Acute Anterior Uveitis and Spondyloarthritis: More Than Meets the Eye

Abstract

Ankylosing spondylitis (AS) and related forms of spondyloarthritis (SpA) are associated with some extra-articular features, and the most common symptomatic association is with acute anterior uveitis (AAU). Thus, approximately 40 % of patients with AS will experience a sudden onset of a unilateral anterior uveitis sometime during the course of their disease. Patients with AAU, especially those who are HLA-B27 positive, should be questioned about inflammatory low back pain and also evaluated for other clinical features of SpA. Since a prolonged delay in diagnosis is common among SpA patients and occurrence of AAU may be the reason for their first interaction with medical care, occurrence of AAU presents a unique opportunity for identifying such undiagnosed SpA patients. Therefore, a novel evidence-based algorithm called Dublin Uveitis Evaluation Tool (DUET) has been proposed to guide ophthalmologists and primary care physicians to refer appropriate AAU patients to rheumatologists. In a large two-phase study, approximately 40 % of patients presenting with idiopathic AAU were noted to have undiagnosed SpA, and DUET algorithm was noted to have excellent sensitivity (96 %) and specificity (97 %). It has a positive likelihood ratio (LR) 41.5 and negative LR 0.03. In most instances, the eye inflammation responds well to corticosteroid and mydriatic eye drops and without the need for additional therapy. Use of oral corticosteroids is reserved for patients, especially with associated chronic inflammatory bowel disease or psoriatic arthritis presenting with bilateral, chronic, anterior, and/or intermediate uveitis, and this treatment is rarely needed for more than a couple of weeks. A very small percentage may be more refractory to such treatment and require potential novel therapies, including the use of tumor necrosis factor blockers.

Clinical Spectrum of HLA-B27-associated Ocular Inflammation

“…69 The novel evidence-based algorithm called the "Dublin Uveitis Evaluation Tool (DUET)" has been proposed to guide ophthalmologists and primary care physicians to refer appropriate AAU patients to rheumatologists. 70…”

Gut Microbiota Composition and Fecal Metabolic Phenotype in Patients With Acute Anterior Uveitis

“…4,5 Previous studies have shown that undiagnosed SpA occurs in about 40% of patients with idiopathic AAU. 6 The human leucocyte antigen B27 (HLA-B27) has been shown to have a strong association with AAU. 7 A significant number of independent genetic associations of AAU and SpA, which cluster in several immunologic pathways such as the IL-17 and -23 pathways, has been revealed by recent genome-wide association studies (GWAS).…”

A referable clinical pattern of spondyloarthritis-associated uveitis

“…According to the Berlin criteria, IBP is defined by at least 2 of the following 4 criteria: morning stiffness of more than 30 minutes; improvement with exercise but not with rest; awakening because of back pain during the second half of the night only; alternating buttock pain [ 22 ]. More recently, ASAS has defined IBP if 4 of the following 5 criteria are met: age at onset below 40 years; insidious onset; improvement with exercise; no improvement with rest; nocturnal back pain [ 23 ].…”