Can lupus cause gritty eyes in a patient, particularly one being treated with hydroxychloroquine (Plaquenil)?

Can Lupus Cause Gritty Eyes?

Yes, lupus can cause gritty eyes, primarily through keratoconjunctivitis sicca (dry eye syndrome), which is the most common ocular manifestation of systemic lupus erythematosus (SLE). 1, 2

Primary Mechanism: Dry Eye Disease

• Keratoconjunctivitis sicca (dry eye) is the most frequent ophthalmic manifestation of SLE, occurring in approximately one-third of patients with ocular involvement. 1
• This condition causes the classic "gritty" sensation in the eyes, along with burning, itching, and foreign body sensation. 1
• The dry eye in lupus can occur as an isolated finding or as part of secondary Sjögren's syndrome, which frequently coexists with SLE. 1

Additional Lupus-Related Eye Manifestations That May Cause Discomfort

While dry eye is the primary cause of grittiness, other lupus-related eye problems can contribute to ocular discomfort:

• Episcleritis and scleritis can present with moderate to intense ocular pain, redness, blurred vision, and lacrimation, sometimes as an initial finding of SLE. 1
• Retinal vasculitis affects around 10% of SLE patients and can cause visual symptoms, though typically not described as "grittiness." 3
• Bilateral retinal vasculitis has been documented as a presenting manifestation of SLE, even in young patients. 3

Important Consideration: Hydroxychloroquine and Eye Symptoms

If you are taking hydroxychloroquine (Plaquenil), this medication does NOT typically cause gritty eyes or dry eye symptoms. 4, 1

What Hydroxychloroquine Actually Causes:

• Vortex keratopathy (corneal deposits) can occur but is usually asymptomatic and does not cause grittiness. 1
• Retinopathy is the serious concern with hydroxychloroquine, but this affects the macula and causes blurred vision or visual field defects, not gritty sensations. 5, 4
• The risk of retinopathy is <1% up to 5 years and <2% up to 10 years when dosed at ≤5 mg/kg actual body weight per day. 6, 4

Critical Monitoring Requirements:

• Annual ophthalmologic examination should begin after 5 years of hydroxychloroquine therapy, or after 1 year if you have additional risk factors (age >60, renal insufficiency with eGFR <60 ml/min per 1.73 m², concomitant tamoxifen use, or pre-existing macular disease). 5
• Screening should include spectral domain optical coherence tomography (SD-OCT) and automated visual field testing of the central 10 degrees. 4, 2

Management Approach for Gritty Eyes in Lupus

For mild dry eye symptoms:

• Lubricating tear drops are typically sufficient as first-line therapy. 1

For moderate to severe keratoconjunctivitis sicca:

• Cyclosporine-A ophthalmic solution may be required. 1
• Glucocorticoids, methotrexate, or other immunosuppressive drugs may be necessary in severe cases. 1
• Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied but available for refractory cases. 1

Critical Pitfall to Avoid

Do not assume gritty eyes are a side effect of hydroxychloroquine and discontinue this medication. Hydroxychloroquine is recommended for all patients with SLE due to multiple beneficial effects including reduced flares, prevention of organ damage, and improved survival. 5, 7, 8 The gritty sensation is almost certainly from lupus-related dry eye disease, not the medication. 1

When to Seek Urgent Evaluation

Obtain prompt ophthalmologic evaluation if you develop:

• Sudden vision changes or vision loss (may indicate retinal vasculitis or other serious complications). 3
• Severe eye pain with redness (may indicate scleritis or episcleritis). 1
• Blurred vision that persists (requires evaluation for retinopathy or other posterior segment disease). 1, 2