Oxnard - Port Hueneme Optometry   Dr. Don Steensma 465 W. Channel Islands Blvd, Port Hueneme, CA 805/486-3585


Autoimmune disease and the eye a 2012 Update

Inflammation is a primary component of many, ocular conditions including ocular surface disease, age related macular generation (ARMD) and uveitis. Corticosteroids and other potent anti-inflammatory drugs are used to treat these conditions. The three most common inflammatory autoimmune diseases are Sjogren's syndrome, rheumatoid arthritis (RA) and multiple sclerosis (MS). Less commonly seen inflammatory autoimmune diseases include systemic lupus erythematosus (SLE), the spondyloarthopies, giant cell arteritis and Graves Disease.

The ocular signs and symptoms of autoimmune disease include:

Keratitis 

Inflammation of the cornea. Often the patient complains of eye pain, a foreign body sensation, red eye and a decrease in vision. Autoimmune keratitis is usually treated with NSAIDs and steroids.

Keratoconjunctivitis sicca (KCS)

This is dry eyes caused by inflammation. Patients note that their eyes are red, burn, have eye pain, feel a foreign body sensation and sometimes a decrease in vision. KCS is treated with lubricant drops of various viscosities, the anti-inflammatory Restasis and sometimes steroids.

Scleritis

inflammation of the sclera. This can cause a dark red to bluish appearance of the eye, boring pain which may radiate into the cheeks and eyebrows with marked light sensitivity. Often there is a reduction in visual acuity. Phenylephrine will not blanch the blood vessels. Scleritis is usually treated with NSAIDs, steroids and immunosuppressive drugs.

Episcleritis

Inflammation of the episclera. The eye will have a bright red area and is often felt as a mild ache which may radiate into the cheeks and eyebrows. Vision is unaffected. Phenylephrine will blanch the blood vessels. Episcleritis is usually treated with NSAIDs or steroids.

Uveitis

Inflammation of the choroid. The eye will be very red and painful. The classic sign is light sensitivity. Vision maybe blurred. Uveitis is only treated with topical steroids and a cycloplegic drug.

Optic neuritis

Inflammation of the optic nerve. Vision is decreased. The classic signs are pain with eye movement and a decrease in color vision. Optic neuritis is treated with IV steroids.


Sjogren's Syndrome

The hallmark of Sjogren's syndrome is xerostomia (dry mouth), xerophthalmia (dry eyes) and arthritis. An overproduction of B-lymphocytes plugs up and destroys the tear, saliva and even sweat glands.

Sjogren's will cause extremely dry eyes. Patients complain of burning, gritty, red eyes.

Sjogren's will cause a very dry mouth and throat. The patient may have difficulty chewing and swallowing. There may be a decreased sense of taste. They often have an increased incidence of cavities. Often there is a dry cough or hoarseness in their voice. The parotid glands are often enlarged leading to a puffiness along the cheek line.

Sjogren's may cause persistent fatigue. Patients often feel very tired and often have aches and pains.

Less common symptoms may include thyroid gland abnormalities, skin rashes, numbness, gastrointestinal problems and irritation of the nerves in the arms and legs. In severe cases, inflammation of the lungs, liver, kidneys and pancreas can cause damage to those organs.

There is no true cure for dry eyes, however there are ways of managing the condition. Lubricant drops may provide relief for a short time and may have to be instilled several times a day. The preservative found in many lubricant drops can be toxic if used several times a day so a non-preserved lubricant drop would be preferred. Gel lubricant drops last on the eyes longer so give more relief but may blur vision.

Restasis (cyclosporine) is an anti-inflammatory drug use on the eye for severe dry eye. Restasis reduces some of the inflammation, actually making the eye less dry. Often a short course of steroid eye drops can jump-start the treatment. In some cases placing small punctal plugs in the tear drainage canal preserves the tears on the eyes longer resulting in less dry eye symptoms.

Dry mouth symptoms may be improved by taking Exovac (cevimeline) by mouth 3 times a day. It increases saliva and sweat secretion. It is contradicted in patients with uncontrolled asthma, acute iritis or narrow angle glaucoma. Side effects may include excess sweating, diarrhea and nausea. This would normally be prescribed by a rheumatologist.


Rheumatoid arthritis (RA)

RA is a systemic inflammatory disease that can affect the entire body. Approximately 1.3 million Americans have RA. Most are females and over 65 years old, but there is also a juvenile form of RA. About 25% of patients with rheumatoid arthritis will have ocular manifestations.

Management of the condition includes systemic suppression of the autoimmune system. Disease modifying antirheumatic drugs (DMARDs) are often prescribed to decrease joint inflammation and destruction. DMARDs are divided into the categories oral or biologic. Oral DMARDs slow the formation of the new cells that can cause joint inflammation. Biologic DMARDs are injected and act in several different ways. DMARDs are very potent medications and patients should be followed closely by a rheumatologist. Frequent blood tests and urinanalysis are often required. Commonly used oral DMARDs are chloroquine, hydroxychloroquine, methotrexate, leflunomide and sulfasalazine. Less commonly used oral DMARDs include cyclosporine and gold salts. Biologic DMARDs include abatacept, anakinra, rituximab and tocilizumab.

Some of the most common systemic side effects caused by DMARDs include blood or protein in the urine, low white blood cell count, liver or lung damage, skin rashes, bone marrow toxicity, nausea and hair loss. Ocular side effects often include ocular surface disease and dry eyes, episcleritis and uveitis. The dry eyes is treated the same as in the treatment of Sjogren's syndrome. Episcleritis and uveitis are treated with steroids. In some cases a very severe condition referred to as "Bull's-eye" maculopathy may develop. This is a change in the structure of the macula which leads to reduced visual acuity and color vision.


Multiple Sclerosis (MS)

MS is caused by inflammation of the myelin sheath around a nerve. The myelin helps insulate the nerve from external electrical impulses. When it is damaged the nerve does not function normally.  The cause is unknown but thought to be an auto-immune disease becuase the disorder sometimes follows a viral infection.  MS is a chronic, recurrent disease characterized by disseminated patches of demyelination in the brain and spinal cord.  MS affects aproximately 350,000 Americans and 2.5 million people worldwide .  The disease is 3 times more common in women than in men.  Typically onset is between ages 20 and 40.  It is more common in older climates.  There may be a relationship between a vitamin D deficiency and MS.  It is more common in Caucasians than in other races.

Many MS patients have mobility issues they restrict their movements. MS patients may develop optic neuritis (inflammation of the optic nerve) which can lead to severe loss of vision. MS patients often develop severe ocular surface disease and dry eye from insufficient tear production. They also may have eyelid lagophthalmous (the lid does not close completely, and possibly uveitis.

Systemic treatment of MS may include Betaseron (interferon) to reduce inflammatory flareups. MS is a chronic condition that needs be managed for a lifetime. There is no cure. Ocular surface disease and dry eyes are treated the same as in the treatment Sjogren's syndrome.


Systemic lupus erythematosus (SLE)

Ocular disease occurs and 20% of patients with SLE. Typical complications include optic neuritis, ischemic optic neuropathy, amaurosis, and visual hallucinations. There may be retinal disease manifested as cotton wool spots, retinal hemorrhages, retinal vasculitis or proliferative retinopathy. Retinal disease has a high morbidity and should be treated aggressively by a retinal specialist.


The spondyloarthropathies

Ankylosing spondylitis or an inflammation of the vertebra is the most common form. Approximately 25% of patients with ankylosing spondylitis develop uveitis.


Reiter's Syndrome

Autoimmune condition that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease. Up to 37% of patients with Reiter's syndrome develop uveitis.

Psoriatic Arthritis

Autoimmune condition they can cause inflammation of the skin, spine, tendons, cartilage, eyes, and lungs. Approximately 20% of patients develop uveitis


Crohn's disease and ulcerative colitis

Autoimmune conditions that cause inflammation of the digestive tract. Approximately 9% of patients with Crohn's disease or ulcerative colitis develop uveitis.


Giant Cell Arteritis (GCA)

Up to 50% of patients with GCA present with ocular symptoms that include pain, vision loss, double vision, jaw or neck pain and temporal artery tenderness. Diagnosis is made based on an elevated sedimentation rate and confirmed with biopsy of the temporal artery. The treatment is immediate intravenous corticosteroids to prevent further vascular consultations, permanent blindness or death.


Graves Disease

Approximately 50% of patients with thyroid disease develop exophthalmous or bulging eyes. Apparently it is strongly associated with smoking. Optic nerve compression may lead to reduced visual acuity, limited visual fields, pupillary anomalies, and color vision defects. Diagnosis is by MRI the orbit.


Myasthenia Gravis

Inflammation of the eyelid muscles result in drooping eyelids when tired. It is treated with several different medications.


Sarcoidosis.

Ocular inflammation results in uveitis, cranial nerve palsy, and enlarged tear glands and sometimes optic neuropathy.


Wegener's Granulomatosis

Ocular inflammation can results in bulging eyes, uveitis, orbital cellulitis, and optic neuropathy.


Betcet's Syndrome

Ocular inflammation results in uveitis.


Polyarteritis Nodosa

Ocular submission results in episcleritis, scleritis and optic neuropathy.


Takayasu's arteritis

Ocular inflammation causes vaso-occlusive retinopathy, cataracts and ischemic optic neuropathy.




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