Lupus and the Eyes
Alastair Denniston, Clinical Lecturer in Ophthalmology, Birmingham and Midland Eye Centre, UK
A significant minority of people with lupus have some sort of eye problem related to their disease. Fortunately in most people only the surface of the eye is affected. This does not damage their vision and is readily treated with eye-drops. Much less commonly the disease may involve the inside of the eye or the visual pathways in the brain. This may reduce vision and usually requires systemic treatment, either by oral or intravenous routes. In this article we will consider the different ways lupus can affect the eyes and the types of treatment available.
"My eyes always feel dry and irritable"
The most common eye problem experienced by people with lupus is 'dry eyes' (or keratoconjunctivitis sicca). Inflammation of the tear-producing glands (lacrimal glands) results in fewer and poorer quality tears. This makes the eyes feel gritty, irritable and dry. Sometimes the eyes will appear red. Although this may vary in severity, 'dry-eye' is generally a persistent problem that requires long-term treatment with artificial tears (eye-drops). Milder cases are usually effectively managed by one's GP although more severe cases may require an ophthalmologist.
There is a wide range of drops available. Watery drops like hypromellose are fine for mild dry-eyes. Their effect does not last very long so some people will need to put them in very frequently. Alternatively one can use one of the gels or ointments. Gels such as carbomer are less watery and last longer in the eye. However they do initially blur the vision and should not be used shortly before driving. Ointments such as paraffin are particularly thick and smeary and so are mainly used at night when the blurred vision is less of a problem. People with moderate or severe 'dry-eye' usually require a combination of drops, for example a gel by day and an ointment at night. Common tear replacement therapies are listed in Table 1.
A very few patients may need additional treatment. Some newer drops are now available that contain sodium hyaluronate. This is a natural product found in normal tears which in drop form improves the symptoms of 'dry-eye'. Another drop that is occasionally used is acetylcysteine which is useful where the 'dry-eye' is associated with abnormal mucus on the surface of the eyes. However it does sting, and so is only used in severe cases.
As well as giving replacement tears we can try to preserve the natural tears we do have by reducing drainage and evaporation. Tears are naturally drained away by the tear ducts. An ophthalmologist can block the tear ducts with temporary or permanent plugs, normally done as a ten-minute procedure in clinic. These plugs are often extremely effective but may need to be used in conjunction with artificial tears. Evaporation of tears from the surface of the eye is harder to control. Some benefit may be gained from using humidifiers, lowering the room temperature or by using moist chamber goggles.
"Ow - my eye really aches and is very red"
Some people with lupus may get inflammation of the white coat of the eyeball (the sclera). This scleritis may be very painful and is usually visible as a bright red patch on the white of the eye. Sometimes the scleritis is widespread so that all the white of the eye appears red. Although one's vision is not usually affected at the outset, scleritis is a sight-threatening condition and should be seen urgently by an ophthalmologist. Milder cases usually respond to oral non-steroidal anti-inflammatory drugs (NSAIDS) like flurbiprofen. More severe cases may require oral or intravenous steroids, or other immunosuppressive drugs.
"My optometrist says the back of my eye looks funny"
A few people with lupus may have tiny haemorrhages or fuzzy areas on the light-sensitive layer at the back of the eye (the retina). Most of the time this lupus retinopathy does not cause any problems with the vision but may be a useful marker that lupus is active elsewhere. Generally this improves as the lupus is brought under control with the usual treatments. Since high blood pressure or anaemia can also cause tiny haemorrhages on the retina, it is important that these are also checked for.
"I can't see properly"
A very few patients with lupus may get severe inflammation of the blood vessels of the retina. The damaged blood vessels are no longer able to supply enough oxygen to the retina that stops working properly causing gradual loss of vision. Sometimes the retina tries to grow new blood vessels. This might sound like a good idea but the new blood vessels are fragile and can cause major problems. Occasionally people with lupus may lose vision suddenly due to these blood vessels either bleeding (vitreous haemorrhage) or pulling the retina from the wall of the eye (retinal detachment). Loss of vision in one eye may also be caused by blockages in one of the retinal blood vessels (retinal vein occlusion or retinal artery occlusion). This particular problem is more common in those people who also have antiphospholipid syndrome.
People with sight-threatening retinopathy need urgent assessment by an ophthalmologist. Intensive treatment is usually with steroids or other immunosuppressive drugs. The new blood vessels may require laser treatment to the retina to make them go away. Very occasionally surgery may be needed.
Sometimes loss of vision is due to inflammation of the optic nerve or brain rather than the eye itself. Although the eyes themselves may look normal it is often possible to work out where the problem is from the pattern of missing vision and other aspects of visual function. Brain scans may sometimes be helpful in this context. Damage to the nerves supplying the eye muscles may cause double vision. Although this may resolve with time, people often benefit from correction with prisms or less commonly with botulinum toxin or surgery.
Summary
Eye problems are not very common in lupus. When they do occur they are more commonly irritating rather than serious. Nevertheless inflammation of the eye (scleritis and retinal disease) needs systemic treatment to protect vision. This can also be a useful warning that the lupus is flaring up elsewhere and may require increased treatment generally.
Our thanks to Alastair Denniston for kindly producing this informative article which we hope members will find of interest.
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