It can happen when you least expect it. Maybe your child is in an active phase of her disease and all of your energy is focused on helping her manage her joint pain. Or maybe you’re breathing a huge sigh of relief because she has been symptom-free for a year – or even two. Regardless of the stage of your child’s arthritis or its treatment, there’s a chance the disease can be causing undetected damage to her eyes – unless she's having regular eye exams.

“Arthritis in children is often accompanied by some specific types of eye problems which usually don’t cause symptoms,” says Paul Howard, MD, a Phoenix rheumatologist who has been treating children with juvenile arthritis for 18 years. 

Following are the two most common problems he and other rheumatologists encounter and why you should take them seriously.

Chronic Iridocyclitis

Often referred to as uveitis, iridocyclitis is an inflammation of the structures of the front of the eye that can occur in children with juvenile rheumatoid arthritis. “The inflammation can lead to scarring of the pupil and the way the eye focuses,” says Dr. Howard. “If the scarring gets bad enough and the problem is not treated, it can lead to blindness.”

The traditional teaching has been that children – particularly young girls – with pauciarticular (few joints) arthritis are the ones at highest risk of eye disease, he says. But a recent study shows that a positive ANA (a blood test showing high levels of antinuclear antibodies, a type of auto-antibody directed at structures in the nuclei of the body’s cells) may be a more accurate predictor than the pattern of joint involvement in determining who is most likely to have this type of eye problem.

Because chronic iridocyclitis usually produces no symptoms such as pain or irritation, there is no way to know if your child is affected without regular eye exams – and Dr. Howard strongly recommends regular exams. Current guidelines from the American Academy of Pediatrics recommend exams as often as every three to four months for children with a positive ANA test and early age of onset of arthritis, to as infrequently as once a year in individuals with the systemic-onset form of JIA. 

Eye exams should continue even if joint symptoms stop, says Dr. Howard. “Even if the arthritis is quiet, children can get eye disease,” he says. He advises his patients to continue regular eye exams for years after symptoms of arthritis have disappeared.

Acute Iridocyclitis

Another condition, called acute iridocyclitis or iritis, is more commonly seen in children with ankylosing spondylitis. As the name implies, iritis is inflammation of the iris, the colored part of the eye that controls the pupil's response to light. As with chronic iridocyclitis, iritis can lead to scarring that can cause vision loss. Unlike the eye disease that occurs with JIA, however, acute iritis may produce symptoms such as redness and pain, but some children don’t always notice these problems.  For this reason, some physicians recommend that their patients with ankylosing spondylitis should have an eye exam periodically, whether or not they experience symptoms of eye disease.

Eye Problems: A Risk of Treatment

In addition to the problems that arthritis itself can cause, some medications used to treat arthritis can lead to problems themselves. One of the medications requiring special monitoring, in children and adults alike, is the antimalarial drug hydroxychloroquine (Plaquenil). It's part of a category of drugs called dease-modifying anti-rheumatic drugs (DMARDs), that actually slow disease progress.

While hydroxychloroquine doesn't damage the eyes the way inflammation does, it can deposit in the back of the eye and over time lead to color vision problems, says Dr. Howard. Fortunately, there are evidence-based guidelines for monitoring such therapy, and such monitoring can help prevent any noticeable effects on color perception or sharpness of vision.

Corticosteroids, including prednisone, which are prescribed to help control inflammation, can also lead to eye problems – chiefly cataracts. In general, it is rarer to see cataracts develop in children than adults. Nevertheless, any child taking corticosteroids regularly for any reason should have regular eye exams, says Dr. Howard.

Eye Problems and How They are Treated

Exams and treatment for arthritis-associated eye problems in children should be handled by a pediatric ophthalmologist (a medical doctor specializing in the diagnosis and treatment of eye diseases in children) working closely with your child’s rheumatologist.

Typically the first line of treatment is a steroid eyedrop to reduce inflammation. Sometimes doctors also prescribe an agent that dilates the pupils to prevent scarring.

When localized treatments aren’t enough to stop the problem, oral or injected medications may be necessary. The most commonly used systemic medication is methotrexate. In the event that methotrexate isn’t effective, the doctor may prescribe another DMARD such as cyclosporine (Neoral) or mycophenolate mofetil (CellCept) or one of a subcategory of DMARDs known as biologic response modifiers such as infliximab (Remicade).

If your child’s arthritis is active, these same medications may control both the arthritis and the related eye disease. In other cases, these drugs are used even if arthritis itself is quiet, says Dr. Howard.  “A lot of times the ophthalmologist will ask us to reinstitute a drug for a child whose joint symptoms have gone away,” he says. “At other times the ophthalmologist may ask the rheumatologist to increase the dosage of a drug that is already sufficient to control the joint disease.”

To a Better Life and Better Sight

With the many drugs available – for both local and systemic use – arthritis-related eye problems are highly treatable. Moreover, with frequent eye exams, says Dr. Howard, these problems are not only treatable, they are preventable.