Ocular Manifestations of Psoriasis

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Article initiated by:

Pamela Davila-Siliezar, MD, Preston H. Tsang, Alexander W. Suh

All contributors:

Andrew Go Lee, MD, Colleen Halfpenny, M.D., Sezen Karakus, MD, Pamela Davila-Siliezar, MD

Assigned editor:

Sezen Karakus, MD

Review:

Assigned status Update Pending

 by Sezen Karakus, MD on April 4, 2024.

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Contributing Editors:	add

Background

Psoriasis is a chronic, immune-mediated skin disease that can have ocular manifestations. Psoriasis is believed to be due to excessive activation of the adaptive immune system. According to the World Health Organization, psoriasis affects 1-3% of the US population and 125 million people worldwide. The most common variant of psoriasis is plaque psoriasis, which accounts for 80% of all psoriasis manifestations. Other less common types include nail psoriasis, guttate psoriasis, inverse psoriasis, pustular psoriasis, erythrodermic psoriasis. The hallmarks of plaque psoriasis include sharply demarcated, erythematous, silver scaly patches or plaques commonly affecting the scalp, trunk, gluteal fold, and extensor surfaces. Lesions can be triggered by changes in weather, changes in stress, and trauma. Pinpoint bleeding after lifting a scale (Auspitz sign) is common but neither specific nor sensitive for psoriasis. We describe the ocular manifestations of psoriasis, including keratoconjunctivitis sicca (dry eyes), blepharitis, uveitis, conjunctivitis, episcleritis, and cataracts.

Disease Entity

Psoriasis is a chronic immune-mediated inflammatory skin disease characterized by hyperproliferation of keratinocytes and the development of distinctive scaly plaques on the skin. Ocular manifestations are particularly associated with arthropathic or pustular psoriasis, and affected patients are more likely to be male. The ocular presentations are typically preceded by an exacerbation of the cutaneous lesions in psoriasis. Left untreated, recurrent episodes of ocular inflammation may lead to chronic scarring, vision impairment, and, in severe cases, blindness.

Pathophysiology

The pathophysiology of psoriasis is not fully understood but is thought to be due to the overactivation of the innate and adaptive immune system. Initial steps are initiated by plasmacytoid dendritic cells which release type I interferons to activate myeloid dendritic cells. The myeloid dendritic cells then secrete Interleukin(IL)-12, causing the differentiation of naïve T cells into Th1 cells and IL-23, which induces the proliferation of Th17 and Th22 cells. Importantly, the IL-23-mediated activation of the Th17 pathway, which leads to the secretion of IL-17, IL-22, and TNF-alpha, is thought to be the predominant pathway of psoriasis. The IL-23 is mediated by tyrosine kinase 2 (TYK2), Janus kinases (JAK), and signal transducers and activators of transcription (STAT) pathways, promoting inflammatory gene transcription. The inflammatory cytokines lead to keratinocyte proliferation and a positive feedback loop that attracts more innate and adaptive immune cells to potentiate the hyperkeratinization and inflammation processes of psoriasis.

Clinical Presentation

The most common ocular manifestations of psoriasis are keratoconjunctivitis sicca (dry eyes) and blepharitis. The meibomian glands line the eyelid margins and secret oils that prevent the evaporation of tears, maintaining eye moisture. Psoriasis is not limited to the skin and is able to affect other organs, including the cornea and lacrimal gland, which can lead to dry eyes. Meibomian gland dysfunction was more prevalent in psoriasis patients relative to healthy control groups by 15%. The clinical presentation of blepharitis in psoriasis patients often includes redness, itching, and scaling of the eyelid margins accompanied with possible crusting and ulceration. The normal eyelid flora may be disrupted, which can lead to the cultivation and overgrowth of Staphylococcus species, contributing to the pathogenesis of blepharitis. Conjunctivitis in psoriasis patients typically presents with tearing, foreign body sensation, and general discomfort. Photophobia and serous or purulent discharge may present depending on the severity of inflammation.

Epidemiological studies have reported a positive association between psoriasis and cataract formation. Gradual clouding or opacification of the eye’s natural lens leads to progressive vision impairment in psoriasis patients with cataracts. Proinflammatory cytokines (e.g., tumor necrosis factor-alpha [TNF- α] and IL-6) in psoriasis can create higher levels of oxidative stress and secondary cataract formation. In addition, long-term use of corticosteroids or PUVA (psoralen plus ultraviolet A) therapy, common treatment options for psoriasis, may increase risk of cataract development.

The mechanism between uveitis and psoriasis remains complex and multifactorial, but the two disorders have been found to share common immunological pathways. T cells and pro-inflammatory cytokines (e.g., TNF- α and IL-17) are immune mediators overactive in uveitis and psoriasis. Therefore, it is postulated that the overactive aberrant immune activation observed in psoriasis is conveyed into ocular tissues, triggering uveitis. The incidence of uveitis in psoriasis cases is estimated to be 7% to 20%, with severe and mild psoriasis cases at increased risk. Patients may display signs of light sensitivity, blurred vision, and sometimes perception of floaters within the visual field.

Diagnosis

The diagnosis of psoriasis is primarily based on clinical indications, with the hallmark being well-demarcated, symmetric, and erythematous scaly plaques. These dermatological manifestations typically occur on the scalp, trunk, and extremities but can occur anywhere. Although psoriasis is often associated with extracutaneous manifestations, ocular findings have been reported to be in approximately 10% of patients. Management of ophthalmic involvement is a critical component of comprehensive care of patients with psoriasis.

Ocular psoriasis may present with symptoms such as eye redness, pain, light sensitivity, blurred vision, dry eyes, itching, and eye discharge. The intensity of symptoms may fluctuate based on flares from stress, temperature changes, or other factors. In symptomatic psoriasis patients, an eye examination should be performed for ocular psoriasis, including redness of the conjunctiva, inflammation of the eyelids (blepharitis), signs of uveitis or episcleritis/scleritis, and any changes in the cornea or iris. The presence of cutaneous manifestations on the skin may support the diagnosis.

Ocular symptoms may overlap with other eye conditions, so it is necessary to rule out other potential causes, such as infections (bacterial, viral, fungal), autoimmune diseases (e.g., rheumatoid arthritis, Sjögren's disease), and dry eye syndrome. In some cases, additional tests may be performed, such as blood tests to check for inflammation markers. Patients with psoriasis have been identified to have a higher risk of retinal vascular complications in the absence of clinical ocular disease. Optical coherence tomography angiography (OCTA) may prove to be a useful tool for classifying more severe diseases.

Response to treatment may assist as a diagnostic criterion. If ocular symptoms improve subsequent to therapies used for systemic psoriasis (e.g., methotrexate), it can support diagnosis. Early diagnosis and intervention are crucial for the prevention of other complications and for preserving eye health.

Differential Diagnosis

• Atopic dermatitis of eyelids
• Conjunctivitis
• Dry Eye Syndrome (Keratoconjunctivitis Sicca)
• Uveitis
• Blepharitis
• Allergic Conjunctivitis
• Corneal Dystrophy
• Ocular Rosacea
• Herpetic Eye Infections
• Keratitis
• Glaucoma
• Other Autoimmune Diseases (e.g., Sjögren's disease, Rheumatoid Arthritis, Sarcoidosis)
• Infection (bacterial, fungal, viral)

Management

Patients with psoriasis suffering from blepharitis are typically managed through a combination of conservative hygiene practices, such as applying warm compresses and gently cleansing the eyelids and lashes with a mild shampoo. Topical corticosteroids may be administered to the eyelids to supplement conservative treatment regimens. 0.1% tacrolimus ointment for psoriasis on the face has also been explored as a safe and effective treatment option.

Lubricating eye drops can alleviate dryness and discomfort associated with ocular psoriasis. In more severe cases, systemic treatments such as oral immunosuppressive agents (e.g., methotrexate, cyclosporine) or biologic therapies (e.g., TNF-alpha inhibitors) may be considered to control both skin and ocular manifestations of psoriasis. Phototherapy with UVB or PUVA has also been explored for some patients. This treatment modality can have dual effectiveness for skin and ocular symptoms but may be related to accelerated cataract formation. In rare cases, surgical interventions (e.g., cataract removal) may be necessary to address vision issues caused by ocular psoriasis.

Overall, management of ocular manifestations of psoriasis often requires a multidisciplinary approach involving dermatologists and ophthalmologists. Moreover, ocular manifestations of psoriasis are not uncommon, warranting ocular screening, even if symptoms are not spontaneously reported. Treatment options also should be tailored to the severity of symptoms. As comprehension of the cellular and autoimmune causes behind the ocular manifestations of psoriasis advances, it is likely that management will transition to a more precise and focused approach to preserve vision and minimize the impact on patients.