Published in Systemic Disease

Autoimmune Dermatologic Disorders and the Eye Study Guide

Maxwell A. Levi

Maxwell A. Levi

Alanna Nattis, DO, FAAO

Alanna Nattis, DO, FAAO

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The eye is frequently involved in numerous autoimmune and dermatologic disorders. In part two of this four-part study guide, we discuss psoriasis, systemic lupus erythematosus, and scleroderma.

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

Psoriasis1-4

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
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Maxwell A. Levi
About Maxwell A. Levi

Maxwell A. Levi is a 3rd year Medical Student with a passion for ophthalmology at Rowan in NJ.

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Maxwell A. Levi
Alanna Nattis, DO, FAAO
About Alanna Nattis, DO, FAAO

Dr. Alanna Nattis is a cornea, cataract and refractive surgeon, as well as the Director of Clinical Research at SightMD. She is an Ophthalmology Editor for Eyes On Eyecare, and serves as an associate professor in ophthalmology and surgery at NYIT-College of Osteopathic Medicine. She completed a prestigious Ophthalmology residency at New York Medical College and gained vast experience with ophthalmic pathology in her training at both Westchester County Medical Center and Metropolitan Hospital Center in Manhattan.

Following her residency, she was chosen to be a cornea/refractive surgical fellow by one of the most sought after sub-specialty ophthalmic fellowships in the country, training with world-renowned eye surgeons Dr. Henry Perry and Dr. Eric Donnenfeld. During residency and fellowship, Dr. Nattis published over 15 articles in peer-reviewed journals, wrote 2 book chapters in ophthalmic textbooks, and has co-authored a landmark Ophthalmology textbook describing every type of eye surgical procedure performed, designed to help guide and teach surgical techniques to Ophthalmology residents and fellows. Additionally, she has been chosen to present over 20 research papers and posters at several national Ophthalmology conferences. In addition to her academic accomplishments, she is an expert in femtosecond laser cataract surgery, corneal refractive surgery including LASIK, PRK, laser resurfacing of the cornea, corneal crosslinking for keratoconus, corneal transplantation, and diagnosing and treating unusual corneal pathology. Dr. Nattis believes that communication and the physician-patient relationship are key when treating patients.

More by Alanna Nattis, DO, FAAO
Alanna Nattis, DO, FAAO
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