Uveitis in spondyloarthritis

Abstract

Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.

Reduction of anterior uveitis flares in patients with axial spondyloarthritis on certolizumab pegol treatment: final 2-year results from the multicenter phase IV C-VIEW study

“…Effective preventive treatments for highly recurrent AAU are limited. 12 Some csDMARDs, including sulfasalazine and methotrexate, may have potential in the management of relapsing AAU, although larger randomized controlled trials are needed to confirm findings as available evidence is currently limited to observational reports. 1 , 2 In addition, sulfasalazine and methotrexate are not indicated for the treatment of axial symptoms in axSpA and are only recommended for cases of prominent peripheral arthritis.…”

“…As C-VIEW only enrolled patients with axSpA and HLA-B27 positivity, our findings are not generalizable to a patient population with HLA-B27 negative disease. However, HLA-B27 is a key genetic marker for axSpA, identified in approximately 90% of patients, 2 , 12 and has been associated with a substantially increased risk (2.6 to 4.2-fold) of developing of AAU. 10 Therefore, it can be expected that this study is representative of the majority of patients with both axSpA and AAU.…”

“… 1 , 2 The onset of flares in highly recurrent AAU is unpredictable, with variable remission periods spanning from weeks to months, and effective preventive treatments are limited. 12 Biological disease-modifying antirheumatic drugs (bDMARDs), especially monoclonal antibodies against tumor necrosis factor (TNF), have been proved effective for the treatment of axSpA. Such treatment may also confer benefit for severe and unresponsive cases of AAU, as well as episodic and recurrent AAU.…”

Clinical Features and Prevalence of Spondyloarthritis in a Cohort of Italian Patients Presenting with Acute Nongranulomatous Anterior Uveitis

“…A clinical assessment of intraocular inflammation by slit-lamp examination shows intraocular cells and the presence of protein exudation in the aqueous humor of the anterior chamber. This can lead to direct leukocyte sedimentation in the anterior chamber (“hypopyon”) and to the formation of posterior synechiae as a secondary sequela, resulting in adhesions between the iris and the lens [ 7 ].…”

Unilateral acute anterior uveitis with macular edema following the use of sildenafil citrate in a patient with HLA-B27 positivity

“… 12 , 13 About 40% of cases with HLA-B27 positive spondylarthritis develop acute anterior uveitis. 14 Approximately 84–90% of patients presenting with AAU who are HLA-B27 positive also have ankylosing spondylitis. 8 …”