 Good morning. I think we will get started. Thank you very much for coming to our pediatric UVIS Grand Rounds It's not just kids stuff or the good the bad and the ugly and or the potentially really horrible presented by Dr. Bird Renee Choi James Bell and James Zimmerman if we have time So just to kind of lay the groundwork a little bit I think pediatric UVIS is not just UVIS for kids It is a topic that deserves special attention because the unique diagnostic management and therapeutic dilemmas Inherit in this population the history and review of systems And a complete accurate examination can be very difficult to obtain and frequently will require examination under anesthesia The differential diagnosis varies with age with an over-representation of infectious Ideologies the presence of pediatric specific masquerade syndromes such as juveniles anthrogranuloma acute myelodysm leukemia or retinoblastoma and Unique endogenous syndrome syndromes like Kawasaki's disease Or juvenile idiopathic arthritis and then atypical presentations of diseases that are otherwise familiar in adults such as sore Codosis in children which is different and this actually affects the laboratories that might one might order in working these kids up the Management issues include the fact that these diseases are insidious and onset chronic and recurrent with the frequent development of complications The presence of complications at presentation is a risk for further complications And I think is a graphic testimony to the diagnostic delay and screening failure In many of these kids and then of course there's the unique risk of amblyopia and kids I I UV is in children is about fourfold less frequent than it is in adults But represents almost 13 percent of UV it is in a tertiary population with about 20,000 kids being affected with JIA alone Complications reducing visual outcome include cataract macular DMA hypotony glaucoma vitreous opacity macular scar These complications are more common in patients with infectious Ideologies and patients with more severe disease just as those with posterior pan uveitis and visual impairment and Severe visual loss is not uncommon You think you we can think about the differential diagnosis as we do in a very simplistic but actually effective manner such as infectious diseases the most common being in anterior uveitis being the herpes group of Viruses posterior uveitis toxoplasmosis again is as an adult's the most common infectious ideology But toxocoriasis is another player that you see in kids for non infectious diseases the most common systemic association of anterior uveitis in children is that associated with juvenile idiopathic arthritis followed by Ti and you tubular Institutional nephritis and uveitis syndrome and then less common disease such as Kawasaki's Intermediate uveitis can represent up to 15 to 20 percent of kids with uveitis in a pediatric population, and of course as I mentioned the masquerade syndrome such as retinoblastoma or leukemia One may also think about the differential diagnosis in terms of the age of presentation for example an infant might be more Likely to present with a congenital infectious syndrome such as rubella as you see here Whereas a child be maybe two to ten would be more I have to present with them an acquired infection such as Toxocoriasis or an endogenous syndrome such as juvenile idiopathic arthritis and uveitis associated disease Adolescents might present with toxoplasmosis or even with a multifocal corditis or other infectious entities such as Dueson or or other multifocal corditis therapeutic dilemmas I Surrounded the concerns using corticosteroids both in terms of their ocular hypertensive and cataractogenic Effects using frequent topical steroids and then growth retardation using chronic corticosteroids in children. This is the other side of this coin is therapeutic timidity, which is associated with concerns using nonsteroidal anti-inflammatory medications or immunomodulation Due to the potential toxicity associated with these medications and then of course there's the greater surgical risks associated with children because they have more exuberant inflammatory response to surgery and then there are certain syndromes such as GA in which there are just inherently more complications surgically So the therapeutic approach as in adults is to eliminate inflammation To institute appropriate antimicrobial therapy in the face of an infection and then a step ladder graded algorithm Depending on the clinical response to starting with aggressive topical steroids followed by oral non-steroidal in certain select groups of patients who might otherwise be on these medications such as kids with arthritic syndromes periocular, intravitrous steroids brief well-defined periods of corticosteroid use and then the early introduction of steroid spearing immunomodulation With both conventional and biological agents. So Julia is going to Present our first case which illustrates some of these points