This article is more than 5 years old. Information may no longer be current.
Suspect spondyloarthropathy in patients with sudden onset unilateral anterior uveitis
Patients with uveitis who are positive for HLA B27 may have one of several forms of seronegative spondyloarthropathy.
|
|
Patients with sudden onset of a unilateral anterior uveitis may have one of a group of systemic conditions called the seronegative spondyloarthropathies, according to a rheuma-tologist who specializes in uveitis.
Clinicians should obtain a history of low back pain and other conditions and consider typing for human leukocyte antigen (HLA) B27 in such patients, said James T. Rosenbaum, MD, of the Casey Eye Institute in Portland, Ore.
Dr. Rosenbaum explained the links between uveitis and the seronegative spondyloarthropathies — a group of spine and joint diseases that lack the classical autoimmune antibodies such as rheumatoid factor — at the American Academy of Ophthalmology meeting.
“Of all the systemic diseases that you are going to encounter in your practice, for the vast majority of you, the seronegative spondyloarthropathies are the most common,” he told the audience.
Prompt use of topical corticosteroids is the first line of treatment for these conditions, Dr. Rosenbaum said.
“Corticosteroids are required as soon as possible to relieve uveitic inflammation,” he said. Periocular or oral corticosteroids may also be called for, he said, and possibly a tumor necrosis factor (TNF) inhibitor such as infliximab.
The spondyloarthropathies include ankylosing spondylitis, reactive arthritis (formerly called Reiter syndrome), psoriatic arthritis and inflammatory bowel disease.
Ankylosing spondylitis, reactive arthritis
Ankylosing spondylitis is a bilateral sacroiliitis with spine involvement, Dr. Rosenbaum said. The prevalence of the condition in the United States may be as high as 1%. Most patients with ankylosing spondylitis develop mild to moderate inflammatory pain in their lower back, he said.
Inflammatory lower pack pain is insidious in onset and is chronic. Patients have morning stiffness that improves with activity, Dr. Rosenbaum said.
Reactive arthritis may follow an infection such as Chlamydia, Shigella or Salmonella. The classic triad of symptoms is arthritis, conjunctivitis and urethritis.
Forty percent of patients with either ankylosing spondylitis or reactive arthritis will develop acute anterior uveitis, he said.
Lower risk
A lower risk of uveitis, about 7%, is seen in patients with psoriatic arthritis. Psoriatic arthritis develops in about 10% of patients with psoriasis, the skin disease that occurs in about 1% of the population.
“The association between uveitis and B27 is weaker in psoriatic arthritis than it is for either ankylosing spondylitis or reactive arthritis. Only about 50% of patients with psoriatic arthritis and uveitis are HLA B27 positive,” he noted.
Inflammatory bowel disease includes both Crohn’s disease and ulcerative colitis. Patients with these conditions have about a 5% chance of developing uveitis. About 50% of patients with uveitis and inflammatory bowel disease are HLA B27 positive.
Patterns of uveitis in patients in inflammatory bowel disease and psoriatic arthritis vary in duration and severity.
Diagnosis
Clinicians should suspect spondyloarthropathy in all patients with the sudden onset of a unilateral, anterior uveitis, Dr. Rosenbaum said.
Diagnosis should include a thorough history concerning low back pain, peripheral arthritis, diarrhea, abdominal pain and psoriasis. An x-ray of sacroiliac joints should be considered.
Dr. Rosenbaum added that HLA B27 blood tests should be considered. The presence of the antigen may give insight into the origin of the uveitis, he said.
For Your Information:
- James T. Rosenbaum, MD, can be reached at the Casey Eye Institute, Uveitis Department, 3375 SW Terwilliger Blvd., Portland, OR 97239-419; 503-494-5023; fax: 503-494-7233.