Question of the Week

A 30-year-old man presents to the clinic with a one-week history of left eye pain, redness, and photophobia for two days. He describes his vision as foggy and slightly distorted. He reports that he has had 3 similar episodes in his left eye in the past year. He denies any recent trauma, fever, skin changes, or travel. He was diagnosed with inflammatory bowel disease last year. Visual acuity is 20/15 OD and 20/30 OS. EOM, IOP, pupils, and visual fields are within normal limits. On slit lamp exam, there is 2+ injection, 2+ cell and flare, keratic precipitates, a few clumps of endothelial pigment on the cornea, and posterior synechiae (shown in image). Dilated fundus exam is normal. Laboratory results revealed that CBC, ESR, and CRP are normal. ANA, C-ANCA, and HLA-B27 are positive. Syphilis serology is negative.

What is the most likely diagnosis?

A. Herpetic anterior uveitis

B. HLA-B27-associated anterior uveitis

C. Sarcoidosis-associated uveitis

D. Behçet disease

Answer

The correct answer is B.

The patient’s presentation of acute unilateral eye pain, redness, photophobia, and posterior synechiae, along with a positive HLA-B27, is most consistent with HLA-B27-associated anterior uveitis. In patients with IBD, HLA-B27 positivity is associated with ocular symptoms such as anterior uveitis. It is typically recurrent, with 1-4 episodes occurring a year. Herpetic anterior uveitis (choice A) can also present with unilateral eye pain, redness, and photophobia, but it is also typically associated with high IOP, iris atrophy, and a history of herpetic lesions. Sarcoidosis-associated uveitis (choice C) causes granulomatous uveitis with “mutton-fat” precipitates and systemic findings like hilar lymphadenopathy, pulmonary symptoms, or skin lesions. Behçet disease (choice D) is a systemic vasculitis that can also cause anterior uveitis, but is classically associated with oral and genital ulcers, as well as skin lesions.

Source: Hendricks T, Obiano O, Warren A, Vogelgesang SA, Haugsdal JM. HLA-B27-associated Acute Anterior Uveitis. EyeRounds.org. September 27, 2022. Available from https://eyerounds.org/cases/334-HLA-B27-associated-Acute-Anterior-Uveitis.htm