Acute pain, blurred vision, and photophobia. Associated systemic complaints may include lower back, or heel pain (typically worse on awakening), arthritis, oral ulcers, pain with urination, gastrointestinal complaints, and rashes.

Critical

Recurrent, unilateral (or alternating bilateral) NGAU.

Other

Severe AC reaction with cell, flare, and fibrin. Common cause of unilateral hypopyon. Tendency to form posterior synechiae early. Ciliary flush. More common in men than women.

• See 12.1, Anterior Uveitis (Iritis/Iridocyclitis).

Types of HLA-B27 Disease

• HLA-B27–associated uveitis without systemic disease.

• Ankylosing spondylitis: Young adult men, often with lower back pain or stiffness, abnormalities on sacroiliac spine radiographs, increased erythrocyte sedimentation rate (ESR), positive HLA-B27, and negative RF (seronegative spondyloarthropathy).

• IBD: Crohn disease and ulcerative colitis. Chronic diarrhea, bloody stool, and crampy abdominal pain. Patients who have IBD and are HLA-B27–negative may be more likely to develop sclerokeratitis or peripheral ulcerative keratitis than uveitis.

• Reactive arthritis (Reiter syndrome): Young adult men, conjunctivitis, urethritis, polyarthritis, occasionally keratitis, increased ESR, and positive HLA-B27. May have recurrent episodes. Arthritis tends to involve the lower extremities.

• Psoriatic arthritis: Characteristic skin findings with arthritis typically involving the extensor surfaces of upper extremities.

NOTE Over half of patients presenting with HLA-B27–positive acute anterior uveitis have an underlying seronegative spondyloarthropathy, and of those, over half are diagnosed only after the onset of uveitis.

1. HLA-B27 serologic antigen or molecular PCR testing to confirm the diagnosis.

2. Rule out other associated systemic autoimmune diseases or infectious diseases. See 12.1, Anterior Uveitis (Iritis/Iridocyclitis).

3. Ankylosing spondylitis: Sacroiliac spine radiographs or CT scan show sclerosis and narrowing of the joint spaces; ESR often elevated but nonspecific.

4. IBD: Consult internal medicine or gastroenterology.

5. Reactive arthritis: Conjunctival and urethral swabs for chlamydia if indicated. Consult medicine or rheumatology.

6. Psoriatic arthritis: Consult rheumatology or dermatology.

See 12.1, Anterior Uveitis (Iritis/Iridocyclitis). Patients with HLA-B27 uveitis often suffer multiple recurrences. For particularly severe or frequently relapsing cases, consider longer-term steroid-sparing immunomodulatory therapy, often in conjunction with rheumatology.