SN7 SHORT NOTE 5M

Describe HLA-B27 associated uveitis and uveitis in the immunosuppressed.

Ophthalmology · 3rd Professional

HLA-B27 is the commonest identifiable cause of acute anterior uveitis, accounting for perhaps half of cases in populations where it is prevalent. It is present in about 6 to 8% of Europeans and rather less in Indians
The characteristic clinical picture — sudden, severe, unilateral, non-granulomatous anterior uveitis with intense pain, photophobia and redness; often with fibrin in the anterior chamber and a hypopyon; recurrent, and characteristically alternating between the two eyes. It is rarely bilateral simultaneously.
Associated seronegative spondyloarthropathies — ankylosing spondylitis (the commonest; uveitis occurs in 25%); reactive arthritis (Reiter syndrome) — the triad of urethritis, arthritis and conjunctivitis, classically after Chlamydia or dysentery; psoriatic arthritis; and inflammatory bowel disease

Condition	Features
Cytomegalovirus retinitis	The commonest ocular opportunistic infection in AIDS, occurring at a CD4 count below 50. A slowly advancing necrotising retinitis with haemorrhage along the vessels — the "pizza-pie", "cottage-cheese-and-ketchup" or "brushfire" appearance — and characteristically minimal vitritis. Treated with ganciclovir or valganciclovir, or intravitreal therapy; and above all with antiretroviral therapy to restore immunity
Immune recovery uveitis	A paradoxical inflammation occurring when antiretroviral therapy restores the CD4 count in a patient with healed CMV retinitis; the newly competent immune system responds to residual antigen. Causes vitritis, macular oedema and epiretinal membrane, and is treated with steroid
Toxoplasmosis in AIDS	Extensive, multifocal, often bilateral and without a pre-existing scar; with less vitritis; and often with cerebral involvement
Ocular tuberculosis and syphilis	Both are commoner and more aggressive in HIV; ocular syphilis in particular should prompt HIV testing, and is managed as neurosyphilis with intravenous penicillin
Progressive outer retinal necrosis (PORN)	A varicella-zoster retinitis in profound immunosuppression: rapid, multifocal, deep retinal opacification with NO inflammation and NO vasculitis; extremely poor prognosis
Others	Cryptococcal and fungal choroiditis; Pneumocystis choroidopathy; HIV retinopathy with cotton-wool spots.

Ask about inflammatory back pain in every acute anterior uveitis; the eye disease commonly precedes the spondyloarthropathy and the question costs nothing
Recognise the alternating pattern; recurrent unilateral attacks in alternate eyes is highly characteristic of HLA-B27 disease
Choose adalimumab or infliximab, not etanercept, where an anti-TNF agent is needed for uveitis; the distinction is well established and clinically important
Screen for tuberculosis before any anti-TNF agent; reactivation is a recognised and serious hazard, especially in India
Test for HIV in ocular syphilis, and treat it as neurosyphilis with intravenous penicillin rather than a single intramuscular dose

All questions in Diseases of the Uveal Tract