A closer look
Patients who suffer from systemic diseases like tuberculosis or AIDS, can also have problems with other organs. Dr. JYOTIRMAY BISWAS looks at how inflammation of the eye can be an indication or the result of other problems.
Advantage ... Ophthalmologists can be the first to detect multi-organ diseases.
THE case: Eight months ago, Mr. Sukumar, a 34-year-old businessman from West Bengal complained of fever, cough and bleeding from the stomach. His physician, after scanning his x-ray, found an abscess in the lung and put him on a treatment for tuberculosis (TB). A month later, Sukumar experienced pain and the white part of his right eye was red. He consulted a local eye specialist but neither the eye nor his systemic condition improved.
He went to Chennai for further treatment where an examination showed that the upper part of the outer coat of one of his eyes had been destroyed. A chest X-ray showed an abscess. Within a week, his blood urea and creatinine, the two parameters that reflected the kidney functioning were found to be abnormal.
After he was admitted, he developed severe pain in the joints and red spots on the legs, hands and the chest. He was referred to a rheumatologist and a nephrologist. Laboratory tests were done along with a biopsy of the kidney. He was diagnosed as having a connective tissue disease called Wegner's granulomatosis that affected the eye, the skin, the joints and the kidney.
Sukumar's case may be rare, but many patients with systemic diseases can have inflammation of the outer coat (sclera) or middle coat of the eye (uvea). Diseases that affect the lungs (tuberculosis, sarcoidosis), the skin (psoriasis, leprosy, Behcet's disease), and the joints (ankylosing spondylitis, rheumatoid arthritis) may also affect the eye quite frequently.
Sometimes the ophthalmologist is the first clinician to detect such diseases. Investigation of new patients at the Institute of Tuberculosis and Chest Disease, Chennai, has shown that 1.4 per cent suffered from ophthalmic lesions. The incidence of ocular lesions may be low in patients with TB, but almost a fourth of them can develop eye lesions in the case of sarcoidosis (another disease that affects the lungs primarily). These patients usually develop an inflammation of the middle coat of the eye (uveitis).
Similarly, patients with spondylitis develop uveitis quite frequently, which can affect either one eye, both eyes, or each eye alternately. In addition, it is often known to recur. The initial symptoms are pain, redness, watering of the eyes, photophobia and blurring of vision. It is not uncommon that patients develop an eye problem first followed by arthritis later. Treatment of one organ does not take care of the other; the patient needs regular care from both the ophthalmologist and the rheumatologist.
In patients with skin diseases, often the eye problem comes after the skin disease. In another case, Mr. Rangarajan of Coimbatore had psoriasis for quite a long time and was under treatment. Suddenly, he developed pain, redness and watering in the eyes. Examination revealed he had severe iritis (inflammation of iris, the front part of the middle coat of the eye). In a week, after treatment with steroid drops and tablets, the inflammation subsided.
Therefore, in many systemic diseases, patients need periodic ophthalmic check up. This is especially so when they develop symptoms like pain, redness and watering. They should report to an ophthalmologist at the earliest. Treatment can be simple, if diagnosed early, but sometimes, one may need to take steroid tablets or injections.
AIDS is another disease that affects the eye. Seventy per cent of the AIDS patients develop eye lesions, particularly during the later stages. It is quite important that an AIDS patient has an ophthalmic examination regularly. Out of 469 patients with AIDS, 38.8 per cent have been found to have one or more ocular lesions. The most common of these is an infection of the retina caused by a virus called cytomegalovirus. Treatment involves intravenous injection of antiviral drugs (gancicolvir of foscarnet). Sometimes, such antiviral drugs can be given by intraocular injection. An implant, which releases the drug at a constant rate (sustained release implant), can also be placed in the eye.
Diseases are often known to affect more than one organ. Therefore, a holistic approach is needed. It is important for a physician to be aware of the involvement of the eye in such multi-organ diseases. Conversely, an ophthalmologist should be aware of the involvement of other organs. Prompt referral and interaction with specialists in other branches of medicine can lead to total care.
(Names of patients have been changed.)
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