Ankylosing Spondylitis & Uveitis: An Ophthalmologist’s Perspective

Spondyloarthropathy Underdiagnosed

Dr. Thorne

Several studies have sought to screen patients with uveitis for the possibility of an under­lying spondyloarthritis. In the SENTINEL study, conducted by researchers in Spain, 798 consecutive patients with more than one episode of anterior uveitis separated by at least three months were prospectively evaluated with a series of clinic appointments with an ophthalmologist and a rheumatologist.⁴

In this cohort, 50.2% of patients were found to have an axial spondyloarthritis and 17.5% of patients had a peripheral spondylo­arthritis, based on Assessment of Spondylo­Arthritis International Society criteria; the prevalence of spondyloarthritis was even higher among HLA-B27-positive patients than HLA-B27-negative patients (69.8% vs. 27.3% with axial disease, 21.9% vs. 11.1% with peripheral disease, respectively). The authors noted that numerous patients with anterior uveitis are likely to have undiagnosed spondyloarthritis and should be screened for these conditions.

Similarly, researchers from Dublin, Ireland, recruited 104 consecutive patients with presumed idiopathic acute anterior uveitis who presented to the ophthalmology emergency department over the course of one year.⁵ These patients each underwent a standardized evaluation that included testing for HLA-B27; clinical screening for symptoms and signs of axial or peripheral arthritis or enthesitis; personal or family history of psoriasis, inflammatory bowel disease or other spondyloarthropathy; and radiographs of the sacroiliac joints and other joints as clinically indicated. Using this algorithm, 41.6% of the patients were found to have undiagnosed spondyloarthropathy, and this algorithm (termed the Dublin Uveitis Evaluation Tool) has now been validated as an instrument to assist first-line clinicians in recommending appropriate referral of uveitis patients to rheumatology clinics.

Screening for HLA-B27

In her own practice, Dr. Thorne makes sure to diligently screen for HLA-B27 status and for signs of conditions like ankylosing spondylitis, while also evaluating for diseases that include syphilis, tuberculosis, Lyme disease, sarcoidosis and other causes of uveitis. The one point Dr. Thorne stresses is that it’s essential for rheumatologists to counsel ankylosing spondylitis and other spondylo­arthritis patients early and often that it’s critical to report any visual symptoms to allow for early ophthalmologic evaluation.

Any spondyloarthritis patient with a red and/or painful eye, new onset of blurry vision, sensation of flashing lights or floaters should be seen quickly by an ophthalmologist, who can perform a slit-lamp examination and evaluate for uveitis. Failure to arrange for this early evaluation can result in misdiagnosis and prolonged or recurrent symptoms for patients, causing them needless suffering.