How does ankylosing spondylitis affect your eyes. What are the symptoms of uveitis in AS patients. How is uveitis related to ankylosing spondylitis treated. Can uveitis from AS lead to vision loss. What role do genetics play in AS-related uveitis. How can you prevent uveitis flare-ups if you have ankylosing spondylitis.

The Link Between Ankylosing Spondylitis and Uveitis

Ankylosing spondylitis (AS) is a form of inflammatory arthritis primarily affecting the spine. However, its impact extends beyond joint pain and stiffness. One of the most significant extra-articular manifestations of AS is uveitis, an inflammatory condition of the eye that can potentially threaten vision if left untreated.

Uveitis occurs in approximately 25-35% of individuals with ankylosing spondylitis, making it one of the most common complications of this rheumatic disease. Understanding the connection between AS and uveitis is crucial for patients and healthcare providers alike to ensure prompt diagnosis and appropriate management.

What is uveitis?

Uveitis refers to inflammation of the uvea, the middle layer of the eye. This layer includes the iris (the colored part of the eye), the ciliary body (which produces fluid inside the eye), and the choroid (a layer of blood vessels that nourishes the retina). Depending on which part of the uvea is affected, uveitis can be classified into different types:

• Anterior uveitis (iritis): Affects the front part of the eye, including the iris
• Intermediate uveitis: Involves the vitreous, the gel-like substance in the eye
• Posterior uveitis (choroiditis): Affects the back of the eye, including the retina and choroid
• Panuveitis: Involves all parts of the uvea

In patients with ankylosing spondylitis, anterior uveitis is the most common form encountered.

The Genetic Connection: HLA-B27 and Uveitis in AS

A significant factor in the relationship between ankylosing spondylitis and uveitis is genetics. The HLA-B27 gene, which is strongly associated with AS, also plays a role in the development of uveitis.

How does HLA-B27 contribute to uveitis risk?

The HLA-B27 gene is present in over 90% of individuals with ankylosing spondylitis. This same gene is also found in a high percentage of patients who develop acute anterior uveitis, even in the absence of AS. The presence of HLA-B27 increases the risk of developing uveitis and may influence its severity and recurrence rate.

While the exact mechanism by which HLA-B27 contributes to uveitis is not fully understood, it is believed to play a role in triggering an abnormal immune response that leads to inflammation in both the joints and the eyes.

Recognizing the Symptoms of Uveitis in AS Patients

Early detection of uveitis is crucial for preventing potential vision loss. Patients with ankylosing spondylitis should be aware of the following symptoms that may indicate the onset of uveitis:

• Eye redness
• Eye pain or discomfort
• Sensitivity to light (photophobia)
• Blurred vision
• Floaters or dark spots in the visual field
• Decreased vision

These symptoms often develop rapidly and may affect one or both eyes. It’s important to note that uveitis can occur even when AS symptoms are well-controlled, so regular eye check-ups are essential for all AS patients.

When should you seek medical attention for eye symptoms?

If you experience any of the above symptoms, especially if they develop suddenly or worsen quickly, it’s crucial to seek immediate medical attention. Prompt treatment can help prevent complications and preserve vision.

The Gut-Eye-Spine Axis: A Unifying Theory

Recent research has shed light on a potential connection between the gut microbiome, ankylosing spondylitis, and uveitis. This concept, known as the gut-eye-spine axis, suggests that disturbances in the gut microbiota may play a role in triggering inflammation not only in the joints but also in the eyes.

How does gut health influence uveitis in AS?

The gut microbiome plays a crucial role in regulating the immune system. When the balance of microbes in the gut is disrupted (a condition known as dysbiosis), it can lead to an overactive immune response. In individuals with AS, this dysregulation may contribute to the development of uveitis by triggering inflammation in the eye.

Some researchers hypothesize that certain gut bacteria may stimulate T cells (a type of immune cell) to attack the eyes, leading to uveitis. This theory aligns with the broader understanding of AS as a systemic inflammatory condition that can affect multiple organs and tissues.

Treatment Approaches for Uveitis in Ankylosing Spondylitis

Managing uveitis in patients with ankylosing spondylitis requires a multidisciplinary approach involving rheumatologists and ophthalmologists. The primary goal of treatment is to rapidly reduce inflammation and prevent recurrence.

How It Can Affect Your Eyes

Written by Linda Rath

• What Is Uveitis?
• Why People With AS Get It
• Symptoms
• Treatments

Ankylosing spondylitis (AS) is a type of arthritis. It causes pain and stiffness, mainly in your spine. But it can also cause eye inflammation called uveitis. Left untreated, uveitis can harm your vision and, in some cases, lead to blindness.

Uveitis is a large group of inflammatory eye diseases. It gets its name from the fact that these diseases mostly strike the uvea, the middle part of your eye. But uveitis can show up almost anywhere inside the eye.

Doctors usually describe uveitis based on where you have it:

Anterior uveitis (also called iritis) happens in the front part of your eye. That includes the iris, the colored part. It’s the most common type of uveitis for people with AS. If it’s not treated, anterior uveitis can lead to cataracts, glaucoma, or a buildup of fluid called retinal edema.

Intermediate uveitis is in the vitreous. That’s the big, fluid-filled space in your eye attached to your retina, a layer of cells that sense light and send signals to your brain.

Posterior uveitis (also called choroiditis) attacks the back of your eye. It may affect your retina and your optic nerve, which connects your eye to your brain.

Panuveitis affects all parts of your eye. It’s the most severe type. It can cause blindness if it’s not treated.

About half of people with ankylosing spondylitis have uveitis at least once. It’s one of the most common complications of that form of arthritis.

Your eye doctor could actually be the first to figure out you have AS. That’s because the same inflammation that makes your back hurt can also cause inflammation in your eyes and other parts of your body.

Some experts think the inflammation starts in a place you might not think of: your gut.

It’s home to trillions of tiny organisms called microbes. They perform so many vital functions that you can’t live without them. One of their main jobs is to control your immune system. When the microbes get out of whack, your immune system does, too.

Uveitis may start when gut bacteria tell immune cells called T cells to attack your eyes. But that’s probably not the whole story. Many people with AS and anterior uveitis have a gene called HLA-B27. This gene makes eye inflammation much more likely.

Keep an eye out for:

• Redness
• Pain
• Blurred vision
• Sensitivity to bright light

These symptoms can come on quickly in one or both eyes. Sometimes uveitis is a one-time thing. In other cases, you may go years between flares. In still others, it can also be long-lasting and need ongoing treatment.

The goal of uveitis treatment is to ease inflammation fast. For anterior uveitis, doctors usually prescribe two types of eye drops:

• Steroid drops to lower inflammation
• Drops that widen your pupil to ease pain

For other types of uveitis, you may need steroid pills or shots around your eyes. Sometimes doctors implant a steroid capsule inside your eye.

Steroids can cause serious side effects, including eye diseases like glaucoma and cataracts. Usually, you won’t use steroids for more than 3 months. As you taper off them, your doctor may start you on another medicine.

Some experts think a change in gut bacteria can ease uveitis. You might try:

Probiotics. These are live, friendly bacteria. You find them in yogurt and other fermented foods. They’re in supplements, too.

Prebiotics. These plant fibers feed healthy bacteria in your gut and make them stronger. You can find them in foods like bananas and onions.

Supplements for gut health like butyrate are another option. A diet that’s mostly plant-based could also help.

Talk with your doctor to find out which treatment might work best for you.

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Why Ankylosing Spondylitis Causes Eye Pain – Cleveland Clinic

Ankylosing spondylitis (AS) is a type of inflammatory arthritis that typically affects your lower back.

While those who have AS may experience stiffness, fatigue and pain, the autoimmune condition can also cause eye inflammation known as uveitis.

Rheumatologist Ahmed Elghawy, DO, explains why you may experience eye problems and what treatments are available.

Why does AS cause eye pain?

The short answer is: Doctors aren’t entirely sure.

“With autoimmune conditions like ankylosing spondylitis, your body is acting inappropriately against its own tissue,” explains Dr. Elghawy. “We think this is also the case when it comes to uveitis. There may have been some sort of pathogen that could have led to the body recognizing a self-antigen instead of the pathogen. The body makes the mistake of attacking itself.”

There may also be a link between a certain gene known as HLA-B27 that’s common in both ankylosing spondylitis and uveitis.

Between 25% to 35% of individuals with ankylosing spondylitis will go on to develop some sort of uveitis.

There are different types of uveitis:

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• Anterior uveitis. This affects the front part of your eye, including your iris. About 90% of people with AS will develop this type.
• Posterior uveitis. The back part of your eye is affected, including your retina and optic nerve.
• Intermediate uveitis. This type attacks your vitreous, the clear fluid between your lens and retina.
• Panuveitis. This type affects every part of your eye. It’s the most severe type.

“The longer the patient has ankylosing spondylitis, the more likely they are to develop uveitis,” says Dr. Elghawy.

Uveitis symptoms

Uveitis typically only affects one eye at a time; though, it’s possible to have symptoms in both eyes at once.

If you have uveitis, you may experience the following symptoms:

• Redness.
• Swelling.
• Inflammation.
• Pain.
• Blurred vision.
• Sensitivity to light.
• Increased floaters or spots in your vision.
• Decreased vision.

“In people who are older, uveitis increases the risk of developing cataracts or glaucoma or making those conditions worse,” says Dr. Elghawy.

Treating eye pain and AS

If not treated, uveitis can harm your vision and could potentially lead to blindness.

“We recommend that those who have eye issues at all, especially who already carry a diagnosis of ankylosing spondylitis, that they let their doctor know immediately because it needs to be it needs to be addressed quickly,” emphasizes Dr. Elghawy.

Your doctor will not only treat uveitis, but will also treat your ankylosing spondylitis. In many cases, your rheumatologist may suggest you see an ophthalmologist, too.

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Treatment options for uveitis may include anti-inflammatory eye drops or eye drops with corticosteroids.

Treatments options for AS can include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Either an over-the-counter or prescription NSAID can work as an anti-inflammatory and help with other symptoms as well.
• Disease-modifying anti-rheumatic drugs (DMARDs). This type of drug can also help control your overactive immune system and help with symptoms.
• Corticosteroids. To help temporarily ease joint pain and inflammation, your doctor may recommend an injection of corticosteroids.

Often, the biologic therapies used for ankylosing spondylitis also address uveitis.

“A common scenario would be a person who has low back pain and was treated with prescription or over-the-counter NSAIDs. They’re doing well, but later they develop eye issues, and then, that’s what kind of prompts us to start the biologic therapy,” explains Dr. Elghawy. “There are other individuals who are on biologic therapy who never go on to develop uveitis and that’s probably because they’re already being treated with the biologic therapy.”

And don’t overlook the importance of regular eye exams, says Dr. Elghawy.

“Sometimes, you may find evidence of uveitis during a typical eye exam, even before you have symptoms,” he adds. “So, it’s important if you do have evidence of uveitis, it’s treated properly to prevent the long-term consequences.”

Ankylosing spondylitis – what is it

The official international name of the disease is ankylosing spondylitis. The term Bechterew’s disease is used only in Russia and until recently was used in Germany.

Ankylosing spondylitis is a systemic inflammatory disease, a type of spondyloarthritis that affects the joints, spine, and entheses (attachments of ligaments and tendons to bones). The difference between the disease and other spondyloarthritis lies in the fact that ankylosing (fusion) of the vertebrae among themselves occurs, as a result, the spine can turn into a single bone and deform. The quality of life in this disease is significantly reduced. The second severe complication of Bechterew’s disease is damage to the hip joints, up to a complete loss of mobility and disability.

Why does this disease occur?

The exact cause of the disease is unknown. According to one hypothesis, certain intestinal microbes can trigger pathological inflammation in entheses and joints. For the appearance of a disease, it is not enough to get a certain infection into the body, a certain state of the body’s immune system is necessary, in which self-sustaining inflammation is possible. Scientifically proven risk factors for the development of ankylosing spondylitis are heredity and smoking.

Symptoms

Ankylosing spondylitis usually begins at a young age. The most common symptom of Bechterew’s disease is back pain. This pain has a number of characteristic features (the so-called “inflammatory back pain”). It increases with prolonged immobility, including during nocturnal sleep, and decreases with motor activity. Pain of an inflammatory nature is often accompanied by a feeling of stiffness, especially in the morning when the patient wakes up. The presence of this symptom is a reason for an immediate appeal to a specialist to clarify the diagnosis. Young people often have pain in the calcaneus or Achilles tendon attachments.

Most often, the disease begins with sacroiliitis, which is manifested by pain in the lower back (lumbar region). But in some cases, the patient may feel pain in the neck or at the level of the thoracic spine. In the later stages, there is a restriction of movements, in especially severe cases, a “posture of the supplicant” is formed.

Often, patients report pain, limited mobility and swelling in peripheral joints, such as the shoulder, hip, small joints of the hands and feet, temporomandibular.

The disease can also cause extra-articular manifestations – damage to organs: heart, kidneys, eyes. The latter is the most common and is manifested by uveitis (pain, photophobia, redness of the eye).

Associated conditions include the presence of psoriasis, inflammatory bowel disease, intestinal or genitourinary infections.

Depending on the area where inflammation develops, central and peripheral forms of the disease are distinguished.

Diagnostics

The diagnosis is confirmed using instrumental and laboratory diagnostic methods. X-ray and MRI in the diagnosis of ankylosing spondylitis are used as complementary methods. Often, ultrasound or MRI of the hands and feet can effectively detect enthesitis (inflammatory lesions of enthesis).

Laboratory diagnostics plays a significant role. 90% of patients with ankylosing spondylitis are carriers of the HLA B-27 gene. This is a genetically determined leukocyte antigen, which is associated with the possibility of developing an autoinflammatory reaction. However, the presence of HLA B-27 does not mean the development of the disease, this gene only indicates an increased risk of ankylosing spondylitis.

Early diagnosis is the key to successful treatment of Bechterew’s disease, but it is not easy to recognize the disease. Much depends on the qualifications of the rheumatologist.

Treatment of ankylosing spondylitis

Drug treatment

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, naproxen, nimesulide, etoricoxib, ketoprofen, aceclofenac, meloxicam, etc. are the mainstay of treatment. They can inhibit ankylosing of the spine , reduce the inflammatory response , improve the prognosis of the development of the disease, increase the range of motion and at the same time can be used as painkillers. The drugs block the self-sustaining autoinflammatory process and block the disease mechanism. Patients with peripheral involvement, in whom arthritis prevails, are recommended to take basic anti-inflammatory drugs (sulfasalazine, leflunomide, methotrexate). In the absence of the effect of taking non-steroidal anti-inflammatory drugs, patients are prescribed genetically engineered drugs from the group of inhibitors of tumor necrosis factor

Surgical treatment

Surgical treatment may be required to correct conditions associated with a complication of the course of the disease, such as severe spinal deformities, vertebral fractures, destruction of the hip joints, and heart damage.

Physiotherapy

Physiotherapeutic methods can be used to relieve pain: massage, acupuncture and other methods. Their disadvantage is that they do not give a long-term sustainable effect. Physiotherapy is not included in the official recommendations for the treatment of Bechterew’s disease.

Exercise therapy

Regular physical exercise in addition to the main therapy helps to maintain mobility in the joints. Especially recommended exercises to strengthen the muscles of the back.

Prevention

The causes of the development of the disease have not been reliably established, therefore, special prevention has not been developed.

General recommendations would be to maintain an active lifestyle while trying to avoid spinal and joint injuries, refraining from smoking, eating a Mediterranean diet is preferable..

Diagnosis and treatment at EMC

Thanks to a wide range of diagnostic methods and modern technologies, the majority of patients with this disease can achieve a good effect in treatment. At the European Medical Center (Moscow), comprehensive care is provided according to the protocols adopted by international rheumatological organizations (ASAS, EULAR, ACR). For patients who cannot come to the clinic, it is possible to arrange a remote consultation.

Bechterew’s disease: possible complications | Clinical Diagnostic Center

“Bekhterev’s disease”: possible complications / Interview with Anna Okhotnikova, 24-hour hospital rheumatologist at the BUZOO “CDC” dorsal joints, which can proceed simultaneously with the defeat of peripheral joints, entheses and internal organs. Anna Okhotnikova, a rheumatologist at the CDC round-the-clock hospital, talks about the symptoms of the disease and its various consequences for the body:

Clinical manifestations of spondyloarthritis are varied, they appear gradually, sometimes imperceptibly for the patient, long spontaneous remissions are often observed at the onset of the disease. Ankylosing spondylitis most often begins with inflammatory back pain (in 75-85% of cases) and peripheral arthritis (in 15-25% of cases)

The following symptoms are characteristic of the onset of ankylosing spondylitis:

Deep-seated pain in the spine associated with restriction of movement in the lumbar

Morning stiffness of the spine that disappears during the day.

The central place in the clinical picture is occupied by the lesion of the axial skeleton (spine, pelvis, hip, shoulder and mandibular joints).

Criteria for inflammatory back pain are:

slow (creeping) onset extending over weeks

nocturnal pain better on waking

better with exercise

worse during sleep and at rest .

Inflammatory pain reflexively causes muscle spasm, which contributes to the development of stiffness of the spine. In the early stages of the disease, the restriction of movements in the spine is due to inflammation and painful spasm of the muscles of the back, in the later stages – mainly ossification of the spine.

If the thoracic spine, costovertebral joints are affected, there is pain in the chest, sometimes encircling, aggravated by coughing, deep breathing, turning the torso. As a result of damage to the costovertebral joints, the respiratory excursion of the chest decreases, while the respiratory function is compensated by the diaphragm.

Damage to the joints of the anterior chest wall (sternoclavicular, sternocostal, manubrium and body of the sternum) can be observed at any stage of the disease. Arthritis of the joints of the anterior chest wall occurs in ankylosing spondylitis in 17% of cases. Symptoms can range from mild soreness to severe, firm swelling.

Involvement of the cervical spine occurs at a later stage of the disease. Initially, pain appears, the range of motion of the neck gradually decreases: rotation and inclinations are limited. In some cases, complete ankylosis of the cervical spine occurs with absolute immobility of the head and neck. Spondylitis of the cervical spine may result in dyscirculatory encephalopathy, accompanied by dizziness, nausea, and headache.

Peripheral joint involvement can occur at any stage of the disease and is sometimes one of the first symptoms. In more than 50% of patients, peripheral joints are involved in the process, including the hip and shoulder joints. Peripheral arthritis can be either a temporary manifestation of the disease and pass without a trace, or a frequently recurring manifestation leading to a permanent dysfunction of the joint. Large and medium joints of the lower extremities (hip, knee, ankle) are predominantly involved, arthritis of individual joints of the toes is possible, temporomandibular joints may be affected.

A special variant of arthritis in this disease is damage to the hip joint (coxitis). It develops in about 1/3 of patients with ankylosing spondylitis; in adults, coxitis develops in the first 10 years of the disease. It is manifested by pain in the inguinal region, which can radiate along the anterior and lateral surface of the thigh, to the buttocks, and the anterior surface of the lower leg. It is possible to identify asymptomatic x-ray changes in the hip joints.

In addition to pain in the joints, there are also pains in the bones. We are talking about inflammation of those places where the tendons are attached to the bones. The very first symptoms of Bechterew’s disease are sometimes pains in the heels, which make standing on a hard floor very unpleasant. Inflammation of the attachment of the tendons at the ischium makes sitting on hard chairs unpleasant. Other tendon attachments may also be affected. Inflammation of the tendon attachments is so characteristic of Bechterew’s disease that, together with other characteristic signs, they can even be considered as a diagnostic criterion.

Bechterew’s disease is a “systemic disease”. The erroneous functioning of the immune system can also manifest itself in other organs, not only in the spine. General clinical manifestations of the disease:

fever in the evening not higher than 37.5 C, lethargy, weight loss with preserved appetite, fatigue.

EYES. Approximately 40% of patients develop eye inflammation at one or more times in their lives. We are talking about iritis (inflammation of the iris). If, in addition to the iris, the adjacent areas of the eye also become inflamed, the doctor speaks of iridocyclitis or uveitis. The eye hurts (especially with large changes in brightness, at which the pupil should constrict), becomes sensitive to pressure and reddens.

HEART. Pathology from the side of the heart occurs more often, the longer the disease lasts and the more severe it is. After a 15-year duration of the disease, 3.5%, and after a 30-year duration, 8-10%. Inflammatory changes in the heart caused by Bechterew’s disease develop where the aorta exits the heart. They can lead to heart valve failure (the valve no longer closes properly and blood flows back into the heart with every heartbeat). But inflammation can also block nerve regulation between the atrium and the main chamber and lead to abnormal heart rhythms. To avoid these unpleasant complications, it is important for patients to eliminate or reduce risk factors such as smoking, high blood pressure, being overweight, and lack of exercise.

LIGHT. Lung function is maintained through abdominal breathing, even with complete ossification of the costal joints. But the volume of breathing can be severely limited. In about 15% of patients, this results in upper lung fibrosis (an overgrowth of the connective tissue in the lung), which makes it easier for bacteria and fungi to infect the lungs. The countermeasure against this side effect (along with stopping smoking as a risk factor) is to maintain as much breathing volume as possible, which can be achieved with the help of breathing exercises and physical training.

KIDNEYS and LIVER. Due to inflammatory processes in almost all organs, there is a deposition of protein molecules, which is called amyloid. In the late stage, the lack of volume of the kidneys and liver can limit the function of these organs. Then they talk about amyloidosis. It is treated with diet and cortisone-containing drugs. Amyloidosis is a compelling reason to use these drugs despite their side effects.

NERVOUS SYSTEM. Rarely, but still, complications in the nervous system occur in the late stage of ankylosing spondylitis.