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Methotrexate and chronic uveitis associated with juvenile idiopathic arthritis.

We read with interest the article by Dr. Foeldvari and colleagues1 about the efficacy of methotrexate (MTX) in the management of chronic uveitis in patients with juvenile idiopathic arthritis. It is to our understanding that ophthalmic data were derived from a review of the patients’ charts. The authors have solicited a thorough pool of information, but 2 areas of important information seem to be overlooked. First, the standard treatment for chronic bilateral anterior uveitis usually comprises topical corticosteroids and mydriatics, followed by immunosuppressive agents in severe cases, and surgical intervention in the event of ophthalmic complications2. It is important to note that even with the commencement of systemic immunosuppressive agents, concomitant topical corticosteroids are usually retained, with frequency of topical application adjusted with observation of anterior chamber inflammation2. In the study in question, information on topical corticosteroid regimens during concurrent MTX therapy was largely lacking. The authors reported a good treatment response with MTX and attributed treatment remission solely to MTX, while disregarding the antiinflammatory therapeutic benefit of concomitant topical corticosteroid. This will undoubtedly incur significant bias and confounding influence. Second, MTX is an immunosuppressive agent not without adverse reactions3. For instance, it was found that as many as 20% of the pediatric patients taking regular MTX developed distressing side effects like nausea3. Hence, inquiries into the potential untoward side effects and the associated precautionary measures for early detection of drug toxicity are almost mandatory in patients taking regular methotrexate3. These important pieces of information were, however, not clearly stated in the article.