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Clinical Review

Diagnosis and management of ankylosing spondylitis

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38954.689583.DE (Published 14 September 2006) Cite this as: BMJ 2006;333:581

Rapid Response:

Ocular Involvement in Ankylosing Spondylitis

We read with interest the paper Diagnosis and Management of
Ankylosing Spondylitis by Claire M McVeigh and Andrew P Cairns BMJ 2006
;333: 581-585.

We were surprised with the omission of ocular involvement as an extra
-articular manifestation of ankylosing spondylitis.

Uveitis associated with ankylosing spondylitis usually is a
unilateral acute anterior uveitis with a high tendency to recur sometimes
in the contralateral eye. Anterior uveitis is associated with the juvenile
onset of the disease and involvement of the lower limbs in AS patients.
The HLA-B*2705 allele is predominant in the anterior uveitis patients,
whilst posterior uveitis is rare and associated to infectious disease.1

The patients with HLA-B27 positive acute anterior uveitis showed the
following characteristics which were significantly different from patients
with HLA-B27 negative acute anterior uveitis: younger age at onset; high
male to female ratio; frequent unilateral alternating eye involvement;
severe ocular symptoms during activity, such as presence of fibrin in the
anterior chamber; absence of mutton fat
keratic precipitates; high incidence of ocular complications; and frequent
association with seronegative spondyloarthropathies. 2

HLA-B27-associated uveitis may be related to severe, sight-
threatening posterior segment manifestations in some patients; this is an
under-recognized phenomenon. These patients may require the use of
aggressive systemic immunosuppressive therapy to control inflammation and
preserve vision. 3

Out of one hundred seventy-five consecutive patients with HLA-B27-
associated uveitis seen in a single centre between January 1996 and March
2001, an HLA-B27-associated extraocular disorder was seen in 136 cases
(77.7%). Of these, ankylosing spondylitis was diagnosed in 81 patients
(46.3%) and presumed in 17 (9.7%). The onset of extraocular symptoms
occurred at a younger age (than the first attack of uveitis. The diagnosis
of an extraocular disease was made only after the appearance of ophthalmic
manifestations in 88 of 136 patients. 4

The prognosis of uveitis usually is excellent with topical treatment,
and only those with posterior pole involvement or a high tendency to recur
or to chronicity might benefit from immunosuppressive therapy.

Treatment of AS patients with biologic agents directed against TNF
α is associated with a significant decrease in the number of anterior
uveitis flares. This reduction was slightly more marked among patients
treated with infliximab, but the difference was not significant.

References

1.Sampaio-Barros PD, Conde RA, Bonfiglioli R, Bertolo MB, Samara
AM.Characterization and outcome of uveitis in 350 patients with
Spondyloarthropathies. Rheumatol Int. 2006 Oct;26(12):1143-6. Epub 2006
Sep 7.

2.Rothova A, Van Veenedaal WG, Linssen A, Glasius E, Kijlstra A, de
Jong PT. Clinical features of acute anterior uveitis. Am J Ophthalmol.
1987 Feb 15;103(2):137-45

3.Rodriguez A, Akova YA, Pedroza-Seres M, Foster CS. Posterior
segment ocular manifestations in patients with HLA-B27-associated uveitis.
Ophthalmology. 1994 101(7):1267-74.

4.Monnet D, Breban M, Hudry C, Dougados M, Brezin AP. Ophthalmic
findings and frequency of extraocular manifestations in patients with HLA-
B27 uveitis: a study of 175 cases. Ophthalmology. 2004

Competing interests:
None declared

Competing interests: No competing interests

01 January 2007
Aires Lobo
Medical Retina Clinical Fellow
Carlos Pavesio
Medical Retina, Moorfields Eye Hospital NHS Foundation Trust, City Road, London EC1V 2PD, UK