P16 Orthoptic led eye screening co-located within the paediatric rheumatology clinic for safer management of children with JIA
Authors: Bouraoui Aicha , Roberts Laura , Landells Alexandra , Law Elizabeth , Geh Vernon , Shrivastava Anupam , Borg Frances 
Published: April 2020

Abstract

Background
Juvenile idiopathic arthritis (JIA) affects 1 in 1000 children. Around 10% to 30% of children with JIA develop anterior uveitis. Particularly in the oligoarticular subtype, this uveitis is chronic and therefore asymptomatic, without the classical red eye and pain of acute uveitis. This leads to insidious but progressive visual loss if unrecognised. Although young age, oligoarticular disease and positive ANA are risk factors for uveitis, these factors are not required, and it can occur at any point in disease course. Hence, it is essential that patients who are diagnosed with JIA have prompt and regular eye screening. Diagnosis of uveitis by slit-lamp examination is essential. Both British Society for Rheumatology and Royal College of Ophthalmologists guidelines recommend initial slit-lamp screening in asymptomatic patients within 6 weeks of initial diagnosis, and then every 3-4 months until the age of 12. A 2014 audit of paediatric rheumatology services in the East of England revealed significant variation between trusts (between 9%-100%) with an average 35.4% of patients with first visit within 6 weeks. In our hospital, less than 25% met this standard. These results showed the need for a more robust pathway.

Methods
The poor performance at Southend in 2012 was due to lack of capacity in general paediatric ophthalmology clinic, despite a prompt referral process, with delays and frequent non-attendance for follow-up screening in existing patients. A slit lamp was obtained to be kept in the Paediatric outpatient department. JIA eye screening clinic was set up in December 2017, running weekly alongside the Rheumatology clinic. This ensures that patients received timely and convenient eye screening as a ‘one-stop’ visit. It also frees capacity in the Eye Unit. New and follow-up patients with JIA are reviewed, with assessment of visual acuity, orthoptic assessment, followed by slit-lamp examination. Exclusions for this clinic include children under 3 years old, uncooperative youngerchildren, and those with uveitis, who are reviewed in the eye unit as previously.

Results
In the initial 18-month period (2017-2019), 41 separate patients were seen across 108 attended appointments. 75% new referrals were reviewed within 6 weeks, 66.6% were seen at 2 monthly intervals for the first 6 months post diagnosis. 7.3% were referred to paediatric ophthalmology consultant. Delays were mainly seen early on as the process was being established.

Conclusion
Issues with capacity in Ophthalmology resulted in significant delays to eye-screening appointments. The orthoptic-led clinic has improved our compliance with national guidelines, allowed for improved communication between the two specialities, ensured timely follow-ups, reduced school time missed and improved patient experience. Multi-disciplinary input is made easier by reviewing in one session, minimising non-attendances.

Disclosures
A. Bouraoui: None. L. roberts: None. A. Landells: None. E. Law: None. V. geh: None. A. Shrivastava: None. F. Borg: None.