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Rôle pronostique de la capillarite occulte dans la panuvéite pédiatrique idiopathique

Pediatric uveitis is characterized by high relapse and complication rate. The aim of this study is to evaluate occult capillaritis as a risk factor of relapse in pediatric idiopathic panuveitis. 

In this retrospective study, we reviewed the files of patients (<16 years) diagnosed with idiopathic panuveitis with a minimum follow up of 1 year and for whom a fluorescein angiography (FA) was performed using ultra-wide-field imaging both at diagnosis (defined as T1 timepoint) and at clinical remission (defined as T2 timepoint). Occult retinal capillaritis is defined as capillary leakage detected with FA at T2. Patients were divided into 3 groups according to capillaritis at T2: absent (No-CAP group), limited to the periphery (PER-CAP group), and peripheral and posterior (POST-CAP group). The 3 groups were compared regarding clinical characteristics of the first episode of uveitis (cumulative steroid dosage, duration of the episode, visual acuity at presentation, slit-lamp findings and rate of complications) and relapse risk.  The influence of various clinical characteristics (including occult capillaritis) on the risk of early relapse (defined as relapse within the first year from remission) and on time to relapse was also assessed.

We analyzed 115 eyes of 69 patients (52.2% males) with a mean age of 10.1 &plusmn; 2.88 years and a mean follow up of 229.0 &plusmn; 94.5 weeks. Forty-seven eyes (40.9%) formed NO CAP group, 40 eyes (34.8%) formed PER-CAP group and 28 eyes (24.3%)formed POST-CAP group. Time to first relapse and duration of first relapse were significantly higher in POST-CAP group (p<0.001). PER-CAP and POST-CAP group had higher steroid dose at the time of relapse compared to NO-CAP group (p<0.001). The presence and the number of regions showing capillaritis at T2 were independent risk factors for early relapse (respectively p<0.001, OR=6.43 (CI 2.34-12.28) and p=0.043, OR = 1.58 (CI 1.08-2.61)) and predictors of time to relapse using Cox regression analysis (p<0.001 and p=0.022 respectively). By contrast, the number of regions showing capillaritis at T1 was not correlated. Patients in POST-CAP and PER-CAP group were characterized by a significantly longer duration of the first episode, lower visual acuity, and higher anterior chamber cell and hyalitis grading. Both PER-CAP group and POST-CAP group showed a significantly higher incidence of secondary epiretinal membrane (ERM)(p=0.003). POST-CAP group was characterized by a higher incidence of schisis (p=0.010), synechiae (p=0.011) and cystoid macular edema (CME)(p=0.003).

In our hypothesis, severe and prolonged first episodes of panuveitis, as well as the presence of extensive occult capillaritis, might result in incomplete reparation of the blood retinal barrier at the moment of clinical remission. This leads to persistent exposure of retinal antigens to immunitary cells in the blood stream and increases the odds of subsequent inflammatory episodes.

Occult capillaritis and its extension, particularly in a postequatorial location, are biomarkers for early relapse and vitreoretinal complications in pediatric idiopathic panuveitis.