moorfields uveitis course 2002 anterior uveitis...• jones np. anterior uveitis. in: evidence-based...
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HLA-B27-related anterior
Uveitis
Nicholas Jones
Manchester Uveitis Clinic
The Royal Eye Hospital
Manchester
Anterior means anterior only
IUSG classification:
Anterior uveitis = Iris
& pars plicata
AU Presentations:
A diagnostic approach
• Acute unilateral non-granulomatous AU
– (60-70% of all new patients)
• Acute bilateral non-granulomatous AU
– (1-2% of all new patients)
• Chronic bilateral, or granulomatous AU
– (10-20%)
• Subacute or chronic AU with unusual features
– (10%)
Acute unilateral non-granulomatous
AU – investigate ?
• History – Known medical diagnosis, treatment
– Ask: arthropathy, bowel, chest, skin, STD, recent illness, travel
• Signs of HLA-B27 positivity (Rothova): – Unilateral acute anterior uveitis
– Age <40 at first attack
– Recurrent attack
– Fibrin or cells +++, NO mutton-fat KP
– Associated AS or Reiter’s syndrome
• Investigations: HLA-B27 only (if necessary)
Typical HLA-B27 related AAU
• Unilateral, photophobia, ciliary congestion
• Posterior synechiae, low IOP, exudate
Severe HLA-B27 related AAU
• Plasmoid AC, fibrin web or clot
• Iris haemorrhage, bloody hypopyon
Severe HLA-B27 related AAU
• IOP very low (<8mmHg)
• Significant cell infiltrate in ANTERIOR vitreous
(including shed ciliary body pigment)
• Macular oedema quite common; occasional papillitis
• Poor or slow response to standard treatment
• Daily subconjunctival steroid +/- oral steroid +/- NSAID
Unusually severe, hyperacute
HLA-B27 related panuveitis
• Very poor visual acuity (<6/60)
• Severe panuveitis with plastic anterior uveitis
• IOP 0-5mmHg
• Aqueous tap for micro-organisms
• Very slow response to treatment
• Frequent relapses – cataract, pre-phthisis
• Oral steroid – oral immunosuppression
• Frequent HLA B27-related ankylosing spondylitis
Mercieca K et al. Ocular Immunology & Inflammation 2010;18:139-41
HLA-B27 related AAU -
Lost/rediscovered treatment skills
• Duke-Elder (1966): • “each attack leaves its mark, producing irreversible changes, and the
end-result is indistinguishable from an acute attack of destructive
severity which terminates in phthisis.”
• “Prompt treatment is therefore the
vital factor in the prognosis – rest,
full atropinisation at the earliest
possible moment, local and, if
necessary systemic steroid therapy..”
HLA-B27 related AAU -
Lost treatment skills
• Introduction of prednisolone acetate:
– Reduced rate of subconjunctival steroid injection
– Therefore reduced usage
of Mydricaine (atropine,
procaine, adrenaline)
• Under-use of atropine
• Under-use of local heat
HLA-B27 related AAU
Old skills regained ?
• Break the synechiae before the patient leaves:
• Vigorous mydriasis:
– Sub-conj Mydricaine or:
– Gt Atr 1% + PE 2.5%
• Then apply local heat:
– Microwaveable pads
– Water-filled glove
• Repeat if necessary!
Then look in the fundus!
Which topical steroid?
• There is very little hard evidence for the relative efficacy of
the various topical steroids • Jones NP. Anterior uveitis. In: Evidence-based ophthalmology, BMJ Books 2004
• There is an abundance of experience-based opinion that
Prednisolone acetate is the most potent
• Loteprednol
– Is it effective enough to treat substantial anterior uveitis?
– Is it reliably less likely to raise IOP (and does it matter)?
Chronic B27-associated uveitis
• Acute intermittent unilateral attacks of AU can:
– become fluctuating and chronic
– involve the posterior segment
– become bilateral
• Inflammation limited to the anterior segment is no less
sight-threatening than posterior uveitis
• Long-term oral immunosuppression is necessary in
some patients with B27-associated anterior or
panuveitis
• Undertreated chronic B27-associated uveitis often leads
to phthisis
Chronic B27 anterior uveitis
• If topical steroid causes IOP to rise:
– Don’t under-treat the inflammation. If you do, this will cause
angle fibrosis and glaucoma anyway.
– The inflammation MUST be controlled adequately:
– and then so must the glaucoma even if it needs tube surgery
– Change to oral immunosuppression if necessary
• Do not tolerate an unsatisfactory “half-way house”
where both uveitis and glaucoma are under-treated
Treating glaucoma in B27-
associated chronic anterior uveitis
• Prostaglandins may theoretically induce inflammation
– but in vitro, only latanoprost does this
– use travoprost or tafluprost by preference
• Many patients have chronic flare, with a high failure
rate for enhanced trabeculectomy
– Primary drainage tube surgery preferred
Managing cataract in B27-associated
uveitis
• Technically these can be among the most
difficult eyes to operate on
• Often heavy flare with risk of post-op
fibrinous uveitis
• Hit very hard with pre-operative and per-
operative steroid, including:
– Moderate-dose oral steroid one week pre-op
– IV methylprednisolone on day of surgery
– Intraocular triamcinolone
Can recurrent HLA B27-associated
AAU be suppressed?
• Sulphasalazine
– 10 pts with >=3 recurrences/yr – 1yr treatment
– Annual recurrence rate 3.4 – 0.9 • Munoz-Fernandez S et al. J Rheumatol 2003;30:1277-9
• Low-dose methotrexate
– 9 pts with >+3 recurrences/yr – 1yr treatment
– Annual recurrence rate 3.4 – 0.9 • Munoz-Fernandez S et al. Eye 2009;23:1130-3
A plea to the busy ophthalmologist:
• Examination findings at first presentation:
– Are at their most distinctive
– May never reappear in this form
– Should be meticulously recorded
– Consider photography
1814-2014