HLA-B27-related anterior Uveitis

Transcription

1 HLA-B27-related anterior Uveitis Nicholas Jones Manchester Uveitis Clinic The Royal Eye Hospital Manchester

2 Anterior means anterior only IUSG classification: Anterior uveitis = Iris & pars plicata

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6 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%)

7 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)

8 Typical HLA-B27 related AAU Unilateral, photophobia, ciliary congestion Posterior synechiae, low IOP, exudate

9 Severe HLA-B27 related AAU Plasmoid AC, fibrin web or clot Iris haemorrhage, bloody hypopyon

10 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

11 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

12 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..

13 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

14 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!

15 Then look in the fundus!

16 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)?

17 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

18 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

19 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

20 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 peroperative steroid, including: Moderate-dose oral steroid one week pre-op IV methylprednisolone on day of surgery Intraocular triamcinolone

21 Can recurrent HLA B27-associated AAU be suppressed? Sulphasalazine 10 pts with >=3 recurrences/yr 1yr treatment Annual recurrence rate Munoz-Fernandez S et al. J Rheumatol 2003;30: Low-dose methotrexate 9 pts with >+3 recurrences/yr 1yr treatment Annual recurrence rate Munoz-Fernandez S et al. Eye 2009;23:1130-3

22 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

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