ABSTRACT

Aim of study: To determine the spectrum and prevalence of ophthalmic manifestations of systemic lupus erythematosus (SLE) in Asian patients.

Methods: We performed a standardised ophthalmic examination on consecutive Asian patients with SLE referred from a tertiary rheumatology unit to an ophthalmology department.

Results: Seventy patients were included in the study. There were 66 females (94%) and 4 males (6%). The mean (range) age of the patients was 32.9 (9 _ 67) years. Five patients (7%) had ophthalmic symptoms while 65 (93%) were asymptomatic. Eighty-three eyes of 45 patients had abnormal Schirmer’s #1 test and 27 of these eyes of 17 patients also had concomitant rose bengal staining of the cornea and/or conjunctiva. Seventeen eyes of 9 patients had retinal vascular lesions. Fourteen of these eyes had mild microangiopathic retinopathy with best- corrected visual acuity (BCVA) 6/12 or better and 3 had retinal vaso-occlusive disease with BCVA worse than 6/12. Twenty-eight eyes of 14 patients had cataract and 3 eyes of 2 patients had raised intraocular pressure. Twelve eyes of 7 patients had BCVA worse than 6/12 because of optic neuropathy (4 eyes), posterior subcapsular cataract (4 eyes), retinal vaso-occlusive disease (3 eyes) and phthisis bulbi (1 eye). None had any eyelid lesion, extraocular motility disorder or retrochiasmal disorder of vision.

Conclusions: Asymptomatic dry eye is the most common ocular finding in patients with SLE. Sight-threatening complications of SLE include retinal vaso-occlusive disease and optic neuropathy.

The ophthalmic manifestations of systemic lupus erythematosus (SLE) are protean. They range from lesions of the eyelid(1) and secondary Sjogren’s syndrome(2) to sight-threatening disorders such as retinal vascular disease(3-8) and neuro-ophthalmic involvement(9-13). Retinal vascular disease can present as cotton wool spots, intraretinal haemorrhages or retinal vaso-occlusive disease with poor visual outcome(6). Severe retinal vaso-occlusive disease is reported to be significantly associated with central nervous system involvement(6). Visual loss from neuro-ophthalmic involvement is often due to lupus optic neuropathy(9-13). Other neuroophthalmic manifestations include cranial nerve palsies secondary to lupus microangiopathy and retrochiasmal disorders of vision. Choroidopathy is an uncommon cause of visual loss but cases have been documented in which there was serous elevation of the retinal pigment epithelium and sensory retina(14). Decreased perfusion of the choroid has also been demonstrated in some patients with SLE(15).

The ophthalmic manifestations of SLE in Asian patients have not been well studied. This study was performed to determine the spectrum and prevalence of ophthalmic manifestations of SLE in these patients.

We evaluated 70 patients in this study. There were 66 females (94%) and 4 (6%) males. The female: male ratio was 16.5:1. The mean (range) age of the patients was 32.9 (9 - 67) years. There were 55 Chinese (78%), 10 Malays (14%), 4 Indians (6%) and one Eurasian (1%).

Table I shows the spectrum and prevalence of ophthalmic manifestations in these patients. Twelve eyes of 7 patients had BCVA worse than 6/12 as a result of various ocular pathologies (Table II).

Five patients (7%) had visual or ocular symptoms while 65 (93%) were asymptomatic. Four patients (6%) complained of decreased vision in one or both eyes. Two of them (patient nos. 16 and 49) had BCVA worse than 6/12 in both eyes due to optic neuropathy while one (patient, no. 66) had counting fingers vision in her right eye due to retinal vaso-occlusive disease (Table II). The fourth patient with a complaint of impaired vision had bilateral posterior subcapsular cataracts but her BCVA was 6/9 in both eyes. The fifth patient complained of bilateral ocular discomfort but her Schirmer’s #1 test was normal and she did not have any abnormal staining of her ocular surface with rose bengal in either eye.

The prevalence of dry eye in patients with SLE varies from study to study depending on the criteria used to define dry eye. Eighty-three eyes of 45 patients in our series had readings of 10 mm or less in 5 minutes on Schirmer’s # 1 test with topical anaesthesia. All of them had no complaints of ocular pain, discomfort, burning sensation, foreign body sensation or other eye irritation. Twenty-seven of these eyes in 17 patients also had concomitant rose bengal staining on the cornea and/or conjunctiva. If we use a combination of abnormal Schirmer’s #1 test and rose bengal staining to indicate dry eye, the prevalence of dry eye is 24% in our survey population (Table I). Asymptomatic dry eye is therefore the most common ophthalmic abnormality in our series.

Twenty-eight eyes of 14 patients had posterior subcapsular cataract. All patients had bilateral involvement and were on oral corticosteroid therapy (Table I). Ten of these patients were below 43 years of age. The majority of eyes with cataract (22 eyes) retained BCVA 6/12 or better. Four eyes had severe cataract causing BCVA worse than 6/12 (Table II). Two other eyes with cataract also had BCVA worse than 6/12 vision but the main cause of the poor vision was attributed to the underlying optic neuropathy (Table II).

Two patients had unilateral iridocyclitis (Table I). Both eyes also had retinopathy. One eye had mild retinopathy and BCVA 6/9. The other eye had BCVA counting fingers two feet because of retinal vaso-occlusive disease.

One eye had phthisis bulbi (Table I) which may have been due to severe involvement of the eye by the SLE disease process.

Asymptomatic dry eye is the most common ocular finding in Asian patients with SLE. Sight-threatening complications of SLE include optic neuropathy and retinal vascular disease. Cataract and raised intraocular pressure occur as complications of corticosteroid therapy in patient with SLE.

K G Au Eong, MMed (Ophth),
FRCS (Edin), FRCS (Glas)
Senior Registrar

W M Cheah, FRCS (Glas),
FRCOphth, FAMS

K Y Fong, MBBS,
MMed (Int Med), FAMS
Consultant

H S Howe, MBBS,
MMed (Int Med), FAMS
Consultant

M L Boey, MMed (Int Med),
FAMS, MD
Senior Consultant and Head

P H Feng, FRCP (Edin),
FRCP (Glas), FAMS
Emeritus Consultant

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