Spondyloarthritis: the eyes have it: uveitis in patients with spondyloarthritis

Combined Ophthalmology and Rheumatology Evaluation in Systemic Autoimmune Diseases with Ocular Involvement: A Third Level Reference Center in Mexico

AIM

A cross-sectional descriptive study to determine the frequency of ocular manifestations associated with systemic autoimmune diseases in a third-level hospital in Mexico.

METHODS

Records from 2014 to 2017 at the Inflammatory Eye Disease Clinic of the Asociación Para Evitar la Cegueraen México were examined by both an ophthalmologist and a rheumatologist on the same day. Diagnosis was achieved from initial ocular manifestations with later systemic assessment.

RESULTS

Out of 311 medical records, 276 were included, 75% of the patients were female. Keratoconjunctivitis sicca was the most frequent ocular manifestation (33.3%), followed by anterior uveitis (29.5%), scleritis (23.2%), and peripheral ulcerative keratitis (7.2%). The leading autoimmune diseases were spondyloarthritis (29%), rheumatoid arthritis (28.6%), primary Sjögren's syndrome (10.5%) and granulomatosis with polyangiitis (9.1%). 41.3% of systemic disease diagnoses were made after an initial ocular manifestation.

CONCLUSIONS

Inflammatory eye manifestations can imply systemic autoimmune diseases. It is crucial to suspect and confirm this association and provide timely interdisciplinary management.

[Polymorphic markers of certain genes in the development of dry keratoconjunctivitis in patients with rheumatoid arthritis and Sjogren's syndrome]

The article reviews literature on relationships between polymorphic variants of the genes THBS1, GTF2I, MUC1, TRIM21, STAT4, PTPN22 with clinical features of dry keratoconjunctivitis in rheumatoid arthritis and Sjogren's syndrome. The development and implementation of a method for analyzing polymorphic gene variants used to diagnose dry keratoconjunctivitis in rheumatoid arthritis and Sjogren's syndrome will allow assessment of the possibility of developing dry keratoconjunctivitis and/or its progression in patients with autoimmune diseases or in people at risk. Determination of clinical and morphological regularities of dry keratoconjunctivitis in accordance with the revealed molecular and genetic changes will contribute to better understanding of the etiology and pathogenesis of ophthalmological manifestations of autoimmune diseases, and will also help improve the diagnostics and prognosis of dry keratoconjunctivitis.

A referable clinical pattern of spondyloarthritis-associated uveitis

Objective. The aim of the study was to identify a clinical pattern of spondyloarthritis (SpA)-associated uveitis in order to facilitate proper rheumatologic referral by ophthalmologists. Methods. Demographic data were recorded and acute phase reactants were measured using standard methods between May and August 2017, for all adult patients (age > 18 years) presenting with acute uveitis (standardization of uveitis nomenclature). Afterwards, they were referred to a rheumatology clinic to be screened for the 2009 Assessment of SpondyloArthritis International Society (ASAS) classification criteria of SpA. SpA and non-SpA patients were then compared using appropriate statistical tests (significant if p < 0.05). All the patients offered a written informed consent and the study was approved by the local ethics committee. Results. The sample included 67 subjects, of whom 32 (47.8%) were classified with SpA, of whom 21 were known with this diagnosis (median disease duration of 13.6 years), while 11 (34.4% of the SpA subgroup) fulfilled the ASAS classification criteria for SpA without a prior diagnosis. Compared to non-SpA patients, SpA patients were more frequently male urban dwellers, they were significantly younger, they had a higher prevalence of HLA-B27 and recurrent uveitis, and they had higher median of C-reactive protein and lower median of white blood counts. Conclusions. Uveitis is an important revelatory manifestation of SpA. Young men presenting in an ophthalmology department with acute anterior uveitis and inflammatory back pain should be referred to a rheumatology unit. Abbreviations: AAU = Acute Anterior Uveitis, AS = Ankylosing Spondylitis, ASAS = Assessment Of Spondyloarthritis International Society, CRP = C-Reactive Protein, ESR = Erythrocyte Sedimentation Rate, HLA = Human Leukocyte Antigen, IBP = Inflammatory Back Pain, IBD = Inflammatory Bowel Disease, IL = Interleukin, MRI = Magnetic Resonance Imaging, Nsaids = Non-Steroidal Anti-Inflammatory Drugs, SD = Standard Deviation, Spa = Spondyloarthritis, Tnfα = Tumour Necrosis Factor Alpha, WBC = White Blood Count.

Observed Incidence of Uveitis Following Certolizumab Pegol Treatment in Patients With Axial Spondyloarthritis

Objective

Axial spondyloarthritis (axial SpA) is characterized by inflammation of the spine and sacroiliac joints and can also affect extraarticular sites, with the most common manifestation being uveitis. Here we report the incidence of uveitis flares in axial SpA patients from the RAPID‐axSpA trial, including ankylosing spondylitis (AS) and nonradiographic (nr) axial SpA.

Methods

The RAPID‐axSpA (NCT01087762) trial is double‐blind and placebo‐controlled to week 24, dose‐blind to week 48, and open‐label to week 204. Patients were randomized to certolizumab pegol (CZP) or placebo. Placebo patients entering the dose‐blind phase were re‐randomized to CZP. Uveitis events were recorded on extraarticular manifestation or adverse event forms. Events were analyzed in patients with/without history of uveitis, and rates reported per 100 patient‐years.

Results

At baseline, 38 of 218 CZP‐randomized patients (17.4%) and 31 of 107 placebo‐randomized patients (29.0%) had past uveitis history. During the 24‐week double‐blind phase, the rate of uveitis flares was lower in CZP (3.0 [95% confidence interval (95% CI) 0.6–8.8] per 100 patient‐years) than in placebo (10.3 [95% CI 2.8–26.3] per 100 patient‐years). All cases observed during the 24‐week double‐blind phase were in patients with a history of uveitis; in these patients, rates were similarly lower for CZP (17.1 [95% CI 3.5–50.1] per 100 patient‐years) than placebo (38.5 [95% CI 10.5–98.5] per 100 patient‐years). Rates of uveitis flares remained low up to week 96 (4.9 [95% CI 3.2–7.4] per 100 patient‐years) and were similar between AS (4.4 [95% CI 2.3–7.7] per 100 patient‐years) and nr‐axial SpA (5.6 [95% CI 2.9–9.8] per 100 patient‐years).

Conclusion

The rate of uveitis flares was lower for axial SpA patients treated with CZP than placebo during the randomized controlled phase. Incidence of uveitis flares remained low to week 96 and was comparable to rates reported for AS patients receiving other anti–tumor necrosis factor antibodies.

Clinical patterns and characteristics of ankylosing spondylitis in China

The study aimed to determine whether unique clinical patterns of AS may exist in China, specifically to explore the different clinical manifestations caused by gender, HLA-B27 status, and age at disease onset. The multicenter cross-sectional survey was conducted and 1251 patients were enrolled across China, representing a broad spectrum of Chinese AS patients. The mean age at onset and diagnosis were 29.2 (11.4) and 33.5 (12.6) years, respectively. The male/female ratio was 2.7:1. Acute anterior uveitis (AAU) was experienced in 10.3% of AS patients and 9.1% patients had juvenile-onset AS (JoAS). Men were significantly younger at onset and diagnosis and showed a higher frequency of HLA-B27 positivity, JoAS, and AAU than women. HLA-B27-positive patients had a younger age of onset than HLA-B27-negative patients. HLA-B27-positive patients were nearly three times as likely to develop AAU than negative patients (P = 0.04). JoAS patients had a family history of AS more often than adult-onset AS (AoAS) patients, and 4.9% of JoAS patients underwent surgical treatments, a rate more than six times that of AoAS patients (P = 0.01). Men had higher levels of C-reactive protein than women, as did HLA-B27 positives compared to negative patients, and JoAS compared to AoAS (all P < 0.05). The clinical patterns of our AS patients were similar to those in other studies in non-Chinese cohort: (1) the age at onset was 29.2 (11.4) years, which was older than found in other studies; (2) men were more likely be HLA-B27 carriers than women; and (3) AAU was less common in Chinese patients.

Innate immune signals in autoimmune and autoinflammatory uveitis

Although traditionally the adaptive immune system has been viewed as the essential contributor to autoimmune diseases, the evidence implicating the innate immune system has grown considerably in recent years. Several multisystem inflammatory diseases affect the uvea and occur as a result of a mutation in a gene coding for a component of the innate immune system. Diseases associated with uveitis such as ankylosing spondylitis, sarcoidosis, Behcet's disease and inflammatory bowel disease can best be conceptually understood by hypotheses that consider microbial infection and innate immunity as contributing factors.