Special article
The Importance of an Ophthalmologic Examination in Patients With Juvenile Idiopathic Arthritis
Importancia de la evaluación oftalmológica en pacientes con artritis idiopática juvenil
Alejandro Rodríguez-García
Servicio de Inmunología Ocular y Uveítis, Instituto de Otalmología y Ciencias Visuales, Escuela de Medicina y Ciencias de la Salud, TEC Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
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(B) Same eye under slit lamp examination showing Tyndall phenomenon (protein exudation) and inflammatory cells (arrow) floating in the aqueous humor of the anterior chamber.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction and Epidemiology</span><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile idiopathic arthritis (JIA) is a chronic, debilitating inflammatory disease, which primarily affects the joints, and in varying degrees presents extra-articular involvement, affecting mainly children.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Reports on the incidence and prevalence of JIA are difficult to compare between populations due to the heterogeneity of the disease, the different classification criteria employed, the nature of the ethnic groups studied and the diagnostic certainty in each case.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> Consequently, the results shown in various studies vary significantly, with an incidence ranging from 0.8 to 22.6/100 000 persons <16 years per year and a prevalence ranging from 7 to 400/100 000 children and adolescents.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Mexico, there are no current figures for the prevalence of JIA; however, it is inferred that it could be at least 2 cases per 100 000 population and with an estimated annual incidence of 0.7–0.8 new cases per 100 000 population.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">JIA is a heterogeneous group of chronic arthropathies with an onset before age 16 and that must have a duration of at least 6 weeks. According to the classification of the International League of Associations for Rheumatology (ILAR), there are 7 subtypes of the disease (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> These subtypes differ in clinical manifestations, autoimmune features, genetic and prognostic determinants.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> These clinical variants, along with some demographic characteristics, have been considered as risk factors for the development of uveitis,<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4–6</span></a> the most frequent extraarticular manifestation of JIA 7. In patients with oligoarticular forms, and particularly in the presence of antinuclear antibodies (ANA), the occurrence of uveitis is approximately 20%, decreasing to 10.5% in patients with polyarticular disease with negative rheumatoid factor, being almost nonexistent in patients with systemic variants and with a positive rheumatoid factor.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">8,9</span></a> In Mexico, prevalence of uveitis associated with JIA has been reported as 16.3%, being more frequent in girls (87.5%) at an early age (5.7 years) with oligoarticular forms (75.0%) and with the presence of ANA in 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a> These findings are consistent with the risk factors most associated with the occurrence of uveitis in JIA reported in the literature, namely: female gender, younger age of onset of arthritis, oligoarticular forms and the presence of ANA.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4,9</span></a> Finally, a meta-analysis of JIA studies published between 1980 and 2004 concluded that early age at onset, positive ANA and oligoarticular and polyarticular forms are the highest risk factors for developing uveitis, while ANA-negative patients with disease onset at 4 years of age are at a moderate risk category, regardless of the presentation of JIA.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Although the highest prevalence of JIA has been reported in Scandinavian countries, followed by countries in northern Europe and North America it is unknown whether uveitis associated with JIA dominates in a particular ethnic group.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> Moreover, to understand the role of genetic traits in the occurrence of uveitis associated with JIA, a large number of pairs of siblings with the disease has been analyzed<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">12</span></a> without sufficient evidence for a specific genetic component linked to the pathogenesis of uveitis associated with JIA.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">13,14</span></a> However, the findings do not rule out a modest association with a specific genetic marker (relative risk genotype) because its frequency is relatively high.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the association with alleles of major histocompatibility complex antigens (HLA), HLA profiles have been studied in patients with oligoarticular JIA associated to early uveitis. Some series found a significant increase in the frequency of HLA-DRB1*1104 (a fragment of HLA-DR5) in patients with chronic uveitis, compared with those without intraocular inflammation.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">16,17</span></a> However, other studies have failed to demonstrate this fact.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a> Moreover, in all series examined, the frequency of HLA-DRB1*01<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a> was reduced.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intraocular Inflammation Associated With Juvenile Idiopathic Arthritis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Uveitis is one of the leading causes of preventable blindness in the world. In the pediatric population, the annual incidence of uveitis has been estimated between 4.3 and 6.9/100 000.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">19–21</span></a> When analyzed in the context of the various causes of childhood uveitis, uveitis associated with JIA represents up to 47% of cases in the United States and Europe,<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">19,22</span></a> and from 1% to 11% of anterior uveitis in highly specialized centers worldwide.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">23,24</span></a> It has been reported that up to 10% of cases, anterior uveitis is the first manifestation of JIA.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a> An important point to consider is that anterior uveitis is often detected during the first ophthalmology visit, early in the clinical course of JIA.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">25</span></a> In a multicenter study conducted in 2007, in which 3271 patients with JIA from 35 centers were analyzed, it was found that 406 patients (12%) had uveitis, of which 115 (28%) patients with a documented clinical course of uveitis were analyzed. The vast majority (79%) had an oligoarticular form of arthritis, started early and were predominantly women with positive ANA. This study revealed that up to 73% of patients with JIA had uveitis before or within the first 12 months of the onset of arthritis, and 77% and 90% occurred within the first 2 and 4 years after its onset,<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a> respectively. Moreover, at the time of presenting JIA, complications had been reported in 67% of uveitis affected eyes.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">27</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The intraocular inflammatory process in patients with JIA is characterized by an insidious anterior uveitis, as well as a chronic silent clinical course which leads to a significant visual loss due to many serious complications, including formation of calcium band keratopathy, posterior and anterior iris synechia, cataract, secondary glaucoma, vitreitis, maculopathy and chronic optic neuropathy and ocular cyclitic hypotony by forming a membrane and complete loss of function with bulbar phthisis.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">28–30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Initially, the patient with intraocular inflammation associated with JIA shows no classic signs or symptoms associated with uveitis, specifically: red eye, eye pain, photophobia and blurred vision 9. This stage is critical in developing eye disease, because the lack of events can last from several months to years, and it is not until the first complications of uveitis appear that patients, their families or the attending physician detect its presence.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">31,32</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is during this stage of the disease that regular ophthalmologist visits are key for the early detection of intraocular inflammation, which can only be noted through careful observation under slit lamp examination which shows inflammatory cells floating in the aqueous humor of the anterior chamber<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">10,31</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The first complications, such as calcium band keratopathy, the appearance of the posterior iris synechiae and the onset of cataract formation, can then produce photophobia and visual loss<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27–29,33</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the only report of Mexican patients with uveitis associated with JIA, eye exams in the first visit found 55.2% of affected eyes with complications, the most common being formation of posterior synechiae of the iris (56.2%), followed by calcium band keratopathy (50.0%) and cataract formation (31.2%).<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a> Then, if uveitis was still undetected, or if medical treatment was inadequate, more serious complications appeared, in addition to the progression of cataracts, such as vitreitis, cystoid macular edema, glaucoma secondary to pupillary blockage or angular closure through the formation of posterior and anterior iris synechia, respectively, and ischemic or inflammatory optic neuropathy, among others<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">5,33</span></a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In a study of 89 children with JIA-associated uveitis, maculopathy (edema and scarring) was found in 26% of affected eyes, as well as epiretinal or neovascular membranes in 10% of eyes, ocular hypotony in 10%, papilledema and optic neuritis in 3%, and retinal detachment in 3% of the eyes.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a> The results of another study that analyzed the ocular complications that seriously threaten the vision of patients with uveitis associated with JIA are equally disappointing, showing high rates of cataract formation (70%), macular edema demonstrated by angiography (32%), vitreous opacity (25%), glaucomatous optic neuropathy (21%) and ocular hypotonia (17%)<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">These figures are compelling clinical evidence that the occurrence of ocular complications is not uncommon in JIA, especially considering that uveitis is often overlooked by the rheumatologist, pediatrician and even the patient, and only becomes apparent until substantial and permanent visual loss occurs.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a> In this regard, it is important to re-emphasize that the vast majority of these uncommunicative children do not present with ocular signs and symptoms that demonstrate the presence of intraocular inflammation. This causes parents and other relatives to not notice the presence of ocular pathology, contrary to what happens with articular and systemic manifestations.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9,35</span></a> This fact makes it imperative to identify the risk factors for onset of uveitis in children with JIA, as well as implement the best strategy for their early detection.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Visual Impact of Uveitis Associated With Juvenile Idiopathic Arthritis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The visual impact of uveitis associated with JIA has been studied and reported by many authors. However, awareness of its importance among multidisciplinary groups involved in the care of these patients has not been sufficiently effective to this day. Substantial visual loss, 47% of legal blindness patients (20/200 or worse) in at least one eye, has been reported during the first visit of patients with uveitis associated with JIA.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27,36</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The severity of ocular disease during the initial eye examination has been considered as a risk factor for a poor long-term visual prognosis in these patients.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">34,36</span></a> Other predictors of poor visual prognosis in these cases include: the onset of uveitis before or at the time of diagnosis of JIA; a short period between the onset of arthritis and uveitis, and male gender.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">34,37–39</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ophthalmologic Monitoring in Patients With Juvenile Idiopathic Arthritis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Monitoring guidelines for the early detection of uveitis in JIA vary across countries and are based on the perception of risk for intraocular inflammation.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">6</span></a> As previously mentioned, the risk factors for developing uveitis in JIA patients that have been considered in most publications include: the pattern of initial presentation of arthritis; gender, status of the ANA and age at onset of arthritis.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4,7,34</span></a> However, most of the guidelines established so far do not address the risk of visual loss in these patients, and reducing blindness must be the primary purpose of monitoring programs and follow-up of<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a> patients with JIA.</p><p id="par0080" class="elsevierStylePara elsevierViewall">With respect to optimal intervals between ophthalmologic evaluations to prevent visual loss, the latest recommendations for monitoring the occurrence of uveitis in JIA patients were published in 2006 by the American Academy of Pediatrics in conjunction with a panel of experts composed of rheumatologists and ophthalmologists.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> A year later the German Uveitis in Children Study Group suggested a number of changes to these guidelines<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The guidelines allow for earlier detection of uveitis in JIA patients, thereby significantly reducing the large proportion of serious ocular complications reported until today during the first visit to specialized clinics. The frequency of ocular complications in children with JIA-associated uveitis has been estimated between 34% and 67% of cases,<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27,36</span></a> reaching an average prevalence of up to 86.3% after 3 years of their initial presentation. The fact that, at the time of her first visit eye, almost half of JIA patients at high risk of developing uveitis present legal blindness in one eye developed from ocular complications secondary to intraocular inflammation is worrysome.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a> In addition, the occurrence of ocular complications and sequelae arising from a prolonged clinical course of the disease during long-term monitoring of these patients does not always receive the necessary consideration by the group of specialists caring for patients with this disease, as evidenced by various publications.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">37,38,40</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Obviously, this becomes very relevant when we consider that these consequences can be avoided if these children and adolescents are monitored and receive appropriate and timely treatment by qualified ophthalmologists.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Recommendations for Ophthalmologic Monitoring and Follow-up of Patients With Juvenile Idiopathic Arthritis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The purpose of this report is to reiterate the commitment that healthcare professional and multidisciplinary teams caring for patients with JIA have to provide for adequate care for these patients. To consolidate this strategy, certain recommendations have been made and have to be effectively applied by the medical team involved in the care of children with JIA. These recommendations are listed below:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Refer immediately (within one month) the patient newly diagnosed with JIA by the rheumatologist to ophthalmologic evaluation for early detection of uveitis.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">7,11,26,41</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0100" class="elsevierStylePara elsevierViewall">After the initial review, regular ophthalmologic visits should be kept, based on the classification and category of risk of the disease (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0105" class="elsevierStylePara elsevierViewall">It is recommended to change the clinical follow-up strategy every 6–12 months in patients with positive ANA and onset of JIA >6 years of age who have not presented uveitis within the first 2 years after diagnosis of JIA.<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">26,27,42</span></a><span class="elsevierStyleItalic">Note</span>: the risk of developing further complications between the 4–6 years after the onset of JIA is minimal, which justifies the change in the monitoring strategy of these patients.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0110" class="elsevierStylePara elsevierViewall">If the patient is older than 6 years old and the rheumatologist has a strong suspicion of JIA or the patient has positive ANA, the specialist must proactively refer the patient to an ophthalmologic examination in search of uveitis.<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">26,27,43</span></a><span class="elsevierStyleItalic">Note</span>: Because the greatest risk for developing uveitis is in patients younger than 2 years old and ANA positive, it is beneficial to schedule an eye examination as soon as possible for these patients. This could be before or on the day of rheumatology evaluation.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0115" class="elsevierStylePara elsevierViewall">It is advisable that all ophthalmic evaluations are conducted under a slit lamp by experienced ophthalmologist pediatricians or preferably, specialists in ocular immunology and uveitis.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">6,7,26</span></a></p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">However, by themselves, these strategies will not eliminate all of the ocular complications. This is because that although some patients are sent to the ophthalmologist from the onset of the joint disease and early detection of uveitis is carried out, other factors such as improper handling of immunosuppression, adverse economic conditions, poor patient therapeutic compliance and the aggressive nature of intraocular inflammation, results in irreversible visual sequelae in a high percentage of cases. Only a dual strategy based on improving early and periodic screening of patients and the development of more effective treatments for the disease can truly prevent eye complications in these patients.</p><p id="par0125" class="elsevierStylePara elsevierViewall">To complete this dual strategy we still have the difficult task of improving the therapeutic regimens, adherence to treatment and education for patients with JIA and their families in order to reach a comprehensive management of eye and joint disease.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of people and animals</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare this research did not perform experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Data confidentiality</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace regarding the publication of data from patients, and all patients included in the study have received sufficient information and gave written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of patients and/or subjects referred to in the article. This document is in the possession of the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres493500" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec515323" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres493501" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec515322" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction and Epidemiology" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Intraocular Inflammation Associated With Juvenile Idiopathic Arthritis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Visual Impact of Uveitis Associated With Juvenile Idiopathic Arthritis" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ophthalmologic Monitoring in Patients With Juvenile Idiopathic Arthritis" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Recommendations for Ophthalmologic Monitoring and Follow-up of Patients With Juvenile Idiopathic Arthritis" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-27" "fechaAceptado" => "2014-08-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec515323" "palabras" => array:5 [ 0 => "Juvenile idiopathic arthritis" 1 => "Uveitis" 2 => "Cataract" 3 => "Glaucoma" 4 => "Blindness" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec515322" "palabras" => array:5 [ 0 => "Artritis idiopática juvenil" 1 => "Uveítis" 2 => "Catarata" 3 => "Glaucoma" 4 => "Ceguera" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Uveitis occurs within the first year of arthritis onset in 73% of patients with juvenile idiopathic arthritis (JIA) considered at risk. The intraocular inflammation is characterized by an insidious onset and a silent and chronic clinical course capable of producing significant visual loss due to complications such as: cataract formation, secondary glaucoma, maculopathy and optic neuropathy. The absence of initial signs and symptoms, along with a deficient ophthalmic monitoring produces a delay in diagnosis with serious consequences. It has been estimated that 47% of JIA patients at risk for developing uveitis are legally blind (20/200 or worse) at least in one eye at the time of their first visit to the ophthalmologist. To reduce ocular complications and improve their visual outcome, it is necessary that rheumatologists refer all patients recently diagnosed (within the first month) with JIA for an ophthalmic evaluation, and maintain periodical follow-up visits based on classification and risk category of the disease.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La uveítis ocurre dentro del primer año del inicio de la artritis en hasta el 73% de los pacientes con artritis idiopática juvenil (AIJ) considerados en riesgo. La inflamación intraocular se caracteriza por un inicio insidioso y un curso clínico silencioso y crónico, capaz de producir pérdida visual significativa debido a complicaciones como: formación de cataratas, glaucoma, maculopatía y neuropatía óptica. La ausencia de signos y síntomas oculares iniciales, aunado a una deficiente monitarización oftalmológica, producen un retraso diagnóstico de graves consecuencias. Se ha reportado ceguera legal (20/200 o peor) en al menos un ojo en hasta el 47% de aquellos pacientes en riesgo para desarrollar uveítis durante la primera visita oftalmológica. Para reducir las complicaciones oculares y mejorar el pronóstico visual, es necesario referir inmediatamente a pacientes recién diagnosticados con AIJ por el reumatólogo a evaluación oftalmológica y mantener visitas periódicas de seguimiento basadas en la clasificación y la categoría de riesgo de la enfermedad.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Rodríguez-García A. Importancia de la evaluación oftalmológica en pacientes con artritis idiopática juvenil. Reumatol Clin. 2015;11:133–138.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 539 "Ancho" => 1299 "Tamanyo" => 77113 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Eye with chronic anterior uveitis associated with JIA without showing evidence of inflammation upon superficial examination. (B) Same eye under slit lamp examination showing Tyndall phenomenon (protein exudation) and inflammatory cells (arrow) floating in the aqueous humor of the anterior chamber.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 846 "Ancho" => 995 "Tamanyo" => 74736 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Extensive posterior iris synechiae and cataract formation secondary to persistent intraocular inflammation and topical steroid use.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 770 "Ancho" => 995 "Tamanyo" => 136813 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Fluorangiography of the retina (late phase) of the left eye of a patient with chronic cystoid macular edema (arrow) due to chronic uveitis secondary to JIA.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from Petty et al.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a>" "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">JIA, juvenile idiopathic arthritis; RF, rheumatoid factor.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">JIA</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Systemic onset JIA</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Oligoarticular JIA</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extended \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Polyarticular JIA RF (−)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Polyarticular JIA RF (+)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Psoriatic arthritis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Enthesitis related arthritis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Undifferentiated</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Does not fall into any category \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enters into more than one category \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab784593.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Classification of JIA According to the International League of Associations for Rheumatology (ILAR).</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ND, not determined.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ocular complication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kotaniemi et al.,<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">25</span></a>% (No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>104) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Woreta et al.,<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">27</span></a>% (No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>75) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kump et al.,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a>% (No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>89) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heiligenhaus et al.,<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a>% (No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">López-Rubio et al.,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a>% (No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Band keratopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Posterior synechiae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Glaucoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cataract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Maculopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Optic neuropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Others<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab784594.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Hypotonia, rubeosis iridis, retinal detachment, vitreous opacity, hemovitreous, others.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ocular Complications Most Frequently Reported in Patients With Uveitis Associated With JIA.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from Heiligenhaus et al.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a>" "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PsA, psoriatic arthritis; RF (−), seronegative; RF (+), HIV positive; NA, not applicable; OA, oligoarticular; PA, polyarticular.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">JIA subgroup \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ANA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Home AIJ age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">JIA duration (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommended screening intervals (months) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF −, PsA, other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">OA; PA RF (−); PsA; other arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enthesitis related arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PA RF(+); systemic arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients with uveitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">According to the course of uveitis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 15 | 29 |
| 2024 October | 81 | 31 | 112 |
| 2024 September | 68 | 23 | 91 |
| 2024 August | 72 | 35 | 107 |
| 2024 July | 91 | 38 | 129 |
| 2024 June | 121 | 46 | 167 |
| 2024 May | 113 | 45 | 158 |
| 2024 April | 68 | 18 | 86 |
| 2024 March | 72 | 37 | 109 |
| 2024 February | 60 | 30 | 90 |
| 2024 January | 75 | 28 | 103 |
| 2023 December | 64 | 24 | 88 |
| 2023 November | 72 | 50 | 122 |
| 2023 October | 83 | 35 | 118 |
| 2023 September | 156 | 38 | 194 |
| 2023 August | 84 | 24 | 108 |
| 2023 July | 81 | 36 | 117 |
| 2023 June | 64 | 28 | 92 |
| 2023 May | 90 | 36 | 126 |
| 2023 April | 45 | 21 | 66 |
| 2023 March | 103 | 36 | 139 |
| 2023 February | 92 | 35 | 127 |
| 2023 January | 90 | 33 | 123 |
| 2022 December | 92 | 47 | 139 |
| 2022 November | 78 | 36 | 114 |
| 2022 October | 100 | 50 | 150 |
| 2022 September | 126 | 59 | 185 |
| 2022 August | 67 | 33 | 100 |
| 2022 July | 74 | 55 | 129 |
| 2022 June | 57 | 38 | 95 |
| 2022 May | 79 | 44 | 123 |
| 2022 April | 95 | 58 | 153 |
| 2022 March | 111 | 57 | 168 |
| 2022 February | 107 | 41 | 148 |
| 2022 January | 81 | 43 | 124 |
| 2021 December | 67 | 42 | 109 |
| 2021 November | 57 | 38 | 95 |
| 2021 October | 105 | 73 | 178 |
| 2021 September | 78 | 43 | 121 |
| 2021 August | 82 | 72 | 154 |
| 2021 July | 49 | 34 | 83 |
| 2021 June | 107 | 42 | 149 |
| 2021 May | 76 | 53 | 129 |
| 2021 April | 169 | 78 | 247 |
| 2021 March | 163 | 31 | 194 |
| 2021 February | 73 | 26 | 99 |
| 2021 January | 74 | 20 | 94 |
| 2020 December | 54 | 25 | 79 |
| 2020 November | 52 | 22 | 74 |
| 2020 October | 36 | 24 | 60 |
| 2020 September | 52 | 43 | 95 |
| 2020 August | 59 | 23 | 82 |
| 2020 July | 53 | 25 | 78 |
| 2020 June | 54 | 27 | 81 |
| 2020 May | 53 | 25 | 78 |
| 2020 April | 53 | 24 | 77 |
| 2020 March | 18 | 11 | 29 |
| 2020 February | 2 | 0 | 2 |
| 2018 May | 10 | 1 | 11 |
| 2018 April | 79 | 8 | 87 |
| 2018 March | 80 | 9 | 89 |
| 2018 February | 57 | 5 | 62 |
| 2018 January | 49 | 6 | 55 |
| 2017 December | 63 | 10 | 73 |
| 2017 November | 62 | 12 | 74 |
| 2017 October | 49 | 10 | 59 |
| 2017 September | 81 | 8 | 89 |
| 2017 August | 62 | 4 | 66 |
| 2017 July | 66 | 8 | 74 |
| 2017 June | 90 | 11 | 101 |
| 2017 May | 106 | 17 | 123 |
| 2017 April | 84 | 15 | 99 |
| 2017 March | 72 | 12 | 84 |
| 2017 February | 55 | 9 | 64 |
| 2017 January | 51 | 4 | 55 |
| 2016 December | 86 | 16 | 102 |
| 2016 November | 110 | 9 | 119 |
| 2016 October | 92 | 10 | 102 |
| 2016 September | 110 | 4 | 114 |
| 2016 August | 83 | 8 | 91 |
| 2016 July | 42 | 4 | 46 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 23 | 24 |
| 2015 October | 1 | 20 | 21 |
| 2015 September | 4 | 0 | 4 |
| 2015 August | 1 | 21 | 22 |
| 2015 July | 32 | 6 | 38 |
| 2015 June | 64 | 20 | 84 |
| 2015 May | 82 | 45 | 127 |
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