EYE INVOLVEMENT IN THE SPONDYLOARTHROPATHIES

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Eye inflammation may be a prominent feature of several rheumatic diseases. The spondyloarthropathies, including ankylosing spondylitis (AS), Reiter's syndrome (RS), psoriatic spondyloarthropathy, spondyloarthritis associated with inflammatory bowel disease (IBD), and undifferentiated spondyloarthropathy, may present a constellation of symptoms, including inflammatory low back pain, peripheral arthritis, enthesitis, recurrent episodes of diarrhea and eye inflammation. Uveitis, conjunctivitis, and episcleritis or scleritis can all occur in patients with known spondyloarthropathies or may be key symptoms for the diagnosis of a previously undiagnosed spondyloarthropathy. Furthermore, a subset of patients with acute anterior uveitis (AAU) with exclusively ocular symptoms are also human leukocyte antigen (HLA) B27 positive and have HLA-B27-related idiopathic anterior uveitis (AU), which should also be included in the spectrum of the spondyloarthropathies. To avoid a superficial treatment of all forms of eye inflammation, this article focuses mainly on uveitis, an ocular manifestation of spondyloarthropathies that entails subtle and complex etiologic, clinical and therapeutic implications.

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DEFINITION

Uveitis is a general term used to define inflammation in the uveal tract, which is the middle layer of the eye (Fig. 1). Uveitis can be classified according to parameters such as anatomic location, clinical course, or laterality. Thus, based on its anatomic location, uveitis may be denominated as anterior when it involves the iris or the ciliary body (also called iritis or iridocyclitis); posterior when it affects the choroid or, by extension, the retina (also called choroiditis or

INCIDENCE OF EYE DISEASE IN SPONDYLOARTHROPATHIES

The reported incidence of rheumatic diseases in patients with uveitis varies substantially in the literature, mainly depending on selection biases and specialty interests.29, 33, 36 Table 2 reflects the likelihood of uveitis in patients with a given spondyloarthropathy and the complementary likelihood of spondyloarthropathy in patients with uveitis. In the authors' experience, roughly one third of patients attending the Uveitis Clinic at the Hospital Clínico San Carlos (HCSC) with any type of

CHARACTERIZATION OF SPONDYLOARTHROPATHY-ASSOCIATED UVEITIS

The clinical presentation of idiopathic, AS and RS HLA-B27–related uveitis is quite characteristic.32 Uveitis associated with psoriatic spondyloarthritis, IBD, or undifferentiated spondyloarthropathy can be less distinctive in its presentation and at times can pose a challenge for the clinician. Furthermore, some of these patients are HLA-B27 positive, whereas others are not. Because many patients present with a mixture of signs and symptoms that do not always fit into established patterns,

THE LINK BETWEEN EYE AND JOINT INFLAMMATION IN SPONDYLOARTHROPATHIES

Current advances in the etiology and physiopathology of the spondyloarthropathies are already outlined in other articles of this issue. Findings linking eye and joint inflammation in these diseases are briefly overviewed here. The similarities and differences in the pathogenesis of uveitis and arthritis remain a matter of discussion and research; however, although a great bulk of data derived from experimental animal models and human research indicate certain common pathogenic features, the

UVEITIS AS A GUIDE FOR THE DIAGNOSIS OF SPONDYLOARTHROPATHY

For the rheumatologist approaching a patient with uveitis, a complete ophthalmologic description of the uveitis is essential and can help to avoid unnecessary tests that can delay the treatment and can be occasionally misleading. A chest roentgenogram and an FTA-ABS test for syphilis should be the only tests ordered routinely in all patients with uveitis because sarcoidosis and syphilis can mimic all other causes of uveitis.31 All other tests should be ordered on the basis of clinical

UVEITIS IN PATIENTS WITH KNOWN SPONDYLOARTHROPATHIES

Another interesting question for the rheumatologist is whether it is possible to anticipate which patients with spondyloarthropathy will develop AAU in the future. In a preliminary study, the authors have compared the clinical characteristics of 89 patients with spondyloarthropathy-related uveitis attended at the Uveitis Clinic with another 100 consecutive patients with spondyloarthropathy without uveitis attended at the Rheumatic Diseases Clinic. No differences were observed between both

TREATMENT

As a rule, with the probable exception of Crohn's disease–related ocular manifestations, ocular symptoms associated with spondyloarthropathies present an excellent response to topical treatment with corticosteroids and mydriatics. Initial treatment should be intense and aggressive and includes hourly administration of topical corticosteroids, such as betamethasone, dexamethasone, or prednisolone, which can be combined with night administration of a topical corticosteroid cream. Mydriatics or

References (42)

  • Y. Aihara et al.

    Acute anterior uveitis in a child with HLA-B60 after Salmonella enteritis associated with the transient appearance of auto-antibody

    Acta Paediatr Jpn

    (1996)
  • S. Baggia et al.

    A novel model of bacterially induced acute anterior uveitis in rats and the lack of effect from HLA-B27 expression

    J Investig Med

    (1997)
  • A. Bañares et al.

    Patterns of uveitis as a guide in making rheumatologic and immunologic diagnoses

    Arthritis Rheum

    (1997)
  • A.A. Bañares et al.

    Bowel inflammation in anterior uveitis and spondyloarthropathy

    J Rheumatol

    (1995)
  • D.J. Careless et al.

    Immunogenetic and microbial factors in acute anterior uveitis

    J Rheumatol

    (1997)
  • M. Dougados et al.

    The use of sulphasalazine for the prevention of attacks of acute anterior uveitis associated with spondyloarthropathy

    Rev Rhum

    (1993)
  • DougadosM. et al.

    Sulfasalazine in spondyloarthropathy: A randomized, multicentre, double-blind, placebo controlled study

    Arthritis Rheum

    (1993)
  • L. Edmunds et al.

    New light on uveitis in ankylosing spondylitis

    J Rheumatol

    (1991)
  • T.E.W. Feltkamp

    Factors involved in the pathogenesis of HLA-B27 associated arthritis

    Scand J Rheumatol

    (1995)
  • T.E.W. Feltkamp

    HLA B27, acute anterior uveitis, and ankylosing spondylitis

    Advances in Inflammation Research

    (1985)
  • T.E.W. Feltkamp

    Ophthalmological significance of HLA associated uveitis

    Eye

    (1990)
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    Address reprint requests to César Hernández-García, Service of Rheumatology, Hospital Clínico San Carlos, c/Prof. Martín Lagos s/n, 28040 Madrid, Spain, [email protected]

    This work was supported by Grant No. 97/0789 from the Fondo de Investigación Sanitaria (FIS) of Spain.

    *

    Service of Rheumatology, Hospital Clínico San Carlos, Madrid, Spain

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