IBD - Ocular Manifestations
5% of IBD patients will have ocular manifestations (more often in
adults)
Episcleritis
- Most common ocular manifestation in IBD
- Inflammation of the episclera (layer beneath the
conjunctiva)
- Presentation
- Conjunctival and scleral hyperemia (one or both eyes)
- Irritation or burning
- Pain or tenderness with palpation is common
- No change in visual acuity
- Occurs during flare of IBD
- Dx
- Eye exam reveals focal or diffuse patches of redness with white
patches of sclera in between. (Due to the dilated episcleral vessels)
- The engorged vessels are superficial and will blanch with
topical application of phenylephrine
- Tx
- Responds to Tx of underlying IBD
- Supportive: Cool compresses, local topical steroids
Scleritis
- Inflammation of deep scleral vessels as well as episclera
- More severe than episcleritis
- Can present at any time (may precede diagnosis of IBD)
- Urgent Assessment and
treatment by optho to prevent Visual Loss
- Presentation
- Severe eye pain
- Tenderness to palpation
- Sclera may appear violet in color, depending on the light
- Posterior ascpect of the eye may become involved - Can lead to retinal detachment and
optic nerve swelling
- Dx
- Differentiate from Episcleritis by the pink sclera between
inflammed vessels (instead of the white slcera seen between inflammed
vessels in episcleritis)
- Scleral vessels do not blanch with application of topical
phenylephrine
- Tx
- Aggressive Tx with systemic steroids, NSAIDs*, or
immunosuppresants
- Treat underlying IBD
- Recurrence is common
Uveitis
- Inflammation in the middle eye chamber
- Urgent assessment by Ophtho (can
progress to blindness if not treated appropriately)
- Presentation
- Visual pain
- Photophobia
- +/- Headache
- Can present at any time (may precede diagnosis of IBD)
- Can recur in contralateral eye
- Not typically related to intestinal
disease activity
- Anterior Uveitis
- Painful eye
- Visual blurring
- Photophobia
- Severe when eye becomes miotic w/ abnormal pupillary
response to light
- Ciliary Flush - redness most intense at limbus and radiates
outward for a short distance
- Posterior Uveitis (or retinal involvement)
- Significant changes in visual acuity
- Immediate evaluation
by Ophtho
- Dx
- Tx
- Topical +/- Systemic steroids
- Cycloplegics
- Some refractory cases have been treated with Azathioprine or
even Infliximab
- Short term COX-2 inhibitors (celecoxib) are sometimes
recommended but...
- NSAIDs* not usually recommended due to potential to worsen IBD
Sx
- Close follow up and repeat eye exams to monitor intraocular
pressure
- Long term complications include:
- Pupillary abnormalities or macular dysfunction
- intraocular adhesions from chronic inflammation leading to:
- secondary glaucoma
- cateracts
- Some refractory cases have been treated with Azathioprine or
even Infliximab
Rare Eye Diseases in IBD
- Keratitis, retinitis
- Pars planitis
- Marginal corneal disease
- Scleromalacia perforans
- Orbital inflammatory disease
- Central and branch retinal artery occlusions
- Central retinal vein occlusion
- Optic neuritis
- Retinal vasculitis
Note:
The patient with a red eye
associated with a visual defect or
severe eye pain requires immediate referral to a specialist.
Vomiting in the context of a unilateral red eye must be managed as
acute angle closure glaucoma until proven otherwise
* NSAIDs not usually recommended due to potential to worsen IBD Sx
**Treatment with topical or systemic steroids may lead to cateracts or
glaucoma
References:
https://academic.oup.com/ibdjournal/article/10/2/135/4706193