Should Systemic Lupus Erythematosus (SLE) patients undergo regular ophthalmic screening?

Ophthalmic Screening for SLE Patients

Yes, patients with Systemic Lupus Erythematosus (SLE) should undergo regular ophthalmic screening as recommended by the European League Against Rheumatism guidelines to prevent sight-threatening complications and monitor for medication-related adverse effects. 1

Baseline and Follow-up Eye Assessments

Indications for Baseline Eye Examination:

• All SLE patients should have a baseline eye examination at diagnosis, especially those:
  • Starting treatment with antimalarials (hydroxychloroquine, chloroquine)
  • Starting treatment with glucocorticoids
  • With any visual symptoms

Follow-up Screening Protocol:

1. For patients on antimalarial drugs (hydroxychloroquine/chloroquine) 1:

   • Low-risk patients: No testing required for first 5 years, then yearly eye assessments after 5 years of treatment
   • High-risk patients: Yearly eye assessments from the start of treatment

   High-risk factors include:

   • Age >60 years
   • Macular degeneration
   • Retinal dystrophy
   • Obesity
   • Liver disease
   • Renal insufficiency
   • Daily dose >6.5 mg/kg for hydroxychloroquine or >3 mg/kg for chloroquine
   • Treatment duration >5 years

2. For patients on glucocorticoids 1:

   • Eye examination recommended for selected high-risk patients (risk of glaucoma or cataracts)
   • Particularly important for patients on >7.5 mg/day of prednisone (19% risk of glaucoma vs. 3% with ≤7.5 mg/day)

3. For all SLE patients:

   • Eye assessment should be considered if symptoms suggesting lupus eye involvement develop
   • Regular screening is warranted as ocular manifestations can occur in approximately one-third of SLE patients 2, 3

Rationale for Ophthalmic Screening

Disease-Related Complications:

• Ocular manifestations occur in up to one-third of SLE patients 2, 3
• Eye involvement often indicates active disease 2
• Early detection can prevent sight-threatening consequences 2
• Ocular manifestations may sometimes precede systemic symptoms 3

Common Ocular Manifestations to Screen For:

1. Keratoconjunctivitis sicca (dry eye syndrome) - most common (31.4%) 4
2. Retinopathy - can cause visual loss of variable severity 2
3. Episcleritis and scleritis - can be initial findings of SLE 2
4. Choroidal disease - can lead to retinal detachment and secondary glaucoma 2
5. Ischemic optic neuropathy - can cause acute binocular visual impairment 2

Medication-Related Complications:

1. Antimalarial toxicity (hydroxychloroquine):

   • Can cause irreversible and sight-threatening maculopathy
   • Risk increases with duration >5 years and cumulative dose >1000g 2

2. Glucocorticoid-related complications:

   • Posterior subcapsular cataracts (21.1% of patients) 4
   • Secondary open-angle glaucoma (2.9% of patients) 4

Important Considerations

• Despite being an "immune-privileged" organ, the eye can be affected by SLE in every structure 5
• Untreated ocular inflammation can lead to significant visual loss or blindness 5
• Most ocular manifestations in outpatients with controlled disease are related to treatment rather than active disease 4
• The prevalence of eye disease due to SLE activity is generally <5% for most manifestations, but clinicians should be aware these conditions tend to be associated with more active systemic disease 6

By implementing regular ophthalmic screening for SLE patients according to these guidelines, clinicians can detect and manage ocular complications early, preventing potentially irreversible vision loss and improving quality of life.