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Acute anterior uveitis (AAU) is the most common form of uveitis associated with any spondyloarthritis. One-half to two-thirds of the patients with AAU are human leukocyte antigen B27 (HLA-B27) positive, and more than half of patients have associated rheumatic diseases.1 Early identification and referral of patients with AAU with suspected inflammatory back pain to a rheumatologist can help support the diagnosis of nr-axSpA.2
Anterior uveitis refers to iritis or iridocyclitis, ie, inflammation predominantly of the anterior chamber in the eye, and also the tissues of the iris and ciliary body. AAU usually has a sudden onset, can last up to 3 months, and is recurrent. Symptoms of AAU may initially present as mild but can increase in severity. AAU episodes typically occur unilaterally, and subsequent episodes may alternate between eyes; uveitis is rarely bilateral or chronic.1,3-6
Symptoms of AAU can include: eye pain, redness, light sensitivity (photophobia), blurred vision, and “floaters” in the field of vision.7 The symptoms of AAU will vary according to severity of the disease. Severe AAU can involve formation of a hypopyon, presence of fibrin in the anterior chamber, posterior synechiae, cystoid macular edema (CME), and severe vitritis. Very severe cases of AAU may result in vision loss if left untreated.5
Note that systemic treatment may be indicated to prevent frequent recurrences in cases of chronic uveitis, but the number of recurrences can taper with time.8 For example, patients can have a bad year with several recurrences, then no recurrences for years.
HLA-B27-associated AAU has a very good prognosis when managed by an opthalmologist.9 Prompt therapeutic management of the uveitis can bring the inflammation under control, reduce the risk of complications, and lead to good visual outcomes.5
Figure 10. Acute Anterior Uveitis
1. Levinson RD, Martin TM, Luo L, et al. Killer cell immunoglobulin-like receptors in HLA-B27-associated acute anterior uveitis, with and without axial spondyloarthropathy. Invest Ophthalmol Vis Sci. 2010;51(3):1505-1510.
2. van Hoeven L, Boonen AERCH, Hazes JMW, Weel AEAM. Work outcome in yet undiagnosed patients with non-radiographic axial spondyloarthritis and ankylosing spondylitis; results of a cross-sectional study among patients with chronic low back pain. Arthritis Res Ther. 2017;19(1):143. doi: 10.1186/s13075-017-1333-x.
3. Martin TM, Zhang G, Luo J, et al. A locus on chromosome 9p predisposes to a specific disease manifestation, acute anterior uveitis, in ankylosing spondylitis, a genetically complex, multisystem, inflammatory disease. Arthritis Rheum. 2005;52(1):269-274.
4. Agrawal RV, Murthy S, Sangwan V et al. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol. 2010 Jan-Feb; 58(1): 11–19.
5. D'Ambrosio EM, La Cava M, Tortorella P, et al. Clinical features and complications of the HLA-B27-associated acute anterior uveitis: a metanalysis. Semin Ophthalmol. 2017;32(6):689-701.
6. Acharya NR, Tham VM, Esterberg E, et al. Incidence and prevalence of uveitis: results from the Pacific Ocular Inflammation Study. JAMA Ophthalmol. 2013;131(11):1405-1412.
7. National Eye Institute. Facts about uveitis. Available at: https://nei.nih.gov/health/uveitis/uveitis. Reviewed August 2011. Accessed April 5, 2019.
8. McCluskey PJ, Towler HM, Lightman S. Management of chronic uveitis. BMJ. 2000;320(7234):555-558.
9. Braakenburg AM, de Valk HW, de Boer J, Rothova A. Human leukocyte antigen-B27-associated uveitis: long-term follow-up and gender differences. Am J Ophthalmol. 2008;145(3):472-479.
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Version: August 2019
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