Spondyloarthropathies and the Eye

The spondyloarthropathies (ankylosing spondylitis or axial spondyloarthritis, reactive arthritis, psoriatic arthritis, inflammatory bowel disease arthropathy and juvenile spondyloarthropathy) share an association with HLA-B27 and with acute anterior uveitis, which is the most common extraarticular manifestation.

• Of people with acute anterior uveitis, about half carry HLA-B27 and a substantial proportion have an undiagnosed spondyloarthropathy. Up to 25 to 40 percent of patients with ankylosing spondylitis will have an episode of uveitis during life, with the risk rising with disease duration.
• The uveitis is typically unilateral at a time, recurrent and often alternating between the eyes. It presents earlier than the joint disease in a significant number of patients, so the eye clinic can make the first diagnosis.
• Uveitis in psoriatic arthritis and in inflammatory bowel disease tends to be more insidious, bilateral and chronic, and may be posterior or intermediate in location.

• Acute anterior uveitis: sudden pain, photophobia, redness with circumcorneal injection, tearing and blurred vision, usually resolving in 6 to 12 weeks without treatment, quicker with treatment. Signs are anterior chamber cells and flare, fibrin, hypopyon, fine nongranulomatous keratic precipitates, posterior synechiae and low IOP initially.
• Complications: posterior synechiae with seclusio pupillae, cystoid macular oedema, cataract (steroid and inflammatory), secondary glaucoma, band keratopathy, hypotony, and disc swelling.
• Reactive arthritis: conjunctivitis (mucopurulent, bilateral, sterile, 1 to 4 weeks after urogenital or enteric infection), subepithelial corneal infiltrates, and anterior uveitis, with the classic triad of urethritis, arthritis and conjunctivitis.
• Psoriatic arthritis: chronic bilateral anterior uveitis, sometimes with vitritis, and ocular surface disease (dry eye, blepharitis).
• Inflammatory bowel disease: episcleritis, scleritis (can be necrotising), anterior uveitis and rarely posterior disease. Ocular activity often tracks gut disease.
• Ankylosing spondylitis: inflammatory back pain (morning stiffness over 30 minutes, improvement with exercise, night pain), reduced spinal mobility, enthesitis, dactylitis.

• Ophthalmic: slit lamp assessment, IOP, dilated fundus examination, macular OCT, fluorescein angiography when posterior segment signs or unexplained vision loss.
• HLA-B27 testing (positive result supports but does not prove the diagnosis, and a negative result does not exclude it).
• Imaging of sacroiliac joints: MRI with STIR sequences for early inflammation, or pelvic radiograph for established sacroiliitis. Whole spine MRI if clinical need.
• Inflammatory markers: ESR and CRP (often normal in axial disease).
• Reactive arthritis: urine or urethral/cervical nucleic acid testing for Chlamydia trachomatis, stool culture for enteric organisms, throat swab where indicated.
• Exclude other causes in a first episode of anterior uveitis: syphilis serology, interferon gamma release assay with chest radiograph for tuberculosis, serum angiotensin converting enzyme and chest imaging for sarcoidosis, and urinalysis; in bowel symptoms, faecal calprotectin and colonoscopy.

• Acute anterior uveitis: prednisolone acetate 1% hourly while awake for 2 to 3 days, then reducing over 4 to 6 weeks according to cells (never stop abruptly). Dilate and rest the pupil with cyclopentolate 1% three times daily or atropine 1% once or twice daily if severe or there are posterior synechiae. Break fresh synechiae with phenylephrine 2.5% and tropicamide 1%, or a subconjunctival injection of mydricaine.
• Severe fibrinous or hypopyon uveitis: periocular triamcinolone 40 mg (sub-Tenon or orbital floor) or a short course of oral prednisolone 0.5 to 1 mg/kg/day for 5 to 7 days then tapering over 2 to 3 weeks.
• IOP elevation: timolol 0.5% twice daily, brimonidine 0.2% three times daily, dorzolamide 2% three times daily. Avoid prostaglandin analogues in active inflammation.
• Cystoid macular oedema: topical or periocular steroid, topical NSAID (nepafenac 0.3% once daily), acetazolamide 250 mg twice daily in short courses, intravitreal triamcinolone 4 mg or dexamethasone implant 0.7 mg.
• Prevention of recurrence (for 2 or more attacks in a year, chronic or bilateral disease, or structural complications): sulfasalazine 500 mg daily increasing by 500 mg weekly to 1.5 g twice daily (reduces attack frequency by about half), methotrexate 15 to 25 mg once weekly with folic acid 5 mg weekly, or adalimumab 40 mg subcutaneously every 2 weeks (reduces flares by more than half and is effective for the joint disease as well), or infliximab 5 mg/kg intravenously at weeks 0, 2 and 6 then every 6 to 8 weeks. Etanercept is less effective for uveitis and has been associated with new onset uveitis, so it is avoided when eye disease is the target. Interleukin-17 inhibitors treat the joint disease but do not reliably prevent uveitis. Screen for tuberculosis, hepatitis B and C and HIV before biologic therapy.
• Reactive arthritis: treatment of the triggering infection (Chlamydia: doxycycline 100 mg twice daily for 7 days or azithromycin 1 g single dose, with partner treatment), NSAIDs for the joint disease, topical lubricants and a short topical steroid course for conjunctivitis or keratitis.
• Inflammatory bowel disease: treatment of the gut disease (including biologics such as infliximab and adalimumab, which treat both) with the gastroenterology team, and local treatment of the eye: prednisolone acetate 1% hourly tapered over 4 to 6 weeks with cyclopentolate 1% three times daily for anterior uveitis, and an oral NSAID such as flurbiprofen 100 mg three times daily or oral prednisolone 1 mg/kg/day for scleritis.
• Cataract surgery only once the eye has been quiet for 3 months, with perioperative oral prednisolone 0.5 to 1 mg/kg/day starting 3 days before and continuing for 2 to 4 weeks, and a posterior chamber intraocular lens.
• Education: patients are told to attend the same day with recurrent redness, pain and photophobia, because early treatment shortens the attack and reduces damage.
• Rheumatology review for back pain, physiotherapy and NSAIDs for the spine, and cardiovascular risk assessment, since aortic and cardiac conduction disease complicate long standing spondyloarthropathy.