Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease where the immune system attacks the body’s own healthy tissues and organs. This systemic inflammatory process does not spare the eyes, making ocular involvement a frequent and significant complication of lupus. Approximately one-third of individuals with SLE will experience some form of eye manifestation during the course of their disease. Ocular issues can range from mild surface irritation to severe, vision-threatening internal complications, often signaling overall disease activity elsewhere in the body.
Surface and Structural Eye Involvement
The most common way lupus affects the eyes is through inflammation of the surface and outer structures. Dry eye syndrome (keratoconjunctivitis sicca) is common. This dryness is frequently due to secondary Sjögren’s Syndrome, an autoimmune condition where the tear glands are attacked, leading to decreased tear production and lubrication. Symptoms of this surface irritation include a gritty sensation, burning, redness, and a feeling of a foreign body in the eye.
Inflammation can also affect the protective outer layers of the eyeball. Episcleritis is a mild inflammation of the episclera, often presenting as redness and mild discomfort. Scleritis, a more serious condition involving the deeper, white part of the eye (the sclera), can cause intense pain, light sensitivity, and blurred vision.
Lupus-related skin conditions can also directly impact the eyelids. Discoid lupus, a form of cutaneous lupus, can manifest as scaly, raised, and sometimes scarring lesions on the eyelids. This inflammation and potential scarring can lead to issues like misdirected eyelashes (trichiasis) or the eyelid turning inward or outward (entropion and ectropion), causing persistent eye irritation.
Vision-Threatening Retinal and Nerve Complications
Internal manifestations of lupus in the posterior segment of the eye pose the most significant risk to vision. The autoimmune mechanism of SLE can lead to Retinal Vasculitis, which is the inflammation and blockage of the tiny blood vessels supplying the retina. This blockage reduces the blood supply, causing areas of the retina to become oxygen-deprived, a condition called ischemia.
These ischemic areas often appear as small, whitish patches on the retina known as “cotton-wool spots.” They are a strong indicator of active systemic inflammation and microvascular damage. If the vasculitis affects the macula, the central part of the retina responsible for sharp, detailed vision, permanent central vision loss can occur.
Another serious, though less common, complication is Lupus Optic Neuropathy, which involves the inflammation of the optic nerve. The optic nerve transmits visual information from the retina to the brain, and its inflammation can result in sudden, often irreversible vision loss in the affected eye. This type of optic nerve damage is a sign of severe, active central nervous system involvement in SLE, necessitating immediate and aggressive treatment.
Necessary Screening and Monitoring Requirements
Given the potential for ocular involvement, regular eye care is necessary for all lupus patients. The frequency of comprehensive eye examinations is guided by overall disease activity and the medications being used. These regular appointments allow an ophthalmologist to monitor for any asymptomatic damage that a patient might not yet notice.
The eye specialist detects subtle retinal changes that are often the first sign of serious internal lupus flares. Diagnostic tools like the fundus examination, where the doctor looks at the back of the eye, are used to check for retinal vasculitis and cotton-wool spots. Optical Coherence Tomography (OCT) scans provide cross-sectional images of the retina and are used to detect fluid buildup or damage, particularly when monitoring for drug toxicity.
Visual field testing, which assesses peripheral and central vision, is also important, especially to screen for damage to the optic nerve or side effects from long-term medication use. For patients taking hydroxychloroquine, an anti-malarial drug commonly used to manage lupus, a baseline eye exam followed by annual screening is required due to the risk of irreversible drug-induced macular toxicity.
Treating Lupus-Related Ocular Issues
The management of lupus-related eye problems is tailored to the specific condition, but often focuses on controlling the underlying systemic inflammation. For mild, surface issues like dry eye syndrome, treatment typically involves frequent use of artificial tears and lubricating gels. Episcleritis can often be managed with topical non-steroidal anti-inflammatory drugs or low-dose topical steroid drops.
Severe inflammatory conditions, such as scleritis or active retinal vasculitis, require aggressive systemic treatment to suppress the autoimmune response. High-dose systemic corticosteroids, delivered orally or intravenously, are the first line of defense to rapidly reduce inflammation and prevent permanent vision loss. Immunosuppressive drugs like cyclophosphamide or mycophenolate mofetil, or newer biologic agents, may be used as “steroid-sparing” options for long-term management of severe ocular disease.
Collaborative care between the rheumatologist and the ophthalmologist is essential. Effective control of the systemic disease is the best way to prevent severe ocular complications, such as retinal or optic nerve damage. The ophthalmologist monitors the eye for disease activity and drug-related side effects, while the rheumatologist adjusts the overall lupus treatment plan.