Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Case Study
  • Published:

Severe uveitis in an HLA-B27-positive patient with ankylosing spondylitis

Abstract

Background A 36-year-old male presented with bilateral, anterior, chronic uveitis, with cystoid macular edema. Decimal visual acuity was 0.25 in the right eye and 0.20 in the left eye. Ankylosing spondylitis had been diagnosed 13 years previously, with peripheral and axial involvement. He had no history of extra-articular manifestations of ankylosing spondylitis before this uveitis attack. Treatment with the anti-tumor necrosis factor agent etanercept was initiated 5 months before the attack of uveitis.

Investigations Slit-lamp biomicroscopy, laser-flare photometry, optical coherence tomography, chest radiography, angiotensin-converting-enzyme test, mycobacterial culture from gastric lavage, serology tests for syphilis, brucellosis, toxoplasmosis, toxocarosis, antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibodies, antimyeloperoxydase antibodies and antiproteinase 3 antibodies.

Diagnosis Atypically severe HLA-B27-positive uveitis, in a patient with ankylosing spondylitis treated with etanercept.

Management Intensive topical corticosteroid and cycloplegic treatment, subtenon triamcinolone acetonide injection, switch in treatment from etanercept to infliximab followed by discontinuation of tumor necrosis factor inhibitors, intravenous pulses of methylprednisolone followed by oral corticosteroids, and intravenous cyclophosphamide.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: A pelvic radiograph showing a fusion of the sacroiliac joints with osteosis of both the iliac and sacral sides.
Figure 2: A photograph of the right eye showing multiple iris–lens synechiae (abnormal adhesion of the posterior surface of the iris to the anterior lens capsule) and pigment deposits on the anterior lens capsule.
Figure 3: Optical coherence tomography imaging of the macula of the right eye.

References

  1. Chang JH et al. (2005) Acute anterior uveitis and HLA-B27. Surv Ophthalmol 50: 364–388

    Article  Google Scholar 

  2. Braun J et al. (2005) Decreased incidence of anterior uveitis in patients with ankylosing spondylitis treated with the anti-tumor necrosis factor agents infliximab and etanercept. Arthritis Rheum 52: 2447–2451

    Article  CAS  Google Scholar 

  3. Monnet D et al. (2004) Ophthalmic findings and frequency of extraocular manifestations in patients with HLA-B27 uveitis: a study of 175 cases. Ophthalmology 111: 802–809

    Article  Google Scholar 

  4. Ladas JG et al. (2005) Laser flare-cell photometry: methodology and clinical applications. Surv Ophthalmol 50: 27–47

    Article  Google Scholar 

  5. Jabs DA et al. (2005) Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 140: 509–516

    Article  Google Scholar 

  6. Markomichelakis NN et al. (2004) Patterns of macular edema in patients with uveitis, qualitative and quantitative assessment using optical coherence tomography. Ophthalmology 111: 946–953

    Article  Google Scholar 

  7. El-Shabrawi Y and Hermann J (2002) Anti-tumor necrosis factor-alpha therapy with infliximab as an alternative to corticosteroids in the treatment of human leukocyte antigen B27-associated acute anterior uveitis. Ophthalmology 109: 2342–2346

    Article  Google Scholar 

  8. Sfikakis PP et al. (2001) Effect of infliximab on sight-threatening panuveitis in Behcet's disease. Lancet 358: 295–296

    Article  CAS  Google Scholar 

  9. Smith JR et al. (2001) Differential efficacy of tumor necrosis factor inhibition in the management of inflammatory eye disease and associated rheumatic disease. Arthritis Rheum 45: 252–257

    Article  CAS  Google Scholar 

  10. Reddy AR and Backhouse OC (2003) Does etanercept induce uveitis? Br J Ophthalmol 87: 925

    Article  CAS  Google Scholar 

  11. Tiliakos AN and Tiliakos NA (2003) Ocular inflammatory disease in patients with RA taking etanercept: is discontinuation of etanercept necessary? J Rheumatol 30: 2727

    PubMed  Google Scholar 

  12. Kasner L et al. (1993) The paradoxical effect of tumor necrosis factor alpha (TNF-alpha) in endotoxin-induced uveitis. Invest Ophthalmol Vis Sci 34: 2911–2917

    CAS  PubMed  Google Scholar 

  13. Sfikakis PP et al. (2005) Psoriasis induced by anti-tumor necrosis factor therapy: a paradoxical adverse reaction. Arthritis Rheum 52: 2513–2518

    Article  CAS  Google Scholar 

  14. Haraoui B (2005) Differentiating the efficacy of tumor necrosis factor inhibitors. J Rheumatol Suppl 74: 3–7

    CAS  PubMed  Google Scholar 

  15. Benitez-Del-Castillo JM et al. (2000) Sulfasalazine in the prevention of anterior uveitis associated with ankylosing spondylitis. Eye 14 (Pt 3A): 340–343

    Article  Google Scholar 

  16. Mohan N et al. (2001) Demyelination occurring during anti-tumor necrosis factor alpha therapy for inflammatory arthritides. Arthritis Rheum 44: 2862–2869

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Antoine P Brézin.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Monnet, D., Moachon, L., Dougados, M. et al. Severe uveitis in an HLA-B27-positive patient with ankylosing spondylitis. Nat Rev Rheumatol 2, 393–397 (2006). https://doi.org/10.1038/ncprheum0225

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0225

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing