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Lupus and Your Eyes

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by Cono Grasso, MD …

by Cono Grasso, MD
Jamaica Hospital Medical Center

Presented at the S.L.E. Lupus Foundation's "Get into the Loop!" New York City Lupus Education Series on October 6, 2010.

Published in: Health & Medicine

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  • 1. Ophthalmic Manifestations of Systemic Lupus Erythematous Cono M. Grasso, M.D. Chairman, Department of Ophthalmology Jamaica Hospital Medical Center
  • 2. Etiology and Pathogenesis
    • Although the etiology is unknown there appears to be a genetic predisposition
    • Is a multisystem autoimmune disease and thus may affect almost any organ system
  • 3. Clinical Features
    • The incidence of SLE has been estimated as 2-9 cases per 100,000 per year
    • Has a chronic course marked by periodic exacerbations of varying severity
  • 4. Clinical Findings
    • Cutaneous disease (85%)
    • Mucosal lesions (40%)
    • Articular disease (80-85%)
    • Renal disease (50%)
    • Neurological disorders
    • Hematological disorders
      • Often have an anemia seen in patient’s with chronic disease
      • Thrombocytopenia (33%)
    • Immunological disorders
  • 5. Treatment
    • Because SLE is a multisystem disease with highly variable features treatment is directed towards the specific symptoms in any given patient.
  • 6. Ocular Manifestations
    • Involvement of the skin and eyelids with cutaneous disease
      • These lesions develop as a red, inflamed patch with a scaling and crusty appearance. The center areas may appear lighter in color with a rim darker than the normal skin
      • Lesions usually involve the lid margins
  • 7. Ocular Manifestations
    • Secondary Sjorgen’s Syndrome
      • Seen in 20% of patients with SLE
      • Indistinguishable from the sicca component that is seen in other patients with rheumatic disorders
  • 8. Dry eye syndrome
  • 9. Dry Eye Syndrome
  • 10. Dry Eye Syndrome
  • 11. Sjorgen’s Syndrome Diagnosis & Treatment
    • Slit Lamp examination
    • Tear Break –up time testing
    • Schirmer (2) testing
    • Tear replacement therapy
    • Restasis
  • 12. Ocular Manifestations
    • Retinopathy
      • The most common form of ocular involvement in SLE patients
      • Retinopathy mainly consists of nerve fiber layer infarcts (cotton-wool spots) with or without intraretinal hemorrhages
        • Frequency of this finding varies with patient population studied
          • 3% of ambulatory patients
          • 28-29% of hospitalized patients with active SLE
  • 13. Nerve Fiber Layer Infarcts
  • 14. Lupus Retinopathy
  • 15. Ocular Manifestations
    • Retinopathy (continued)
      • Occurs independently of hypertension
      • IVFA suggests mild background retinopathy with microaneurisms and telangiectatic vessels may be relatively common
      • Doppler ultrasound suggests altered microcirculatory hemodynamics in the ophthalmic artery and central retinal artery
  • 16. Ocular Manifestations
    • Retinopathy (continued)
      • Severity of the retinovascular changes correlates with the activity of the disease
      • May see vascular occlusive disease
        • CRAO
        • CRVO
        • BRAO
        • BRVO
        • Diffuse retinal vaso-occlusive disease
          • Poorest prognosis with 50% of affected eyes becoming blind
  • 17. Branch Vein Occlusion
  • 18. Central Retinal Vein Occlusion
  • 19. Branch Retinal Artery Occlusion
  • 20. Central Retinal Artery Occlusion
  • 21. Ocular Manifestations
    • Retinopathy (continued)
      • Choroidopathy is rather uncommon
      • Usually seen when patients have hypertension because if lupus nephropathy or systemic vasculitis
  • 22. Lupus Choroidopathy
  • 23. Ocular Manifestations Treatment
    • Retinopathy
      • Treatment of often directed towards that of the underlying disease
        • Systemic corticosteroids
        • Immunosuppressive agents
      • In patients with diffuse retinovascular disease often panretinal photocoagulation is of benefit
        • 50% of eyes with severe vaso-occlusive disease become legally blind
        • In the more common mild retinopathy patients visual loss is unusual
  • 24. Ocular Manifestations
    • Neuro-ophthalmic involvement
      • Any of the cranial nerve palsies
      • May get visual field defects
      • May get visual hallucinations
      • Lupus Optic neuropathy (1-2%)
        • May be a retrobulbar neuritis
  • 25. Ocular Manifestations
    • Scleritis
      • Less common in SLE than the other rheumatic disorders (4%)
      • Any type of scleritis may be seen but the anterior form is more common
        • Diffuse
        • Nodular
        • Necrotizing
  • 26. Scleritis
  • 27. Scleritis
  • 28. Scleritis
  • 29. Scleritis
  • 30. Ocular Manifestations Treatment
    • Scleritis
      • Usually directed towards controlling the patient’s SLE
      • Oral non-steroidal anti-inflammatory agents
      • Topical steroids
      • Low –dose oral steroids
      • In necrotizing scleritis may use oral cytotoxic agents
  • 31. Complications of treatment
    • Cataracts
      • (secondary to corticosteroid usage)
    • Bulls-eye retinopathy
      • (secondary to hydroxychoroquine or chloroquine)
      • Side effects are dose related
      • Less than 5% when on hydroxychoroquine less than 400mg per day
      • May be reversible if caught early
  • 32. Cataract
  • 33. Cataract
  • 34. Complications of Treatment
    • Bulls –eye maculopathy (continued)
      • Patients need base-line ophthalmic exam
      • Visual field testing
      • Follow-up examinations
        • If dose is 400mg daily – every 6 months
        • If dose is 200 mg daily – once per year
  • 35. Chloroquine retinopathy
  • 36. Chloroquine retinopathy