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Autoimmune Diseases, Treatment, and Contact Lens Wear Autoimmune Diseases, Treatment, and Contact Lens Wear Content written by: June Smith-Jeffries – FCLSA, NCLE, COT Content originally published in the Summer 2015 edition of The Eighth Line Table of Contents • Introduction • Autoimmune Diabetes o Type 1 Diabetes Mellitus o Latent Autoimmune Diabetes of Adulthood (LADA) • Sjögren’s Syndrome • Fibromyalgia • Rheumatoid Arthritis (RA) • Systemic Lupus Erythematosus (SLE) • Ankylosing Spondylitis (AS) • Systemic Sclerosis (Scleroderma) • Raynaud’s Phenomenon • Sarcoidosis • Multiple Sclerosis (MS) • Myasthenia Gravis • Ulcerative Colitis • Corticosteroids and Dilated Eye Exams • Post Test Introduction Autoimmune diseases occur when a person’s immune system does not distinguish between healthy tissue and antigens. An antigen is any substance foreign to the body that evokes an immune response. As a result, the body sets off a reaction that destroys normal tissues. Normally the white blood cells in the body’s immune system help to protect against harmful substances such as bacteria, viruses, toxins, cancer cells and blood and tissue from outside the body. These substances contain antigens. The immune system produces antibodies against these antigens that enable it to destroy these damaging substances. 1 | Page An autoimmune disease may affect one or more organ and various types of tissue. Areas often affected by autoimmune diseases include: connective tissues, joints, muscles, blood vessels, the skin and endocrine glands. There is significant overlap in endocrine and autoimmune diseases because many autoimmune diseases originate in an endocrine gland, for instance, type 2 diabetes, thyroid diseases and Addison’s disease. Autoimmune diseases have been found in virtually every organ system in the body. Most autoimmune diseases continue for the lifetime of the patient because there are no cures. Patients who have autoimmune diseases often require continual care. Some conditions may go into temporary remission, requiring only intermittent care. Many the medications prescribed for treating these diseases are expensive and have unfortunate side effects. The exact cause of autoimmune disease is unknown. One theory is that some microorganisms (bacteria or viruses) or drugs may trigger changes that confuse the immune system. Autoimmune diseases tend to affect far more women than men. While there are several theories, the most commonly agreed upon is that estrogen production puts women at a greater risk. There are at least eighty known autoimmune diseases, all of which of course cannot be discussed within the confines of this article. If you have a patient who has any type of autoimmune disease it is advisable to educate yourself about the condition so that you will know how the disease affects the patient and its possible ocular complications. 2 | Page The Two Types of Autoimmune Diabetes Type 1 Diabetes Mellitus Insulin dependent diabetes mellitus is an inflammatory autoimmune disease of the pancreas, which results in a lack of insulin production. Insulin is produced in the pancreas by beta cells of the islets of Langerhans. The main source of energy for all cells and especially for brain cells is glucose. Insulin is necessary for glucose to get into cells and be used for energy production. After eating, the glucose level in blood rises, which leads to insulin being released from the pancreas. In a person with type 1 diabetes, beta cells of Langerhans are damaged by autoimmune inflammation, leading to an insufficiency of insulin. When the glucose level in blood rises, cells do not have enough energy for proper metabolism. Type 1 diabetes is typically diagnosed early in childhood or adolescence. Patients with type 1 diabetes become insulin dependent very rapidly. Latent Autoimmune Diabetes of Adulthood (LADA) Latent autoimmune diabetes of adulthood (LADA) is a relatively newly discovered form of diabetes. Previously, patients who had LADA were often diagnosed as having type II diabetes. LADA, also known as diabetes type 1.5, is a slowly progressive form of type 1 diabetes mellitus. To confirm a diagnosis of LADA a patient must be at least 30 years of age or older, positive for at least one of the autoantibodies found in Type I diabetes, have a lean build or a low body mass index (BMI). Having a low BMI is a major difference from type II diabetes, in which patients have a high body mass index usually as a result of obesity. Patients with LADA eventually must take insulin injections, but never within the first six months of the diagnosis. Ocular Signs and Symptoms Autoimmune Diabetes and Contact Lens Wear Patients with autoimmune type diabetes are at significant risk of developing corneal lesions. There is also a possibly of the development of corneal numbness. For these reasons, these patients should not be fit with contact lenses. Keratoconjunctivitis sicca is a major problem for patients with autoimmune type diabetes, just as it is in endocrine related type 2 diabetes, as is the very real possibility of diabetic retinopathy. Sjögren’s (pronounced show-grins) Sjogren’s syndrome often accompanies other immune system disorders such as rheumatoid arthritis and lupus. In Sjogren’s syndrome, the mucous membranes and moisture-secreting glands of eyes and mouth are usually affected first. The condition may affect other parts of the body, including the lungs and kidneys. The cause of Sjögren’s syndrome is unknown. Although it can develop at younger ages and in men, Sjögren’s syndrome occurs most often in women between the ages of 40 to 50. 3 | Page Ocular Signs and Symptoms Severe keratoconjunctivitis sicca is a major complication of this disorder. In most cases, contact lenses should not be fit. Under unusual circumstances in which a patient cannot achieve functional visual acuity with eye glasses, such as in keratoconus, a scleral lens may give the best result. Systane®; an eye drop, should be advised and in such a case, the patient will require frequent follow up with an optometrist or an ophthalmologist, in conjunction with the fitter seeing the patient more often than normal. Fibromyalgia Fibromyalgia, also known as fibro myositis and fibrositis, is a common chronic disease which is characterized by widespread, constant pain throughout the body, sleep disturbances and exhaustion. The majority of patients with fibromyalgia are women. Typically, symptoms appear between the ages of 20 and 50. However, fibromyalgia can also affect older women, men, teenagers and children. Ocular Signs and Symptoms Fibromyalgia patients suffer from mucous membrane dryness of the nose and mouth and the eyes. It has been reported that tear production may be decreased in approximately 90 percent of patients with the disorder. Medications prescribed for fibromyalgia usually include a combination of sleep medications, muscle relaxants and antidepressants, all of which will likely worsen the drying effect. As with anyone who has keratoconjunctivitis sicca, careful evaluation of tear production and the quality of the tear film must be undertaken before considering contact lens fitting. Many patients who have fibromyalgia cannot tolerate any type of soft lens. Success is usually greater with RGP lenses. Rheumatoid arthritis (RA) RA is a highly inflammatory disease. It causes pain, swelling, deformity and destruction of the joints leading to loss of function. The most commonly affected joints are the small joints of the fingers, thumbs, wrists, feet and ankles. However, any joint may be affected. This condition also affects organs, such as the heart and kidneys. Severity of the disease varies; however some patients with RA are wheel-chair bound. Ocular Signs and Symptoms Keratoconjunctivitis sicca is the most common ocular manifestation of RA and has a reported prevalence of 15 to 25 percent. Additional ocular conditions include scleritis, episcleritis and keratitis. Other, less common ocular manifestations of RA include choroiditis, retinal vasculitis, episcleral nodules, exudative or serous retinal detachments and macular edema. Disease modifying drugs are used to ease painful symptoms and to help slow the progression of the disease. Methotrexate is usually the first drug of choice. It has many unpleasant side effects; however, the only ocular 4 | Page complication is possible blurred vision. Patients with RA suffer from joint stiffness and swelling of the fingers along with keratoconjunctivitis sicca. Therefore, careful consideration should be made before fitting an RA patient with contact lenses. If a patient who has RA is fit, follow up visits should be more frequent. Systane® eye drops should also be advised. Systemic Lupus Erythematosus (SLE) Women are eight times more likely than men to develop this disease. SLE is a chronic and complex disease that can affect multiple organs and regions of the body causing a wide range of symptoms. Most people with SLE develop joint and muscle pain. The small joints of the hands and feet tend to be the ones affected most. Joint stiffness is common and is usually worse first thing in the morning. Mild joint swelling may occur but severe arthritis with joint damage is unusual. A form of lupus dermatitis that is isolated to the skin without internal disease is called discoid lupus. Plaquenil (chloroquine) is one of the main drugs used to treat SLE. This drug has a propensity to cause retinopathy, consequently, patient taking Plaquenil must have semi-annual dilated retinal examinations. Ocular Signs and Symptoms SLE manifests in episodes of episcleritis, keratitis, and keratoconjunctivitis
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