Ophthalmologic Manifestations of Reactive Arthritis Treatment & Management

  • Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 14, 2012
 

Medical Care

  • Nongonococcal urethritis and other infections can be treated specifically with systemic antibiotics.
  • Physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and intralesional corticosteroids may be helpful for joint, tendon, and fascial inflammation.
  • Keratolytics or topical corticosteroids may improve cutaneous lesions.
  • Topical corticosteroids may be useful for iridocyclitis.
  • Corticosteroids
    • Topical corticosteroids and mydriatics should be used early and aggressively to reduce tissue damage.
    • The use of systemic corticosteroids may be necessary; they should be used for a short period of time with the same precautions noted with other inflammatory diseases.
    • Prolonged topical treatment is necessary for several weeks after the inflammation has cleared; early withdrawal of topical corticosteroids frequently results in the return of inflammatory changes.
  • NSAIDs
    • The use of oral nonsteroidal anti-inflammatory agents, such as indomethacin or naproxen, may be helpful. Chronic therapy may be necessary.
    • NSAIDs may reduce the intensity and the frequency of recurrences of the ocular inflammation and allow a decrease in the corticosteroid dosage, which helps to decrease the chances of cataract formation and other associated corticosteroid effects.
    • The decreased awareness of pain sometimes seen with these medications may alter the patient's recognition of recurrences. Patients should be examined whenever any change in symptoms occurs to evaluate for recurrence of an acute episode of inflammation. Ocular involvement may parallel systemic and joint disease relapses.
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Surgical Care

  • The posterior spillover of inflammatory material in chronic iridocyclitis associated with reactive arthritis may result in persistent vitreous opacification. The cumulative effects of secondary involvement of the vitreous may result in visually disabling vitreous debris and opacification, making these eyes good candidates for vitrectomy. Although vitrectomy should be considered only after prolonged follow-up care and thorough planning, it appears to offer a definitive improvement in vision in certain cases.
  • Because of the intense episodes of recurrent inflammation, rendering these eyes as quiet as possible before surgery by using topical, periocular, or systemic corticosteroids is essential. At least 3 months of cell-free slit lamp examinations should be documented prior to elective surgical intervention. This should be extended to 6 months for younger patients and severe cases.
  • Preoperative ultrasonography is helpful in determining the degree of vitreous opacification, the thickening of the choroid, and the presence of a cyclitic membrane, which can create significant problems at surgery.
  • The major objective of surgery in patients with complicated uveitic cataract and vitreous opacification is to improve vision.
  • Vitrectomy may favorably modify the dynamics of the uveitic process, although lensectomy-vitrectomy does not reduce the inflammatory reaction in all cases.
  • Cystoid macular edema is the major cause of decreased visual acuity following surgery; however, this is a common and serious complication of chronic uveitis even without surgery. Vitrectomy may actually reduce cystoid macular edema with gradual resolution over a year with an improvement in vision in some patients.
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Consultations

  • Rheumatology: The consulting rheumatologist may be extremely helpful in suggesting an appropriate oral NSAID or immunosuppressive agent to augment topical and periocular corticosteroid therapy.
  • Internal medicine
    • A medical consultation should be sought when prolonged systemic corticosteroid therapy is anticipated, especially in patients with concomitant diabetes or hypertension.
    • Even the most experienced uveitis specialists appreciate assistance in the treatment of patients who may have potentially lethal adverse effects from corticosteroids, potent NSAIDs, or immunosuppressive cytotoxic agents.
  • Dermatology
    • Dermatologic involvement may occur with several uveitic syndromes.
    • An accurate description of these lesions may help establish the diagnosis in some cases.
  • Dentistry: Consultation and treatment by a dentist, an oral surgeon, or a periodontist may be useful for patients with aphthous ulcers.
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Contributor Information and Disclosures
Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS  Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

John D Sheppard Jr, MD, MMSc  Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical 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, MD 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

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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  5. Banares A, Hernandez-Garcia C, Fernandez-Gutierrez B, Jover JA. Eye involvement in the spondyloarthropathies. Rheum Dis Clin North Am. Nov 1998;24(4):771-84, ix. [Medline].

  6. Kohnke SJ. Reactive arthritis. A clinical approach. Orthop Nurs. Jul-Aug 2004;23(4):274-80. [Medline].

  7. Lee DA, Barker SM, Su WP, Allen GL, Liesegang TJ, Ilstrup DM. The clinical diagnosis of Reiter's syndrome. Ophthalmic and nonophthalmic aspects. Ophthalmology. Mar 1986;93(3):350-6. [Medline].

  8. Mahoney BP. Rheumatologic disease and associated ocular manifestations. J Am Optom Assoc. Jun 1993;64(6):403-15. [Medline].

  9. Ostler HB. Oculogenital disease. Surv Ophthalmol. Jan-Feb 1976;20(4):233-46. [Medline].

 
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