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.