Ocular Manifestations in SLE: Cloudiness Around the Eye
Yes, cloudiness around the eye can occur in SLE patients, though the specific manifestation depends on which ocular structure is affected—most commonly presenting as keratoconjunctivitis sicca (dry eye), episcleritis, scleritis, or keratitis, all of which can cause visual cloudiness or blurring. 1, 2
Most Common Ocular Manifestations
Keratoconjunctivitis sicca (dry eye syndrome) is the most frequent ocular manifestation of SLE, occurring in approximately one-third of patients, and can cause cloudiness or blurred vision due to inadequate tear film. 2, 3
Anterior Segment Involvement
Episcleritis presents with hyperemic (red) sclera and conjunctiva, which may be painless but can cause itching, burning sensation, and visual cloudiness. 1, 2
Scleritis causes moderate to intense ocular pain, redness, blurred vision, and lacrimation, and can occur as an isolated manifestation of SLE even without other systemic involvement. 4, 2
Keratitis (corneal inflammation) can cause significant cloudiness and visual impairment, and has been documented as an isolated ocular manifestation requiring steroids and disease-modifying therapy. 4
Vision-Threatening Manifestations
Retinal vasculitis and optic neuropathy are the most sight-threatening complications, causing severe visual loss and requiring urgent ophthalmologic evaluation and aggressive immunosuppression. 3, 5
Retinal Disease
Retinal vasculitis affects approximately 10% of SLE patients and presents with bilateral blurred vision, diffuse hemorrhages, white retinal lesions, and blurred optic disc margins. 5, 2
Vaso-occlusive retinopathy results from vasculitis of retinal capillaries and arterioles, causing variable severity of visual loss. 2, 6
Bilateral retinal vasculitis can be the first presenting manifestation of SLE, even in patients with minimal or no other organ involvement. 5
Optic Nerve Involvement
Optic neuropathy (both inflammatory optic neuritis and ischemic optic neuropathy) causes acute-onset progressive binocular visual impairment with optic disc edema in 30-40% of cases. 1, 2
Optic neuritis in SLE is commonly bilateral and requires distinction from ischemic optic neuropathy, particularly in patients with antiphospholipid antibodies. 1
Visual outcome is often poor, with only 30% of patients maintaining visual acuity greater than 20/25 despite treatment. 1
Diagnostic Approach
Patients presenting with cloudiness or blurred vision require urgent ophthalmologic examination including slit-lamp evaluation, fundoscopy, and fluorescein angiography to assess the extent of vascular involvement. 6, 1
Key Diagnostic Steps
Complete ophthalmological evaluation should include funduscopy, fluoroangiography, MRI, and visual evoked potentials when optic nerve involvement is suspected. 1
Episcleritis may not require systemic treatment and usually responds to topical steroids or NSAIDs, whereas more severe manifestations require aggressive immunosuppression. 1
Orbital inflammation and masses are relatively rare but may require biopsy control to exclude other pathology. 2
Treatment Algorithm
For severe vaso-occlusive retinopathy or optic neuropathy, initiate high-dose intravenous methylprednisolone (500-2500 mg total over 1-3 days) combined with cyclophosphamide immediately, as delays in treatment correlate with poor visual recovery. 6
Mild to Moderate Disease
Keratoconjunctivitis sicca may be managed with lubricating tear drops in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids, or methotrexate may be required in severe cases. 2
Episcleritis typically responds to topical steroids or NSAIDs without requiring systemic immunosuppression. 1
Severe Disease
Pulse intravenous methylprednisolone in combination with intravenous cyclophosphamide is recommended for optic neuritis, though failures are common. 1
Anticoagulation should be added if antiphospholipid antibodies are positive, as thrombotic mechanisms may contribute to retinal vascular occlusion. 6, 1
Intravitreal bevacizumab should be considered for severe vaso-occlusive retinopathy and laser photocoagulation for neovascularization. 2
Critical Monitoring Considerations
All SLE patients require baseline ophthalmological examination before starting hydroxychloroquine, with yearly screening after 5 years of treatment in low-risk patients and yearly screening from the start in high-risk patients. 1
Drug-Related Complications
Hydroxychloroquine retinopathy risk increases with duration >5 years, daily dose >6.5 mg/kg, renal insufficiency, or preexisting macular degeneration, though the incidence remains low at 0.5%. 1, 2
Systemic glucocorticoids increase risk of cataracts and glaucoma, with glaucoma occurring in 19% of patients treated with >7.5 mg/day prednisone versus 3% with lower doses. 1
Common Pitfalls
Ocular inflammation in SLE can antedate the diagnosis of systemic disease, so cloudiness or blurred vision may be the presenting symptom requiring skilled ophthalmic evaluation even when other organ involvement is minimal. 5, 7
Ocular manifestations are usually indicative of active systemic disease, necessitating evaluation for other organ involvement and aggressive treatment to prevent sight-threatening consequences. 2
Delays in initiating immunosuppressive therapy beyond 2 weeks are associated with severe neurological deficit and poor visual outcomes, making urgent treatment paramount. 1, 6