In considering this month’s focus on systemic disease and the eye, I see three areas of significance for our profession: the now-mainstream role of systemic medications in optometry, the value of routine eye exams in allowing us to diagnose numerous systemic diseases, and the importance of inter-professional communications with physicians who manage systemic health. All point to better care and convenience for our patients.
Oral Meds and Optometry
We in optometry often have the opportunity to marvel at just how well the body is connected. Many patients with ocular manifestations of systemic disease won’t improve until their systemic health does.
I recall a patient sent to me with a diagnosis of a chemical burn while working in an Eastern Kentucky coal mine. We tried to get his very large corneal abrasion to close, using bandage lenses, pressure patching and ample lubrication (no amniotic membrane options at that time). After seven days battling a persistent epithelial defect, we asked if he had any symptoms of fatigue, increased urination or frequent thirst. He affirmed all three, so we ordered fasting blood levels. A normal reading is below 100; his measured 496!
After a few days of treatment with metformin by a specialist, he not only felt better—his persistent epithelial defect had closed. It was a clear example of how an ocular condition related to a systemic disease will not resolve fully unless the systemic disease is controlled.
Such connections often influence our therapeutic choices, as when we treat MGD and rosacea with oral tetracyclines, preseptal cellulitis with oral antibiotics, or Sjögren’s with oral secretagogues. We must also be vigilant for ocular side effects of oral drugs patients may be taking, such as Plaquenil (which requires monitoring for bull’s eye retinopathy), or ocular dryness due to drugs such as antihistamines, contraceptives and antidepressants.
Healthy Bodies, Healthy Eyes
I’m fascinated that it’s considered “the norm” to visit a dentist every six months, even in the absence of scientific evidence of a need for semi-annual dental visits. Dentists reinforce this behavior by performing teeth cleaning, so that people get a tangible benefit from the experience. They also emphasize oral and systemic wellness, looking for diseases ranging from lingual cancers to Sjögren’s syndrome.
Surely, an eye examination goes much further than a dental visit in ensuring systemic health and ocular wellness—nearly every patient would consider the loss of vision far worse than losing teeth. We have an incredible opportunity to educate patients of the need for wellness exams, perhaps not every six months but at least yearly. Statistics show that most patients only see an eye doctor once every 26 months!
Perhaps we need to educate the patient that, via a thorough eye exam, we can determine cholesterol levels (arcus of the cornea, retinal Hollenhorst plaques), diabetes (retinal exam, lens autofluorescence), hypertension, brain tumors, rheumatoid arthritis, sarcoid, rosacea, lupus, Sjögren’s and many more.
I think patients would be thrilled to know these conditions are on our radar during an ocular health examination. It would help us reinforce the need for a wellness visit at least yearly. I can tell you that patients who have been diagnosed with serious systemic diseases at my office were truly grateful for that “routine” eye exam.
Years ago, I made a preliminary diagnosis of Sjögren’s in a 48-year-old lady with severe dry mouth, nose bleeds, significant tooth decay and severe dry eye. In a letter to a local rheumatologist, I stated, “As you know, there is a very high correlation between non-Hodgkin’s lymphoma and Sjögren’s. Yearly monitoring would be appreciated.”
Three days later, he called to thank me for the letter. He said he’d check all his Sjögren’s patients for NHL going forward. Two years later, he approached me at a meeting and said he had diagnosed NHL in at least a half dozen patients since our collaboration. And since then, he has referred over 100 Sjögren’s patients to the practice!
We can debate whether the eyes are the window to the soul, but they truly are to the body. And we are the gatekeepers.