The Ultimate Guide on Pain Management for Dogs The Ultimate Guide Pain Management for Dogs By Dana Brown, DVM – Sep 2, 2017 There are few things as frustrating for a dog owner as knowing their dog is in pain and not being able to do anything about it. That is why today, we are going to talk about pain management for dogs and things you can do to help relieve your dog’s discomfort. Dogs are naturally reluctant to show pain . This makes it difficult for most pet owners to identify when their canines are hurting. If you pay attention to your dog’s body language, however, you can learn to identify subtle signs of pain, which makes it easier to manage, treat and prevent it in the future. Remember that these signs may be indicative of, but are not exclusive to dogs experiencing pain. We’ll take a look at the signs of pain in dogs, their clinical assessment, common treatments and types of science-based pain management for dogs, based on animal studies and partially on the research guide provided by The National Academies of Sciences and Engineering ( some studies can be found here ). Signs of Pain in Dogs The most common signs of pain in dogs are: Excessive panting Constant whining and crying Tucking of the tail Just like with stress in dogs , it’s important that you know your dog’s normal behavior when he’s healthy so you can deduce when things are going bad from him. Your veterinarian should always be your first point of contact should you notice unusual behavior in your dog which you assume to be due to pain. “Without a knowledge of their normal and abnormal behavior and appearance, assessment of pain in animals is difficult, because animals are unable to communicate in ways in which they can be readily understood by people.” (Hughes and Lang, 1983; Soma, 1987; source ) Panting is a common sign of pain in dogs , particularly in senior dogs with arthritis . While all dogs pant, it’s easy to notice when it reaches the point of “excessive.” This type of panting cannot be relieved by cooling your dog or offering water to your dog. Pacing is a good indicator of pain , and you’ll see your dog pace back and forth when in pain. This is usually a result of not being able to get comfortable due to a health problem, injury or general experience of pain somewhere in the body. Restlessness is also common for dogs in pain to experience due to an inability to get comfortable and in an effort to cope with their pain. You may notice your dog shifting constantly or getting up and laying down repetitively. Behavioral changes in dogs can be indicative of pain as well. You may observe your dog becoming less tolerant of being bothered, they might seek solitude instead of company, or they may change their eating, drinking, and/or bathroom behavior. Unfortunately, behavioral changes can be indicative of many other things in addition to pain, so it’s important to talk to your veterinarian as soon as possible. Physical signs can be also be observed in dogs experiencing pain. They could limp, may be reluctant to put weight on a limb, have outward signs of injury, show bruising, be bleeding, show changes in respiration or show other signs of physical change. Physical changes in your dog should be evaluated by your vet to find the cause of the pain and provide the necessary pain management. Vocalization is the quickest giveaway (Lefebvre and Carli, 1985; Cooper and Vierck, 1986). Dogs that are in serious pain will often cry or whine, particularly when the source of their pain is stimulated or manipulated. Dogs will generally avoid vocalization unless in serious distress. If your dog is vocalizing their pain, seek veterinary help immediately. Note that spontaneous barking is very rare; your dog is most likely to whimper and howl instead. Tucking of the tail between their legs is another commonly seen sign in dogs who are in pain. This should not be confused with dogs in a fearful or anxiety inducing situation who may take on a similar posture. Tail tucking is most commonly seen in dogs experiencing joint pain due to arthritis. Mild pain: Studies show that dogs in pain of mild severity are generally less alert and become unusually quiet, with an unwillingness to move as normal and appear to have stiff bodies. Severe pain: It’s been observed that dogs experiencing serious pain will be the opposite to those with mild pain, and express many of the signs mentioned above. Shivering, lack of appetite and increased respiration are the most commonly observed signs in clinical research. Now that you know what signs you should be looking for, we need to discuss pain management for dogs and what you can do about it. There are some canine pain management tips you can do yourself, but remember to always check with your veterinarian for an underlying cause to the pain. Another important thing to note is that dog owners must familiarize themselves with first aid for dogs and all of its aspects. If you perform pain management for dogs on an animal with an underlying injury, you could actually do more harm than good. For example, massaging a pulled muscle could cause your pup a lot of pain. The Ultimate Guide on Pain Management for Dogs 1 First Steps When Your Dog is in Pain Once you’re aware of the signs of pain in dog, and you’re positive that your pet may be experiencing some level of pain, there are a set of steps for pain management for dogs that you need to take to effectivelly help your canine deal with it. Identify the source Locate where your dog’s pain is coming from if you are able to do so. For example, does your dog have a history of arthritis? Is he holding one leg off the floor like you see in the photo above? Is he pawing at one part of his body? Is his abdomen swollen or distended? The source of your dog’s pain may not always be obvious. However, if you are able to locate it, you can get a better idea of the proper pain management for dogs techniques to use. If you are unable to locate the source of your dog’s pain and no physical symptoms offer more information, call your vet. If your vet is closed, call the emergency vet. Unknown sources of pain can range from mild illness to critical injury. Pain where blood is present Mild cuts and scrapes can be treated at home with antiseptic spray and covered with a liquid bandage. This type of wound should not be too painful, but if your dog continuously bothers the area take a closer look. Make sure there is no foreign object in the wound and that it is healing well. If it is not healing or your dog seems to be in a lot of pain, go to the vet for a second opinion. To treat the pain related to more significant injuries, stem the bleeding and have the wound treated by your vet. Once treated, your vet will likely prescribe a prescription pain killer like Tramadol for dogs, or a nonsteroidal anti-inflammatory like Meloxicam or Carprofen . Pain related to puncture wounds Puncture wounds should always be seen by a veterinarian. Depending on the source of the puncture, your vet may administer an antivenin, or clean the wound and prescribe antibiotics along with NSAID’s or painkillers. Pain related to an area hot to the touch Heat is often a sign of infection. If your dog is already on antibiotics for an existing infection, it’s likely the antibiotics are not effectively treating the bacteria. Drop into your vet and let them know that your dog may need an alternate antibiotic. If your dog is not already on a course of antibiotics for an infection, note any other symptoms and head to your vet. The only way to treat pain related to infection is to reduce swelling with NSAID’s and treat the infection with antibiotics. You can reduce swelling while you wait for your vet appointment by using an ice pack. Never use heat on an infected injury. Pain related to broken bones Broken bones require immediate veterinary treatment. Your vet will x-ray the injury, reset the bone and write a prescription for pain management. Both NSAID’s and narcotic medications are used for pain relief related to broken bones. Your vet may also prescribe antibiotics. If your dog seems unsettled despite being on pain medication for a broken bone and is not due for another dose, it is likely that they are simply not used to their cast. You may also notice your dog acting out of character due to their pain medication side effects. Pain due to bloating Bloating can be a sign of gastric torsion which requires immediate veterinary intervention. If your dog has gas pains related to stomach problems with no other signs of gastric torsion, various medications can help. Your vet can prescribe carminative to reduce gas or recommend human alternatives in safe doses. Your vet may also recommend feeding your dog more slowly, changing your dog’s diet, eliminating dairy products, and not feeding your dog immediately after exercise. Pain due to limping Limping can be the result of a simple strain or a more serious torn ligament or fracture. If your dog refuses to weight bear on their limb, pay your vet a visit immediately. If your dog is still weight bearing but limping, check the foot for injury. If no injury is noticeable, restrict exercise for a few days and ice any swelling. If limping continues for more than two days, seek veterinary assistance. Pain due to arthritis Dogs with a history of arthritis or older dogs who have not yet been diagnosed with arthritis, often experience pain and stiffness. Dogs with an existing diagnosis and prescription pain killers or anti-inflammatories may require new medication or new dosing. Make an appointment with your vet to adjust your dog’s treatment plan. Older dogs who show signs of stiffness and pain in their joints should be assessed for arthritis. Depending on the severity of arthritis, treatment will vary. Early arthritis can be supplemented with glucosamine and chondroitin, fish oil, and regular low impact exercise. Medium severity arthritis can be treated as above along with pain killers and NSAID’s as needed. Severe arthritis can be treated the same way as medium severity arthritis with more regular use of pain killers and NSAID’s. These dogs also benefit from injectable medications like Adequan and exercise through hydrotherapy. 2 Using Heat for Pain Management in Dogs Heat therapy is recommended for pain related to injuries older than 48 hours and is often one of the first solutions in pain management for dogs performed by a vet in the clinic. Heat can be used to relieve pain related to injury and arthritis. When applied, heat increases blood flow to an injured area to promote healing. Heat also helps to stop spasms of muscle tissue and decrease stiffness. Heat can also loosen up muscles and joints prior to exercise. In some instances, heat is also used to draw out infection from wounds, but it should only be used under the supervision of a vet. Heat should not be applied after exercise to muscle pain or to areas affected by inflammation. You can apply heat to your dog’s problem area by: Using a hot water bottle wrapped in a clean towel Applying a warm wet compress Bathing your dog in warm water Using a heating pad wrapped in a clean towel Remember to never apply heat directly to your dog’s skin. When applying heat, apply for 10 minutes at a time allowing at least 20 minutes rest between sessions. Always check periodically to make sure your dog’s skin is not being burned. 3 When to Use Ice in Pain Management for Dogs Ice therapy is recommended in pain management for dogs when the source is inflammation. The cool contact dulls the pain associated with tissues swelling. Ice therapy should not be used for muscle pain or on sensitive painful areas. You can apply ice to your dog’s problem area by: Using ice packs wrapped in a clean towel Applying a cool wet compress Using packaged frozen foods wrapped in a clean towel Remember to never apply ice directly to your dog’s skin. When applying ice as the first pain management for dogs solution, apply for 10 minutes at a time allowing at least 20 minutes rest between sessions. Check your dog’s skin periodically to ensure they have not been burned or damaged by ice contact. 4 What You Need to Know About Pain Management Medications Pain meds for dogs are used frequently in veterinary medicine and come in various classes. There has been a ton of research on which pharmacologic and non-pharmacologic modalities work best for pain management in dogs. A good start is the evidence-based 2015 AAHA/AAFP research. NSAID’s NSAID’s are the most popularly prescribed medications for pain and inflammation in dogs. NSAID’s like Metacam, Rimadyl, Deramaxx, Previcox, and Etodolac are the canine-safe equivalent of Ibuprofen. NSAID’s come with fewer side effects than other pain management treatments, but often cause stomach upset. Opiates Opiates are the heavy hitters when it comes to pain management for dogs. These should be used sparingly and for short term treatment of serious pain. Drugs like Morphine, Codeine, Buprenorphine, and Paregoric are most often used for post-surgery pain. Opiates are addictive medications . They are also very strong, come with a range of side effects , and can cause damage to the body if taken for too long. Supplements or Nutraceuticals Nutraceuticals and supplements like glucosamine chondroitin, Omega Fatty Acids, and MSM can provide minimal or supplemental pain management. This treatment is often combined with prescription medication for management of chronic conditions like arthritis. Steroids Steroids like Prednisone, Corticosteroids, and Dexamethasone are used to control inflammation that leads to pain. Steroids are not used as often as they used to be because they suppress the immune system . This can lead to a number of chronic health conditions like Cushing’s Disease. Antidepressants When other medications prove ineffective or are not well tolerated, antidepressants may be an option. Some antidepressants like Elavil, Tofranil, or Prozac provide effective pain management. Alternative Treatments Overall, studies have shown that pharmacological treatments are most effective for pain management for dogs. However, alternative methods also exist and those include holistic and herbal treatments. Massage , acupuncture, thermotherapy, and laser therapy are all popular choices, but there’s no evidence to their efficacy or safety. If you’d rather go the alternative route, make sure to find a licensed holistic or alternative veterinarian locally with good reputation and reviews who can guide you through these less traditional treatments. RELATED: What Is Holistic Veterinary Medicine for Dogs Choose the Right Pain Management for Dogs Solution Which pain management solution is right for your dog depends on the cause of their pain, their current health, their age, your budget, and co-existing health conditions. Make an appointment to talk with your vet about the pain management for dogs that is available and which would be best for your pet. Be honest with your vet about your concerns as well as your financial situation if this is a potential roadblock to treatment. Table of Contents
Home General Painkillers — Short-Term Gain, Long-Term Risk Painkillers — Short-Term Gain, Long-Term Risk
In our culture of instant gratification, the temptation is to look for quick and easy answers to pain. However, the evidence reveals that this tendency comes with a high risk. Are painkillers helpful? Is so, what’s the long-term risk? Let’s look at the answers to these problems as well as alternatives that can help you deal with pain. Problem of Pain One of the difficulties associated with the treatment of pain is how we define pain. For instance, some doctors ask their patients to rate their pain on a scale of one to 10, but a three for one person might be a 10 for another. This means that the perception of pain is highly subjective. For some people, even the slightest discomfort is perceived as severe pain. Another obstacle to treating pain is that the cause might be multifactorial. Let’s say you hurt your back lifting a heavy box. If you’re also stressed out about job or family issues, then your perception of pain might be amplified. If you only get treated with painkillers, you might not get the relief you need since other factors like social or emotional are still bothering you. The multifactorial nature of pain makes it hard for doctors to diagnose and treat the problem. Surgeons, for instance, focus more on physical signs and symptoms and aren’t fully trained in the psychological causes of pain. It requires a diverse set of skills to treat pain. However, many physicians lack this kind of holistic training. Types of Painkillers and How They Work There are several classes of commonly used painkillers. The variety of medications available adds yet another layer of complexity to the treatment of pain. Different types of painkillers have different mechanisms of action and potential side effects. The major categories are: Paracetamol (acetaminophen) : Thought to inhibit cyclooxygenase (COX) enzyme activities in the brain, which leads to pain relief. Might also modulate the endogenous cannabinoid system in the brain to help reduce pain. Nonsteroidal anti-inflammatory drugs (NSAIDS) : Include aspirin, ibuprofen, and naproxen. Block COX enzymes in the brain and the body, which not only treats pain but also decreases inflammation. Opioids : Binds to opioid receptors, which are found in the central nervous system (brain and spinal cord) and the peripheral nervous system (nerve endings in the body). Corticosteroids : Not technically a painkiller but used to treat some chronic pain disorders like arthritis. Mainly works by decreasing inflammation. Sometimes, the medications listed above may be used in combinations. Some formulations even combine two classes of medication into a single pill to take advantage of different mechanisms to reduce pain. Effects and Side Effects of Painkillers Every class of pain medication has a primary goal to reduce or eliminate pain. Some also reduce inflammation which can also help with pain relief. However, like any medication, every class of painkiller has potential side effects. In some cases, these side effects may occur immediately or over a certain time period. Let’s look at each class of painkiller and their potential side effects. Paracetamol Side Effects One of the most widely used painkillers worldwide, paracetamol is generally considered to be quite safe. Still, if used for a long period, or if you take too much, this drug can cause liver damage or even liver failure. The risk of liver damage is increased if you already have liver problems or if you consume alcohol. Also, the combination of paracetamol with other medications metabolized by the liver can increase your risk for toxicity. In 2013, the United States Food and Drug Administration (FDA) issued a warning about paracetamol stating the drug could cause rare and possibly fatal skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Nonsteroidal Anti-inflammatory Drugs Side Effects The most commonly reported side effects of NSAIDs are in the gastrointestinal tract. For starters, these drugs directly irritate your stomach lining upon contact. Also, NSAIDs relieve pain by COX enzyme inhibition, but in the GI tract, this can cause problems. COX inhibition decreases protective prostaglandins, which leads to increased stomach acid secretion and other changes that make your stomach lining more vulnerable. Common GI side effects of NSAIDs include: Nausea or vomiting Dyspepsias like heartburn and indigestion Gastric ulcers and bleeding Other potential adverse effects of NSAIDs are: Kidney damage Increased risk of heart attack, although aspirin may be heart protective Bleeding disorder Photosensitivity or increased sensitivity to sunlight Problems with pregnancy Interactions with other medications Opioid Side Effects Opioids can cause nausea, vomiting, drowsiness, constipation and breathing trouble. Still, the most concerning side effect of opioids is drug dependence and addiction. A recent analysis from Blue Cross Blue Shield revealed some chilling numbers about the problem. From 2010 to 2016, the number of their members diagnosed with an addiction to opioids — including legal prescriptions and illicit drugs — climbed 493 percent. In 2010, there were 1.4 opioid use disorders for every 1,000 people. In 2016, that rate had soared to 8.3 incidences per 1,000 members. Once you get addicted to opioids, it’s extremely hard to quit the drug. Once addicted, even if your original pain problem has been resolved, your body demands the drug. If you stop taking the medication, you feel horrible and can have nausea, vomiting, sweating, irritability and chills. This creates a vicious cycle since these unpleasant symptoms go away if you take more of the drug. In the end, this may lead to drug-seeking behavior. In some cases, people end up obtaining opiates from street dealers, even to the point of consuming injectable drugs, such as heroin. Corticosteroid Side Effects Corticosteroids like prednisone are not technically painkillers. However, they can provide great relief to chronic pain problems such as arthritis. For the short term, this might be useful, but long-term steroid use is very dangerous and not recommended. The side effects of corticosteroid use include: Glaucoma and cataracts Fluid retention and leg swelling High blood pressure Mood, memory and other behavior problems, including psychosis Fat accumulations around your abdomen, face and the back of the neck High blood sugar or diabetes Higher risk of infections or a weakened immune system Thin bones (osteoporosis) and bone fractures Suppressed adrenal gland function Thin skin, easy bruising, and poor wound healing Worth the Risk? As you can see, even the safest painkillers have risks for serious side effects. One has to ask then, is it worth the risk? Can I stand some discomfort to avoid risk? Maybe an even more important issue is to know about other methods of pain relief. Alternative Pain Treatments If you want to minimize the number of pain medications you are taking, consider these pain treatment alternatives. Controlled breathing : Take long slow breaths in and out, with pauses in between. Concentrate on the act of breathing to reduce pain. Muscle relaxation : Contract and then relax a specific muscle in your body one at a time, such as those in the hands, arms, legs, stomach, and face. Tighten the muscle hard for 10 seconds, relax for 10 seconds and then repeat. Focus on the muscle and release tension. Cognitive behavioral therapy : Mental health therapist helps you change how you perceive and react to pain. Psychological counseling : A mental health specialist who specializes in pain disorders may help identify how to decrease pain without depending on the medication. Sleep : Adequate rest may help reduce pain levels. You should try to get seven to nine hours of sleep every night. Also, specific disorders might need different treatment. For instance, those who suffer from fibromyalgia might benefit from therapies, such as: Exercise : Regular exercise may diminish pain in the long run. Physiotherapy : Therapist directed treatment involving exercise, movements, massage and local heat. Cryotherapy : Using extreme cold to parts of the body to relieve pain. Trigger point injection : Specific areas of pain are injected with a local anesthetic, saline, or corticosteroid. May change how nerve endings react to pain. Massage therapy : Muscles and joints are rubbed and manipulated to bring relief. Biofeedback : You have sensors applied to your muscles. They help you know when you have muscle tension. Transcutaneous electrical nerve stimulation (TENS) : Uses low voltage electricity applied to the skin. May work by a similar mechanism as trigger point injection. Conclusion Modern society constantly tries to make things easier and faster. The issue of pain relief, however, can be very complex. Short-term solutions like painkillers might give you rapid relief, but the long-term effects may not be worth the risk. When you have pain, look into all the potential treatment options. Don’t just reach for a pill. Look for more complete solutions instead. Show References References:
America’s opioid epidemic and its effect on the nation’s commercially-insured population | Blue Cross Blue Shield. (n.d.). Retrieved from https://www.bcbs.com/the-health-of-america/reports/americas-opioid-epidemic-and-its-effect-on-the-nations-commercially-insured
Pain in the Nation – Trust for America’s Health. (n.d.). Retrieved from http://www.healthyamericans.org/reports/paininthenation/
Prednisone and other corticosteroids: Balance the risks and benefits. (2015, November 26). Retrieved from https://www.mayoclinic.org/steroids/art-20045692
Safe and Effective Methods for Fibromyalgia Relief – Exercises For Injuries. (2017, July 6). Retrieved from https://exercisesforinjuries.com/safe-and-effective-methods-for-fibromyalgia-relief/
The different groups of painkillers. (2011, November 29). Retrieved from https://www.health24.com/Medical/Pain-Management/Different-painkilling-drugs/The-different-groups-of-painkillers-20120721
ocular manifestation of systemic lupus erythematosus
Systemic lupus erythematosus (SLE) can involve many parts of the eye, including the eyelid, ocular adnexa, sclera, cornea, uvea, retina and optic nerve. Ocular manifestations of SLE are common and may lead to permanent blindness from the underlying disease or therapeutic side effects. Keratoconjunctivitis sicca is the most common manifestation. However, vision loss may result from involvement of the retina, choroid and optic nerve. Ocular symptoms are correlated to systemic disease activity and can present as an initial manifestation of SLE. The established treatment includes prompt systemic corticosteroids, steroid-sparing immunosuppressive drugs and biological agents. Local ocular therapies are options with promising efficacy. The early recognition of disease and treatment provides reduction of visual morbidity and mortality.
Systemic lupus erythematosus (SLE) is a complex connective tissue disorder that involves multiple organs. Lupus erythematosus was first described and distinguished from lupus vulgaris by Cazenave and Schedel in 1833. In 1845, skin lesions were reported by Hebra and later biopsied in 1872 by Kaposi who also pointed to systemic symptoms. 1 The first report of lupus in the eye was in 1929, and Semon and Wolff, in 1933, described the histopathological characteristics of choroiditis and subretinal exudation. 2 Ocular involvement may correlate with systemic disease activity and precede other systemic symptoms stressing the important role the ophthalmologist may play. 3
The reported prevalence of SLE in the population is 20–150 cases per 100 000. 4–6 The prevalence of SLE is different between age, gender, geographic and racial distributions. The female-to-male ratio is close to 9:1, and the estimated prevalence is 1/1000 among American women above the age of 17. 7 , 8 Due to improved identification at mild disease stage and better approaches to therapy, the incidence of SLE has nearly tripled over the past four decades
The pathogenesis of SLE is multifactorial and complex. Various genetic, epigenetic, immunoregulatory, environmental and infectious factors contribute to the susceptibility, onset, progression and prognosis of the clinical disease in a given patient. 3 , 10 The concordance rate has been reported between 24% and 57% in monozygotic twins, which outweighs the rate of 0–2% in dizygotic twins or siblings. 11 , 12 Thirty-one susceptibility loci for SLE have been identified by genome-wide association studies and other gene mapping studies. 13 Aberrant epigenetic regulation including DNA methylation, histone modifications and microRNA-mediated regulation may contribute to the complex array of immune abnormalities and disease manifestations in SLE. 14
Inflammation in lupus is caused by the formation of autoantibodies and immune complexes and can cause inflammatory responses and activate the complement system. This results in multiorgan damage that manifests as nephritis, vasculitis and arthritis. 3 Immunohistochemical studies of an animal model with retinal vasculitis disclosed immune complex deposition within the vessel walls, which ultimately caused vaso-occlusion in the eye. 15 The key role of aberrant B cell autoreactivity in SLE was revealed in a landmark murine study using a knockout gene mutation to prevent lupus mice from developing B cells, which resulted in a lack of autoantibody formation and clinical manifestations (nephritis or vasculitis). 16 Autoimmunity in SLE is a consequence of the progressive adaptive immune responses to autoantigens by not only B cells but also T cells. 17 There are changes in T cells in patients with SLE, which cause increase in the proinflammatory Th17 cell population and decrease in the anti-inflammatory T regulatory cell population. 14
The diagnostic criteria for SLE were developed by American College of Rheumatology (ACR). 18 , 19 It was based on 4 of 11 criteria, either at the present time or at some time in the past; malar rash, discoid rash, photosensitivity, oral ulcers, non-erosive arthritis, serositis, renal disorder, neurological disorder (seizures or psychosis), haematological disorder (anaemia, leucopenia, thrombocytopenia), immunological disorder (anti-DNA antibody, anti-Sm antibody and false positive Venereal Disease Research Laboratory testing) and presence of antinuclear antibodies.
Ocular manifestations of SLE vary from patient to patient and can correlate to the systemic disease activity. Ocular involvement is moderately common in SLE and can be vision threatening. 20 Findings may include abnormalities of the eyelid, ocular adnexa, keratoconjunctivitis sicca, iridocyclitis, retinal vasculitis, vaso-occlusive disorder, choroidopathy and optic neuropathy. Keratoconjunctivitis sicca is the most common manifestation while retinal and choroidal involvement are most associated with visual loss. 21 , 22 Active inflammation in the retina and choroid can echo vasculitis in other organs, especially in cerebral vascular disease ( table 1 ). 23–27 In addition, though uncommon, vision-threatening disease of the posterior segment involving the retina and optic nerve can precede systemic features and may aid in early diagnosis and prompt treatment of patients with SLE. 28–30 Early diagnosis is the key to successful treatment and better prognosis.
External eye disease
Orbital involvement is a less common manifestation in SLE. Many case reports describe bilateral orbital involvement and unilateral periorbital involvement despite systemic nature of SLE. 31–35 Inflammation manifesting as myositis and panniculitis has been described. 32–34 , 36 Patients may present with painful or painless proptosis, chemosis, ptosis, lid oedema or limited ocular movement. Inflammation can be confined to the orbit or spread to neighbouring tissues, which may lead to vision loss from optic neuropathy. 35 Further biopsy, serological workup and long-term follow-up are essential to facilitate the proper diagnosis.
Discoid lupus-type rash over the eyelids typically appears in the lower eyelid as an irritating, discrete, slightly raised erythematous scaly plaque, which can involve the lid margin and can be complicated by scarring and madarosis. 31 , 37 Lid biopsy and direct immunohistochemistry studies are valuable in confirming the diagnosis. Topical corticosteroids and oral antimalarial drugs are typically effective.
lacrimal System disorder
Dry eye syndrome (keratoconjunctivitis sicca) is the most common ocular feature of SLE (around a third of patients) and is often associated with secondary Sjögren’s syndrome (SS). 38 , 39 The International Dry Eye Work Shop classified Sjögren’s as an aqueous tear-deficient dry eye, reflecting failure of lacrimal tear secretion. Schirmer I test (≤5 mm in 5 min) or rose bengal score (≥4 according to van Bijsterveld’s scoring system) are important tests for diagnosis of dry eye syndrome associated with SS. 40 However, given patient discomfort after rose bengal instillation, lissamine green could be used as a substitute for rose bengal with similar staining patterns and greater tolerability to patients
Anterior Segment disease
Corneal involvement in SLE involves the superficial epithelium manifesting as superficial punctate keratitis and may be secondary to SS. 42 Peripheral ulcerative keratitis rarely occurs in SLE and is more commonly associated with rheumatoid arthritis. 43 However, some cases of peripheral ulcerative keratitis have been reported in both non-infiltrative and infiltrative Patterns.
episclera & sclera
Episcleritis is characterised by painless or mildly uncomfortable red eye with dilated episcleral vessels, which are non-tender and markedly reduced by topical phenylephrine. Unlike episcleritis, scleritis is a severe vision-threatening, progressively destructive inflammatory condition, which is more often associated with systemic disorders. Necrotising scleritis, though rare, is the type of scleritis most often associated with ocular complications and decreased vision. We reported a series of 585 patients with scleritis and episcleritis. We found that disease association was observed in 35.8% of patients with scleritis versus 27.1% of patients with episcleritis. 44 A more recent analysis of 1358 cases of scleritis performed by Heron et al 45 reported a 2% prevalence of SLE-associated scleritis compared with 6.4–10.4% of rheumatoid arthritis-related scleritis
There are few reports of iritis or iridocyclitis secondary to SLE particularly in adults. One adult case presented with bilateral keratitis and iridocyclitis and responded well to chloroquine. 46 Nevertheless, visual deterioration is uncommon in isolated iritis. The inflammation in the anterior segment can present as hypopyon or fibrinous anterior uveitis. 35 , 47 The inflammation in the anterior segment usually improves with the systemic immunosuppressants; however, atypical recalcitrant presentations have been reported to result in severe visual Damage.
posterior segement disease
Lupus retinopathy is a potentially blinding ocular manifestation of SLE. In the pre-steroid era, retinopathy was present in up to half of patients with SLE. However, with the advent of steroids and immunosuppressive therapy, the incidence of retinopathy has declined considerably . The prevalence of retinopathy varies among various populations, ranging from 3% in well-controlled patients to 29% of patients with more active systemic disease. Retinal involvement corresponded to activity of systemic and cerebral SLE. The major pathology of lupus retinopathy is attributed to vasculopathy, most commonly, microangiopathy. It is thought to be an immune complex-mediated vasculopathy .
The autoimmune process can affect the retina and choroid in two ways: directly, by immune complex-mediated vasculitis, and indirectly, by secondary hypertension from renal involvement. Hence, there are three types of direct retinal damage by lupus: microangiopathy, severe vaso-occlusion and vasculitis.
Fundus photograph (left) and fluorescein angiogram (right) of a 54-year-old woman who presented with acute severe vision loss in both eyes. Fundus photo (left) and angiogram (right) note extensive retinal capillary non-perfusion and macular ischaemia. Oral prednisone and anticoagulant were employed without steroid-sparing immunosuppressant. Final visual acuity was no light perception in 3 months later.
The terminology of ‘vasculitis’ in lupus retinopathy can be confounding among clinical presentation and pathogenesis. Though immune complex deposition leading to complement activation is well known in lupus retinopathy, clinically presenting vasculitis is fairly uncommon. The classic sign of vasculitis is vascular sheathing, which can present in arterioles and/or venules. Vaso-occlusion is a common end-point of vasculitis that may alter visual function
Fundus photograph (left) and early-phase fluorescein angiogram (right) of a 37-year-old woman who previously presented with lupus retinal vasculitis and was treated with scattered laser photocoagulation in 2006. Significant hyperfluorescent leakage represented the recurrence of neovascularisation . She received oral prednisone, methotrexate and intravenous cyclophosphamide. Initial visual acuity and visual acuity 8 years later were 20/60 and 20/100, respectively.
Renal involvement by SLE will generally lead to secondary hypertension. When prolonged, it usually affects retina and choroid and is characterised by retinal arterial narrowing, arteriovenous crossing changes, microaneurysms, intraretinal haemorrhages, hard exudates, disc oedema and multifocal serous or pigment epithelial detachment.
Lupus choroidopathy can occur either independently or with lupus retinopathy and may present with good visual acuity. Nguyen et al reported a total of 28 patients with lupus choroidopathy and found 64% of presenting visual acuity of 20/40 or better. The common manifestations include single or multiple areas of serous or exudative retinal detachment (36%), detachment of the retinal pigment epithelium (32%) or retinal pigment epitheliopathy (21%). 25 Choroidal ischaemia can present as subretinal hypopigmented patches and angiography can help confirm ischaemic areas ( figure 3 ). Secondary angle-closure glaucoma has also been reported secondary to choroidal effusion, leading to an anterior shift of the lens–iris diaphragm, narrow angles and increased intraocular pressure. 60 , 61 Appropriate immunosuppressive treatment leads to resolution of lupus choroidopathy followed by recovered Vision
Fundus photograph (left) and fluorescein angiogram (right) of a 46-year-old woman diagnosed with lupus-associated catastrophic antiphospholipid syndrome with bilateral choroidal infarction and uveitis. Image from the right eye demonstrates unremarkable retinal vasculature and distinct geographic subretinal patches. These hypopigmented patches correspond to extensive absence of choroid filling pattern in angiogram. Given intravenous methylprednisolone, rituximab and anticoagulant, the patient maintained visual acuity of 20/600 5 years later.
Neuro-ophthalmic manifestations of lupus are not common. The prevalence is 3.6% in adults and 1.6% in children. Findings are highly variable, with the most common presentation being optic neuritis, followed by myasthenia gravis, visual field defects and optic disc oedema. 67 Optic neuropathy, which may manifest as the presenting feature of disease, 68 is the most common finding and occurs in about 1% of patients with SLE 22 , 67 ( table 1 ). Initial visual loss can be severe in SLE-associated optic neuritis, causing no light perception vision. 69 , 70 Presentations can vary based on the location of pathology. Patients may present with painless or painful progressive visual loss, with or without pain on eye movement, optic disc swelling or pallor on examination. 50 , 68 , 69 Optic neuritis generally responds well to corticosteroid treatment. Visual prognosis following optic neuropathy is generally moderate to poor, although good outcomes have been reported. 68 , 69 In addition, for patients with SLE with suspected optic neuritis and relapsing myelitis, testing for the aquaporin-4 autoantibody would help confirm the correct diagnosis of neuromyelitis optica. 71 , 72 Ischaemic optic neuropathy 73 , 74 and chiasmopathy 69 in SLE have also been described.
Eye movement abnormalities are more common in SLE and have been reported in up to 29% of patients. 75 Pseudotumor cerebri has been reported in both children and adults with SLE, and may be the presenting feature of the disease.
Prognosis & systemic association
Visual prognosis of retinal involvement depends on pattern of retinopathy, and vaso-occlusion usually leads to poor visual outcome. Two reviews of retinopathy and choroidopathy pointed out that these two entities are indicative of guarded to poor survival. 25 , 27 Unlike demyelinating processes in which association between optic neuritis and brain is common, a review of SLE presenting as optic neuropathy revealed no association to CNS disorder. 68 This may reflect and support the ischaemic aetiology of SLE-related neuro-ophthalmological disorders
The heterogeneous nature and multisystem involvement make treatment of SLE difficult. Nevertheless, the general goals of therapy are to induce and maintain remission of the disease, and prevent relapses. Proper management requires a team approach that may include specialists in the fields of rheumatology, nephrology, dermatology and ophthalmology. Treatment strategies for SLE include non-steroidal anti-inflammatory drugs, hydroxychloroquine, systemic corticosteroids, immunosuppressive therapy and biologics. The effective immunosuppressive drugs include azathioprine, methotrexate, mycophenolate mofetil and cyclophosphamide. Increasingly, patients with lupus who do not respond to conventional immunosuppressive drugs are considered for targeted biological therapies aimed at cytokines, B and T lymphocytes, and B-cell-activating factors. Rituximab, B-cell-depleting therapy, has been used when conventional drugs have proven ineffective. 80 Combination of rituximab and cyclophosphamide infusions employed early in the course of retinal vasculitis and vaso-occlusive disease also granted rapid resolution as well as dramatic improvement in vision. 81 Belimumab, a monoclonal human antibody that inactivates B-cell-activating factor, is the first biologic recently approved by the US Food and Drug Administration after 50 years as an add-on therapy for active SLE. 80 , 82 In addition, epratuzumab and sifalimumab, biological response modifiers currently being investigated, also showed positive outcome. The treatment of CD22-targeted monoclonal antibody epratuzumab in adults with moderately to severely active SLE was reportedly associated with improvements in disease activity. 83 Sifalimumab, a human anti-interferon-α monoclonal antibody, was proven to be safe, and clinical activity profile supports its continued clinical development for SLE. 80
Hydroxychloroquine is an effective medication for SLE. It is now recommended long term for all patients with SLE. 84 Correlation between discontinuation of chloroquine and retinal vaso-occlusion was described by el-Asrar et al. 57 Patients must be made aware of the possible risk of macular toxicity and have regular eye check-up to monitor for this complication. 85
Local treatment also plays an important role in treatment of recalcitrant intraocular inflammation. Ocular findings in SLE are not specific and share common manifestations with other systemic diseases, such as lupus scleritis and rheumatoid scleritis, lupus retinopathy with hypertensive and diabetic retinopathy. As such, local treatment strategies should be tailored to the specific pathology. Laser photocoagulation has been known as standard treatment in ischaemic retinal disorders such as diabetic retinopathy and ischaemic retinal vascular occlusion. Panretinal photocoagulation showed promising efficacy in regression of neovascularisation before the antivascular endothelial growth factor (anti-VEGF) era. 54 However, the administration of immunosuppressants and panretinal photocoagulation (PRP) was insufficient to prevent the neovascularisation process in many case reports. 54 , 86 , 87
VEGF plays a vital role in inflammatory processes and in the pathogenesis of uveitic complications such as cystoid macular oedema, choroidal neovascularisation and retinal neovascularisation (RNV). 88 The VEGF serum concentration in patients with SLE was significantly higher than healthy controls and may be a useful marker of disease activity and internal organ involvement in patients with SLE. 89 , 90 Recently, anti-VEGF has been reported as a powerful tool for vaso-occlusion and vasculitis in patients with lupus. It showed efficacy in regressing RNV even after employment of immunosuppressive treatment and PRP. 86 , 87 While VEGF inhibition seems reasonable to treat RNV, the role of anti-VEGF therapy to treat inflammation is less clear and needs to be investigated. 88 Repeat anti-VEGF injections in vaso-occlusion with macular ischaemia should be performed only if monitoring FFA can be done to prevent worsening of macular ischaemia. Finally, vitrectomy can also be helpful in complicated neovascularisation, vitreous haemorrhage and traction retinal detachment.