6.1.4.3 Ocular Manifestations

Although conjunctivitis and anterior uveitis are the most common ocular manifestation in ReA, scleritis and episcleritis may occasionally occur. Other potential ocular problems include keratitis, retinitis, secondary glaucoma, and optic neuritis. Ophthalmic involvement usually follows rheumatological and genitourinary manifestations. In a study performed on 113 patients with ReA, ocular manifestations developed within a mean of 2.9 years after the diagnosis of ReA [254].

Conjunctivitis

Conjunctivitis is the most common ocular problem in ReA, occurring in 58% of patients [254]. It usually appears within a few weeks of the onset of arthritis or urethritis, but occasionally may be the Þrst manifestation of the disease [255]. The conjunctivitis is usually mild, bilateral, with mucopurulent discharge and a papillary or follicular reaction. It lasts 7Ð10 days without treatment, and cultures are negative. Rarely, a small, nontender, enlarged preauricular lymph node and mild symblepharon formation may occur.

Anterior Uveitis

Anterior uveitis occurs in about 12% of patients with ReA [254]. It is usually unilateral, nongranulomatous, with Þne to medium-sized white keratic precipitates, mild cellular reaction, and ßare. Posterior iris-lens synechiae and some cells in the vitreous are occasionally seen and there is no hypopyon; in severe cases, however, explosive uveitis with hypopyon may occur. Secondary glaucoma can develop from posterior irisÐlens synechiae (pupillary block), peripheral anterior synechiae, or trabeculitis [254, 255]. Anterior uveitis usually appears in recurrent rather than initial attacks of the disease. It is more frequent in patients who are HLA-B27 positive and/or who have sacroiliitis [252]. ReA must always be considered in the differential diagnosis of anterior uveitis.

Scleritis

Although rare, scleritis may occur in patients with ReA. It usually occurs in the later stages of the disease, and after other ocular manifestations, such as conjunctivitis or anterior uveitis, have

developed. Diffuse anterior scleritis is the most frequent type of scleritis in patients with ReA, and although it may be recurrent it never progresses to necrotizing scleritis.

In our own series of 500 patients with scleritis, three patients had ReA (0.6%). All patients were men with a mean age of 56 years (range, 50Ð67 years) and all patients had recurrent diffuse anterior scleritis. In two patients, the scleritis was bilateral. The scleritis appeared an average of 6 years after the ReA diagnosis in all patients. Scleritis occurred after several episodes of anterior uveitis in all patients and was associated with the presence of moderate anterior uveitis in one patient. Secondary glaucoma developed in one but responded to sclerouveitis anti-inßammatory therapy. There were no corneal lesions, cataract, or macular edema, and although the initial visual acuity (during sclerouveitis attack) was worse than 20/80 in one patient the Þnal visual acuity was not affected. Any patient who develops diffuse anterior scleritis after previous episodes of recurrent anterior uveitis should be examined for ReA or AS.

Episcleritis

Episcleritis is also rare in ReA [252, 254, 256]. It may take the form of simple or nodular episcleritis and usually occurs after years of active ReA. In our own series of 85 patients with episcleritis, there were no patients with ReA.

Other Ocular Findings

Keratitis in ReA may be isolated but usually occurs associated with conjunctivitis and, less often, anterior uveitis. It consists of punctate epithelial lesions which may coalesce to form an ulcer. Occasionally, subjacent anterior stroma inÞltrates or micropannus occur [254, 255].

Disk edema and recurrent retinal edema have been occasionally reported in ReA but, as in AS-associated uveitis, posterior segment manifestations are rare [257, 258].

6.1.4.4 Laboratory and Radiographic Findings

The ESR is frequently elevated, but there is little or no correlation between the sedimentation rate and disease severity or prognosis. Mild hypo or