Autoimmune Dermatologic Disorders and the Eye Study Guide

Introduction

Autoimmune diseases have a variety of systemic manifestations; the eye is frequently involved in numerous autoimmune and rheumatologic disorders. Ocular manifestations are frequently nonspecific and different diseases may affect different parts of the eye, but early recognition of symptoms can help avoid or delay both systemic and ocular sequelae.

The most common autoimmune diseases that affect the eyes can be separated into four categories:

1. Rheumatologic
2. Dermatologic
3. Endocrine
4. Vascular

This is part two of a four-part series in which we discuss the autoimmune dermatologic diseases and the eye including:

1. Psoriasis
2. Systemic lupus erythematosus
3. Scleroderma

Psoriasis^1-4

Psoriasis - Epidemiology

• Disease
  • Prevalence
    • 0.5-11.4%
  • Incidence
    • 100 per 100,000
  • Men: Women (1:1)
  • Ages
    • 30-39
    • 50-69
• Eye manifestations
  • 10% of the disease group
  • Preceded by skin symptoms
  • Men>women

Psoriasis - Mechanism

• Immune-mediated disease
  • T-lymphocytes
  • Dendritic cells
  • IL-17, IL-23, TNF
• Hyperproliferation and abnormal differentiation of
  • Epidermis
  • Inflammatory cells
  • Vasculature

Psoriasis - Screening guidelines

• None to date (to screen for ophthalmic complications)
• Good eye questions
  • Eye discomfort (pain/irritation//foreign body sensation/dry eye/photophobia)
  • Swollen/painful eyelids
  • History of red eye
  • Periocular lesions
  • Changes in vision

Psoriasis - Presentation

General

• Well-demarcated plaques predominately on extensor surfaces
  • Pink/salmon colored
• Silvery-white scale
• Nail pitting
• Psoriatic arthritis
• Koebner phenomenon
• Auspitz sign

Ocular

• Occur during psoriasis exacerbation
• Involve conjunctiva or eyelid
• Psoriatic arthritis may be linked to iritis

Breakdown by location in eye

Eyelid

Blepharitis

• Most prevalent ocular finding
• Mechanism (proposed)
  • ↑ epithelial turnover
  • ↑ volume of cell production
    • ↑ shedding
    • ↑ Block meibomian duct
    • Presents as
      • Meibomian duct blockage
        • Burning
        • Itching
        • Red/swollen lid
        • Crusty/flaky lid
        • Ectropion 🡪 trichiasis 🡪 madarosis 🡪 loss of lid tissue 🡪 vision impairment
      • Psoriatic plaque on lid
        • 2.3-7% patients with psoriasis
      • Complication
        • Meibomian gland dysfunction
        • ↓ Tear breakup time
        • Abnormal gland secretions
        • ↑ plugging and thickness indices

Treatment for blepharitis, psoriatic plaque, and ectropion, trichiasis

• Blepharitis
  • Lid hygiene
  • Warm compress
  • Eyelid massage
  • Lid scrubs (baby shampoo)
  • Erythromycin ophthalmic ointment at night
• Psoriatic plaque
  • Topical corticosteroid
  • Topical tacrolimus
  • May need co-management with dermatologist
• Ectropion, Trichiasis
  • Lubricating drops/ointment

Conjunctiva

• Presentation
  • Chronic nonspecific conjunctivitis with or without eyelid margin lesions
    • Redness
    • Tearing
    • Thick yellow discharge
    • Plaque formation on conjunctiva
• Complications
  • Xerosis, symblepharon, trichiasis
  • Dry eye
• Management
  • Artificial tears
  • Erythromycin ophthalmic ointment

Cornea

• Presentation
  • Punctuate epithelial keratitis
    • Superficial or deep opacities
    • Stromal infiltrates
    • Neovascularization
    • Erosions
    • Scarring
    • Stromal melts
  • 3 components
    • Thickening of epithelium with erosions
    • Infiltrated zone under bowman later with superficial vascularization
    • Homogenous deep stromal opacity
• Other
  • Eye pain
  • Discomfort
  • ↓ visual acuity
• Potential management
  • IV methotrexate (psoriasis treatment)
    • Keratitis
    • Conjunctival injection
    • Dry eye
  • UV therapy (psoriasis treatment)
    • Eye pain

Uvea

• Anterior uveitis
  • 7-20% of patients with psoriasis
• Bilateral: 62% of cases
• Duration: 11.2 weeks
• Symptoms
  • Acute
    • Pain
    • Red eye
    • Photophobia
    • ↓ vision
    • Minimally reactive pupil
    • Posterior synechiae may create irregular pupil
• Associated with
  • Psoriatic arthritis
  • HLA-B27
• Treatment options
  • Corticosteroids
  • Cycloplegic agents
  • Immunomodulatory therapy
  • Anti-TNF
• Lens
  • 63/100 had bilateral cataract (Incidental finding)
• Diagnosis
  • Clinical
  • Biopsy
    • Acanthosis
    • Parakeratotic scaling
    • Increase size of stratum spinosum
    • Decrease size of stratum granulosum
    • Munro micro-abscesses
  • Labs
  • Genetic testing
• Management
  • Dependent on region of eye affected