Ocular Manifestation of Ankylosing Spondylitis

Mantsha Rayeen, B. Optom

Fellow Optometrist, Dr. Shroff’s Charity Eye Hospital, New Delhi, India

Ankylosing Spondylitis (AS) is a form of arthritis that is long-lasting (chronic) and most often affects the spine. But it also causes eye inflammation called uveitis, and if left untreated it can harm your vision and, in some cases, lead to blindness. Ankylosing spondylitis is one of the seronegative spondyloarthropathies, a group of multisystem inflammatory diseases that affects the spine, (Figure 1) peripheral joints, adjacent soft tissues, and extra-articular structures. Most of these disorders are associated with the human leukocyte antigen B27 (HLA -B27). ⁽¹⁾

Figure 1:  Ankylosing spondylitis  that affects the spine

This condition usually begins during the second decade of life, and mostly occurs in the male-to-female ratio that is estimated to be 2:1.⁽²⁾ Patients who are HLA -B27 positive appear to have more severe diseases in terms of anterior chamber inflammation and vitritis. More severe and recurrent attacks will tend to cause structural complications such as cataracts, anterior and posterior synechiae, elevated intraocular pressure, secondary glaucoma, and CME.

But uncommonly can also coexist with prominent involvement of the vitreous and the posterior segment.⁽³⁾ Patients with ankylosing spondylitis who have peripheral arthritis also have a higher prevalence of uveitis. ^(4-6) People with Ankylosing spondylitis can develop inflammation of the iris, and this is referred to as iritis. Recurrent attacks of the iritis can affect their eye and are characterised by eye pain and redness with photophobia. In addition to the iris the ciliary body and choroid of the eye can be inflamed, and this is collectively referred to as uveitis.

Iritis and uveitis can be a serious complication of AS that can damage the eye and impair vision. About half of the people with AS have uveitis at least once. It is the most common complication of that form of arthritis. Your eye doctor could be the first to figure out you have AS that’s because the same inflammation that makes your back hurt can also cause inflammation in your eyes and other parts of the body. Uveitis may start from gut bacteria to immune cells called T cells that attack your eyes but many people with AS and anterior uveitis have a gene called HLA-B27. This gene makes eye inflammation much more likely.

Various eye symptoms, treatment responses, and management of uveitis are investigated with questionnaires in patients with AS. It is necessary to identify patients who remain undiagnosed and to be more active in managing uveitis.

The arthritis foundation notes that anyone with an inflammatory type of arthritis, like AS, has an increased risk of glaucoma. Those who use corticosteroids also have a high risk of glaucoma and cataract.

References:-

1. Colbert RA, Delay ML, Layh-Schmitt G, Sowders DP. HLA-B27 misfolding and spondyloarthropathies. Prion. 2009 Jan 3. 3(1)
2. Wakefield D, Clarke D, McCluskey P. Recent Developments in HLA B27 Anterior Uveitis. Front Immunol. 2020. 11:608134.
3. Dodds EM, Lowder CY, Meisler DM. Posterior segment inflammation in HLA-B27+ acute anterior uveitis: clinical characteristics. Ocul Immunol Inflamm. 1999 Jun. 7 (2):85-92.
4. Singh G, Lawrence A, Agarwal V, Misra R, Aggarwal A. Higher prevalence of extra-articular manifestations in ankylosing spondylitis with peripheral arthritis. J Clin Rheumatol. 2008 Oct. 14(5):264-6
5. Venkatesh P, Gogia V, Shah B, Gupta S, Sagar P, Garg S. Patterns of uveitis at the Apex Institute for Eye Care in India: Results from a prospectively enrolled patient data base (2011-2013). Int Ophthalmol. 2015 Sep 25
6. Yu H, Liu Y, Zhang L, Wu L, Zheng M, Cheng L, et al. FoxO1 gene confers genetic predisposition to acute anterior uveitis with ankylosing spondylitis. Invest Ophthalmol Vis Sci. 2014 Nov 20. 55 (12):7970-4.