Today’s optometrists play a crucial role in identifying and managing ocular manifestations of many systemic conditions, including those associated with psoriasis and psoriatic arthritis. Psoriasis is an autoimmune disease that affects more than 7.5 million U.S. adults,¹ which is why it should be on the OD’s radar.

This article discusses how ODs can help manage patients who have psoriasis by reviewing the patient history, recognizing the ocular and non-ocular signs, understanding the ocular effects of psoriasis treatments, and how to coordinate care with a patient’s other health care providers.

Reviewing the patient history

When reviewing the patient history form, optometrists should note whether patients marked a history of autoimmune disease, which could indicate psoriasis, and discuss with the patient, accordingly.

In addition, when taking the patient’s history, ODs should ask whether the patient has been treated for psoriasis, as treatments may cause side effects. (See “Understanding ocular effects of psoriasis treatments,” below).

Recognizing the ocular and non-ocular signs

According to Mohammad Rafieetary, OD, FAAO, of Charles Retina Institute in Germantown, Tenn., optometrists should be aware of the key ocular signs and symptoms of psoriasis — including redness, itching, foreign body sensation, or photophobia — to effectively diagnose and manage the condition’s ocular complications. Changes in the tear film or conjunctival surface, lesions on the eyelids, or disruption of the meibomian glands can also signal psoriasis as a possible underlying etiology.²

Optometrists should also be observant of non-ocular signs, such as potential skin lesions on the scalp, face, hands, or elbows, says Dr. Rafieetary. “In addition to dermatological findings, psoriasis and psoriatic arthritis often coexist and can affect the ocular tissue, leading to conditions like conjunctivitis, dry eye syndrome, blepharitis, uveitis, and scleritis,” he explains.^3-5

There are also other physical signs that may indicate psoriasis and psoriatic arthritis, notes David Boatright, MD, a rheumatologist with the Rheumatology & Osteoporosis Center of Memphis, in Tenn.

“Inflammatory arthritis findings of joint swelling and tenderness are commonly present with active psoriatic arthritis,” he explains. “Careful inspection of the skin and nails will assist the seeking clinician diagnostically. Nail pitting, thickening and the characteristic flaky, erythematous skin change can be seen in active psoriasis.”

Understanding the ocular effects of psoriasis treatments

There are some psoriasis treatments that can cause ocular side effects. For example, methotrexate, which is prescribed to treat severe cases of psoriasis, is known to cause ocular conditions, including ocular pain, conjunctivitis, and blepharitis, according to Dr. Rafieetary.

Additionally, acitretin, prescribed to treat pustular psoriasis, can cause dry eye disease. When phototherapy is used to treat psoriasis, ultraviolet rays can penetrate into the ocular lens, contributing to cataract formation.²

Because of the chance of such side effects, optometrists should, when looking at the patient’s medication history, ask what the purpose of any listed biologics are, says Dr. Rafieetary; similarly, if psoriasis is listed in the patient’s medical history, then the patient should be questioned about what, if any, therapy has been prescribed.

Dr. Boatright explains that there are some medical agents that can treat both the ocular and arthritic disease manifestations.

“For example, adalimumab has efficacy in the treatment of psoriatic arthritis and uveitis,” and has been FDA approved for both disease states, he says.

How to coordinate care

In cases in which the patient is not already under care for psoriasis, says Dr. Rafieetary, optometrists should refer those patients to their primary care providers, who can then recommend the pursuit of subspecialists.

If the patient is receiving care for psoriasis, he recommends optometrists communicate the ocular findings associated with either psoriasis or medication side effects to the patient’s other health care providers for their knowledge.

Dr. Boatright says that multidisciplinary care from the ocular, cutaneous, and musculoskeletal perspectives can lead to highly effective disease management for psoriasis patients. A coordinated approach across disciplines often yields the best result for treating this condition, he says. OM

References:

1.  Armstrong AW, Mehta MD, Schupp CW, et al. Psoriasis Prevalence in Adults in the United States. JAMA Dermatol. 2021;157(8):940–946. doi:10.1001/jamadermatol.2021.2007

2. Chimenti MS, Triggianese P, Salandri G, et al. A Multimodal Eye Assessment in Psoriatic Arthritis Patients sine-Psoriasis: Evidence for a Potential Association with Systemic Inflammation. J Clin Med. 2020;9(3):719. doi: 10.3390/jcm9030719.

3. Doumazos S, Kandarakis SA, Petrou P, et al. Posterior Scleritis in a Patient with Psoriasis Masquerading as Acute Angle Closure Glaucoma. Case Rep Ophthalmol. 2022;13(3):717-723. doi: 10.1159/000526714.

4. Constantin MM, Ciurduc MD, Bucur S, et al. Psoriasis beyond the skin: Ophthalmological changes (Review). Exp Ther Med. 2021;22(3):981. doi: 10.3892/etm.2021.10413.

5. Dopytalska K, Sobolewski P, Błaszczak A, Szymańska E, Walecka I. Psoriasis in special localizations. Reumatologia. 2018;56(6):392-398. doi: 10.5114/reum.2018.80718.