Which ocular findings are characteristic of reactive arthritis (ReA)?

Updated: Dec 24, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Conjunctivitis is a component of the original triad and is one of the hallmarks of the disease, reported to appear in 33-100% of patients. It tends to occur early in the disease, especially during the initial attack; it may be missed if patients are seen only during subsequent attacks.

An intense red, velvetlike conjunctival injection characterizes the conjunctivitis. Bilateral involvement is common. Edema and a purulent discharge are not rare. The conjunctivitis may be mild and painless or may cause severe symptoms with blepharospasm and photophobia. It usually resolves spontaneously within 2 weeks.

Anterior uveitis (including iritis, iridocyclitis, or cyclitis) is the second most common ocular finding. Iridocyclitis may be the initial ocular manifestation in some patients. Uveitis may occur in 12-37% [68] (or possibly as many as 50%) of patients with ReA and is more frequently found in patients with HLA-B27 and those with sacroiliitis. At clinical examination, redness, pain, impaired vision, and exudation with hypopyon can suggest iritis. Rarely, an ReA patient may have permanent visual loss from macular infarction or foveal scarring. [75]

A particularly serious ocular manifestation is recurrent nongranulomatous iridocyclitis. Recurrences are usually associated with an acute iridocyclitis that has a rapid onset with conjunctival and episcleral edema and injection. The corneal endothelium has cellular debris and poorly defined, small- to medium-sized keratic precipitates. Heavy flare and cells and a very early tendency toward formation of posterior synechiae are characteristic, more so than in most other forms of acute iridocyclitis.

Even the most aggressive pupil-dilation management is sometimes inadequate to prevent synechiae formation. A peripheral iridectomy may be necessary to prevent iris bombé and angle closure if the synechiae cannot be broken.

Heavy flare is sometimes so plasmoid that cells are immobile, and a fibrinlike clot may be seen in the pupillary opening as the inflammation resolves. An acute hypopyon may occur. Cells and inflammatory debris may be seen in the vitreous, and blurring of the disc margins and macular edema may occur with severe or prolonged episodes. Spillover vitreitis may be more common in patients with reactive arthritis than those with ankylosing spondylitis.

Other ocular findings that may be noted in ReA include the following:

  • Scleritis

  • Keratitis - Rarely (4% of cases), patients may develop a punctate epithelial keratitis that may lead to central loss of the corneal epithelium and subepithelial infiltrates [76]

  • Cataracts - Lens clouding and posterior subcapsular cataracts occur with prolonged or repeated episodes

  • Hypotony - This may occur after a severe or prolonged course and may persist after resolution

  • Glaucoma - Secondary open-angle glaucoma may occur because of the anterior chamber reaction and the trabecular obstruction or trabeculitis; it usually resolves with aggressive anti-inflammatory therapy; with repeated recurrences, damage to the trabecular meshwork may occur, resulting in secondary glaucoma

  • Corneal ulceration

  • Disc or retinal edema

  • Retinal vasculitis

  • Optic neuritis

  • Dacryoadenitis (occurs rarely in the setting of chlamydial urethritis) [77]


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