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SAA has introduced a new benefit for members - monthly podcasts. Members can access monthly podcasts in the Member Area of spondylitis.org.

For the Member podcast for September 2008, we interviewed James Rosenbaum, MD, Professor of Ophthalmology and Cell Biology, Head of the Uveitis Clinic and Director of Inflammation Research at Oregon Health and Sciences University in Portland, Oregon. He has also been a member of our Medical Advisory Board for several years. Here are some excerpts from that podcast.

Jim Rosenbaum, MD: The uvea is the middle portion of the eye. The eye has three layers and the mid portion would be the iris at the front that's adjacent to the ciliary body, which is a part of the eye that makes some of the fluid that's in the eye and then the back of the uvea is the choroid, which is next to the retina. The choroid is a very vascular network. It brings blood and oxygen to the retina. So, uveitis would be an inflammation at any one of those tissues, iritis, or when the ciliary body's involved, iridocyclitis or if the choroid's involved, choroiditis.

And then, when you have uveitis, often the tissue next to it is often inflamed, as well, so chorioretinitis would be a type of uveitis. Sometimes the entire uveal tract's involved and that's called a panuveitis. So, iritis is a subset of uveitis and it refers to when the front part of the uveal tract to the iris is inflamed. Maybe I should define inflammation, would that be helpful to you?

Melissa Velez Coelho: Yes, I think so.

Jim Rosenbaum, MD: Well each of us is fortunate to have an immune system. Our immune system would be primarily our white blood cells and our white blood cells are a little bit like the Coast Guard. They're vigilant. They're on alert. They're looking for any kind of danger signal. And when our immune system senses that something's amiss, it goes and attacks.

Now, if it's attacking an infection like bacteria, a virus, it does its job perfectly and it gets rid of that infection. But there are diseases like ankylosing spondylitis, or reactive arthritis, where the immune system seems to be misreading a signal, so in ankylosing spondylitis it causes inflammation in the sacroiliac joints. In iritis, the white cells are sent to attack the iris as if the body thinks there's an infection there, but as best we can discern medically and scientifically, there is no infection, but they sent the warriors out and the warriors do collateral damage.

Melissa Velez Coelho: When somebody who gets uveitis or iritis, what are some of the symptoms that they might see?

Jim Rosenbaum, MD: Well the inflammation in different parts of the uveal tract results in different symptoms, but in iritis, when it starts suddenly, the eye is red, you have pain and you have sensitivity to light. Now, there are patients who have juvenile arthritis and they have a form of iritis that's very different from the iritis we seen in ankylosing spondylitis. They have a severe and potentially blinding iritis, but typically in retinas and it doesn't cause any pain. And the choroids doesn't have the same symptoms or sensitivity to pain that the iris does, so a chorioretinitis usually is painless and the eye may not be red, but vision is distorted with a choroiditis or chorioretinitis.

Melissa Velez Coelho: Doesn't it typically only occur in one eye?

Jim Rosenbaum, MD: The iritis that is classically associated with ankylosing spondylitis is only in one eye at a time. It will start suddenly; patients very frequently know a day or two before that something's amiss. The eye usually feels a little bit scratchy as if there's a foreign body present, and then, it's active in one eye. Sometimes when that eye resolves, it definitely has a tendency to recur and in some people it jumps over to the other eye and recurs in the other eye. But, it is unusual for both eyes to be inflamed simultaneously.

There are exceptions and especially when you have spondylitis associated with inflammatory bowel disease or spondylitis associated with psoriasis, those exceptions do more frequent, but if you have only ankylosing spondylitis, 95 percent of the time, only one eye is involved at any given point in time.

Melissa Velez Coelho: Who would diagnose somebody with iritis and then what would be the typical treatment plan?

Jim Rosenbaum, MD: Iritis certainly can be suspected by a rheumatologist and it can be accurately suspected by the patient, but in order to make a definitive diagnosis you need what's called a slit lamp, which is basically a microscope that allows you to see those white cells attacking the iris. An ophthalmologist or an optometrist could diagnose iritis because it's a medical condition associated the systemic disease; my personal preference is that an ophthalmologist is more appropriate. The treatment really depends upon the severity.

The mainstay therapy would be a drop, which we call a topical corticosteroid; usually Prednisolone acetate and those drops are generally very effective. There are some risks, as would be true with any medication. One risk in some patients it raises the pressure in the eye to levels that could damage the nerve and chronic drops could cause a cataract. You have a lens in your eye and when that lens get cloudy, you call that a cataract. But, for most people, at least, a corticosteroid drop, a Prednisolone acetate drop is the mainstay therapy.

We also dilate the eye with another drop and that helps to relieve some of the pain. It also prevents the pupil from getting stuck and in iritis, especially iritis associated with ankylosing spondylitis, the fluid in the eye can get sticky and as a result, the iris can adhere to the lens, which is behind it, and become immobilized. You need to move your iris because the iris creates the pupil and you want your pupil to accommodate to light and dark. Now, those two drops, the dilating drop and the steroid drop, those are the mainstays of therapy.

In some people the iritis is so severe that we might inject cortisone around the eye, just the way you would inject a shoulder or a knee that's flaring in ankylosing spondylitis. In some people, we might give some prednisone for anywhere from a few days to a few weeks, but usually not chronically. In some people we might recommend an oral non-steroidal, like ibuprofen to try to reduce the pain.

And then, it would be a very, very rare individual for whom we'd need to do something in addition, either to prevent recurrent attacks or to really try to stem an extremely severe attack. I've been doing this now since 1985, so for 23 years and I'd say 99 percent of the time, what I've outlined so far is all that's necessary.

Melissa Velez Coelho: How soon should somebody seek treatment once they think that an iritis attack is coming on?

Jim Rosenbaum, MD: The sooner the better. The drops, in particular inhibit the body's ability to make some of the substances that cause inflammation, there are the prednisone drops, so the sooner they're started, the more effective they are. And for patients who have recurrent attacks those patients are often better at predicting whether an attack is on the way the physician. So, many patients are aware of the symptoms form their body, that have recurrent attacks, I will have them carry some prednisolone acetate wherever he or she goes.

Melissa Velez Coelho: What percentage of people with spondyloarthritis, typically get at least one bout of iritis?

Jim Rosenbaum, MD: You know, different studies give you different numbers, but 40 percent is pretty accurate. It is by far the most common non-articular manifestation of spondyloarthritis. In other words, besides involving the joints, if it's going to involve another part of the body, the eye is the most likely.

Melissa Velez Coelho: Can you talk about what's going on in uveitis research or have there been any new developments?

Jim Rosenbaum, MD: Research, of course, never advances as quickly as we'd like, but I think actually that this is a renaissance time for uveitis research. I'm extremely biased in this regard, but I think that the best work is coming from a group of us who are working together in Portland, at the Oregon Health and Science University and the Casey Eye Institute. One individual is Tammy Martin who is the world's expert on the genetics of uveitis. Tammy has been literally collecting blood samples from all over the world to try to identify any genes that would predispose to developing iritis.

We know that one gene, of course, is HLA-B27 and you could pick up iritis without having any spondylitis, especially if you're HLA-B27 positive, but Tammy's identified a couple other areas of chromosomes that seem to predispose to iritis, at least one of which doesn't seem to predispose to the sacroiliitis and spondyloarthritis. As the technology for doing this gets better and better and better, we think that it's highly likely that Tammy will be able to identify specific genes and those genes are going to give us insights into what's causing this and those insights, we hope, will lead to new therapies.

Someone else in my group who's doing very innovative things, with regard to iritis, is a young scientist who's name is Holly Rosenzwieg. She has been studying a mouse model in which the mice are immunized with a protein called aggrecan. Aggrecan is found in tendons and sacroiliac joints and when she immunizes the mice with aggrecan, she's observed, as a couple of other people have observed, that the mice get sacroiliitis, which of course is the form of arthritis that allows us to diagnose spondyloarthritis.

But what Holly's uniquely observed is that not only do many of these mice get the sacroiliitis, but they also get an iritis along with it. This is the very first time that we've had a mouse model in which both iritis and sacroiliitis have occurred together. She has applied to the National Institutes of Health for additional monies to be able to study this. They ask questions such as: Are the same factors that drive the iritis identical to what causes the sacroiliitis? Will we find some substances that are unique to the eye, some unique to the sacroiliac joints, and then some substances perhaps that are common to both? So, that's a very exciting innovation.

The third thing, which we're trying to do in Portland, is to look in the blood of patients who have iritis and literally measure 50,000 different genes in the blood. So, we all have the same number of genes, but different cells express different genes, so a cell in the skin is going to express something that's different from what's in the liver.

When you go to your doctor, your doctor might do a blood test and measure five things or ten things or a dozen things. We can measure on a gene level, an RNA level, 50,000 different things at once in the blood and we're hoping that that study will also give us unique clues about what's going on in both the eye and in the sacroiliac joints. That work is moving along well, but it's slow in part because we get so much information that it's hard to know what's relatively important. It's also difficult because we're looking in the blood and the inflammation, of course, is in the joint and in the eye and we don't know for sure how well what's in the blood is going to reflect what's in the joint and the eye.

But we're excited and we have some preliminary observations, at least, that we hope to share at the American College of Rheumatology meeting when it meets in San Francisco at the end of October. So, we need to recruit more subjects for that. We need to make more observations, but that's a third novel approach that we're trying to understand iritis and especially to say, "If I've got ankylosing spondylitis, and active iritis, am I going to have different genes activated in my blood compared to someone with ankylosing spondylitis and no iritis." Melissa Velez Coelho: How can our members get involved with uveitis research?

Jim Rosenbaum, MD: Well, for the genetics work, Dr. Martin is really collecting samples from all over the country; individuals could call my office. That number is 503-494-5023. There are ethical issues and confidentiality issues and validation of the diagnosis issues that we'd have to address if you wanted to participate, so that we could include you in our genetic studies. Obviously, you can't really participate in the mouse study, but you can do things like be sure that your Congressman or Congresswoman is aware of how important medical research to you.

Our special thanks to Dr. Rosenbaum for his time, expertise and participation in September's Member Podcast.

To listen to this podcast in its entirety including questions from SAA Members, log on to the Member Area of spondylitis.org.

If you have a question you wanted answered by our spondylitis experts on a future podcast, send your questions to Melissa Velez Coelho, Director of Program Services, at melissa.velez@spondylitis.org.