Ankylosing Spondylitis, Ophthalmologic Perspective

Ankylosing spondylitis (AS) is a type of progressive arthritis that leads to chronic inflammation of the spine and the area where the spine joins the pelvis (sacroiliac joints). Ankylosing spondylitis primarily affects the axial skeleton (skeleton of the head and trunk) and the related ligaments and joints. Ankylosing spondylitis can also affect other joints and organs in the body, including the eyes, lungs, kidneys, shoulders, knees, hips, heart, and ankles.

Ankylosing means stiffening and inflammation of the spine. Ankylosing spondylitis causes stiffness, aching, and pain around the spine and pelvis. The spine stiffens because of inflammation of the joints between the bones of the spine. This inflammation can cause the vertebrae to fuse together and eventually can lead to a total fusion of the spine. This fusion occurs when the vertebrae (spinal bones) actually grow together, fusing the spine due to calcification of the ligaments and disks between each vertebra. If the vertebrae fuse together, the spine loses its mobility, leaving the vertebrae brittle and vulnerable to fractures. Ankylosing spondylitis may also cause a curvature of the spine. 

Ankylosing spondylitis is often referred to as a form of spinal inflammation called seronegative spondyloarthropathy. In the case of ankylosing spondylitis, the term seronegative means that the blood test result does not show the presence of rheumatoid arthritis. The term spondyloarthropathy means a disease that affects the joints of the spine. 

Ankylosing spondylitis primarily affects young adult males and is approximately 9 times more common in males than in females. This disease is also approximately 3 times more common in whites than in African Americans. The onset of ankylosing spondylitis is most common in men aged 17-35 years. In women, the symptoms of ankylosing spondylitis often first appear during pregnancy.

A specific gene for the HLA-B27 tissue type is present in many people who have ankylosing spondylitis. Of people with ankylosing spondylitis, 80-95% also have the gene for HLA-B27. This does not mean, however, that if a person has the gene he or she will automatically get ankylosing spondylitis. Although about 8% of Americans have the gene for HLA-B27, only about 1% of them actually have ankylosing spondylitis. However, if a person is thought to have ankylosing spondylitis, a blood test is useful to determine if that person has the gene for HLA-B27.

In the early stages of ankylosing spondylitis, determining a definite diagnosis is sometimes difficult. If a person has the symptoms of ankylosing spondylitis and he or she has the gene for HLA-B27, the diagnosis of ankylosing spondylitis is likely correct. 

The diagnosis of ankylosing spondylitis is made on the basis of a history, a physical exam, x-ray films, and laboratory tests.

A cure for ankylosing spondylitis does not currently exist; however, effective treatment options can relieve pain and improve a person’s condition. The general approach to treatment includes medication, physical therapy, and exercise.

Surgery may be necessary to treat problems caused by ankylosing spondylitis in the spine and other joints of the body.

About 30% of people with ankylosing spondylitis develop anterior uveitis sometime in the course of their disease. Anterior uveitis is an inflammation of the front part of the eye called the uvea, which includes the iris and ciliary body.  

The cause of anterior uveitis is unknown; however, the immune response associated with ankylosing spondylitis that causes the spinal problems is most likely similar to that which causes anterior uveitis.

Many other possible causes of anterior uveitis exist, but when ankylosing spondylitis is present, the development of anterior uveitis is most likely related to ankylosing spondylitis.

The symptoms of anterior uveitis may include eye redness, light sensitivity (photophobia), tearing, eye pain, and blurred vision. Discharge from the eyes is uncommon. The eye pain associated with anterior uveitis is described as being deep and is made worse by bright light.

Eye symptoms usually develop over a few hours. Anterior uveitis associated with ankylosing spondylitis may occur in one eye or both eyes and tends to be recurrent.

An ophthalmologist (a medical doctor who specializes in eye care and surgery) examining a person with anterior uveitis obtains a medical history that includes specific questions about the presence of low back pain. In fact, an ophthalmologist may be the first doctor to make the diagnosis of ankylosing spondylitis. 

An ophthalmologist also performs a complete eye exam on a person with anterior uveitis. The exam includes a visual acuity test, a pupil examination, a slit-lamp examination, an intraocular pressure measurement, and a careful inspection of the back of the eye after dilating the pupils.

Treatment of anterior uveitis usually consists of dilating eye drops called cycloplegics. Cycloplegic eye drops dilate the pupil and relieve the pain caused by the spasm of the iris. Cycloplegic eye drops also temporarily paralyze the focusing mechanism of the eye. Cycloplegic eye drops include the following:

• Tropicamide (Mydriacyl, Opticyl, Tropicacyl)



• Homatropine (Isopto Homatropine)



• Scopolamine ophthalmic (Isopto Hyoscine)  

Additional medications that may be used include 1 or more of the following:

•  Anti-inflammatory drops

• Corticosteroids (prednisolone [Pred Forte])



• Nonsteroidal anti-inflammatory drops (flurbiprofen [Ocufen], ketorolac [Acular]) 

In certain cases, oral corticosteroids, such as prednisone, oral nonsteroidal anti-inflammatory drugs, such as ibuprofen, or both may be used. See Understanding Ankylosing Spondylitis Medications for more information.

Occasionally, the severity of inflammation may require treatment with corticosteroid injections around the eye. If the intraocular  pressure is elevated, additional eye drops may be required to decrease the pressure.

The person’s primary care doctor may recommend other oral immunosuppressive drugs to be taken in conjunction with the eye drops prescribed by the ophthalmologist.

Complications of repeated episodes of anterior uveitis caused by ankylosing spondylitis may include adhesions of the iris to the lens (the iris sticks to the lens), cataract formation, glaucoma, and macular edema. Macular edema is a swelling of the center of the retina and can cause decreased vision. To minimize the occurrence of these complications, the ophthalmologist closely observes the person and promptly treats any episodes of anterior uveitis.

Some people who have recurrent anterior uveitis may require continual treatment with eye drops to prevent these recurrences. People with ankylosing spondylitis must understand that any eye redness or eye pain requires prompt attention by their ophthalmologist.

The ophthalmologist usually consults with the person's primary care doctor, the rheumatologist (a medical doctor who specializes in diseases of the joints, muscles, and bones), or both, and together, they use a team approach to manage the care of the person with ankylosing spondylitis and anterior uveitis. Ankylosing spondylitis is a chronic condition that requires a person to be aware of and understand the disease process as well as to be an active participant in the treatment process.

Spondylitis Association of America
PO Box 5872
Sherman Oaks, CA 91413
Phone (US only): (800) 777-8189
Phone: (818) 981-1616
Email: info@spondylitis.org

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345-4300
Phone: (404) 633-3777

American Academy of Ophthalmology
655 Beach Street
Box 7424
San Francisco, CA 94120
Phone: (415) 561-8500

|Web Links|

Spondylitis Association of America, Frequently Asked Questions About Spondylitis

American College of Rheumatology, Ankylosing Spondylitis

American Academy of Ophthalmology, Medical Library, Eye Health

MayoClinic.com, Ankylosing spondylitis

Media file 1: Diagrams of the eye.

Media type:  Illustration

ankylosing spondylitis, AS, arthritis, sacroiliac joints, inflammation of the spine, seronegative spondyloarthropathy, rheumatoid arthritis, HLA-B27, HLA-B27 gene, anterior uveitis, inflammation of the uvea, Marie-Strumpell disease

Author: Andrew A Dahl, MD, Consulting Staff, Department of Ophthalmology, Vassar Brothers Hospital.

Editors: Richard W Allinson, MD, Associate Professor, Division of Ophthalmology, Texas A&M University Health Science Center, Associate Professor, Department of Surgery, Scott and White Clinic; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, .com, Inc; Robert H Graham, MD, Ophthalmologist, Robert H Graham, MD, PC; Affiliated With Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona and Carl T Hayden VA Medical Center, Phoenix, Arizona.