Women at greater risk for autoimmune
diseases with ocular manifestations
Communication with physicians managing
the patient’s systemic disease is crucial.By Katrina Altersitz
continued from page-1
“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, 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
Dr. Foster said that scleritis and peripheral keratitis
are all “absolutely dreadful” ocular manifestations of
rheumatoid disease that require systemic therapy, often
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.”