What is your process for treatment and referral when you suspect your patient has a systemic concern?
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Pay attention to history
Systemic diseases are frequently the underlying cause of many ocular conditions. Also, ocular findings often provide clues that there may be an undiagnosed systemic disease. The first step in identifying a systemic etiology is a thorough history. Obviously, the questions asked are targeted based on the eye condition. For some conditions, I will initiate the workup myself. Then, depending upon the findings, I may need to refer, whether to the primary care physician or a specialist. This may include conditions such as ocular surface diseases (dry eye disease, episcleritis, scleritis, lid margin disease) and uveitis.
For posterior segment inflammatory disorders, I tend to refer to a retina specialist for the workup and management. For anterior segment conditions, I typically initiate therapy and the workup myself. Often, these conditions may still need systemic therapy, requiring co-management with a rheumatologist, dermatologist or internist. Regardless of the condition, one of the most critical components is communication. Typically, poor communication between physicians leads to patient confusion and things falling through the cracks. It is essential that there is a point person to quarterback the patient and make sure that all of the treating physicians are on the same page. This team approach seems to be the most important component to managing a patient with an underlying systemic issue.
Kenneth A. Beckman, MD, FACS, is a Healio/OSN Board Member. Disclosure: Beckman reports no relevant financial disclosures.
Look for indicators
The ocular surface disease exam is like a many-layered onion that can make you cry.
In the course of a detailed external exam, I hunt for findings that are particularly rich as indicators of potential systemic disease. Every patient is assessed for blinking pattern, lid position and lid tissue laxity, and staining patterns with vital dyes (including lissamine green).
Within these routine aspects of a detailed examination, I find associations with systemic disease with surprising frequency.
Blinking: An abnormally infrequent blinking pattern can suggest Parkinson’s disease. In fact, changes in the blink pacemaker mechanism are a subtle yet powerful clue to early Parkinson’s disease. When I see this characteristic dysfunction in blink mechanics, I will ask detailed neurologic review of symptoms (ROS) questions, observe patient gait and refer to the neurologist I work closely with. They are always amazed at how I pick up these cases in the earliest stages. The altered blink pattern can lead to early dry eye and explains why we uncover early Parkinson’s disease cases in the dry eye services clinic.
Lid laxity: The American Society of Cataract and Refractive Surgery preoperative ocular surface disease algorithm astutely directs us to LLPP — look, lift, push, pull. When I see the floppy eyelid syndrome triad of temporal upper eyelid eyelash ptosis, papillary conjunctival changes and excess upper eyelid laxity, I know the patient has a more than 90% chance of having obstructive sleep apnea. The sleep specialist in town says I am batting a thousand on these referrals. It is critical to identify these cases early because treatment with continuous positive airway pressure (CPAP) can not only improve the lid laxity over time, CPAP can add years to a patient’s life. It is rewarding to hear from patients how CPAP treatment improves their quality of life.
Lissamine green: This humble, underutilized vital dye can unveil evidence of possible systemic disease. When I see significant conjunctival staining with lissamine green, my index of suspicion for autoimmune disease skyrockets. Autoimmune disease is more common in dry eye patients than we think. Significant staining prompts an order for detailed lab work with Sjögren’s syndrome early biomarkers, rheumatoid arthritis, scleroderma and others. I will ask more detailed ROS questions (including Raynaud’s symptoms) and more detailed family history questions. I also examine the ungual nail base for subtle erythema and the nail bed for longitudinal ridging, splinter hemorrhages and ragged cuticles. A quick palpitation of the finger pads may reveal tender nodules. I find that the Sjögren’s early biomarkers are best ordered by the ophthalmologist or optometrist. If positive, I refer to my local rheumatology colleague for systemic workup and evaluation for other (extraocular) end-organ damage.
Lid position: Any evidence of thyroid eye disease (TED) prompts referral to my rheumatology, endocrine and oculoplastics colleagues. A new monoclonal antibody, teprotumumab (Horizon), is in final FDA review and is an exciting new development in the field. Instead of simply managing severe TED complications, it may be possible to limit disease severity with early identification and treatment.
Laura M. Periman, MD, is a Healio/OSN Board Member. Disclosure: Periman reports she is a consultant to Horizon Therapeutics.