¡¡¡¡DISCUSSION

¡¡¡¡Sarcoidosis is a chronic multisystem disease with variable clinical manifestation. In children 5 years and older, the most common clinical findings include lymphadenopathy, pulmonary abnormalities, and uveitis[1]. Neurological involvement from the disease is not uncommon. Therefore, management of childhood sarcoidosis requires input from ophthalmologists, neurologists and paediatricians. Ocular manifestation of childhood sarcoidosis can result in visual impairment from chronic uveitis, band keratopathy, cataracts, persistent macular oedema and secondary glaucoma. Corticosteroids are the mainstay of treatment for chronic anterior uveitis but longª²term treatment in any route of administration is associated with adverse ocular and systemic sideª²effects[2ª²4]. The combined use of a steroid sparing medication can reduce the dependence on high dose steroids to control ocular inflammation. MTX is a folate analogue that inhibits dihydrofolate reductase which is necessary for DNA synthesis. This antiproliferative effect on rapidly dividing immune cells is the basis of its immunosuppressive properties. Low dose MTX is well tolerated in the paediatric age group. Its use in the treatment of chronic uveitis secondary to juvenile idiopathic arthritis (JIA) and sarcoidosis has been well documented[5ª²7]. The sideª²effects of MTX include cytopenia, pneumonitis and hepatotoxicity.

¡¡¡¡Secondary cataracts in such cases are commonly attributable to chronic uveitis or longª²term use of topical corticosteroids. There are several factors to consider in the timing of cataract surgery, which include the risk of amblyopia, quiescence of uveitis and child/parents¬ð decision. The Acrysof¡k MA60AC acrylic foldable intraocular lens implant was chosen because of its stability in the capsular bag, size of its optic diameter and more inert compared to other intraocular lens implant material. The concurrent use of corticosteroids and low dose MTX in this case for cataract surgery had reduced the risk of severe postª²operative uveitis. We found two reported case series with the use of MTX in the treatment of refractory uveitis for ocular sarcoidosis in the paediatric age group (16 years old and below) in English literature using the Medline and EMBASE search. Shetty et al[6] assessed the use of oral MTX in 4 patients with uveitis related to both JIA and sarcoidosis not adequately controlled by corticosteroids. All 4 patients tolerated MTX therapy without any adverse effects. Malik et al[7] reported the use of a low dose of oral MTX in conjunction with topical corticosteroids to control ocular inflammation in 10 children with idiopathic uveitis and presumed sarcoidosis. All children received folic acid 2.5ª²5mg per day upon commencement of MTX therapy. Mild nausea was reported in 2 patients but there was no other adverse events reported to discontinue the use of MTX. None of these previous published case series described that any one of their subjects had undergone uncomplicated cataract surgery. In conclusion, sarcoidosis is a multisystem disease and requires multidisciplinary input from ophthalmologists, neurologists and paediatricians. Medical and surgical treatment of such ocular manifestations is challenging. We recommend the use of an ultraviolet absorbing, biconvex, acrylic intraocular lens with a large haptic (10ª²11mm) and optic diameter (5.75ª²6.0mm) for cataract surgery in children. The Acrysof¡k MA60AC has a complex haptic which can prevent decentration and backward movements of the lens, ensuring very good stability inside capsular bag. Its hydrophobic properties reduce the incidence of both anterior capsular phimosis and posterior capsular opacification[8]. This case report and previous case series also reinforce the safety of low dose MTX in the management of childhood chronic uveitis. Serum electrolytes, full blood count and liver function tests (especially serum alanine or aspartate aminotransferase) should be measured monthly to monitor MTX toxicity. Its concurrent use with corticosteroids can reduce the risk of postª²operative cataract surgery complications such as augmented uveitis and persistent macular oedema. It is effective and well tolerated as a corticosteroid sparing agent and should be considered early in the management of such cases to avert significant morbidity from this disease.

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¡¡¡¡1 Hoover DL, Khan JA, Giangiacomo J. Pediatric ocular sarcoidosis. Surv Ophthalmol 1986; 30(4): 215ª²228

¡¡¡¡2 Solomon SD,Cunningham Jr ET.Use of corticosteroids and nonª²corticosteroid immunosuppressive agents in patients with uveitis. Comprehens Ophthalmol Update 2001;1:273ª²286

¡¡¡¡3 Nussenblatt RB, Whitcup SM, Palestine AG. Uveitis, fundamentals and clinical practice. 2nd ed. St Louis: Mosby; 1996:97ª²129

¡¡¡¡4 Jabs DA, Rosenbaum JT, Foster CS, Holland GN, Jaffe GJ, Louie JS, Nussenblatt RB, Stiehm ER, Tessler H, Van Gelder RN, Whitcup SM, Yocum D. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol 2000;130(4):492ª²513

¡¡¡¡5 Weiss HA, Wallace AC, Sherry DD. Methotrexate for resistant chronic uveitis in children with juvenile rheumatoid arthritis. J Paediatr 1998;133(2):266ª²268

¡¡¡¡6 Shetty AK, Zganjar BE, Ellis GS Jr, Ludwig IH, Gedalia A. Lowª²dose methotrexate in the treatment of severe juvenile rheumatoid arthritis and sarcoid iritis. J Paediatr Ophthalmol Strabismus 1999;36(3):125ª²128

¡¡¡¡7 Malik AR, Pavesio C. The use of low dose methotrexate in children with chronic anterior and intermediate uveitis. Br J Ophthalmol 2005;89(7):806ª²808

¡¡¡¡8 Mian SI, Fahim K, Marcovitch A, Gada H, Musch DC, Sugar A. Nd:YAG capsulotomy rates after use of the AcrySof acrylic three piece and one piece intraocular lenses. Br J Ophthalmol 2005;89(11):1453ª²1457

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