Reconsidering treatment options in childhood uveitis

The expert panel producing guidelines in 2000 for the immunosuppressive therapy of ocular inflammatory disease specifically listed eight steroid-sparing agents.1 At the 2004 International Uveitis Study Group meeting in Venice, 10 different drugs were reported to be in use in patients with paediatric uveitis. Nearly 2 years on, there have been reports published of experience in paediatric uveitis using infliximab, etanarcept and methotrexate. In the British Journal of Ophthalmology, Doycheva et al2 describe the safety and outcomes with mycophenolate mofetil (see page 180).

Placebo-controlled trials or comparison between treatments are rare in the discipline of ocular inflammatory disease, and, when they do take place, rarely confirm the initial enthusiasm surrounding early reports of success.3 There are widespread concerns about the scarcity of drug trials specific for children. Trials are especially problematic in paediatric ocular inflammatory diseases as they are rare, the course of disease often runs into decades and many patients are concurrently treated for extraocular inflammatory disease. To understand how one can rationally choose between the wide range of treatments available, it is helpful to know how this large menu of drugs arose and on what basis drug effectiveness might be evaluated in paediatric uveitis.

Treatment has largely derived, second-hand, from the immunosuppressants developed for life-threatening conditions such as lymphoid malignancies, solid organ transplants and severe autoinflammatory diseases such as systemic vasculitis. The central role of T cells in transplant rejection, both in animal models of uveitis and in occasional pathological specimens of human uveitis, has resulted in medical ophthalmologists …