Re: oligoarticular juvenile idiopathic arthritis among Saudi children.

To the Editor: With reference to the interesting study by Moued et al,1 uveitis is a potentially vision-threatening extra-articular manifestation of oligoarticular juvenile idiopathic arthritis (JIA) that manifests in approximately 13% of all patients. Oligoarticular JIA–associated uveitis can lead to serious ocular complications such as synechiae, band keratopathy, cataract, glaucoma, macula edema, and blindness.2 Moued et al1 stated that 2 (5.4%) out of 37 oligoarticular JIA patients presented with uveitis, while only 1 patient subsequently developed uveitis. Apart from the 2 limitations addressed by Moued et al1 namely, small sample size and retrospective nature of the study, I presume that the following 3 points can additionally explain the markedly low prevalence of oligoarticular JIA–associated uveitis: (1) There might be a delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with JIA. Delay in access to pediatric rheumatology assessment is common with complex pathways of referral. Many children were found to be subjected to inappropriate invasive investigations and many had prolonged untreated active disease at the initial assessment. This delay is likely to affect the long-term outcome of the disease.3 (2) Moued et al1 stated that the mean age of the studied patients was 10.9 years. Also, the mean age of the patients at presentation was 6.9 years, while the mean age at diagnosis was 7.2 years. However, they neither addressed the frequency distribution of the studied cohort according to age groups nor mentioned the age of uveitis patients. This is important to be considered because an age-associated risk of uveitis has been observed in children younger than 3 years at the time of JIA onset.4,5 (3) Moued et al1 stated that the erythrocyte sedimentation rate (ESR) was performed in 26 (70.3%) of the 37 patients. The ESR values ranged from 8 to 96 mm/hour (reference range, 0–20 mm/hour). A total of 19 patients (51.4%) had a high ESR at the presentation (mean, 41.8 [25.4] mm/hour); the results were normal in 7 patients (18.9%). However, they did not mention the ESR of uveitis patients. Again, this is important to be considered because ESR values at arthritis onset higher than 22 mm/hour has been noticed to be related to uveitis development. 5 In spite of the low reported prevalence of oligoarticular JIA—associated uveitis in the study by Moued et al,1 close collaboration between ophthalmologist and pediatric rheumatologist is needed. Ophthalmologic examination ought to be done immediately after the diagnosis of oligoarticular JIA and regularly repeated during the follow-up.