Transcript With back pains

UVEA Rounds
Crissa Marie A. Gay-ya, MD
April 27, 2009
Case
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A.D.
38/M
Seaman
Right eye pain
HPI
• Recurrent uveitis
– 2001, right eye
– 2003, left eye
– 2005, left eye
– 2007, right eye
– Intra-ocular steroids
– Prednisolone acetate eye drops, 2 drops 4 x a day
5 days PTC
eye pain, right
(+) redness, tearing, and
blurring of vision, right
ER consult
Ocular Exam
SC
PH
AT
OD
20/20 -2
NI
15
OS
20/20
15
AC deep
AC deep
• Fundoscopy:
– OD:
• (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e
– OS:
• (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e
ER Diagnosis and Plan
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Anterior uveitis, right
Ibuprofen 400mg BID
Tobramycin 1gtt QID, OD
Tropicamide 1gtt TID, OD
Refer to Uvea Clinic
Uvea Clinic
• Slight improvement of eye pain
• Past Medical History
– No hypertension or DM
– With scoliosis (?)
– With hemorrhoids
• Family History
– No heredofamilial disease
Review of Systems
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No fever, no loss of appetite
No headache, no tinnitus
No difficulty of breathing, no cough
No chest pain, no palpitations
With changes in bowel movement
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No changes in urination, no genital ulcers
With back pains, no joint pains
No easy bruising
No polydypsia, polyphagia, polyuria
No loss of consiousness, no seizures
Ocular Exam
OD
SC
20/40
OS
20/32
PH
20/20
AT
20
20
No RAPD
(+) Gross Color Perception
Shallowing of AC
Shallowing of AC
• Fundoscopy:
– OD:
• (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e
– OS:
• (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) h/e
Salient Features
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38/M
Recurrent uveitis, both eyes
Eye pain, redness, BOV,
Conjunctivits, iritis, posterior synechiae
Shallowing of AC
Back pain
No joint pains
No genitourinary symptoms
Uvea Diagnosis and Plan
• t/c Ankylosing Spondylitis
• Meds:
– Prednisolone acetate 1gtt q 1, OD
– Methylprednisolone 40mg/ml, transeptal, OD
• Labs:
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RF
ANA
HLA B-27
Sacroiliac x-ray
CXR
PPR
ESR
CBC with platelet
Sadly, the patient was lost to
follow-up.
HLA-B27-Associated Anterior
Uveitis with Systemic Disease
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Ankylosing spondylitis
Reitier’s syndrome
Inflammatory bowel disease
Psoriatic arthritis
Post-infectious arhtritis
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Incidence
Role of HLA-B27
Ocular and Systemic manifestations
Treatment
Ankylosing Spondylitis:
Incidence
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2.5 to 3 Male: 1 Female
Females have milder disease
96% have (+) HLA-B27
Only 1.3% of all HLA-B27-positive patients
develop the disease
Ankylosing Spondylitis:
HLA-B27
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No clear association
Infection with gram negative bacteria
Theories on HLA-B27:
1. Receptor for infectious agent
2. Cross-react with foreign antigens
3. Marker for immune response gene
Ankylosing Spondylitis:
Ocular Manifestations
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25%
Bilateral in 80%, but rarely simultaneous
Recurrence
Iritis
Conjunctivitis
• Symptoms occur 1-2 days before clinical
signs
• Anterior chamber reaction
– Blurring of vision
– Fibrin clot
– Posterior synechiae
Ankylosing Spondylitis:
Systemic Manifestations
• Sacroilitis
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• Uveitis does not correlate with the severity
of the spondylitis
• Aortic insufficiency
• Cardiomegaly
• Conduction defects
Ankylosing Spondylitis:
Treatment
• If the disease is recognized and treated
early, spinal deformity can be prevented
• Physical therapy
• NSAIDs
Ankylosing
Spondylitis
Male predominance
Patient
√
HLA-B27
?
Bilateral
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Recurrence
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Iritis, conjuntivitis
√
Symptoms
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Sacroilitis
+/-
Reiter’s Syndrome
Reiter’s Syndrome:
Incidence
• Most common cause of inflammatory
oligoarthropathy in young males
Reiter’s Syndrome:
HLA-B27
• 1% with non-specific urethritis
– Chlamydia trachomatis
– Ureaplasma urealyticum
• 2% dysentery
– Shigella, Salmonella, Yersinia
– Treatment does not alter the development or
course of the syndrome
Reiter’s Syndrome:
Manifestations
Reiter’s Syndrome:
Ocular Manifestations
• Conjunctivitis
– Mucoid discharge
• Keratitis
– Multifocal punctate subepithelial and stromal
infiltrates
• Iritis
– Mild, non-granulomatous
Reiter’s Syndrome:
Treatment
• Ocular
– Topical corticosterooids
– Mydriatic agents
• Joint involvement
– NSAIDs
– Immunosuppresive therapy
Uveitis and spondyloarthritis:
prevalence and relationship with
joint disease
Faculdade Evangélica de Medicina do
Paraná, and Hospital Universitário
Evangélico de Curitiba, Curitiba, PR,
Brazil. [email protected]
• PURPOSE: To study uveitis prevalence in
the local population with spondyloarthritis
and its temporal relationship with joint
complaints.
• METHODS: We reviewed seventy-seven
charts of spondyloarthropathy patients
from the rheumatology clinic of the
"Hospital Universitário Evangélico de
Curitiba" for spondyloarthritis class,
patients' sex and age, occurrence of
uveitis and its location and relationship
between the first episode of uveitis and
initial joint complaints.
• RESULTS: Uveitis was found in 12 of 77
patients (15.6%) which was anterior in
83.3% of the cases, without preference for
spondyloarthropathy class (p=0.72) and
patients' sex (p=0.74). In patients with
reactive arthritis, the mean time between
uveitis appearance and joint complaints
was 4.04 months and in ankylosing
spondylitis 73 months (p=0.009).
• CONCLUSION: Spondyloarthropathy
patients have uveitis that is anterior in
most of the cases and that appears earlier
in reactive arthritis than in ankylosing
spondylitis
Ophthalmological involvement
in rheumatic disease]
Spitalul Clinic de Urgente
Oftalmologice, Bucuresti.
• PURPOSE: The main objective of this
study was to identify the prevalence of
ocular manifestations in rheumatic patients
admitted in a specialized clinic.
• METHODS: Information regarding
rheumatic and ocular diseases was
extracted from medical records system
available in "Dr. I. Cantacuzino" Clinical
Hospital from Bucharest. The prevalence
of ocular involvement reported passively
by rheumatologists (retrospective
descriptive study of 375 different cases of
rheumatic patients) was compared with
the literature data.
• RESULTS: There were 45 cases of ocular
manifestations. Keratoconjunctivitis sicca was noted in
16 patients with rheumatoid arthritis, two patients with
systemic lupus erythematosus and one patient with
scleroderma. Anterior uveitis was found in seven patients
with ankylosing spondylitis, one patient with reactive
arthritis, two patients with psoriatic arthritis and one
patient with LES. Conjunctivitis was present in two
patients with reactive arthritis. In LES ocular involvement
also included four cases of retinal vasculitis.
Complications clearly related to steroid therapy were
nine cases of cataracts. One case with typical "bull's
eye" maculopathy due to Hydroxychloroquine treatment
was detected.
• CONCLUSIONS: The main conclusion of
our study is that the rheumatic patients
need to be referred to an ophthalmologist
for the diagnosis and the optimal treatment
of ocular involvement.
Thank you.
Good morning.