Eyeworld

FEB 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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52 EW CORNEA February 2012 Anterior segment inflammation and rheumatologic conditions by Faith A. Hayden EyeWorld Staff Writer then there's an obvious point for in- tervention," said John D. Sheppard, M.D., professor of ophthalmology, Eastern Virginia Medical School, Norfolk. "But when patients have an obvious severe dry eye that may have gone unaddressed, you can tell they have gingivitis just by looking at them, and their dry eye is a lot worse than you'd expect it to be for their age, then it makes a lot of sense to look for Sjogren's." If a Sjogren's diagnosis is made, it's important to get the patient to a rheumatologist immediately because these patients almost invariably will need some sort of systemic immuno- suppression, which most ophthal- mologists should not feel comfortable managing on their own. "These are very potent medica- tions with systemic side effects, so once we're getting into the world of oral anti-inflammation, I recom- mend strongly that we enlist a rheumatologist to help us," Dr. de Luise said. "Rheumatologists are a very friendly sort. Patients are very amendable to going, and I need the rheumatologist to make sure the medications are given in the right amount." Furthermore, oral medications don't always work. In those cases, the patient needs intramuscular or intravenous administration, some- thing ophthalmologists just aren't used to doing on a day-to-day basis. Treatments an ophthalmologist Proper diagnosing of Sjogren's and scleritis can save lives I t might be a cliché, but the creator of the old English proverb "the eyes are the win- dows to the soul" may have been onto something. Many eye diseases, such as Sjogren's syn- drome and scleritis, are often the first sign of a far more nefarious ill- ness than simple dry eye or inflam- mation: Rheumatoid arthritis, lupus, or even Wegener's could be possible culprits. These conditions can go un- diagnosed or even ignored for years, slowly debilitating the patient, until suddenly the person shows up in an ophthalmologist's office with an in- flamed eye and a big problem. "The eye is often a barometer of a systemic vasculitis," said Vincent de Luise, M.D., assistant clinical professor of ophthalmology, Yale University, New Haven, Conn. "This is the tip of the iceberg. The oph- thalmologist is in the perfect posi- tion to save some of these patients' lives." In order to do that, though, a proper diagnosis has to be made. For Sjogren's and scleritis, this can be challenging and often comes down to asking patients the right ques- tions and taking an extensive his- tory. Sjorgen's syndrome "The dry eye of Sjogren's is the same dry eye we see in everyone," Dr. de Luise said. "Sjogren's is saying that this patient is not only inflamed in the eye but also inflamed in the mouth." If you suspect a patient has Sjogren's, some questions to ask are "Do your joints ache in the morn- ing?" "Do you have dry mouth?" and "Do you have trouble urinat- ing?" "Certainly, when we are think- ing of dry eye, we not only have to think about the ophthalmic conse- quences of ocular dryness, but we have to try to get more informa- tion," Dr. de Luise said. For example, new patients should be asked to fill out a sheet that requests all past medical his- tory, social history, and a problem- oriented record. Doctors should also rule out any obvious environmental factors such as contact lens use, motorcycle riding, or even anti- psychotic drugs. "If a patient works in a factory with high-velocity fans, enjoys sky diving, or takes three Claritins a day, can give include cyclosporine, which helps with tear quantity. New strate- gies in the pipeline are androgen eye drops, designed to improve the qual- ity of the tear and address the rela- tive androgen insensitivity in older women, one of the critical reasons more women suffer from dry eye than men. The hope is the androgen drops would work synergistically with cyclosporine, for a whole eye approach. "Giving oral androgens to a woman would have many disruptive side effects of secondary sexual char- acteristics such as increased body hair and changes in one's voice," Dr. de Luise said. "But in terms of an eye drop, such a small amount of andro- gen is getting into the system that it is now believed to be safe and is cer- tainly effective in patients who are dry from this relative androgen sen- sitivity." continued on page 55

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