.8 weeks and 14.2±10.0 weeks for groups 1 and 2 (p=0.028). U-Biologic was 134.6±46.0 weeks and 82.3±43.3 weeks for groups 1 and 2 (p=0.0016). Corticosteroid use >3 times daily was 85.9±52.7 weeks and 14.6±11.1 weeks for groups 1 and 2. Multivariate regression showed methotrexate initiation within 6 months of uveitis onset lowered the likelihood of needing ophthalmic surgery at 3.5 years (OR=6.2, 95% CI 1.2 to 33.4; p=0.033). Univariate regression demonstrated biological addition within 18 months of uveitis onset reduced the likelihood of requiring ophthalmic surgery (OR 12.57, 95% CI 1.28 to 123.48; p=0.030). CONCLUSION: Earlier control of uveitis by addition of immunosuppressive therapy reduced the need for ophthalmic surgery.

Clinical features of infectious posterior segment uveitis.

OBJECTIVE: To assess the clinical findings and microbiology investigations in patients with suspected infectious posterior segment uveitis (PSU). DESIGN: Retrospective case study. METHODS: Between January and December 2014, medical records of 270 patients with PSU were reviewed. Baseline ocular examination, presumed and final diagnoses, microbiology investigations from aqueous or vitreous fluid, and peripheral blood were reviewed. RESULTS: Infectious PSU was suspected in 28 patients among 270 PSU cases (10.4%, 28/270), and 11 cases were of infectious origin (4.1%, 11/270). Six patients were immunocompromised: 5 patients in the confirmed infectious PSU group (45.5%, 5/11) and 1 in the confirmed noninfectious group (5.9%, 1/17; p = 0.002). Initial visual acuity was 1.8 ± 0.35 logMAR and 0.9 ± 0.23 logMAR for patients with confirmed infectious and noninfectious PSU, respectively (p = 0.04). Anterior chamber reaction was worse in patients with confirmed infectious PSU (1.8 ± 0.49) than confirmed noninfectious cases (0.5 ± 0.1; p = 0.003). The frequency of chorioretinitis among patients with confirmed infectious and noninfectious PSU is 54.5% (6/11) and 11.8% (2/17; p = 0.03), respectively. Onset of confirmed infectious uveitis was more acute (≤6 weeks in duration) than noninfectious cases (p = 0.0015). Among the 11 patients with positive blood culture or serology, 6 had anterior and vitreous chamber fluid analysis. The rate of positive cultures and PCR is 16.7% (1/6) for aqueous humour and 50% (3/6) for vitreous samples. CONCLUSIONS: Clinical features more suggestive of infectious PSU include immunosuppression, worse initial visual acuity, acute onset, worse anterior chamber reaction, and chorioretinitis. Further studies are needed to enhance the diagnostic yields of aqueous and vitreous fluid analyses.