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:

Rheumatologic
Dermatologic
Endocrine
Vascular

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

Psoriasis
Systemic lupus erythematosus
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

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