2020–2021 BCSC Basic and Clinical Science Course™
8 External Disease and Cornea
Chapter 11: Diagnosis and Management of Immune-Related Disorders of the External Eye
Immune-Mediated Disorders of the Conjunctiva
Conjunctivitis/Episcleritis Associated With Reactive Arthritis
Reactive arthritis (formerly called Reiter syndrome) is a systemic disorder characterized by the classic triad of ocular (conjunctivitis/episcleritis, iridocyclitis, or keratitis), urethral, and joint inflammation. The joint inflammation is often highly asymmetric and involves a few joints (oligoarticular). These manifestations can appear simultaneously or separately, in any sequence. Less common manifestations include keratoderma blennorrhagicum (a scaling skin eruption), balanitis, aphthous stomatitis, fever, lymphadenopathy, pneumonitis, pericarditis, and myocarditis. Attacks are self-limited, lasting from 2 to several months, but they may recur periodically over the course of several years.
Reactive arthritis may occur after dysentery due to gram-negative bacteria (most frequently Salmonella, Shigella, and Yersinia species) or after nongonococcal urethritis caused by Chlamydia trachomatis. More than 75% of patients with reactive arthritis are HLA-B27–positive. See BCSC Section 9, Uveitis and Ocular Inflammation, for discussion of HLA-B27–related diseases and illustrations of nonocular manifestations of reactive arthritis.
The most common ocular finding in reactive arthritis is a bilateral papillary conjunctivitis with mucopurulent discharge, which has been reported in 30%–60% of patients. The conjunctivitis is self-limited, lasting for days to weeks. Some patients present more often with episcleritis rather than with conjunctivitis. Mild nongranulomatous anterior uveitis has been reported to occur in 3%–12% of patients. Various forms of keratitis—including diffuse punctate epithelial erosions, superficial or deep focal infiltrates, or superficial or deep vascularization—may occur in rare cases. Reactive arthritis should be considered in any case of chronic, nonfollicular, mucopurulent conjunctivitis with negative culture results.
Treatment is mainly palliative. Corneal infiltrates and vascularization often respond to topical corticosteroids. Systemic treatment of any related infection with oral antibiotics may be beneficial. Occasionally, the intraocular (uveitic) component of the disease can be very severe and require systemic immunosuppression (see BCSC Section 9, Uveitis and Ocular Inflammation).
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.