UVEA Rounds Crissa Marie A. Gay-ya, MD April 27, 2009

Case A.D. 38/M Seaman Right eye pain

HPI Recurrent uveitis –2001, right eye –2003, left eye –2005, left eye –2007, right eye –Intra-ocular steroids –Prednisolone acetate eye drops, 2 drops 4 x a day

5 days PTC eye pain, right (+) redness, tearing, and blurring of vision, right ER consult

Ocular Exam SCPHAT OD20/20 -2NI15 OS20/2015

AC deep

Fundoscopy: –OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e –OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e

ER Diagnosis and Plan Anterior uveitis, right Ibuprofen 400mg BID Tobramycin 1gtt QID, OD Tropicamide 1gtt TID, OD Refer to Uvea Clinic

Uvea Clinic Slight improvement of eye pain Past Medical History –No hypertension or DM –With scoliosis (?) –With hemorrhoids Family History –No heredofamilial disease

Review of Systems No fever, no loss of appetite No headache, no tinnitus No difficulty of breathing, no cough No chest pain, no palpitations With changes in bowel movement

No changes in urination, no genital ulcers With back pains, no joint pains No easy bruising No polydypsia, polyphagia, polyuria No loss of consiousness, no seizures

Ocular Exam SCPHAT OD20/4020/2020 OS20/3220

No RAPD (+) Gross Color Perception

Shallowing of AC

Fundoscopy: –OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e –OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e

Salient Features 38/M Recurrent uveitis, both eyes Eye pain, redness, BOV, Conjunctivits, iritis, posterior synechiae Shallowing of AC Back pain No joint pains No genitourinary symptoms

Uvea Diagnosis and Plan t/c Ankylosing Spondylitis Meds: –Prednisolone acetate 1gtt q 1, OD –Methylprednisolone 40mg/ml, transeptal, OD Labs: –RF –ANA –HLA B-27 –Sacroiliac x-ray –CXR –PPR –ESR –CBC with platelet

Sadly, the patient was lost to follow-up.

HLA-B27-Associated Anterior Uveitis with Systemic Disease Ankylosing spondylitis Reitier’s syndrome Inflammatory bowel disease Psoriatic arthritis Post-infectious arhtritis

Incidence Role of HLA-B27 Ocular and Systemic manifestations Treatment

Ankylosing Spondylitis: Incidence 2.5 to 3 Male: 1 Female Females have milder disease 96% have (+) HLA-B27 Only 1.3% of all HLA-B27-positive patients develop the disease

Ankylosing Spondylitis: HLA-B27 No clear association Infection with gram negative bacteria Theories on HLA-B27: 1.Receptor for infectious agent 2.Cross-react with foreign antigens 3.Marker for immune response gene

Ankylosing Spondylitis: Ocular Manifestations 25% Bilateral in 80%, but rarely simultaneous Recurrence Iritis Conjunctivitis

Symptoms occur 1-2 days before clinical signs Anterior chamber reaction –Blurring of vision –Fibrin clot –Posterior synechiae

Sacroilitis Ankylosing Spondylitis: Systemic Manifestations

Uveitis does not correlate with the severity of the spondylitis Aortic insufficiency Cardiomegaly Conduction defects

If the disease is recognized and treated early, spinal deformity can be prevented Physical therapy NSAIDs Ankylosing Spondylitis: Treatment

Ankylosing Spondylitis Patient Male predominance√ HLA-B27? Bilateral√ Recurrence√ Iritis, conjuntivitis√ Symptoms√ Sacroilitis +/-

Reiter’s Syndrome

Reiter’s Syndrome: Incidence Most common cause of inflammatory oligoarthropathy in young males

Reiter’s Syndrome: HLA-B27 1% with non-specific urethritis –Chlamydia trachomatis –Ureaplasma urealyticum 2% dysentery –Shigella, Salmonella, Yersinia –Treatment does not alter the development or course of the syndrome

Reiter’s Syndrome: Manifestations

Reiter’s Syndrome: Ocular Manifestations Conjunctivitis –Mucoid discharge Keratitis –Multifocal punctate subepithelial and stromal infiltrates Iritis –Mild, non-granulomatous

Reiter’s Syndrome: Treatment Ocular –Topical corticosterooids –Mydriatic agents Joint involvement –NSAIDs –Immunosuppresive therapy

Uveitis and spondyloarthritis: prevalence and relationship with joint disease Faculdade Evangélica de Medicina do Paraná, and Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil.

PURPOSE: To study uveitis prevalence in the local population with spondyloarthritis and its temporal relationship with joint complaints.

METHODS: We reviewed seventy-seven charts of spondyloarthropathy patients from the rheumatology clinic of the "Hospital Universitário Evangélico de Curitiba" for spondyloarthritis class, patients' sex and age, occurrence of uveitis and its location and relationship between the first episode of uveitis and initial joint complaints.

RESULTS: Uveitis was found in 12 of 77 patients (15.6%) which was anterior in 83.3% of the cases, without preference for spondyloarthropathy class (p=0.72) and patients' sex (p=0.74). In patients with reactive arthritis, the mean time between uveitis appearance and joint complaints was 4.04 months and in ankylosing spondylitis 73 months (p=0.009).

CONCLUSION: Spondyloarthropathy patients have uveitis that is anterior in most of the cases and that appears earlier in reactive arthritis than in ankylosing spondylitis

Ophthalmological involvement in rheumatic disease] Spitalul Clinic de Urgente Oftalmologice, Bucuresti.

PURPOSE: The main objective of this study was to identify the prevalence of ocular manifestations in rheumatic patients admitted in a specialized clinic.

METHODS: Information regarding rheumatic and ocular diseases was extracted from medical records system available in "Dr. I. Cantacuzino" Clinical Hospital from Bucharest. The prevalence of ocular involvement reported passively by rheumatologists (retrospective descriptive study of 375 different cases of rheumatic patients) was compared with the literature data.

RESULTS: There were 45 cases of ocular manifestations. Keratoconjunctivitis sicca was noted in 16 patients with rheumatoid arthritis, two patients with systemic lupus erythematosus and one patient with scleroderma. Anterior uveitis was found in seven patients with ankylosing spondylitis, one patient with reactive arthritis, two patients with psoriatic arthritis and one patient with LES. Conjunctivitis was present in two patients with reactive arthritis. In LES ocular involvement also included four cases of retinal vasculitis. Complications clearly related to steroid therapy were nine cases of cataracts. One case with typical "bull's eye" maculopathy due to Hydroxychloroquine treatment was detected.

CONCLUSIONS: The main conclusion of our study is that the rheumatic patients need to be referred to an ophthalmologist for the diagnosis and the optimal treatment of ocular involvement.

Thank you. Good morning.