Ocular Manifestations of

Inflammatory Bowel

DiseaseRaed Behbehani , MD FRCSC

Burrill Bernard Crohn

• Reported two cases with

UC who severe pain and

photophobia and

peripheral corneal

ulcerations .

• Crohn, B. B. (1925). Ocular lesions

complicating ulcerative colitis. Amer. J.

med. Sci., 169, 260-267.

Etiology of IBD

• Multiple etiologic factors.

• Genetic (Nod2 gene on chromosome 16)

• Infectious

• Immunological dysregulation (increased TNF-

alpha and IFN gamma)

Extra-Intestinal

Manifestations

• Skin , Eye , Joints , Hepato-biliary system.

• Ocular manifestations occur in 4-10% of patients.

• conjunctivitis, episcleritis, scleritis, marginal

keratitis, anterior uveitis, retinitis, retinal

vascular occlusive disease, optic neuritis, and

orbital inflammatory disease

Ocular Manifestations

• Risk is higher in patients with colitis and

ileocolitis than ileitis.

• Patient with Arthritis have 33% risk for ocular

involvement.

• 50% have more than one ocular complication

and 68% of patients with ophthalmic

complications may also have at least one other

extraintestinal manifestation.

Pathophysiology of Ocular

Involvement

• Circulating antigen-antibody complexe.

• Autoantibody production against cellular antigens.

• Damage to GI mucosa allows leakage of proteins

and microorganisms—> reactive lymphoid

hyerplasia —> Antigen-Antibody complex —>

Systemic involvement.

• Higher prevalence of HLA-B27.

Episcleritis

• The most common

ocular manifestation in

IBD.

• Nodular , diffuse

• Injection (sectoral or

diffuse)

• Blanches with topical

application of

phenylephrine.

Episcleritis

• Vessels can be moved with a

cotton tip applicator.

• Pain is mild to moderate.

• In CD can indicate disease

activity .

Episcleritis

DiffuseNodular

Episcleritis Treatment

• Mild-Idiopathic : Tear drops , topical NSAID

• Moderate-Severe : Systemic NSAID , topical

steroids

• Must treat underlying disease (anti-TNF e.g,

Infliximab)

Scleritis

• Less common in IBD.

• Deep more sever pain.

• More morbidity.

• 50% have an underlying

systemic disease

• Needs more aggressive

treatment.

Scleritis

• Anterior - Posterior

• Nodular- Diffuse

• Necrotizing-Nonnecrtozing

Scleritis

• Recurrent scleritis can lead to

scleromalacia.

Scleritis Treatment

• NSAID.

• Steroids.

• Immunosuppressive agents (azathioprine,

mycophenolate mofetil, cyclophosphamide, or

cyclosporine)

• Anti-TNF (infliximab or adalimumab)

Anterior Uveitis

• Uveitis (Anterior, intermediate

, posterior)

• Pain , photophobia.

• Association between CD, and

sacroiliitis.

• HLA-B27

Uveitis

• Low grade non-

granulomatous iritis.

• Insidious and may persist up

to 6 months.

• 60% recurrent anterior uveitis .

• 10% non-recurrent anterior

uveitis.

• 30% panuveitis. (choroiditis)

Uveitis , Scleritis , Episcleritis

Optic Neuritis in IBD

Neuro-ophthalmic

Manifestations

• Associated with iritis, vitritis,retinal vas- culitis,

and choroiditis.

• Optic neuropathy secondary to dietary deficiency

.

• Vasocclusive complications (Hemiparesis , gaze

palsy, Hemianopia)

Keratitis

• Sub-epithelial keratitis

• Small subepithelial corneal

infiltrates.

• Bilateral and symmetric.

Orbital Complications

• 1% cases of proptosis.

• Orbital inflammatory syndrome , orbital myositis.

• Responds to steroids.

• Must differentiate from Orbital Cellulitis.

Retinal Complications

• Rare

• Retinal vascular occlusion , retinal edema and

serous detachments of the retina.

• Retinal arteriolar and vein occlusion.

• Cystoid macular edema (20%) in posterior

uveitis.

Retinal Vasculitis

Cystoid Macular Edema

Central Serous Retinopathy

Management

• Topical steroids.

• Periocualr steroids.

• Systemic steroids , NSAID.

• Cytotoxic immunosuppressive.

• Monoclonal antibody (anti-tTNF) e.g.

adalimumab, infliximab

Glaucoma and Uveitis

Glaucoma Treatment

• Medical : Topical Beta-blockers (Timolol) , Alpha-

agonists (Brimonidne) , Prostaglandin analogues.

• Surgical : Laser for acute angle closer glaucoma

, Filtering surgery (trabeculectomy, Glaucoma

drainage device) , Ciliary body ablation.

Trabeculectomy

Galucoma Drainage Device

Cataract and Uveitis

Other Ocular Complications

• Endogenous endophthalmitis (central line)

• Nutritional Optic neuropathy and retinopathy ,

Wernicke’s Encephalopathy (B12, thiamine

deficiency)

• Cyclosporine in Crohn’s disease ( optic

neuropathy, ophthalmoplegia, and nystagmus).

Anti-TNF alpha and Risk of

Optic Neuritis• Anti-TNF alpha associated with demyelination.

• 17 cases reported in literature.

• Large cohort study (SABER) incidence of ON 5–5-10

per 100,000 patient-years.

• Not different from non-biologic disease modifying

drugs.

• In patients with underlying demyelinating disease ,

anti-TNF alpha should be avoided.

Summary

• Episcleritis , scleritis and anterior uveitis are the most

common eye manifestation of IBD.

• Ocular manifestations are common in patients with

colitis and other extra-GI manifestation.

• Treatment of underlying IBD is often effective.

• Steroids , immunuppressives and anti-TNF agents are

used in resistant cases.

• Cataract and glaucoma are sequelae of uveitis in IBD.