Women at greater risk for autoimmune diseases with ocular manifestations

  episcleritis

Communication with physicians managing the patient’s systemic disease is crucial.

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“There is a danger dose, which is measured in milligrams per kilogram, so a smaller person would be more likely to be at that danger dose using a regular dose of Plaquenil,” Dr. Colby said. “It causes a retinopathy, basically dysfunction of the retina cells.”

The site for some of the most serious ocular complications of lupus is the retina, Dr. Foster said.

“Patients with lupus can develop an immune complex vasculitis with the lodging of immune complexes forming in the vasculature, both in the choroid and in the retinal vasculature itself,” he explained.

This ophthalmic emergency can cause permanent vision loss, but it can also be a prompt for systemic lupus testing in an as yet undiagnosed patient or a sign of similar immune complexes in other areas of the body.

“Ophthalmologists have a spectacular opportunity not only to influence the situation but also to be lifesavers as well if they make the diagnosis of lupus in the patient,” Dr. Foster said. “The presence of lupus retinopathy with retinal vasculitis or choroidopathy is a terrifically reliable hallmark of the presence of these immune complexes lodging in other areas as well, most particularly the brain and the kidney. The likelihood of the patient dying from one of those sites being affected by lupus nephropathy or lupus affecting the central nervous system is very high in the patient with lupus retinopathy who is not properly, appropriately and aggressively treated.”

Rheumatoid arthritis

Rheumatoid arthritis, another collagen vascular disease, is four times more common in women than men and presents problems similar to those with lupus, including dry eye.

“You can also get scleritis and pretty severe inflammatory disorders, things like melting of the peripheral cornea,” Dr. Colby said. “There’s a lot of overlap with lupus.”

Dr. Foster said the approach to treating dry eye or secondary Sjögren’s in rheumatoid arthritis patients is much like that in lupus, including the use of Restasis (cyclosporine ophthalmic emulsion, Allergan) along with heat and massage to improve the function of the meibomian glands.

In addition, he said, the ophthalmologist must be aware of the patient’s systemic disease management to best treat its ocular manifestations.

“See if there is any evidence of the underlying rheumatoid disease being active, so to speak, even if it’s not active in the joints,” Dr. Foster said. “Are there markers in the blood that would indicate that chronic low-grade inflammatory activity is afoot? If so, deal with that systemically with a sprucing up of the systemic medication program.”

Dr. Foster said that scleritis and peripheral keratitis are all “absolutely dreadful” ocular manifestations of rheumatoid disease that require systemic therapy, often aggressive.

Dr. Colby added, “The important thing with the systemic diseases is, the better the systemic diseases are managed, the easier it is to manage the ophthalmic manifestations. I can treat someone’s rheumatoid-associated dry eye all I want, but if their systemic rheumatoid disease is not under control it’s like sticking your finger in the dike.”