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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 2  |  Page : 164-168

Ocular manifestations of psoriasis: A case-control study


1 Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Submission20-Jan-2021
Date of Acceptance01-Apr-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Jasmita Satapathy
Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_7_21

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  Abstract 


Background: Psoriasis is primarily a skin disorder with many extracutaneous manifestations. Relationship between eye lesions and psoriasis has been reported in literature. However, much data are not available on ocular manifestations of psoriasis in the Indian population. Objective: The objectives of this study were to assess the frequency of ocular manifestations in psoriasis and to correlate it with factors such as age, gender, duration of disease, type of psoriasis, and severity of psoriasis. Materials and Methods: A total of 100 patients with psoriasis and 100 healthy controls were enrolled in the study. Clinical types of psoriasis, duration of disease, site of involvement, and severity of psoriasis were noted. Slit lamp examination, fluorescein staining of ocular surface, and fundoscopy were done for both groups. Dry eye evaluation was performed by measuring the values of Schirmer 1 and tear film breakup time. Results: Prevalence rate of ocular involvement in psoriasis was found to be 61% as compared to 30% in controls. Most common ocular finding was conjunctival hyperaemia (47%) followed by dry eye (36%) and blepharitis (27%). Scalp psoriasis was found to be significantly associated with blepharitis (P < 0.0001). There was corneal involvement in 9 cases and uveitis in three cases. No correlation was found between the frequency of ocular manifestations and factors such as age, gender, duration, and the severity of psoriasis. Conclusion: Ocular manifestations in psoriasis are common and they affect mostly the anterior segment of the eye. Routine ophthalmological evaluation is important in these patients for early diagnosis, which in turn can prevent sight threatening complications.

Keywords: Blepharitis, ocular involvement, psoriasis, psoriasis area and severity index score


How to cite this article:
Shah RD, Satapathy J, Panigrahi PK, Kar BR, Mohapatra RC. Ocular manifestations of psoriasis: A case-control study. TNOA J Ophthalmic Sci Res 2021;59:164-8

How to cite this URL:
Shah RD, Satapathy J, Panigrahi PK, Kar BR, Mohapatra RC. Ocular manifestations of psoriasis: A case-control study. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 27];59:164-8. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/164/319265




  Introduction Top


Psoriasis is a chronic, relapsing inflammatory disorder that affects around 0.1%–3% of the global population.[1],[2] Different environmental conditions (extremes of temperature), dietary habits and genetic differences are found to play a major role in its prevalence. In India, the prevalence of psoriasis varies from 0.44% to 2.8%.[2] It commonly affects skin, nails, joints and has various systemic associations including the eye. A number of studies have been reported worldwide, but they are mostly from Europe and far east Asia.[3],[4],[5],[6],[7] Literature is sparse on this issue as far as data from Indian subcontinent are concerned. This study reveals the ocular manifestations of psoriasis from Eastern India.


  Materials and Methods Top


This is a case-control study conducted from October 2018 to February 2020 in the Department of Ophthalmology in association with the Department of Dermatology, in a tertiary care hospital in Eastern India. Following the description of Helsinki Declaration, approval of the institutional ethical committee was obtained. Newly diagnosed patients with psoriasis as well as previously diagnosed cases who were not on treatment at least for the last 3 months, at the time of recruitment, were included in the study. The patients were referred from the department of Dermatology for detailed ophthalmological evaluation. Equal number of age- and gender-matched healthy individuals after satisfying the exclusion criteria was taken as controls. Informed consent was obtained from each patient in both the groups.

Inclusion criteria

All patients with psoriasis >18 years of age who were recently diagnosed clinically by at least two dermatologists or those old cases of psoriasis who had not received any treatment for the past 3 months were considered for inclusion.

Exclusion criteria

Patients were excluded for the following reasons:

  1. Previously diagnosed cases of psoriasis who received treatment in the last 3 months
  2. Patients with a history of ocular trauma or allergy, Stevens-Johnson's syndrome, diabetes mellitus, renal disease, rheumatoid arthritis or other autoimmune/collagen vascular diseases like sarcoidosis, systemic lupus erythematosus, behcet's disease, etc.
  3. Patients using contact lenses
  4. Patients on chronic ophthalmic medications and disease-modifying agents like immunosuppressive drugs
  5. Patients <18 years of age.


A detailed history was taken and data regarding age of onset, gender, duration of psoriasis, and the treatment last received (if any) was collected. Clinical types of psoriasis, site of involvement, and the severity of the disease using psoriasis area and severity index (PASI) were noted. All patients underwent a comprehensive ophthalmic examination which included measurement of visual acuity, assessment of anterior segment of eye including ocular adnexa by slit lamp biomicroscopy and fundus examination. Ocular surface was evaluated by fluorescein staining. Dry eye evaluation was done by performing Schirmer 1 and tear film break up time (TBUT). Schirmer's value <10 mm and TBUT <10 s were taken as abnormal. Intraocular pressure was measured using Goldman's applanation tonometer. Ocular examination and dry eye evaluation were also done for the controls. The data thus collected were entered in a Microsoft Excel sheet and the statistical analysis was done using Z test, Pearson's correlation coefficient, linear regression coefficient, and ANOVA, wherever appropriate. A P < 0.05 was considered statistically significant.


  Results Top


A total of 100 patients with psoriasis were enrolled in the study. Their mean age was 48 ± 15 Years (range from 18 to 80 years). Fifty eight percent (n = 58) cases were male. Equal number of age and gender matched healthy individuals (n = 100) were recruited as controls, with a mean age of 48 ± 14.7 years and 60% of males. The mean duration of psoriasis was 7.84 ± 6.79 years (range from 1 month to 35 years). Majority of patients had psoriasis vulgaris (87%). Other clinical types of psoriasis found in the study group were erythrodermic (6%), pustular (4%), and guttate type (3%). Thirty-three percent (n = 33) cases were newly diagnosed and rest were old biopsy proven cases.

The mean PASI score was 4.43 ± 3.2 (range from 0.1 to 14). Scalp (61%) was the most common site of involvement, followed by the nail (46%) and joint (16%). Some of the patients had multiple sites of involvement and around 27% of cases had neither scalp nor nail/joint involvement. One or more ocular signs were seen among 61% of cases in psoriasis group and 30% in control group. This was statistically significant (P < 0.0001). In the psoriasis group, 52 (85.24%) cases with ocular involvement had psoriasis vulgaris. Most of the cases in psoriasis group (86.8%) had bilateral ocular involvement. Ocular signs seen in the study group were blepharitis, conjunctival hyperaemia, dry eye, corneal opacities, punctate epithelial erosion, uveitis, and cataract [Table 1].
Table 1: Frequency distribution of ocular manifestations among cases and controls

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Blepharitis was commonly seen in patients with scalp psoriasis. Out of 27 cases of blepharitis [Figure 1], scalp involvement was seen in 17 cases (62.96%). This shows a statistically significant correlation (P < 0.0001) between blepharitis and scalp psoriasis [Table 2]. Six out of 9 patients with corneal signs, had nail psoriasis (66.7%) and all of them had bilateral punctate epithelial erosion. Rest three patients had no nail involvement and had unilateral nebular corneal opacities. However, statistical significance of corneal involvement in psoriasis could not be calculated due to small sample size. Out of 36% of cases of dry eye among the psoriasis group, 19 cases (52.77%) had symptoms of dry eye along with abnormal Schirmer 1 and TBUT values as compared to 16% (n = 04) cases of dry eye among the control group [Table 3]. This was statistically significant (P < 0.0001). Only 3 patients in the psoriasis group had features of uveitis [Figure 2]. Out of them, 2 had joint involvement and one had no joint involvement. Statistical significance could not be calculated due to small sample size.
Figure 1: Eyelid psoriasis with blepharitis

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Table 2: Association of blepharitis and scalp psoriasis

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Table 3: Comparison of abnormal test values with presence of dry eye symptoms in cases and controls

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Figure 2: Uveitis with keratic precipitates in a patient of psoriasis

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We did not find any statistically significant correlation of ocular involvement with age, gender, duration, and the severity of psoriasis [Table 4].
Table 4: Correlation of ocular involvement and age, gender, disease duration, and psoriasis area and severity index score among the study group

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  Discussion Top


Ocular involvement in psoriasis is not well described in the literature. Prior publications, from Europe and far east Asia, have reported the incidence rates for ocular findings in psoriasis to be about 10%.[4],[8],[9] However, higher rates varying from 50 to 80% have been reported in recent studies.[3],[5],[6] Due to climatic and racial differences between the Indian population and the population from Europe and far east Asia, the manifestations of ocular psoriasis would differ. Very few studies have been done showing ocular manifestations of psoriasis in India.[10]

In our study, conducted in Eastern India, we enrolled patients of age group ranging from 18 to 80 years with a mean age of 48 ± 15 years. There is a slight male preponderance, probably due to more access of male patients to health care services in our country. This finding is consistent with studies reported earlier.[5],[10],[11] We detected ocular findings in 61% of patients with psoriasis and 30% of the controls. This is nearly similar to the values detected in previous studies.[3],[4],[5],[6],[7] However, Abbagani et al. found a much higher (80%) prevalence rate.[10]

Chronic nonspecific conjunctivitis is commonly associated with psoriasis.[3] We found conjunctival hyperemia (47%) as the most common ocular manifestation in psoriatic patients in the current study. It was statistically significant (P < 0.0001) when compared to the control group. Similar to our result, conjunctival injection was detected among 40% of patients with psoriasis in a study by Omar and Helaly.[12] However, some studies have reported lower rate of the prevalence of chronic conjunctivitis.[13],[14],[15],[16] Higher prevalence in our study could be due to the fact that common ocular manifestations like dry eye and blepharitis can also present with conjunctival hyperemia.

We found blepharitis affecting 27% of the patients with psoriasis in our study which is significantly higher (P < 0.0001) when compared to controls. Similar results were reported by various other studies.[15],[16] The prevalence of blepharitis reported in the study by Erbagci et al.[6] (64.5%), Abbagani et al.[10] (63%), and Kilic et al.[3] (39%) were much higher than our study. However, there are studies which did not find significant cases of blepharitis in patients with psoriasis as compared to controls.[11],[12],[14] We found statistically significant relationship between scalp psoriasis and blepharitis, which is consistent with the study done by Abbagani et al.[10]

There is an increased incidence of dry eye in patients with psoriasis. We observed 36% of patients with psoriasis to have dry eye disease. Similar results were reported by Kolli et al.[15] (37%), Maitray et al.[16] (37.3%) and Abbagani et al.[10] (44.7%). Some authors have observed a significantly lower TBUT as compared to Schirmer 1 among the psoriasis patients having dry eye.[17],[18],[19] They have suggested that the tear film instability is secondary to a reduction in mucin layer of tear film. Similarly, Erbagci et al.[6] and Demirci et al.[20] found significantly higher tear film osmolarity in cases with psoriasis along with lower TBUT, but no significant differences were detected in Schirmer's values. In the current study, we found a significant decrease in both Schirmer 1 and TBUT values. This is consistent with the findings of various other studies.[3],[10],[11],[14]

Corneal involvement in psoriasis is usually secondary to dry eye disease and/or eyelid complication like trichiasis.[4],[7],[21] The most common presentation is punctate epithelial keratitis, but lesions can include superficial or deep corneal opacities, stromal infiltrates, neovascularization, erosions, scarring, and even stromal melts.[4],[7],[22] In the present study, we noted corneal involvement in the form of punctate epithelial erosion and superficial corneal opacities in 9% cases of psoriasis, which is statistically significant (P = 0.0017) when compared to the control group. Kilic et al.[3] have also detected significant cases of corneal involvement (16%) among the psoriatic patients. However, Maitray et al.[16] and Abbagani et al.[10] did not document corneal involvement as an association of psoriasis. We noted punctate epithelial erosion in 6 patients out of 9 cases of corneal involvement and all of them were found to have nail psoriasis. This might be due to micro injuries to corneal surface similar to Koebner phenomenon of skin or as part of the dry eye process as suggested by Catsarou-Catsari et al.[21]

Previous studies have suggested that uveitis is diagnosed particularly in patients with psoriatic arthritis or severe pustular psoriasis.[5],[6],[21],[23] The authors have found that mostly it is anterior, bilateral, and showing tendency to recur.[21],[22],[23],[24],[25] Some studies have also reported complications of uveitis like posterior synechia, hypopyon, and cystoid macular edema in psoriasis.[5],[26] We ascertained three cases of anterior uveitis in the psoriasis group and all cases had bilateral involvement, whereas no uveitis was identified in the control group. Two of these 3 cases had joint involvement. We did not observe any complications due to uveitis as described in previous studies.

When we compared the presence of episcleritis, no statistically significant difference was determined between the cases and controls. Lack of significant difference was also reported by Kilic et al.[3]

Regarding the presence of cataract, unlike Chandran et al. we did not find a statistically significant difference between the patient and the control group, suggesting it as a normal aging process in both groups.[5]

We did not observe any statistically significant relationship between the rate of prevalence of ocular findings and the factors such as age, gender, duration of psoriasis, and PASI scores. This is consistent with results reported in earlier publications.[3],[6]


  Conclusion Top


Ocular manifestations in psoriasis are common and they can affect mostly the anterior segment of eye. This research from Eastern India reveals the occurrence and spectrum of ocular manifestations in newly diagnosed patients with psoriasis as well as previously diagnosed cases who are not on treatment currently. Blepharitis and dry eyes are common manifestations in our study. Scalp psoriasis has a greater association with blepharitis. We noted lower Schirmer 1 and TBUT values in psoriasis patients having dry eye than the control group. Conjunctival hyperemia is the most frequent occurrence in this study, which may also be explained by the presence of dry eye and blepharitis. It should be kept in mind that ocular signs of psoriasis may progress independent of factors such as duration, type, and severity of the disease. It is therefore prudent to keep these patients under regular follow-up.

Limitations

Sample size of different clinical variants of psoriasis except psoriasis vulgaris was very small. Hence, we could not calculate the statistical significance of ocular involvement in these groups. Very few patients had severe disease with PASI score more than 10 in our study. This might have affected the final outcome.

Acknowledgment

We acknowledge Mr. P. K. Brahma for his help in statistical analysis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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