| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Ophthalmology > CONNECTIVE TISSUE DISORDERS
Ankylosing Spondylitis
Article Last Updated: Jan 5, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Diseases Service, Assistant Department of Ophthalmology, Assistant Dean for Graduate Medical Education and Continuing Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Coauthor(s):
Kathryn L Reed, MD, Consulting Staff, Department of Ophthalmology, The Eye Group
Editors: Andrew A Dahl, MD, Residency Director, Ophthalmology, Kingston Hospital, Department of Ophthalmology, Assistant Professor of Surgery (Ophthalmology), Mid Hudson Family Practice Institute; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
AS, human leukocyte antigen B27, HLA-B27, seronegative spondyloarthropathies, uveitis, anterior uveitis, acute anterior uveitis, AAU, ankylosing spondylitis associated uveitis, AS associated uveitis, HLA-B27 associated uveitis, inflammatory diseases
Background
Ankylosing spondylitis (AS) is a chronic, progressive inflammatory disorder primarily affecting the axial skeleton. AS is one of the seronegative spondyloarthropathies, a group of multisystem inflammatory diseases that affects the spine, peripheral joints, adjacent soft tissues, and extra-articular structures. Most of these disorders are associated with the human leukocyte antigen B27 (HLA-B27) antigen. In addition to AS, the seronegative spondyloarthropathies include the following: - Reactive arthritis (also referred to as Reiter syndrome)
- Inflammatory bowel disease associated arthritis
- Psoriatic arthropathy
- Juvenile spondyloarthropathy
- Undifferentiated spondyloarthropathies
Several of these disorders share some clinical features, such as sacroiliitis, spondylitis, asymmetric peripheral arthritis, aortitis, clinically evident or occult bowel lesions, and uveitis. On the other hand, some clinical features are more disease specific, such as the urethritis or cervicitis of reactive arthritis or the skin lesions and nail changes in psoriatic arthritis. Diagnosis of AS is established by clinical and radiographic criteria. The Modified New York Criteria require 1 of 3 clinical features, as well as characteristic radiographic features, to diagnose AS. Clinical criteria for diagnosis of AS include the following: lower back pain greater than 3 months in duration that improves with activity but is not relieved by rest, limited lumbar spine motion in the sagittal and frontal planes, and decreased chest expansion. Characteristic radiographic findings include the following: pseudowidening of the sacroiliac joints, sclerosis, narrowing, and ankylosis. HLA-B27 typing is not necessary to establish the diagnosis, although it is a useful prognostic indicator in patients with uveitis.
Pathophysiology
Acute anterior uveitis occurs in as many as 30% of patients with AS, particularly in those with the HLA-B27 allele. The exact role of HLA-B27 in the pathology of uveitis is not precisely known, but several theories for its role in disease exist. The oldest theory is that of molecular mimicry, in which an infectious agent triggers an immune response against autoantigens. The HLA-B27 antigen shares some amino acid homology with proteins from several gram-negative bacteria, including Yersinia enterocolitica, Shigella flexneri, and Chlamydia trachomatis, as well as gram-negative bacteria found in the GI tract. Other theories include the arthritogenic peptide theory, in which the immune response is directed against a peptide presented by HLA-B27; the altered self theory, in which a reactive sulfhydryl group on the HLA-B27 molecule interacts with other self peptides, thereby inducing antigenicity; and, finally, the theory that the HLA-B27 allele confers an altered immune response that directly relates to the disease.
Frequency
United States
Anterior uveitis occurs in 25-30% of patients at some time during the course of the AS.
Mortality/Morbidity
Patients with AS and the HLA-B27 antigen tend to develop uveitis at a younger age, have a longer duration of ocular disease, and have more recurrences. Additionally, patients who are HLA-B27 positive appear to have more severe disease in terms of anterior chamber inflammation and vitritis, resulting in a higher incidence of complications and the requirement for more aggressive therapy.
Age
Uveitis is seen at an earlier age than with idiopathic uveitis.
History
A thorough history should be performed, to include the following: - Chief complaint and history of present illness
- Patients often complain of redness, pain, photophobia, blurry vision, and occasionally tearing. No history of ocular discharge is present.
- Many cases of uveitis are unilateral but may be bilateral.
- Attacks often are relatively acute in onset. Some patients may present with chronic symptoms of blurring and ocular hyperemia.
- Past medical history is important to establish the diagnosis of AS.
- Age at onset - Systemic symptoms often develop during late adolescence through early adulthood.
- Systemic manifestations
- Chronic lower back pain
- Chronic back stiffness
- Hip/shoulder involvement
- Neurologic involvement - Symptoms associated with spinal dislocations, subluxations, fractures, cauda equina syndrome
- Cardiovascular manifestations - Aortitis, aortic/mitral insufficiency, conduction defects
- Current medications for systemic manifestations
- Past ocular history should include the following:
- Previous episodes, duration, and treatment
- Previous complications
- Cataract
- Glaucoma
- Cystoid macular edema (CME)
- Epiretinal membrane
Physical
Patients suspected of having AS should undergo a thorough physical examination, preferably by a rheumatologist. - A complete ophthalmic examination should be performed with special emphasis on the following:
- Best-corrected distance and near acuity
- Pupil examination
- Slit lamp examination
- Conjunctiva and sclera - Conjunctival injection, watery discharge, no follicles or papillae
- Cornea - Small-to-medium keratic precipitates
- Anterior chamber - Cells and flare, fibrin, and/or hypopyon not uncommon
- Iris - Posterior synechiae, peripheral anterior synechiae, pupillary membrane, no nodules
- Lens - Posterior subcapsular cataract
- Vitreous - Anterior vitreous cells, vitritis
- Intraocular pressure - Often low during acute exacerbations, secondary glaucoma, hypotony, phthisis
- Dilated fundus examination - Vitritis, CME, retinal vasculitis, epiretinal membrane
Causes
The cause of AS is unknown.
Ocular Manifestations of Syphilis
Sarcoidosis
Uveitis, Anterior, Nongranulomatous
Uveitis, Intermediate
Lab Studies
- HLA-B27 typing: A positive result narrows the differential diagnosis to the seronegative spondyloarthropathies. This also may be a useful prognostic indicator for the severity of ocular disease.
- Antinuclear antibody (ANA): ANA results are negative in AS but positive in many patients with collagen vascular diseases. Also, the results are positive in children with juvenile idiopathic arthritis (JIA) who are at high risk to develop uveitis.
- Rheumatoid factor (RF): Most patients with JIA are RF negative.
- Complete blood count: A mild anemia may be noted in some patients with a seronegative spondyloarthropathy, JIA, or collagen vascular disease.
- Venereal Disease Research Laboratory (VDRL) test and fluorescent treponemal antibody absorption (FTA-ABS) test should be performed to rule out syphilis as a cause of the uveitis.
- Lyme titer is useful only in patients with a history of a tick bite and a rash typical for erythema chronicum migrans.
- Purified protein derivative (PPD) should be performed to rule out tuberculosis as a cause of the uveitis.
- Angiotensin converting enzyme (ACE) often is elevated in patients with sarcoidosis.
Imaging Studies
- Sacroiliac x-rays are very useful in patients suspected of having AS.
- Chest x-ray may be useful in patients with findings suggestive of sarcoidosis or tuberculosis. A normal report does not rule out either diagnosis.
Other Tests
- Fluorescein angiography may be useful in patients with CME and/or retinal vasculitis.
Medical Care
The objectives of treatment of patients with uveitis include reduction of inflammation (corticosteroids), relief of symptoms (cycloplegics and anti-inflammatories), and preservation or restoration of vision. If systemic treatment is required, it is necessary to determine whether there are medical contraindications to systemic corticosteroids, particularly in children and in elderly patients. Systemic corticosteroids suppress growth in children. They may exacerbate diabetes mellitus in susceptible individuals. Weight gain and fluid retention are expected effects. Electrolyte imbalance is a common complication. Long-term hazards include osteoporosis, compression of the spine, gastrointestinal hemorrhage, and reduction in immune response to infection, especially tuberculosis. - Cycloplegia - Reduces ciliary spasm and pain, and prevents the development of posterior synechiae.
- Tropicamide 1%, 3 times a day (mild disease)
- Homatropine 5%, 2-4 times a day (moderate-to-severe inflammation, hypopyon)
- Corticosteroids decrease the recruitment of inflammatory cells and alter cell function. They may be administered topically, via periocular injection, or systemically, and then tapered slowly.
- Topical steroids are used to treat disease limited to the anterior segment. Prednisolone acetate 1% is most effective in reducing anterior chamber inflammation. Adverse effects include cataract formation and increased intraocular pressure. Therapeutic levels of corticosteroids cannot be achieved in the vitreous via the topical route; therefore, this method of administration is ineffective for posterior segment disease. An alternative route of delivery may be considered when the anterior uveitis is severe or unresponsive to topical treatment. However, before injecting depot steroids, a 4- to 6-week course of topical steroids may be useful to ensure that the patient is not a steroid responder.
- Periocular corticosteroids (triamcinolone acetamide 40 mg) may be used to treat severe anterior uveitis, intermediate uveitis, or posterior uveitis and CME. Complications include cataract formation and increased intraocular pressure, which may be refractory to all forms of therapy, short of surgical removal of the injected material.
- Systemically administered corticosteroids may be considered for vision-threatening uveitis unresponsive to maximal topical and periocular therapy. An internal medicine or rheumatology consultation is advisable in the management of these patients.
- Immunodulatory therapy is often useful in patients who are unresponsive to short courses of corticosteroids, in patients with chronic uveitis, or in patients who develop adverse effects of corticosteroid therapy.
- A number of agents have been used, including methotrexate, azathioprine, cyclosporin A, mycophenolate mofetil, cyclophosphamide, and chlorambucil. Myelosuppression and secondary infection are among the most common adverse effects of these agents.
- Tumor necrosis factor alpha (TNF-alpha) inhibitors may be useful in patients with the seronegative spondyloarthropathies, including AS. TNF-alpha inhibitors that are available include infliximab, etanercept, and adalimumab. Reports suggest that these agents are effective in reducing the number of flares of anterior uveitis in patients with AS.
- A rheumatologist, an internist, or an oncologist is an essential member of the team in the management of patients treated with immunomodulatory agents.
Consultations
- Rheumatology - For evaluation and management of the systemic disease; useful for team approach for patients requiring immunosuppressive therapy
- Physical therapy - For strength and range of motion
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Cycloplegics
For reduction of ciliary spasm and pain, and for prevention of posterior synechiae formation.
| Drug Name | Tropicamide (Mydriacyl, Opticyl, Tropicacyl) |
|---|
| Description | Blocks sphincter muscle of iris and muscle of ciliary body from responding to cholinergic stimulation. |
|---|
| Adult Dose | 1% solution: 1 gtt qd/tid |
|---|
| Pediatric Dose | Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; narrow-angle glaucoma |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | May result in behavioral disturbances in children especially at higher concentrations; may increase intraocular pressure |
|---|
| Drug Name | Homatropine 2 and 5% (Isopto Homatropine) |
|---|
| Description | Blocks responses of sphincter muscle of iris and muscle of ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia). |
|---|
| Adult Dose | 2% or 5% solutions: 1 gtt bid/tid up to q3-4h if needed |
|---|
| Pediatric Dose | Infants and young children: Not recommended
2% solution: 1 gtt of bid/tid |
|---|
| Contraindications | Documented hypersensitivity; narrow-angle glaucoma; acute hemorrhage |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Caution in hypertension, cardiac disease, or increased intraocular pressure; not established in infants and young children (caution due to susceptibility of systemic effects); use with caution in patients with obstructive uropathy, paralytic ileus, ulcerative colitis, unstable cardiovascular status |
|---|
Drug Category: Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
| Drug Name | Prednisolone acetate 1% (Pred Forte) |
|---|
| Description | Topical corticosteroids are used to treat anterior segment inflammation. Little or no effect on vitritis or other posterior segment inflammation. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. |
|---|
| Adult Dose | Severe inflammation: 1 gtt q1h during day and q2h at night until clinical response; taper off based upon clinical response
Mild-moderate inflammation: 1 gtt 4-6 times/d until clinical response, followed by gradual taper until discontinued |
|---|
| Pediatric Dose | Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; acute fungal, bacterial, or HSV keratitis |
|---|
| Interactions | None reported |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Known to cause cataract formation with chronic use; may increase intraocular pressure; with chronic therapy, withdraw treatment by gradually decreasing frequency of applications |
|---|
| Drug Name | Triamcinolone acetonide (Kenalog) |
|---|
| Description | Depot preparations often are used to treat severe anterior segment inflammation, posterior segment inflammation (vitritis), and CME. |
|---|
| Adult Dose | Moderate infection: Up to 40 mg into sub-Tenon space
Severe disease: 2-4 injections over 8-wk period |
|---|
| Pediatric Dose | Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial ocular infections |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Systemic absorption may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia and glycosuria |
|---|
| Drug Name | Prednisone (Deltasone, Sterapred, Orasone) |
|---|
| Description | Useful for severe sight-threatening intraocular inflammation. Consider in bilateral disease and those with posterior segment inflammation or CME. |
|---|
| Adult Dose | 1-1.5 mg/kg PO qd |
|---|
| Pediatric Dose | Moderate inflammation: 0.5-1 mg/kg PO qd
Severe inflammation: 1-1.5 mg/kg PO qd |
|---|
| Contraindications | Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections |
|---|
| Interactions | Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Long-term use may result in growth retardation in children; use with caution in patients with diabetes mellitus and congestive heart failure; may cause gastrointestinal bleeding, aseptic necrosis of the hip, myopathy, osteoporosis, increased risk for infections, cushingoid state, mental disturbances, and skin changes; supraphysiologic dosages may cause adrenocortical insufficiency, which may persist for up to 1 y; after the initial clinical response, taper gradually to avoid rebound inflammation and acute adrenal insufficiency or steroid withdrawal syndrome |
|---|
Drug Category: Antirheumatic, disease modifying
Agents in this category may improve symptoms of the disease by decreasing inflammatory and immune responses.
| Drug Name | Infliximab (Remicade) |
|---|
| Description | Neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Mix in 250-cc normal saline for infusion over 2 h. Must use with low-protein-binding filter (1.2 µm or less). Indicated to reduce signs and symptoms of active ankylosing spondylitis. |
|---|
| Adult Dose | 5 mg/kg IV infusion at 0, 2, and 6 wk as induction regimen, then 5 mg/kg IV q6wk for maintenance
IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile, nonpyrogenic, low-protein-binding filter (pore size <1.2 µm)
|
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | None reported |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of superinfections; more cases of lymphoma were observed in TNF-alpha blockers compared to controlled groups; may increase risk of reactivation of tuberculosis in patients with particular granulomatous infections |
|---|
| Drug Name | Etanercept (Enbrel) |
|---|
| Description | Soluble p75 TNF receptor fusion protein (sTNFR-Ig). Inhibits TNF binding to cell surface receptors and thereby decreases inflammatory and immune responses. |
|---|
| Adult Dose | 25 mg SC 2 times/wk |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; sepsis |
|---|
| Interactions | Do not administer within 3 mo of live virus vaccines (eg, MMR) |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Serious infections may develop and therapy should be discontinued if they occur; possible adverse effects include injection site pain, redness and swelling at injection site, and headaches; rare cases of lupus-like symptoms and heart failure have been reported (discontinue treatment if symptoms develop) |
|---|
Drug Category: Monoclonal antibody
Agents in this category may help by improving symptoms of the disease.
| Drug Name | Adalimumab (Humira) |
|---|
| Description | Recombinant human IgG1 monoclonal antibody specific for human TNF. Indicated to reduce signs and symptoms in patients with active ankylosing spondylitis. Can be used alone or in combination with methotrexate or other disease-modifying antirheumatic drugs (DMARDs). |
|---|
| Adult Dose | 40 mg SC q2wk |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; active infection |
|---|
| Interactions | May interfere with immune response to live virus vaccine (eg, MMR) and reduce efficacy; methotrexate (MTX) decreases clearance (available data do not support adjusting dose of either adalimumab or MTX); coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause additive adverse effects, particularly development of serious infections |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Causes immunosuppression; may be associated with serious infections (some fatal), including reactivation of tuberculosis, sepsis, or opportunistic infections; increases risk for lymphoma development; associated with CNS demyelination (rare); discontinue if serious infection develops; autoantibody development may occur, causing lupus-like syndrome; may cause hypersensitivity reactions, including anaphylaxis and hematologic adverse effects (ie, pancytopenia, aplastic anemia); exacerbation of CHF or new onset CHF has been observed with TNF-blocking agents |
|---|
Further Outpatient Care
- Long-term outpatient follow-up care is necessary for this chronic condition.
Complications
- Anterior and posterior segment inflammation is greater than with idiopathic uveitis, especially if ocular surgery is performed.
Prognosis
- Ocular prognosis is dependent on the ability to control the inflammatory response.
Patient Education
- Patients should understand that this is a chronic condition and long-term follow-up care will be necessary.
Medical/Legal Pitfalls
- Early diagnosis and treatment will help to provide realistic patient expectations.
- Anglade E, Whitcup SM. The diagnosis and management of uveitis. Drugs. Feb 1995;49(2):213-23. [Medline].
- Archer JR, Keat AC. Ankylosing spondylitis: time to focus on ankylosis. J Rheumatol. Apr 1999;26(4):761-4. [Medline].
- Banares A, Jover JA, Fernandez-Gutierrez B, Benitez del Castillo JM, Garcia J, Vargas E, et al. Patterns of uveitis as a guide in making rheumatologic and immunologic diagnoses. Arthritis Rheum. Feb 1997;40(2):358-70. [Medline].
- Braun J, Baraliakos X, Listing J, Sieper J. Decreased incidence of anterior uveitis in patients with ankylosing spondylitis treated with the anti-tumor necrosis factor agents infliximab and etanercept. Arthritis Rheum. Aug 2005;52(8):2447-51. [Medline].
- Burgos-Vargas R, Pacheco-Tena C, Vazquez-Mellado J. Juvenile-onset spondyloarthropathies. Rheum Dis Clin North Am. Aug 1997;23(3):569-98. [Medline].
- El-Shabrawi Y, Mangge H, Hermann J. Anti-tumour necrosis factor alpha treatment in chronic recurrent inflammation of the anterior segment of the eye in patients resistant to standard immunomodulatory treatment. Ann Rheum Dis. Dec 2003;62(12):1243-4. [Medline].
- Foster CS, Alter G, DeBarge LR, Raizman MB, Crabb JL, Santos CI, et al. Efficacy and safety of rimexolone 1% ophthalmic suspension vs 1% prednisolone acetate in the treatment of uveitis. Am J Ophthalmol. Aug 1996;122(2):171-82. [Medline].
- Gladman DD. Clinical aspects of the spondyloarthropathies. Am J Med Sci. Oct 1998;316(4):234-8. [Medline].
- Henderly DE, Genstler AJ, Smith RE, Rao NA. Changing patterns of uveitis. Am J Ophthalmol. Feb 15 1987;103(2):131-6. [Medline].
- Lightman S. New therapeutic options in uveitis. Eye. 1997;11 (Pt 2):222-6. [Medline].
- Linssen A, Meenken C. Outcomes of HLA-B27-positive and HLA-B27-negative acute anterior uveitis. Am J Ophthalmol. Sep 1995;120(3):351-61. [Medline].
- Lyons JL, Rosenbaum JT. Uveitis associated with inflammatory bowel disease compared with uveitis associated with spondyloarthropathy. Arch Ophthalmol. Jan 1997;115(1):61-4. [Medline].
- Martin TM, Smith JR, Rosenbaum JT. Anterior uveitis: current concepts of pathogenesis and interactions with the spondyloarthropathies. Curr Opin Rheumatol. Jul 2002;14(4):337-41. [Medline].
- Reveille JD. HLA-B27 and the seronegative spondyloarthropathies. Am J Med Sci. Oct 1998;316(4):239-49. [Medline].
- Rodriguez A, Akova YA, Pedroza-Seres M, Foster CS. Posterior segment ocular manifestations in patients with HLA-B27-associated uveitis. Ophthalmology. Jul 1994;101(7):1267-74. [Medline].
- Rosenbaum JT. Anterior Uveitis and Systemic Disease. chap 4.
- Rosenbaum JT. HLA-B27-Associated Diseases. chap 39; 475-484.
- Rothova A, Buitenhuis HJ, Meenken C, Brinkman CJ, Linssen A, Alberts C, et al. Uveitis and systemic disease. Br J Ophthalmol. Mar 1992;76(3):137-41. [Medline].
- Rothova A, van Veenedaal WG, Linssen A, Glasius E, Kijlstra A, de Jong PT. Clinical features of acute anterior uveitis. Am J Ophthalmol. Feb 15 1987;103(2):137-45. [Medline].
- Suhler EB, Martin TM, Rosenbaum JT. HLA-B27-associated uveitis: overview and current perspectives. Curr Opin Ophthalmol. Dec 2003;14(6):378-83. [Medline].
- Tay-Kearney ML, Schwam BL, Lowder C, Dunn JP, Meisler DM, Vitale S, et al. Clinical features and associated systemic diseases of HLA-B27 uveitis. Am J Ophthalmol. Jan 1996;121(1):47-56. [Medline].
- Toussirot E, Wendling D. Current guidelines for the drug treatment of ankylosing spondylitis. Drugs. Aug 1998;56(2):225-40. [Medline].
Ankylosing Spondylitis excerpt Article Last Updated: Jan 5, 2008
|
