Ophthalmological manifestations in autoimmune diseases: Overcoming diagnostic and therapeutic challenges

Table 1 Frequently encountered ocular diseases and manifestations associated with autoimmune diseases, their clinical symptoms, their differential diagnoses, and the most common complications

Condition/manifestation	Primary location	Clinical features	Common autoimmune diseases	Non-autoimmune/differential diagnoses	Complications	Ref.
Uveitis	Uvea (iris, ciliary body, choroid)	Redness, pain, photophobia, blurred vision, floaters	RA, SS, BD, CD, UC, MS, celiac, sarcoidosis	HSV, VZV, CMV, toxoplasmosis, TB, trauma, leukemia, Lyme disease	Macular edema, glaucoma, cataracts, Horner’s syndrome	[7,9,12-27,60-63]
Keratitis	Cornea	Redness, photophobia, blurred vision, pain, FB sensation	RA, SS, SLE, celiac, Hashimoto’s, vasculitis	HSV, HHV-6, fungi, bacteria, trichiasis, trauma	Ulceration, perforation, corneal thickening	[9,17,21,30-38,61,62,64]
Optic neuritis	Optic nerve	Visual impairment (unilateral or bilateral), pain with eye movement	MS, NMO, MOG-AD, sarcoidosis, SLE, SS	Syphilis, TB, Lyme disease, compressive lesions, toxins	Blindness, demyelination, optic atrophy	[40-42,46-53,65]
Episcleritis	Episcleral tissue	Mild pain, redness, irritation	RA, SS, CD, UC, dermatomyositis	Syphilis, Lyme disease, TB, HZV, hypersensitivity reactions	Generally self-limiting	[16,54,56,66-70]
Scleritis	Sclera	Severe pain, photophobia, possible vision loss	RA, SS, CD, UC, GPA, PAN, BD	Monkeypox, TB, HZV, syphilis, post-op, bisphosphonates	Necrotizing inflammation, retinal vasculitis, vision loss	[10,16,54-59,62,66,67,71]
Keratoconjunctivitis sicca	Cornea/Conjunctiva	Dryness, photophobia, gritty sensation	RA, SS, CD, celiac, GBS, MG, GD, Hashimoto’s, psoriasis, SSc	Medications, meibomian gland dysfunction, environment, HIV/AIDS	Corneal damage, infection risk	[72,73]
Conjunctivitis	Conjunctiva	Redness, edema, lacrimation, discomfort	RA, CD, psoriasis, celiac	Allergens, irritants, viruses (e.g., SARS-CoV-2, flavivirus)	Persistent inflammation, scarring	[61,62,74,75]
Blepharitis	Eyelids	Burning, photophobia, irritation, redness	RA, CD, MG, psoriasis	Staph, VZV, meibomian dysfunction, rosacea	Chronic discomfort, eyelid scarring	[76,77]
Retinal vasculitis	Retina	Floaters, scotoma, color vision changes	RA, SS, BD, CD	CMV, TB, syphilis, Lyme disease, flavivirus	Vision loss, retinal ischemia	[60,61,78]
Macular edema	Macula	Blurry vision, micro/macropsia, color impairment	RA, BD, GBS, DM1	RVO, tumors, trauma, radiation	Vision loss, distortion	[79,80]
Choroiditis	Choroid	Floaters, metamorphopsia, central vision loss	RA	TB, vector-borne infections	Vision distortion, scarring	[60,81]
Photophobia	Nonspecific	Light intolerance	SS, GBS, Hashimoto’s	Migraine, TBI, optic/chiasmal pathology	Underlying diagnosis-dependent	[82,83]
Retinal detachment	Retina	Flashes, floaters, shadow over vision	RA, BD, UC, MS, SSc	Trauma, tumors, medications	Vision loss	[84]
Vitreal/retinal hemorrhage	Vitreous/retina	Floaters, cobwebs, haziness	BD, MS, GBS, dermatomyositis	Endocarditis, trauma, PCV, flavivirus	Vision loss	[62,72,77,85]
Retinal vein occlusion	Retina	Vision loss, RAPD	BD, UC, celiac, dermatomyositis	Polycythemia vera, thrombophilia, drugs	Edema, hemorrhage, ischemia	[86]
Glaucoma	Optic nerve	Progressive vision loss, dark adaptation delay	BD, MS, GD, DM1	Ocular HTN, steroids, surgery, trauma	Irreversible blindness	[87]
Corneal ulcers	Cornea	Pain, redness, photophobia, discharge	SS, CD, celiac	Bacteria, HHV-6, trauma	Vision loss, perforation	[71,72]
Diplopia	EOMs/CNS	Double vision	GBS, MG, GD, Hashimoto’s, SSc, dermatomyositis	Orbital mass, refractive error, neuromuscular issues	Falls, impaired depth perception	[88,89]
Optic atrophy	Optic nerve	Vision loss, field defects	BD	Ischemic, infectious, compressive, toxic	Permanent vision loss	[65]
Cataracts	Lens	Blurry vision, glare, color desaturation	CD, Celiac, MS, DM1, psoriasis, SSc, dermatomyositis	Corticosteroids, trauma, radiation	Progressive vision loss	[90]

RA: Rheumatoid arthritis; SS: Sjögren’s syndrome; BD: Behçet’s disease; CD: Crohn’s disease; UC: Ulcerative colitis; MS: Multiple sclerosis; SLE: Systemic lupus erythematosus; NMO: Neuromyelitis optica; MOG-AD: Myelin oligodendrocyte glycoprotein antibody-associated disease; GPA: Granulomatosis with polyangiitis; PAN: Polyarteritis nodosa; GBS: Guillain–Barré syndrome; MG: Myasthenia gravis; GD: Gaucher disease; SSc: Systemic sclerosis; DM1: Diabetes mellitus 1; HSV: Herpes simplex virus; VZV: Varicella zoster virus; CMV: Cytomegalovirus, TB: Tuberculosis; HHV-6: Human herpesvirus 6; HZV: Herpes zoster virus; AIDS: Acquired immunodeficiency syndrome; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; RVO: Retinal vein occlusion; TBI: Traumatic brain injury; PCV: Polypoidal choroidal vasculopathy; HTN: Hypertension; FB: Foreign body; RAPD: Relative afferent pupillary defect; EOM: Extraocular movements; CNS: Central nervous system.