Female predilection exists for some ocular disorders
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Ocular conditions in women depend on several factors, including genes, hormones, comorbidities, physiological changes, stress levels and lifestyles.
Many of the conditions are detectable and manageable in the early stages. In this column, we would like to share some of our views and experiences in eye diseases common in women, such as uveitis, episcleritis, dry eye, chlamydial infection, pregnancy-induced changes, closed-angle glaucoma and Graves’ disease.
Uveitis
Inflammation of the uvea, the highly vascular inner coat of the eye, is called uveitis. The presenting symptoms are redness, photophobia and pain. When retinal involvement such as macular edema, vitritis or panuveitis exists, vision loss manifests (Figure 1). Women with preexisting autoimmune disorders such as rheumatoid arthritis, skin diseases such as psoriasis, systemic lupus and collagen vascular diseases have a high risk of developing uveitis. Vogt-Koyanagi-Harada disease, a typical bilateral panuveitis, has a female predilection (Figure 2). It is a multisystemic disorder that involves the eyes, ears, skin, hair and meninges. The second eye becomes involved within 2 weeks after initial presentation. Timely diagnosis and immediate steroid treatment restore vision in the majority of patients. However, recurrences need regular follow-up and maintenance treatment. In this modern era, stress-induced uveitis has become a common cause for uveal inflammation. Women between the ages of 30 and 40 years are usually affected. Recurrence or repeated episodes of redness and pain may be present (Figure 3). Autoimmune conditions causing changes in cell- or humoral-mediated immunity are common in women; hence, ocular disorders related to autoimmunity are also noted.
Source: Dhivya Ashok Kumar, MD, FRCS, FICO, FAICO, and Amar Agarwal, MS, FRCS, FRCOphth
Women are more susceptible to a variety of autoimmune diseases including systemic lupus erythematosus, multiple sclerosis, primary biliary cirrhosis, rheumatoid arthritis and Hashimoto’s thyroiditis. A study in a U.S.-based population found that women were at 2.7 times greater risk than men to acquire an autoimmune disease. In another report, Gleicher and colleagues suggested that estrogens favor the antibody production-enhancing Th2 response and, by doing so, possibly increase the risk toward abnormal autoimmune function. Others have suggested that women are genetically predisposed toward abnormal autoimmune function, possibly because the X chromosome may confer susceptibility toward tolerance breakdown.
Episcleritis and scleritis
Sudden-onset painful red eye is the common symptom of episcleritis. Localized or diffuse episcleral congestion is often noted (Figure 4). Spontaneous resolution happens in the majority of patients. However, recurrences are known to happen. Nodular scleritis can present as a nodule in the sclera with scleral inflammatory signs. Anterior segment OCT can be a useful tool to detect fluid lines and thickening in scleritis. In severe cases, it can lead to scleral melting. Rheumatoid arthritis is a common systemic association in women, which shows more predilection for scleritis, scleral melting or scleromalacia perforans (Figure 5). Episcleritis can be stress induced in middle-aged women. Systemic autoimmune conditions such as inflammatory bowel disease, skin diseases and joint-related problems are common associations. Blood evaluation with antibody assay, total count, differential count, erythrocyte sedimentation rate, C-reactive protein, RA factor, antinuclear antibody, antineutrophil cytoplasmic antibodies and inflammatory markers can help in diagnosing the associated illness.
Dry eye
Dry eye is more common in women, especially after menopause. The main symptoms of dry eye are grittiness, foreign body sensation, discomfort and epiphora. Other symptoms may include stinging or burning of the eye; episodes of excess tearing that follow periods of very dry sensation; a stringy discharge from the eye; and pain and redness of the eye. Sometimes people with dry eye experience heaviness of the eyelids or blurred, changing or decreased vision. Corneal examination may show epithelial erosions on fluorescein stain (Figure 6). Tear breakup time and Schirmer test are used for evaluation. Other factors such as lid evaluation for lagophthalmos, inadequate blink, meibomian gland abnormality, posterior blepharitis and contact lens wear should be considered. Middle-aged women with rheumatoid arthritis can develop keratoconjunctivitis sicca. In the initial stages, topical preservative-free lubricants and protective shields are useful. Severe dry eye will need punctal plugs (Figure 7), amniotic membrane transplantation, autologous serum, immunomodulatory therapy and long-term follow-up. Management of associated systemic illness such as rheumatoid arthritis or systemic sclerosis is vital. Rheumatological consultation can be obtained in specific cases for systemic follow-up.
Chlamydial infection
Lid infections are seen in women due to excess use of cosmetics. Chlamydial infection can cause trachoma and scarring of lids. This is seen when one continues to have unhygienic use of eye makeup. Lid itching, redness and heaviness can be the presenting symptoms. In the acute stage, it can present as follicular conjunctivitis, and in the chronic stage as scarred conjunctiva, lid abnormalities such as entropion, trichiasis and corneal scar. Following the SAFE (surgery, antibiotic, facial cleanliness, environment improvement) strategy, the condition can be reduced. Lid and corneal sequelae may need surgical treatment. However, acute conditions can be treated with topical azithromycin and lubricants. Trichiasis, if minimal, can be corrected by epilation. Proper personal hygiene and social cleanliness can prevent the spread of infection. Education and awareness should be raised about the infection and preventive measures.
Thyroid eye disease
Graves’ disease is an autoimmune disease in which the thyroid is overactive, producing an excessive amount of thyroid hormone. Studies have shown it to be high in women. Graves’ thyroid ophthalmopathy can present as lid retraction, exophthalmos, excess dryness, redness, double vision, glaucoma or squint (Figure 8). In severe cases, vision-threatening complications such as optic nerve compression and corneal ulceration can develop. Abnormal low secretion can cause puffiness around the eyes, facial swelling and weight gain. Regular endocrinologist review along with ophthalmological follow-up is advised.
Dark circles
Dark eye circles are seen commonly in women, with hyperpigmentation around the eyes with or without skin changes. This hyperpigmentation may be due to aging, excess tiredness or insomnia.
Pregnancy-induced changes
Pregnancy can induce changes in the eyes. In addition, patients with preexisting diabetes can have an independent risk for diabetic retinopathy. Similarly, if there is high blood pressure, termed as preeclampsia or pregnancy-induced hypertension, it can affect the optic nerve when there is uncontrolled hypertension. Hence, it is more important for pregnancy screening in high blood pressure or sugar levels. Early diagnosis can prevent complications at an early stage. Women with a history of ocular toxoplasmosis are at risk for reactivation of retinochoroiditis during pregnancy. One should consult with the patient’s obstetrician and an infectious disease specialist before considering systemic treatment in pregnancy for ocular toxoplasmosis. Patients should also be informed about the options and theoretical risks of anti-Toxoplasma medical therapy during the first trimester of pregnancy. Although spiramycin is known as a safe alternative in pregnancy, it may not be effective in ocular disease. There have been reports of effective use of intravitreal clindamycin and dexamethasone in pregnancy to treat ocular toxoplasmosis. In the anterior segment, pregnancy-induced changes in corneal biomechanics can pose changes in refraction. Those with post-refractive surgery corneal ectasia are especially at risk for progression during this period. They can have transient visual changes and changes in spectacle power. With any visual symptoms during pregnancy, it is vital to have serial corneal topography analysis for progression. Patients with a history of uveitis can also have a flare-up of symptoms during pregnancy and postpartum (Figure 9).
Blepharochalasis
Blepharochalasis occurs after repeated abnormal lid swelling with pain, which can coincide with the menstrual cycle. It usually starts in the premenstrual days and resolves spontaneously. This may be recurrent and lead to loose upper lid skin with puffiness. Papery upper lid skin with prominent visible vessels is the typical sign. Blepharoplasty can be performed if there is a significant cosmetic difference.
Angle-closure glaucoma
Angle-closure glaucoma has often been noted in women. The predominant presentation may be attributed to the narrowed biological angles in women as compared with men. In angle-closure glaucoma, there can be sudden-onset pain, redness and blurring of vision. When untreated, it can lead to permanent visual loss. Ophthalmic evaluation should include slit lamp biomicroscopy, IOP examination by applanation tonometer, corneal thickness, fundus examination, gonioscopy, anterior segment OCT (Figure 10) and perimetry for prompt diagnosis. Early treatment includes peripheral laser iridotomy. In eyes with coexisting cataract, lens removal will open the angle. Pupilloplasty can also be used in pseudophakic eyes with persistent angle-closure glaucoma. Nonresolving chronic angle closure will need trabeculectomy in some cases.
Computer vision syndrome
In this growing high-tech world, computer vision syndrome occurs because of continuous overwork in front of computer monitors for long hours. Prolonged staring into the monitor reduces the normal blink rate and can affect tear film stability. Moreover, insomnia, accommodation defect and improper posture will add to existing problems. Women can have symptoms starting from simple headache to excess dryness, irritation and diplopia.
Prevention and treatment
Although the predisposition for eye problems may be genetic and hormonal, women can decrease the associated risk by following certain precautions and medical treatment.
Patients with uveitis should undergo blood tests, routine and special antibody assay. In some cases, rheumatologist opinion is required. Treatment is given depending upon the etiology, and regular follow-up is advised. Good sleep, low stress and relaxation can prevent recurrences.
In dry eye, women can use goggles or coolers when they go out to prevent direct air exposure, which can increase the tear film evaporation rate. Topical lubricant eye drops are also advised. In severe cases, medical or surgical treatment is required. Any existing problem such as blepharitis should be controlled. Proper lid hygiene can decrease lid infection in many women.
Women in computer-based professions can take regular breaks. Simple relaxation by closing the eyes for some time, seeing distant objects and washing the eyes may help reduce symptoms in mild disease. However, in eyes with convergence insufficiency, eye exercises are recommended. Ultraviolet protective spectacles can be worn in professions with more UV exposure, such as high-intensity UV lights and direct work under the sun.
Local treatment with peeling agents or fillers can give good cosmetic results for dark circles. Good sleep and avoidance of stress can also prevent dark circle formation. Women with thyroid disorder should always undergo an ophthalmic examination irrespective of ocular complaints.
Conclusion
When it comes to women’s health, there are various medical conditions that have a female predilection. This can happen with the eyes as well. The eye is the window of one’s mind, revealing what we think and expressing what we feel. The highlight of this column is to create awareness among practitioners to take the necessary precautions and be aware of such gender-specific ocular conditions to prevent them at an early stage and manage them efficiently.
- References:
- Gleicher N, et al. J Autoimmun. 2007;doi:10.1016/j.jaut.2006.12.004.
- Holland GN. Am J Ophthalmol. 2004;doi:10.1016/j.ajo.2003.10.032.
- Jacobson DL, et al. Clin Immunol Immunopathol. 1997;doi:10.1006/clin.1997.4412.
- Lertsumitkul S, et al. Graefes Arch Clin Exp Ophthalmol. 1999;doi:10.1007/s004170050342.
- Narang P, et al. Indian J Ophthalmol. 2018;doi:10.4103/ijo.IJO_559_17.
- Savku E, et al. Turk J Ophthalmol. 2015;doi:10.4274/tjo.93609.
- Sobrin L, et al. Ophthalmology. 2020;doi:10.1016/j.ophtha.2020.04.034.
- Yeung IY, et al. Int Ophthalmol Clin. 2015;doi:10.1097/IIO.0000000000000072.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books published by SLACK Books, sister company of Healio publisher Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; email: aehl19c@gmail.com; website: www.dragarwal.com.
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