Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
JIA History:
Type of JIA (systemic, oligoarticular, polyarticular, enthesitis-related, psoriatic)
Age at diagnosis
Current JIA disease activity (active vs. inactive)
Uveitis Symptoms (present/absent):
Blurred vision
Floaters
Light sensitivity (photophobia)
Eye pain
Redness in the eye(s)
Duration of Uveitis Symptoms
Previous Treatment for Uveitis (medications, complications)
Objective:
Visual Acuity: Measured using Snellen chart or other appropriate method.
Slit Lamp Examination: Evaluation of the anterior chamber for signs of inflammation (cells, flare), iris involvement (synechiae), and keratic precipitates.
Fundus Examination (if possible): Evaluation of the vitreous, retina, and optic nerve for signs of inflammation or other complications.
May require pupil dilation for adequate visualization.
Intraocular Pressure (IOP) measurement (if indicated): Elevated IOP can be a complication of uveitis.
Assessment:
Juvenile idiopathic arthritis (confirmed type)
JIA disease activity
JIA-associated uveitis (anterior, intermediate, posterior, panuveitis) based on clinical findings.
Severity of uveitis (mild, moderate, severe) based on symptoms and examination findings.
Visual acuity impairment (if present)
Plan:
Consultation: Consider urgent consultation with an ophthalmologist specializing in uveitis for definitive diagnosis and treatment plan.
Uveitis Treatment: Ophthalmologist will recommend specific medications based on the severity and type of uveitis. This may include topical corticosteroids, cycloplegic agents, and/or systemic immunosuppressive medications.
JIA Management: Continue or adjust JIA medications as needed to control overall disease activity, potentially impacting uveitis.
Serial Ophthalmic Examinations: Schedule regular follow-up appointments with the ophthalmologist to monitor uveitis activity and response to treatment. This may involve monitoring visual acuity, slit lamp examination, and IOP measurement.
Patient Education: Educate the patient and family about JIA-associated uveitis, symptoms to watch for, and the importance of medication adherence and follow-up appointments.
Referral (if indicated): Consider referral to a pediatric rheumatologist in addition to the ophthalmologist for comprehensive JIA management, especially if:
Complex or severe JIA course
Difficulty controlling JIA disease activity
Follow-up:
Schedule next appointment in [interval] based on the severity of uveitis and treatment plan. This may be more frequent initially and less frequent as uveitis becomes controlled.