1. Rheumatology for Eye Doctors
Dr. James Brick

2. I have no conflicts. No money, no trips, no research support from drug, device or implant markers.

3. Advice Don't scare patients unnecessarily
Be aware of the actual toxicities of rheumatologic drugs. You should learn to use them.
Be aware of the important eye complications of common rheumatic diseases

4. RA in the eye Dry eye Episcleritis discomfort, usually benign
Scleromalacia
Corneal melt

5. Episcleritis/ scleromalacia/ corneal melt almost all are sero positive, long standing nodular erosive.
MTX/steroids much less experience with Rituximab and mycophenolate. Thankfully this appears to be declining numbers.

6. GCA/ Temporal Arthritis/PMR
Old white people
BX (+) in rare pure PMR
Most BX are negative
Bilat BX pick up a few more but still most are negative
BX remains (+) after a few weeks/months of steroids

7. GCA/ Temporal Arthritis/PMR
BX “false neg” in ~ 10%
No controlled trials steroid efficacy but spilt dose no better than single AM
Begin single dose mg prednisone/GCA
IV 1mg solumedrol x3 days may be the best start for GCA
PMR 10-20mg swift response
Remember ESR CRP

8. Iritis W/WO spondyloarthropath Whole host of other causes 40% HLA B27
If chronic recurrent - MTX

9. Sjogrens Dry eyes/Mouth
Occas non Hodgkin's lymphoma, neuropathy, cryoglobs, nephritis, parotid enlargement (mikulicz), lung disease rashes, eycetc
4/100,000 Olmsted Co
60-80% Ro/La +, Rft most
Bx mnorgland lower lip lymphocytic sialadenitis
Thyroid disease

10. Treatment Sjogrens Artificial tears/saliva
Muscarinic agents pilocarpine and cevimeline cholinergic side effects
Plaquenil Trails
Rituxan case report

11. Ant Uveitis Spondyloarihropathies/psoriasis/IBD Sarcoid Behcets
Kawasaki
Polychondritis
Sjogrens
Lupus
ect

12. Drugs Etanercept-Enbrel Adalimumab-Humira Inflximab-Remicade
MTX- Most experience
Cytopenias
Mucositis/GI
Liver- Weekly dose, no etoh
Lung- rare, real?
AZA- cytopenia
Mucositis/ GI
Cancer
Biologics –all very expensive
All local and systemic Rxn’s
Even pure human
Etanercept-Enbrel
Adalimumab-Humira
Inflximab-Remicade
Rituxamab-Rituan
Etc
Mycophenalate-cellcept

13. Antimalarials
Chloroquine
Hydroxychloroquine
Quinacrine

14. Hydroxychloroquine Safest drug Rheumatologists have
Rare toxicity in adults <400mg day, or wt based
Early detection with monitors is key
Mechanism of action is unknown

15. Hydroxychloroquine uses
Sjogrens
RA sero positive or sero negative
SLE
Inflammatory OA
Skin lupus
JRA
Psoriatic arthritis
ETC

16. Problems with Rheum/Opth interface
I cant examine the organ
DX Often based on appearance
I have no way to follow progress
Often no confirmatory labs, no BX
Treatment often based on a few case reports
The meds are dangerous