If You Have Psoriatic Disease Keep an Eye Out for Uveitis Transcript
“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”
Takieyah: My name is Takieyah Mathis and I'll be your moderator for today's episode. I'm here with board certified and nationally recognized ophthalmologist Dr. Timothy Milton Janetos from Northwestern Medicine, Department of Ophthalmology, whose primary specialty is ocular inflammation such as uveitis and cataract surgery, which we'll discuss today. I know I'm curious to learn more about both and the relationship to psoriatic disease. So welcome, Dr. Janetos. It's a pleasure having you on Psound Bytes.
Dr. Janetos: Thank you so much for having me here today with you. I'm really excited to talk to you today.
Takieyah: Let's start with a discussion about what uveitis is and why do you think it is connected to psoriasis? So is it true that the diagnosis of one increases the risk of developing the other?
Dr. Janetos: Yeah. So uveitis is sort of an umbrella term for any inflammation in the eye. Whether that be due to an infection that's causing inflammation in the eye or due to an immune disease. About half of the time, uveitis is caused by some sort of underlying or at least associated with some sort of underlying immune disease. Psoriatic arthritis, psoriasis, being one of those causes. And typically psoriatic arthritis and psoriasis, it’s associated with the type of uveitis that affects really the front part of the eye. The eye becomes very red, painful and light sensitive. But again, uveitis is a huge spectrum of different diseases, different associations. You can have inflammation in the front of the eye, in the middle part of the eye, in the back of the eye. Inflammation can come once and it can go away forever. It can come once, it can go away and come back in five years. Or it can be what we call chronic disease in that once it starts, unless you're treating it consistently, it'll be present throughout the course of the entire illness and requires long term treatment. So in terms of does one cause the other? I don't like to think of it as more of a cause. It's just an association. Both of these are immune conditions. At the end of the day, there's that association, that link is there, but sometimes you can have very well controlled psoriatic arthritis, but your inflammation in the eye is flaring. Sometimes the eye is very quiet and the skin disease is really flaring so that link is definitely there.
Takieyah: Wow, that's great to know. And Dr. Janetos, what would you say is the prevalence of uveitis among those who have psoriasis and psoriatic arthritis? Is uveitis more frequent among those who are HLA-B27 positive with psoriatic arthritis?
Dr. Janetos: Yeah. So that marker HLA-B27, it's actually a very common marker. It's present in probably 10% of the population. But it definitely increases the risk of developing uveitis as well as psoriatic arthritis and other B27 related diseases, like ankylosing spondylitis is another example. People who are HLA-B27 positive or who have psoriatic arthritis or one of the HLA-B27 immune diseases at some point during the course of their life, about 20% of those patients, will experience uveitis in one form or another. So it's definitely common. It's not the majority of patients, but it is common among this group and again, I wanna stress that that genetic marker it makes you at increased risk, but a lot of people have that B27 marker and don't ever develop uveitis, don't ever develop arthritis as well.
Takieyah: Is uveitis related to other chronic health conditions common to psoriatic arthritis or psoriatic disease, and if so, what are they?
Dr. Janetos: Yeah, uveitis is. It's really quite a spectrum of disease and about half of uveitis is associated with some sort of chronic immune health condition. Psoriatic arthritis is one of those conditions, but there are other things like rheumatoid arthritis, sarcoidosis. All of those have common associations with uveitis as well. And they all present a little bit differently. Obviously, the systemic disease is very different, but the uveitis associated with those diseases can be quite different disease courses and require quite different treatment. About half the time, we never find a reason for uveitis. So it's just a primary inflammation in the eye - can almost think of it as like a primary immune disease of the eye. And again it's just quite a different spectrum for sure.
Takieyah: What are typical symptoms that indicate someone has uveitis? I know I've seen photos of uveitis where the eye is like red, but at what point should I seek help from my ophthalmologist?
Dr. Janetos: That's a great question. I mean, certainly a red eye can indicate uveitis. But red eye can also indicate a lot of different things, from benign things such as dryness in the eye or just irritation, allergies, things like that. Uveitis, as I've sort of mentioned is really a spectrum. So talking about inflammation that is associated with psoriatic arthritis. Typically that sort of uveitis is a red, painful eye. Can be one eye, can be both eyes. And the eye can be very light sensitive. Vision can be blurred as well, and it's typically very sudden onset. Other types of uveitis that's more sort of indolent course, just sort of blurred vision, floaters, but the eye tends to be white. Those sort of uveitis are less commonly associated with psoriatic arthritis. Usually that is that red painful eye, very light sensitive. What I would say for anybody who has a condition like psoriatic arthritis or those HLA-B27 conditions, I would seek help from an ophthalmologist if anything is really out of the normal for you. So if you wake up red, painful eye, light sensitive, seek help right away. Don't wait on it because the longer you wait on uveitis, well a) you're gonna be in a lot of discomfort. But b) the longer you wait, the more risk of scar tissue formation, the more risk of damage to the eye if it's not promptly treated. And what I typically tell patients is it's better to be cautious than to sit at home and worrying about something. So it could be nothing. That's true. But it's always a good idea to go get help from a professional, an ophthalmologist, to see exactly what's going on. The sooner that you start treatment for uveitis, the better the outcome in terms of long term vision.
Takieyah: OK. So now how is uveitis diagnosed? Like, what's the process?
Dr. Janetos: Yeah. Uveitis can really only be diagnosed by a trained ophthalmologist or an optometrist. Typically optometrists, those are not medical doctors, but they do more glasses and contact lenses. They as well have the equipment to diagnose uveitis. It requires a dedicated slit lamp examination and dedicated imaging in a ophthalmology office. So a lot of times what I end up seeing in my practice is a patient has issues with their eye, they go to the emergency room. Eventually you'll find your way to an ophthalmologist through that route. I would stress that if you are having an issue with your eye, red, painful eye, decreased vision, sensitive to light, emergency room is one option, but you ultimately need an examination by an ophthalmologist. Most ophthalmology offices have same day urgent appointments that you can get in and get a diagnosis. Or at least reassurance that uveitis isn't occurring. You go to an emergency room, they may or may not have an ophthalmologist on the call. You may or may not be sitting there for 24 hours before you're eventually referred to an ophthalmologist. So diagnosis of uveitis really requires a dedicated eye exam which can only be done by a trained ophthalmologist or optometrist.
Takieyah: Nice to know. So given your experience and expertise in uveitis, what do you feel are the best treatment options?
Dr. Janetos: So treatments up front for uveitis, especially the type that is associated with psoriatic arthritis is always gonna be to start with corticosteroid eye drops. These are things like prednisolone eye drops, those medications for the type of uveitis that's associated with psoriatic arthritis and need to be administered very promptly. They're typically very, very frequent. So to start, if somebody's having a new episode of uveitis, it's like taking those eye drops every hour around the clock while awake to start with. And if there's really, really significant or resistant inflammation for an initial episode or for an acute episode, then oral corticosteroids, like prednisone, can also be taken. There are also some periocular around the eyes, steroid injections. All of those treat an acute episode of uveitis that's associated with psoriatic arthritis. Once that acute episode has been treated, we tend to very slowly taper off these medications. If we taper too fast, the inflammation can come back. Now again, I mentioned that uveitis can come in a lot of different forms. The form again associated with psoriatic arthritis tends to be recurrent, but it isn't always. Sometimes you can have a one and done episode. You treat it with these medications and you taper off those medications and the inflammation doesn't come back. If it becomes recurrent, you're getting multiple episodes a year, then those steroid options, although they are appropriate again for an acute episode of inflammation, they do come with side effects. So you can raise the eye pressure by using those medications. The more prednisone or corticosteroids in and around the eye or systemically can lead to cataract development. So in those cases where somebody is having many, many episodes of inflammation that is requiring a lot of steroids, I tend to and most uveitis specialists, would want these patients on a long term treatment that is corticosteroid sparing. These are medications that also treat the psoriatic arthritis or treat the other HLA-B27 related diseases, but they do not have steroids in them, so they do not come with all those similar side effects. Long term steroids as well can lead to things such as high blood pressure, diabetes, brittle bones. So my goal, whenever I put somebody on corticosteroids systemically or oral prednisone, my number one goal is always to get them off of that medication as soon as possible. And again, if they're requiring repeat courses of these treatments than one of those other corticosteroid sparing agents for both prevention of a flare of inflammation and for treating inflammation is the best option. The issue is those corticosteroid sparing agents, they do not work as fast or typically as well for an acute episode of inflammation. So you always have to treat that acute episode with steroids, but once they've sort of built up a steady state within the body, they'll prevent inflammation from occurring again and hopefully reduce that steroid burden.
Takieyah: Well speaking about the injection. So I've heard of things, but I never knew, like is it like an injection in the eye? How does that injection exactly work?
Dr. Janetos: So there's several different types. Some are actually into the eye itself, which sounds a lot freakier than it really is. These are all things that we do in the clinic. So they're done right in the exam room, and your eye is completely numbed up. You don't see a needle. You're looking in the opposite direction. Most people don't feel anything at all with those sort of injections. There's also some injections that go around the eye, so kind of like behind the eye or in the front white part of the eye. And these injections, they are usually steroid medications. There's some other non-steroid medications that we sometimes use for inflammation, but the majority are steroid medications and they are again really good at sort of treating that inflammation right away. But they come with those side effects. Eye pressure can raise. You can increase cataract formation. And they don't typically last long term. There are some injections that are made for long term treatment. Some of them last even two to three years, but most of these injections, they last maybe three to six months or so. But every year I mean they are working on different medications. New injections, things like that. So there are other things on the horizon.
Takieyah: Wow, you're teaching me a lot today. So uveitis is not the only eye disease people with psoriatic disease are at risk for developing. I recently learned that there's an association between psoriasis and the development of cataracts. Is this also related to the inflammatory process you mentioned earlier in our discussion?
Dr. Janetos: Well, it's both due to inflammation and the treatment for inflammation. So it's true that patients not only with psoriatic arthritis but other immune conditions that cause inflammation in the eye or in the body, have cataracts sooner. But part of the reason is due to the treatment of those conditions. So like I was saying, prednisone or corticosteroids, they accelerate the natural aging process of a cataract. And they cause sort of an environment that is pro cataract formation. Inflammation in and of itself too, can also accelerate the process of a cataract developing, especially uveitis in the eyes. So it's both of those reasons that we tend to see cataracts forming sooner in people with immune disease and especially in patients that develop uveitis as well.
Takieyah: So how do cataracts develop, and what are the symptoms? How does someone know if they have a cataract?
Dr. Janetos: The symptoms of cataracts are usually insidious in nature. It's blurring of vision over weeks to months, night vision issues, difficulty driving at night, glare or halos around lights. But ultimately, the only way to know if you have a cataract is again to have an eye exam with an ophthalmologist or an optometrist to dilate the eye and to look at the lens in the eye and see if there's a cataract or not.
Takieyah: What's the typical treatment for cataracts? You often hear people say their eye doctor is waiting for their cataract to grow before it can be removed. Is surgical treatment the only option?
Dr. Janetos: So the only option to remove a cataract is surgery and it is the most commonly performed surgery in the United States and the world. But it's still a surgery, so it comes with risks of surgery. Risk of cataract surgery for a complication that is vision threatening is very rare. We're talking about less than 1%. So overall it's a very safe procedure. What I tell my patients, though who come to me and ask me if a) if they have a cataract, and b) if they need surgery, I usually tell them that it doesn't really matter so much what I see. It matters what they see. So cataracts are quite a spectrum and I never tell a patient that they need cataract surgery. You really never need surgery. Leaving a cataract in an eye for longer is not causing any permanent damage to the eye. So it just depends on how that patient is functioning with their vision and how bothered they are by a cataract. So sometimes I see patients who have a cataract that I would consider to be a very large cataract or a very dense cataract. But they are very happy with their vision. They're able to perform all their daily tasks and function. In that case, I would not recommend cataract surgery for that patient. On the other hand, I tend to see patients as well who have what I would grade as a more milder cataract, but they are very bothered by their vision. They may have a job that really requires very fine detail. They can't drive at night due to the cataract. In those patients, it would be reasonable to remove their cataract. So really it just depends on what the patient is telling you, how bothered the patient is by their cataract and leave it up to the patient when you discuss the risks and benefits of cataract surgery for them to decide if they are ready to undergo the procedure. The alternative to cataract surgery is no cataract surgery. It's updating the glasses prescription. It's increasing the brightness in the room, different ways to increase their ability to complete tasks. The cataract can stay the same over time. It can get worse. It will never get better on its own, but again, the most common thing that I stress to patients is that keeping the cataract in the eye for longer is not causing any permanent damage. So if at some point that patient then realizes that it is time for them to undergo cataract surgery, if that's in six months, if it's in a year, if it's in two years, it doesn't really matter. The cataract is taken out of the eye and the eye goes back to what it was before they had the cataract. Now it's a little bit different of a situation for patients who have cataracts that have also experienced uveitis, or inflammation in the eye. Those cataracts they can be more complex of a surgery and they come with higher risks to the surgery. The biggest risk that patients with uveitis have who are undergoing cataract surgery is stirring up the inflammation after the surgery and that can lead to real complications with their vision, suboptimal outcomes after the surgery. So for those patients, I really recommend that they see if they are having a cataract or they've been told that they've had a cataract, I recommend that they see a dedicated uveitis specialist who does surgical management for cataracts, because those people are gonna be really adept at knowing how to care for the patient before and after the surgery to prevent inflammation from flaring up. We have a typical rule of thumb and that is that the eye should be completely inflammation free for at least three months. And I typically like to wait longer than three months unless it is at a more emergent situation before doing any surgery on an eye that has had inflammation in it. And around the time of surgery we use a lot of different steroid medications just to really make sure that no inflammation comes back after surgery for a cataract that has had uveitis in the eye.
Takieyah: Are there any new advancements or emerging therapies that could change the treatment of uveitis or cataracts? What does the future hold?
Dr. Janetos: So for uveitis, in the past 20 years and really all immune disease, there's really been a revolution in new systemic therapies. Before 20, 25 years ago there were very few treatment options that were available that worked other than what I had mentioned previously. Oral prednisone, which is a very poor medication to be on long term. Now, there are biologic therapies that specifically target key aspects of the immune system that are thought to be overactive in immune disease, including uveitis, and more frequently than not, I am using these biologic medications as the first line therapy for chronic disease management for my uveitis patients. They tend to be extremely well tolerated medications. Most patients don't experience any side effects on them. You do have to of course monitor these patients. Lab work every few months to make sure that you know it's not messing with any blood levels or blood counts, but they tend to be extremely well tolerated. Easily administered medications that really work quite well for preventing inflammation. Older medications before 25 years ago included things like methotrexate, mycophenolate, and while these medications do work for the treatment of uveitis and we certainly still use them for the treatment of uveitis, they come with much more side effects that the patient experiences. They take much longer to work, we're talking on the order of months before they really start to work fully and when you are taking them, they tend not to work as frequently as the biologic medications. So those are a new avenue that has really revolutionized the way that we treat uveitis. In terms of cataracts every decade, I would say they are coming out with more and more technology that makes cataract surgery more precise, uses less energy, and really decreases the risk of any complication. 40 years ago if you were to have cataract surgery, you would stay overnight in the hospital. It would be a huge procedure. It would be a very difficult procedure. Now it is the bread and butter of every ophthalmologist. It's an outpatient procedure. People go home the same day. They usually notice even by the next day their vision is significantly improved. What does the future hold? That's a good question. I think that more and more we are gonna see different aspects of the immune system targeted by these new biologic medications. There are also more and more local eye injections, local eye treatments that also target a specific immune response within the eye itself. That will help prevent patients from having to take systemic therapy and instead just be treated locally in the eye instead of having to use steroid medication. So there's a lot of things on the horizon.
Takieyah: That sounds promising. Thank you Dr Janetos for that update. Let's now turn to general eye health actions someone with psoriasis can do to reduce their risk. Are there any lifestyle changes that could help enhance eye health?
Dr. Janetos: Well, that's a really good question. And my patients always ask me this question. You know, what should I be eating? Are there any supplements that I should be taking to help reduce inflammation? And what's tough about that question is we know that the answer to it is yes. There are things that can be done, but we don't know enough about it to really make a recommendation. We really know that diet does influence inflammation. The gut microbiome really has an impact on inflammation overall in the body and in the eye. But what we don't know yet is, is there a specific diet? Are there specific things that patients can be doing that will influence that microbiome to decrease inflammation? It's a very complicated system and there's a lot of research out there currently to try to figure these things out, but we just don't have enough information to make a educated recommendation. Now there are things for sure that we know that influence not only inflammation, but eye health in general. The biggest link that we know that has good evidence is smoking. Smoking cessation not only will prevent flares of inflammation within the eye and within the body, but it's also very well established that smoking is associated with other ocular conditions such as macular degeneration and cataract formation. So if there is one thing that you know I can impart on patients to say, hey, we have good evidence for this and that is if they are current smokers, trying to decrease smoking or smoking cessation is definitely a good idea to help with overall eye health. For everyone else, I say you know what? There's no downside to a healthy diet and a healthy diet filled with green leafy vegetables. All those things can only help, but I just don't have enough evidence at this point, or enough good data to really make a informed recommendation on a specific supplement or diet.
Takieyah: So how important is it to eye health to keep systemic inflammation associated with psoriasis and psoriatic arthritis in control?
Dr. Janetos: Well, you know, they're hand in hand, right? And sometimes we see that the eye inflammation is the driver of the patient's main issues. Sometimes we see that the skin disease is the driver of the patient's main issue. And so when I'm sharing these patients with rheumatologists, dermatologists, we're all in conjugation and discussing, “OK, what is the best therapy for this patient to be on, to control all of the components of the disease?” And sometimes it's really the skin disease that's the driver of inflammation. Sometimes it's the eye disease that's the driver of inflammation. Either way, it's very important to treat one and not forget about the other. So when I'm seeing the patient, I'm thinking about the eyes. But I also recognize that they have other things going on so I need to have that conversation with the rheumatologist, with the dermatologist to say “hey, you know, I want to start this medication. What is it gonna do for their skin disease or the dermatologist, rheumatologist might say “I want to put them on this medication to control the skin disease. Is that gonna be appropriate for the eye?” So it's really important to think about both of those components when you're developing a treatment plan for patients.
Takieyah: And Dr. Janetos, what else can someone do to maintain overall eye health?
Dr. Janetos: So certainly a routine eye exam is important for patients who are a little bit older. So I mean 50’s and 60 year old just routine eye exam annually to monitor for things like glaucoma, macular degeneration, or cataract formation, especially if you have a family history of eye problems. That can be done with either an optometrist. An optometrist is somebody who goes to optometry school. They're trained in diagnosing conditions and glasses prescription, and they are typically good at triaging people if they think they need to go see an ophthalmologist. An ophthalmologist can also do these routine eye exams, especially comprehensive ophthalmologist. But they are medical doctors. They are trained in more specialized treatment of different conditions. Treatment including surgical or medication treatment.
Ophthalmologists are subspecialty trained. There's like 8 subspecialties within ophthalmology, like how can you break the eye? The eye is already like tiny, tiny little thing.
Takieyah: Right.
Dr. Janetos: And now you got, like, eight different doctors and it's sort of funny. You go to the ophthalmologist and one of them will tell you “Oh no, I'm a front of the eye doctor. You need to go see the back of the eye doctor.” And patients are a little confused. It's this tiny little thing. But there is a subspecialty, which is what I'm trained in, specifically in uveitis, so if you do have uveitis or especially chronic uveitis, it is something a little bit more complicated, a dedicated uveitis specialist is very important. For patients that have underlying conditions, such as psoriatic arthritis or other immune disease, what I would recommend for them is if they develop any sort of issue with their eye, they should be seen by an ophthalmologist right away. Sometimes patients come in to see me and they're concerned about something about their eye, and everything looks fine to me and I provide them that reassurance. And they say, “oh, I'm sorry that I wasted your time. I shouldn't have come in.” And I say “no, no, no. I would rather you come in 100 times and for there to be nothing wrong with the eye than for you to stay at home worried about some eye condition that you might have and not get it checked out, and then when you do go in for it to be advanced and require a lot more treatment and potentially have complications.” So it's better to come in if you have any issue with your eye, especially if you do have an immune disease. Again, I have mentioned those symptoms - redness, pain, light sensitivity. But really uveitis again is that spectrum of diseases, so you can have very mild symptoms and if you are experiencing any of those mild symptoms, a few new floaters, vision is a little blurrier, something is off about your vision. Just come in and be seen by an ophthalmologist to get it checked out. It's better to do that early and catch things early so that the appropriate treatment can be started early.
Takieyah: Thank you Dr. Janetos for being here today for such an eye opening discussion about uveitis, cataracts, and eye health. I'm so glad we can have this discussion as I learned so much about both. As a psoriatic patient and advocate, it’s really important for me to learn more about these conditions and learn more about my own health as I've been through certain things and I never knew some of the things we talked about today. So I just want to say thank you for speaking out and again being here with us. Do you have any final comments you would like to share with our listeners?
Dr. Janetos: Well, thank you so much for having me here today. It's really been a pleasure to talk to you and I would just reemphasize again as someone like yourself who's living with psoriasis, just be an advocate when it comes to your eye health. So if something doesn't feel right, even if you're not sure about it, whether it's a minor change in vision or the eyes a little light sensitive or painful, or you just have a hunch that something's not right, don't wait. Reach out to your care team. Include an eye specialist in that conversation early and get your eyes checked out. Because, again, with that early detection and right treatment can definitely stop these things before they cause any issues. And the worst that can happen is you go in and there's nothing wrong and you get that reassurance. So that's what I would wanna impart on everyone, including the listeners.
Takieyah: Thank you very much.
Dr. Janetos: Well, thanks for having me. It was so nice to speak to you.
Takieyah: Thank you again, Dr. Janetos for our discussion about uveitis, cataracts and overall eye health. It's been a pleasure speaking with you today as we uncover the relationship between certain eye diseases and psoriasis. For our listeners, please share the episode link with anyone you know who is in need of the information about eye health and at risk for developing uveitis. For more information about psoriasis and psoriatic arthritis, contact our Patient Navigation Center at education@psoriasis.org. And finally, thank you for listening to Psound Byes, which will become Psoriasis Uncovered in July.
We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.
Return to the Episode Page
Go to episodeKeep Listening
We have tons of great content in our Watch and Listen section. Check out our latest episodes now.
Questions about psoriatic disease?
Our Patient Navigators are here to help. Connect with our Patient Navigation Center for free resources and answers to your questions.