How Do We Manage HLA-B27-associated Ocular Inflammation Refractory or Intolerant to Conventional Immunomodulatory Therapy?

The HLA-B27 gene is among the most studied genes in the history of medicine, and its relationship to ocular inflammation is well established. In particular, it has been known to be associated primarily with anterior chamber inflammation with clinical manifestations of nongranulomatous keratic precipitates, anterior chamber cells and flare, and in some cases, fibrin and/or hypopyon. With modern advanced imaging technologies, posterior segment involvement, including papillitis and retinal vasculitis can be detected in up to 31% of patients with HLAB27-associated uveitis.[1] Moreover, wide-angle imaging has allowed the diagnosis of peripheral retinal vasculitis that may be missed by standard imaging modalities. Although the long-term visual prognosis of HLA-B27-associated acute anterior uveitis (AAU) is generally favorable,[4] patients with HLA-B27- associated AAU are approximately five times more likely to have a visual acuity of 20/200 or worse as compared to patients without HLAB27-positivity.[5] Suboptimal visual outcomes may be complicated by steroid-induced side effects or delay in treatment of refractory cases; therefore, close monitoring with multimodality imaging and employing a stepladder approach in the management is necessary in every patient. Unfortunately, since relatively few studies have examined HLA-B27-associated AAU, and even fewer have focused on refractory cases, HLA-B27- associated AAU remains a significant therapeutic challenge for uveitis specialists. In their well-written manuscript and well-designed study published in the current issue of Journal of Ophthalmic and Vision Research (JOVR), Bajwa and colleagues[6] contribute to the literature by discussing the utility of infliximab in managing this particularly challenging disease.