What is the recommended treatment for acute anterior uveitis in a patient with ankylosing spondylitis?

Treatment of Eye Complications in Ankylosing Spondylitis

All patients with acute anterior uveitis (iritis) in ankylosing spondylitis must be treated immediately by an ophthalmologist with topical corticosteroids to prevent vision-threatening complications including glaucoma, cataracts, and permanent vision loss. 1, 2, 3

Acute Episode Management

Immediate ophthalmology referral is mandatory for proper diagnosis, severity assessment, and selection of appropriate local treatments—ophthalmologists have specialized expertise that is critical for preventing complications. 1, 2, 3

First-Line Topical Therapy

• Topical prednisolone acetate 1% or dexamethasone are the preferred corticosteroid formulations for acute anterior uveitis. 2, 3
• These agents serve as first-line therapy and should never be replaced with NSAIDs as monotherapy. 3
• NSAIDs may be added as adjunctive therapy to allow steroid dose reduction, but lack efficacy when used alone. 3

Dosing Strategy to Minimize Complications

• Keep topical corticosteroid doses ≤3 drops daily during extended treatment to minimize cataract risk. 3
• Doses ≤2 drops daily have demonstrated zero incidence of cataract formation per eye-year of follow-up. 3
• High-dose topical steroids (>3 drops daily) significantly increase cataract and glaucoma risk independent of inflammation severity. 3

Prevention of Recurrent Episodes

Patient-Initiated Treatment Protocol

Patients with recurrent uveitis should receive prescriptions for topical corticosteroids to initiate at home when typical symptoms develop—this approach decreases episode severity and duration while reducing the likelihood of ocular complications. 1, 3

This strategy should be restricted to patients with recurrent episodes who are knowledgeable about iritis symptoms, and must be implemented within a care plan that includes prompt ophthalmologic examination. 1, 3

Systemic Biologic Therapy for Recurrent Disease

For patients with recurrent uveitis requiring systemic therapy, use adalimumab or infliximab instead of etanercept. 1, 2, 3

The evidence supporting this recommendation is compelling:

• Adalimumab and infliximab reduce uveitis recurrence rates by 30% compared to etanercept in observational studies and pooled trial analyses. 2, 3
• A large observational study reported uveitis rates (per 100 patient-years) of 13.6 for adalimumab, 27.5 for infliximab, and 60.3 for etanercept, compared to pre-treatment rates of 36.8,45.5, and 41.6 respectively. 1
• Etanercept may paradoxically worsen or trigger new uveitis episodes in AS patients, with documented increased risk compared to other TNF inhibitors. 2, 3

Certolizumab or golimumab may also be considered for recurrent uveitis, although supporting data are less substantial than for adalimumab or infliximab. 1, 4

Evidence on IL-17 Inhibitors

• Secukinumab showed no difference in uveitis flare rates compared to placebo in clinical trials, and was not efficacious for panuveitis or posterior uveitis. 1
• Rates of uveitis flares with ixekizumab have not been well-defined. 1

Escalation to Systemic Immunosuppression

Initiate systemic immunosuppression when topical steroids are insufficient to eliminate inflammation or when doses required create unacceptable risks (cataracts, glaucoma). 3

Indications for Immediate Systemic Therapy

Immediate systemic therapy is indicated if poor prognostic factors are present at first visit: 3

• Posterior synechiae
• Band keratopathy
• Glaucoma
• Cataract
• Poor initial vision
• Hypotony
• Macular edema
• Dense vitreous opacification

Systemic Treatment Algorithm

1. Methotrexate is the preferred initial disease-modifying agent for moderate to severe disease, achieving remission in approximately 52% of patients. 2, 3

2. For inadequate response to methotrexate, add monoclonal antibody TNF inhibitors (adalimumab or infliximab). 3

3. Infliximab provides similar efficacy to adalimumab, with complete remission in 30-85% of patients and rapid reduction in inflammation within 2 weeks. 2

Critical Pitfalls to Avoid

Never use etanercept in AS patients with uveitis history—it is explicitly contraindicated by the American College of Rheumatology and may worsen disease. 1, 2, 3

Never exceed 3 drops daily of topical corticosteroids chronically without compelling indication due to exponential cataract risk. 3

Never use NSAIDs as monotherapy—they are only adjunctive to corticosteroids and lack efficacy alone. 3

Regular ophthalmologic monitoring is essential to detect subclinical progression of posterior uveitis, which can be asymptomatic yet still progress to irreversible vision loss. 2

Special Consideration: Concurrent Inflammatory Bowel Disease

For AS patients with both recurrent uveitis and inflammatory bowel disease, TNF inhibitor monoclonal antibodies (infliximab or adalimumab) are strongly preferred over etanercept, as they address both conditions effectively. 1, 3

Infliximab, adalimumab, and certolizumab are approved for Crohn's disease, while infliximab, adalimumab, and golimumab are approved for ulcerative colitis—etanercept is not approved for either condition. 1

Secukinumab and ixekizumab have been associated with new onset or exacerbation of Crohn's disease and should be avoided in this population. 1