15 Questions with Dr. Mary Beth Rhomberg - How Lupus Can Affect the Eyes
Dr. Mary Beth Rhomberg graduated from the University of Missouri-St. Louis College of Optometry in 1997. She completed an optometric residency in Family Practice in 1998, also from the UMSL College of Optometry. Currently, Dr. Rhomberg is an Associate Director of the American Optometric Association and an Adjunct Assistant Professor at UMSL College of Optometry.
Is there was any association between the macular degeneration and autoimmune diseases such as lupus? Albany, NY
Macular degeneration is a broad descriptive term that can include many types of changes in this tissue. The macula is an area of the retina, which is the thin lining inside the eye that receives the images of light traveling through the eye and then sends these signals to the brain for interpretation. A camera analogy for the eye is often used, and the retina is described as the film. The macula is the area of the retina that receives the visual information that is central in our field of view – not the peripheral or side vision. It allows for fine details and color vision. Degeneration can occur in this area due to various causes. The most common type is age-related macular degeneration (AMD). Autoimmune diseases are not listed as typical risk factors for AMD. However changes in the macula can be found in individuals with lupus. The macula is pigmented tissue, and pigmentary changes can occur from some of the medications used to treat the disease. Also, the blood vessels in the macular tissue can be affected by lupus, possibly causing the changes in the macular tissue.
Episcleritis, an inflammatory condition involving the outer lining of the “white” of the eye, is associated with lupus. Macular degeneration or macular changes may be due to the medications used to treat lupus or due to the retinal vascular disease associated with lupus. Most common retinal changes due to SLE are cotton wool spots (areas indicating lack of adequate blood supply) and intraretinal hemorrhages (leaking of the blood vessels due to small occlusions in the blood vessels).
Both lupus and some of the medications used to treat lupus can affect the eye. Hydroxycholoquine (Plaquenil) is an antimalarial drug used in the treatment of SLE. Typically, only dosages higher than 6.5mg/kg per day are associated with retinopathy, but a few cases of this toxic retinopathy have been described at lower dosages. Retinal pigment findings, called bulls-eye retinopathy, may be permanent. Other side effects of this drug toxicity would include diminished color vision and/or some central vision changes or loss of visual acuity.
The necessity of other testing would depend on the cause of the bleeding. If the pattern of bleeding in the patient’s retina is associated with and consistent with a known (previously diagnosed) systemic disease, such as SLE, diabetes mellitus, or hypertension, then controlling the systemic disease helps to resolve the leaky blood vessels in the retina. If the cause of the bleeding is unknown, other testing would be indicated to identify the cause of the retinal bleeding. The type of testing would depend on the doctor’s suspicions (differential diagnosis) as to the cause of the bleeding.
Peripheral (the portion of the cornea closer to the white of the eye versus the central location of the cornea) corneal ulcers can be associated with SLE, but are less common of the corneal manifestations of the disease. Dry eye is a much more common finding in SLE. And the lack of an adequate tear film, which serves to bathe the cornea, can cause the outer layers of the cornea to break down. So if the peripheral ulceration is due to inadequate tear film, then treatments would target improving the lubrication of the ocular surface. These treatments often include frequent application of non-preserved ophthalmic lubrication drops and ointments, occlusion of the tear drainage structures, and topical ophthalmic prescriptive cyclosporine drops. Use of room humidifiers and avoidance of windy environments may also help.
Yes, dry eye is a common ocular association of SLE, although for most patients the symptoms are not severe. In one study, approximately 60% of patients with SLE reported at least one symptom of dry eye. The lacrimal gland, which produces tears, can be affected by autoimmune diseases such as rheumatoid arthritis and lupus.
Central serous retinopathy is associated with corticosteroid use. More well known ocular side effects of prednisone (a corticosteroid) include cataract and glaucoma. When reviewing the literature, central serous retinopathy is not noted as a common finding in patients with SLE.
Macular swelling is a term that is used to describe fluid in retinal spaces where it is typically not found. This can be due to leaky blood vessels in the retina or below the retinal layers. If the swelling is a well-defined circumferential swelling, it may be central serous retinopathy, and may be a side effect of the prednisone. When the swelling is directly due to SLE affecting the retinal vasculature and causing the leaky blood vessels, it is an indication of active systemic disease in most patients. When the systemic disease is controlled, if these retinal findings are due to the SLE, they resolve in over 80% of patients.
Commonly used medications in the treatment of SLE, specifically antimalarial drugs choloroquine and hydroxycholoroquine, can cause some sight-threatening eye diseases. To monitor the health of the eyes while on these medications, visual field testing and color vision testing are recommended at regular intervals. These tests can be early detectors of these sight-threatening side effects. If vision loss is detected, medications can be altered to help prevent permanent vision loss.
The macula, which provides for central vision, is affected by this medication. However, your change in peripheral vision could be caused by many conditions, and you should ask your optometrist or ophthalmologist specifically about this.
Dry eye is a common ocular manifestation of SLE. Depending on the severity of your dry eyes, contact lenses may not be recommended. Certainly the dry eye condition would need to be controlled before a successful trial of contact lenses could be attempted. I advise against LASIK for patients with SLE. Extreme caution should be used when considering any excimer laser surgery, an elective procedure that removes corneal tissue for the correction of refractive error, for any patients with connective tissue disease. Some autoimmune patients, even with inactive rheumatologic disease, have reported complications after this procedure.
Cataracts, specifically posterior subcapsular cataracts, from prednisone are a well-known side-effect of this medication. I am unfamiliar with the term lupus cataracts. Some SLE patients experience inflammation inside the eye. Cataracts that may be caused by inflammatory conditions inside the eye, like any cataract, are permanent. The impact that the cataracts may have on vision will depend on their size, location and severity (degree of “opaqueness” or ability to scatter or block light from passing). If caused by severe inflammatory conditions inside the eye, other incidents of this inflammation may cause more cataracts.
Dry eye is a common finding in persons who have SLE. Many individuals have a mild form of dry eye, when others have a more significant condition. I would recommend you see your eye care provider to evaluate the dry eye and make recommendations based on the finding of this evaluation. The tears, coating the front surface of the eye, play an important role in the health of the eye as well as the quality of vision. It is the first surface that light is transmitted when entering the eye. If the tear film is not smooth and consistent, visual distortion will occur. This distortion is transitory, and can cause vision to change with blinking.
The discomfort due to light sensitivity will dissipate when the ocular surface is improved through treatment. Treatment often includes ocular lubrication with artificial tear drops, ointments, ocular nutritional supplements, prescription eye drops, and occlusion of the tear drainage structures. Eyelids will also be evaluated for position and health. Any eyelid conditions, such as blepharitis or meibomian gland dysfunction, would also need to be treated to improve the quality of tears.
Individuals with SLE may have specific ocular complaints, such as dry eyes, which should be evaluated during the eye exam. Also the disease can cause changes in the blood vessels in the retina. These ocular manifestations of the disease should be monitored and treated, as needed. The medications used in the treatment of SLE include corticosteroids (prednisone), which can cause increased intraocular pressure and cataracts. The antimalarial drugs used in the treatment of SLE can cause retinal toxicity, as described above in question 9. The macular portion of the retinal should be evaluated carefully, and visual field tests and color vision tests are also used to monitor the macula while on these medications.
The increase in dry eye symptoms can be from the Lupus, as this is a common ocular finding of the disease. The diuretic may make the condition worse. Many different formulations of artificial tears exist. Some are thicker, and last longer, but may temporarily blur the vision. These thicker drops would be better to apply before sleeping, or at times when sharper vision is not required. Thinner formulations would need to be applied more frequently. Preservative-free formulations would be best with frequent applications. For patients who do not produce adequate tears, a prescription eye drop (cyclosporine) may be beneficial. For those with eyelid disease, which may affect the oil in the tear film and cause quicker evaporation of tears, eyelid treatment is recommended.
I was recently diagnosed with retinopathy in both eyes. I don't have high blood pressure or diabetes. I was told that it is a reflection of the health of my vascular system. I am wondering if this is correct and what should I be doing to improve the health of my blood vessels? Cambridge, NE
Three to 29% of patients with SLE will have retinal involvement. There is correlation between the vascular retinopathy in the eyes and the activity of the SLE systemically. Most patients with mild retinopathy are at low risk for vision loss. Once the disease is controlled systemically, the retinal vasculature changes should resolve.
Connect with Us: