来源： 尖峰打杂组 整理 尖峰眼科
第四节 人类白细胞抗原(HLA)-B27相关性葡萄膜炎
【症状】
急性眼痛，视物模糊，畏光;全身症状包括背痛，关节炎，日腔溃疡(疼痛比Behcet病轻)，尿道炎，银屑病性关节炎，炎症性肠道疾病。
【主要体征】
复发性的单侧或双侧的前葡萄膜炎。
【其他体征】
严重的前房反应:房水细胞、闪辉和纤维蛋白渗出，可有前房积脓，早期即可出现虹膜后粘连;睫状体充血。男性比女性更常见。
【鉴别诊断】
1.其他的前房积脓性葡萄膜炎：Behcet病(与HLA-27相关性葡萄膜炎相比，Behcet
病的眼后节受累更常见)、感染性眼内炎、视网膜母细胞瘤、转移性肿瘤、服用利福布汀、结节病、伪装综合征。
2.特发性的前葡萄膜炎。
【HLA-27相关性疾病分类】
1.单纯的HLA-27相关性葡萄膜炎 无全身性病变。
2.强直性脊柱炎 多发于青年男性，通常伴有低位背痛，骶髂关节X线检查异常，血沉加快，HLA-B27阳性。
3.炎症性肠道病变Crohn病和溃疡性结肠炎。慢性腹泻。
4.Reiter综合征 青年男性，结膜炎、尿道炎、多发性关节炎(多下肢受累)、偶有角膜炎，血沉加快，HLA-B27阳性。易复发。
5.银屑病性关节炎 皮肤特征性改变，关节炎多累及上肢。
【检查】
1.检测HLA-B27 明确诊断。
2.强直性脊柱炎 骸骼关节X线示关节硬化和关节腔狭窄，查血沉。
3.炎症性肠道疾病 内科和消化内科会诊。
4.Reiter综合征 结膜、尿道、前列腺分泌物培养，查找衣原体;合并关节炎时行关节X线检查;请内科或风湿病会诊。
5.银屑病性关节炎 请风湿病科或皮肤病科会诊。
【治疗】
治疗参见本章第一节前葡萄膜病。HLA-B27相关性葡萄膜炎易复发。
12.4 Human Leukocyte Antigen (Hla)–B27–Associated Uveitis
Symptoms
Acute pain, blurred vision, photophobia. Associated systemic complaints include back pain, arthritis, oral ulcers (typically not as painful as those seen in Behçet disease), urethritis, psoriatic arthritis, inflammatory bowel disease.
Signs
Critical. Recurrent, unilateral (or bilateral) anterior uveitis.
Other. Severe anterior chamber reaction with cell, flare, and fibrin. May have hypopyon.
Tendency to form posterior synechiae early. Ciliary flush. More common in men than women.
Differential Diagnosis
Other hypopyon uveitides:Behçet disease (posterior involvement more common than in HLA-B27), infectious endophthalmitis, retinoblastoma, metastatic tumors, rifabutin, sarcoidosis, masquerade syndromes.
Idiopathic anterior uveitis.
Types of HLA-B27 Disease
HLA-B27–associated uveitis without systemic disease.
Ankylosing spondylitis: Young adult men, often with low back pain, abnormalities on sacroiliac spine radiographs, increased ESR, positive HLA-B27.
Inflammatory bowel disease: Crohn disease and ulcerative colitis. Chronic diarrhea.
Reiter syndrome: Young adult men, conjunctivitis, urethritis, polyarthritis, occasionally keratitis, increased ESR, positive HLA-B27, may have recurrent episodes. Arthritis tends to involve the lower extremities.
Psoriatic arthritis: Characteristic skin findings and arthritis typically involves the upper extremities.
Work-Up
HLA-B27 to confirm diagnosis.
Ankylosing spondylitis: Sacroiliac spine radiographs show sclerosis and narrowing of the joint spaces, ESR.
Inflammatory bowel disease: Medical or Gastrointestinal consult.
Reiter syndrome: Conjunctival and urethral swabs for Chlamydia if indicated; a medical or Rheumatology consult.
Psoriatic arthritis: A Rheumatology or Dermatology consult.
Treatment
See 12.1, Anterior Uveitis. HLA-B27 uveitis often recurs.