Keeping Your Eyes Healthy With Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a type of chronic, inflammatory arthritis that primarily affects the joints, ligaments, and tendons of the spine. But it’s also associated with several extra-articular manifestations — or nonjoint conditions or symptoms —including uveitis, the inflammation of the uvea, which is one of the layers of eye tissue that encloses and nourishes the eyeball.

Uveitis typically causes eye pain, redness, blurred vision, and sensitivity to light. These symptoms can come on suddenly or gradually, and anyone who is experiencing them should see an ophthalmologist as soon as possible to prevent irreversible damage to the eye.

• Anterior uveitis: Also known as iritis, anterior uveitis causes inflammation in front of the lens and behind the cornea.
• Intermediate uveitis: This mainly develops in the jellylike substance in the middle of the eye, called the vitreous. While severe vision loss is uncommon, visual impairment can occur.

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• Posterior uveitis: This type affects the retina, choroid, and optic nerve, and it can lead to permanent vision loss.

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• Panuveitis: This affects the front, middle, and back of the eye similarly.

James T. Rosenbaum, MD, chair emeritus of the Legacy Devers Eye Institute and member of the Spondylitis Association of America’s Medical and Scientific Advisory Board, says that anterior uveitis has specific characteristics in people with AS.

“With AS, the uveitis is usually anterior and sudden in onset. This results in a red, painful eye that is sensitive to light,” says Dr. Rosenbaum. “Patients with recurrent episodes of anterior uveitis often report a vague sensation that something with the eye is amiss 12 to 24 hours before the eye becomes red.”

He also notes that uveitis is an essential early cue that you should look into whether you might have AS, especially if you have other symptoms that could be explained by AS.

“Uveitis is often the first symptom to prompt the recognition that chronic back pain or a swollen joint or tendon might be part of the AS spectrum,” says Rosenbaum. “If the uveitis began suddenly with redness, pain, and light sensitivity in one eye and then responded promptly to therapy with eye drops, the likelihood of associated AS is especially high.”

Christine Anastasiou, MD, clinical assistant professor in the division of immunology and rheumatology at Stanford Medicine, says that if you have uveitis and the following coinciding symptoms, your doctor may want to explore AS testing:

• Chronic lower back pain that started before age 45, improves with exercise but not with rest, and persists for more than three months
• Morning stiffness in the back or hips that lasts more than 30 minutes
• Reduced flexibility or mobility in the spine or hips
• A family history of nonradiographic axial spondyloarthritis, psoriasis, or inflammatory bowel disease
• Joint pain, swelling, or stiffness in the hands and feet

Rosenbaum explains that testing for HLA-B27 is insufficient for predicting uveitis. “We can test for genes that predispose to uveitis, such as HLA-B27, and we know that local trauma can also trigger an attack,” he says. “But currently, we lack a perfect way to predict who will develop uveitis or when that attack will begin.”

“Although genes like HLA-B27 are strongly linked to AS and uveitis, many people with HLA-B27 never develop the disease,” adds Dr. Anastasiou. “People with a family history of AS are at higher risk to develop AS and associated uveitis.”

• Rapidly developing eye pain
• Sensitivity to light
• Eye redness
• Blurred vision
• Seeing spots in your vision, known as floaters

The different types of uveitis can cause somewhat different symptoms:

• Anterior uveitis may cause redness, blurry vision, light sensitivity, and eye pain.
• Intermediate uveitis symptoms include floaters and blurred vision. 
• Posterior uveitis symptoms include difficulties seeing color or a loss of night vision, floaters, reduced visual sharpness, blurred vision, and sensitivity to light.
• Panuveitis can cause any of these symptoms.

See a doctor immediately if you have any of these signs or symptoms. Without treatment, uveitis can permanently damage the eye.

Diagnosis

• A vision exam to evaluate your visual acuity and see how your pupils respond to light
• A slit lamp exam to examine the structures of your eye and look for inflammatory cells
• Tonometry, to measure the pressure inside your eye (called intraocular pressure)

Steroids

• Prescription steroid eye drops: These may help to reduce inflammation in the eye and include difluprednate (Durezol), dexamethasone (Maxidex, Dexycu), prednisolone acetate (Pred Forte), fluorometholone (Flarex, FML, FML Forte), and loteprednol (Lotemax, Alrex, Inveltys).
• Steroid implant: An implant in the eye works by releasing steroids slowly over time.

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• Steroid injections in or around the eye: Also known as periocular injections, these might be necessary for people with severe uveitis, individuals with uveitis with fluid buildup and swelling in the eye, or those who can’t use systemic corticosteroids.
• Systemic steroids: If uveitis is so severe that it risks vision loss or the condition has not responded to eye drops or injections, an ophthalmologist may consider intravenous steroids such as methylprednisolone, or oral steroid medications such as prednisone.

Using steroids comes with a considerable risk of side effects, and the higher the dose and longer an individual takes them, the greater that risk becomes. In the eye, steroid use can lead to increased eye pressure, glaucoma, and cataracts.

• Diabetes
• High blood pressure
• Stomach ulcers
• Sleep difficulties
• Osteoporosis

Systemic Therapies

Immunosuppressant drugs, which reduce immune system activity, include:

• Antimetabolites such as azathioprine, methotrexate, or mycophenolate mofetil
• Calcineurin inhibitors, including cyclosporine and tacrolimus
• Alkylating agents, like chlorambucil and cyclophosphamide

“Biologic medications used in AS target specific parts of the immune system that drive inflammation,” explains Dr Anastasiou. “By blocking the pro-inflammatory substances, they reduce inflammation in both the spine and eyes.”

• Anti-interleukin drugs
• Interferons
• Intravenous immunoglobulin
• Janus kinase inhibitors

• Infection
• Allergic reaction
• Reactivation of some diseases, such as hepatitis B and tuberculosis
• Central nervous system disorders
• Cardiac issues
• Lupus-like syndrome

After you finish treatment for uveitis, you’ll need to be rechecked by an eye doctor — potentially several times — to make sure the condition hasn’t come back, as well as to look for any scarring that may have occurred.

Complications of uveitis or its treatment include cataracts (clouding of the lens of the eye) and glaucoma (an eye condition that causes damage to the optic nerve).

• Dim, cloudy, or blurry vision
• Poor night vision
• Light sensitivity
• Needing brighter light during certain activities, such as reading
• Regular prescription changes for spectacles or contact lenses
• Colors appearing to fade or become more yellow
• Double vision in a single eye

• Pain
• Blurred vision
• Headaches
• An avoidance of light
• A colored ring (halo) around vision

The first step is having an eye doctor check out any possible symptoms of eye inflammation.

“Patients with eyes that experience pain, light sensitivity, or a change in the ability to see should consult with a specialist in eye care as soon as possible,” advises Rosenbaum.

He says that starting corticosteroid eye drops as soon as possible after a uveitis episode helps to shorten the attack.

• Get an annual eye exam: Getting an eye exam every one to two years can help you catch and treat eye issues early.
• Wear protective eyewear: This guideline applies when you’re in situations that could lead to eye injuries, such as playing contact sports, using power tools, or if your workplace or leisure activities otherwise pose any risk to your eyes.
• Treat eye infections: This can prevent them from getting worse or spreading.

These precautions may not be enough to prevent uveitis, so it’s important to remain vigilant about any vision changes that occur, especially as a recent episode of uveitis may suggest that another is imminent in some people. “One of the best predictors is having had a prior episode of uveitis, especially if that episode was recent,” says Rosenbaum. “But some individuals have a single episode of uveitis and never have a recurrence.”

• The inflammation that causes ankylosing spondylitis can also lead to uveitis, or inflammation of the eye’s middle layer.
• If you have sudden redness, pain, and light sensitivity in one or both eyes, see an eye specialist as soon as possible.
• Complications of uveitis and its treatments can include cataracts, glaucoma, and vision loss, so prompt treatment is crucial.
• Steroids, immunosuppressants, and biologics can treat uveitis, and some biologics can reduce inflammation for both ankylosing spondylitis and uveitis. Discuss your risk of uveitis with the doctor managing your AS.