Ocular Manifestations of Psoriasis

Key Points at a Glance

Key Points of This Disease

Psoriasis is a chronic immune-mediated skin disease, and approximately 10% of patients have ocular complications. The most common ocular symptoms are dry eye (keratoconjunctivitis sicca) and blepharitis. The incidence of uveitis is 7–20%, and it is more common in psoriatic arthritis and pustular psoriasis. In Japan, most cases of psoriatic uveitis are non-granulomatous anterior uveitis, and many are HLA-A2 positive. Psoriasis and ocular inflammation share the IL-23/Th17 pathway as a common pathological basis. Response to steroid treatment is good, but uveitis tends to recur and requires long-term management. Collaboration between dermatologists and ophthalmologists is key to management.

1. What are the ocular symptoms of psoriasis?

Psoriasis is a chronic immune-mediated skin disease caused by overactivation of the adaptive immune system. It affects 1–3% of the US population and approximately 125 million people worldwide.

The most common type is plaque psoriasis (psoriasis vulgaris), accounting for 80% of all cases. Other types include nail psoriasis, guttate psoriasis, inverse psoriasis, pustular psoriasis, and erythrodermic psoriasis.

Approximately 10% of psoriasis patients develop ocular symptoms. The main ocular complications are as follows:

• Keratoconjunctivitis sicca (dry eye): the most frequent ocular symptom
• Blepharitis: redness, scaling, and crusting of the eyelid margins
• Uveitis: incidence 7–20%
• Conjunctivitis: tearing, foreign body sensation, discharge
• Episcleritis: inflammation of the superficial sclera
• Cataract: due to inflammatory cytokines or treatment effects

Ocular symptoms are particularly associated with psoriatic arthritis and pustular psoriasis, and are more common in men. They often appear following exacerbation of skin lesions.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Ocular symptoms associated with psoriasis are diverse and vary depending on the affected site.

• Dryness and foreign body sensation: The most common subjective symptom associated with dry eye.
• Redness: Occurs with conjunctivitis, episcleritis, and uveitis.
• Tearing: Occurs with conjunctivitis.
• Photophobia (sensitivity to light): Occurs with uveitis and corneal epithelial disorders.
• Blurred vision: Occurs with uveitis and cataracts.
• Floaters: Occur with uveitis accompanied by vitritis.
• Eye pain: Associated with scleritis or severe uveitis.

The intensity of symptoms may fluctuate in response to stress, temperature changes, and flares of skin lesions.

Clinical Findings

Dry Eye

Meibomian gland dysfunction (MGD): Prevalence is 15% higher than in healthy individuals. It causes evaporative dry eye.

Tear film instability: Shortened tear break-up time (TBUT) and decreased Schirmer test values are observed.

Blepharitis

Changes in the eyelid margin: Accompanied by redness, scaling, crusting, and ulcer formation.

Changes in bacterial flora: The normal eyelid bacterial flora may be disrupted, leading to overgrowth of Staphylococcus species.

Uveitis

Primarily anterior uveitis: Often non-granulomatous. Cases with arthritis may present with hypopyon.

Complications: May include macular edema and optic nerve swelling.

Cataract

Inflammatory mechanism: Oxidative stress from TNF-α and IL-6 promotes lens opacification.

Iatrogenic factors: Long-term steroid use and PUVA therapy also increase cataract risk.

Psoriatic uveitis is slightly more common in men, with an average age in the early 40s. Psoriasis vulgaris is the most common type, followed by association with psoriatic arthritis. In Japan, HLA-A2 positivity is reported to be frequent.

An analysis of uveitis associated with psoriasis and psoriatic arthritis showed that anterior uveitis was the most common, with complications including vitreous opacity 41.1%, cataract 29.7%, posterior vitreous detachment 25.9%, elevated intraocular pressure 17%, and dry eye 13.3%¹⁾.

Q When should a patient with psoriasis see an ophthalmologist?

A

Patients with psoriasis should see an ophthalmologist when symptoms such as eye redness, pain, photophobia, blurred vision, or dry eyes appear. Since eye symptoms are often not reported spontaneously, regular ophthalmologic screening is recommended during dermatology visits. For details, see the “Standard Treatment” section.

3. Causes and Risk Factors

The core of psoriasis pathogenesis is overactivation of the IL-23/Th17 pathway. Plasmacytoid dendritic cells release type I interferon, activating myeloid dendritic cells. Myeloid dendritic cells secrete IL-12 to promote differentiation into Th1 cells and IL-23 to induce proliferation of Th17 and Th22 cells.

IL-17, IL-22, and TNF-α secreted from Th17 cells cause excessive proliferation of keratinocytes, forming a positive feedback loop that recruits more immune cells. This pathway promotes transcription of inflammatory genes via the TYK2/JAK/STAT pathway.

Risk factors for ocular symptoms include the following:

• Psoriasis subtype: Psoriatic arthritis and pustular psoriasis have a high risk of uveitis
• Severity of skin lesions: Both severe and mild cases increase risk
• HLA-A2 positive: Common in Japanese psoriatic uveitis
• Arthritis comorbidity: Risk factor for uveitis with hypopyon
• Serum osteopontin: Suggested association with ocular complications

Prevention and Daily Care

If you have been diagnosed with psoriasis, please have regular eye examinations even if you have no eye symptoms. Be especially careful during flares of skin symptoms. Stress management and lifestyle improvements may help stabilize both skin and eye symptoms.

Q Do any psoriasis treatments affect the eyes?

A

Long-term systemic use of steroids increases the risk of cataracts and glaucoma. PUVA therapy (psoralen plus ultraviolet A irradiation) has also been reported to be associated with cataract development. Biologics (such as TNF-α inhibitors) are also used to treat uveitis, but rarely may cause ocular side effects.

4. Diagnosis and Examination Methods

Diagnosis of ocular complications of psoriasis is based on clinical findings. Skin psoriasis often precedes, and the presence of well-demarcated erythematous scaly plaques provides a diagnostic clue.

Ophthalmic Examination

• Slit-lamp microscopy: Evaluates blepharitis scales and redness, corneal epithelial damage, anterior chamber inflammation (cells and flare), and hypopyon
• Tear film tests: Schirmer test (tear secretion), tear film breakup time (TBUT) to evaluate dry eye
• Fundus examination: Check for vitreous opacities, macular edema, and retinal vascular changes
• Optical coherence tomography angiography (OCTA): Useful for evaluating retinal vascular changes and may help classify disease severity
• Intraocular pressure measurement: Evaluate elevated intraocular pressure associated with uveitis or steroid-induced glaucoma

Differential Diagnosis

The following diseases need to be differentiated.

• Sjögren’s syndrome: Other autoimmune causes of dry eye
• Rheumatoid arthritis-related ocular symptoms: Keratoconjunctivitis sicca, scleritis
• Atopic dermatitis of the eyelids: Differential diagnosis of blepharitis
• Sarcoidosis: Granulomatous uveitis
• Ankylosing spondylitis: Acute anterior uveitis (HLA-B27 associated)
• Infectious uveitis: Viral, bacterial, fungal

If ocular symptoms improve with systemic treatment (e.g., methotrexate), it supports the diagnosis of psoriatic ocular complications.

5. Standard Treatment

Treatment of ocular symptoms of psoriasis is performed stepwise according to the site and severity of the lesion. Collaboration between dermatologists and ophthalmologists is essential.

Treatment of Dry Eye and Blepharitis

• Warm compress and eyelid hygiene: Cleaning the eyelids and eyelashes with a mild shampoo. Basic management of blepharitis.
• Artificial tears: Hyalein ophthalmic solution (0.1%) instilled 4–6 times daily.
• Topical steroids for eyelids: Used as an adjunct to conservative treatment.
• Tacrolimus ointment (0.1%): A safe and effective option for facial psoriasis.

Treatment of Uveitis

Treatment of psoriatic uveitis is performed in a stepwise manner.

• First-line: Topical steroid therapy (Rinderon ophthalmic solution 0.1%, 2–6 times daily) + mydriatics (Mydrin P ophthalmic solution + Neosynesin Kowa ophthalmic solution 5%, 3 times daily).
• Second-line: Systemic steroid administration (when topical therapy is insufficient).
• Third-line: Immunosuppressive drugs (e.g., methotrexate, cyclosporine).
• Fourth-line: Biologic agents (e.g., TNF-α inhibitors). Used for refractory or recurrent cases.

Response to steroid treatment is generally good, and visual prognosis is relatively favorable. However, uveitis tends to recur; in case of recurrence, consider adding immunosuppressive drugs or biologic agents. Systemic treatment should be performed in consultation with a dermatologist.

Precautions and Side Effects of Treatment

Long-term use of steroids may induce cataracts or glaucoma. PUVA therapy is effective for both skin and eyes but may increase the risk of cataracts. Since uveitis is prone to recurrence, do not discontinue treatment on your own even if symptoms improve; follow your ophthalmologist’s instructions.

Q Can ocular symptoms of psoriasis be cured?

A

Dry eye and blepharitis can be well controlled with appropriate management. Uveitis responds well to steroids and has a relatively good visual prognosis, but it tends to recur, so long-term follow-up is necessary. Since psoriasis itself is a chronic disease, continuous management of ocular symptoms is also required.

6. Pathophysiology and Detailed Pathogenesis

Ocular complications of psoriasis arise from systemic immune abnormalities spreading to ocular tissues.

Common Pathways of Psoriasis and Uveitis

T cells and cytokines (TNF-α, IL-17) that are hyperactivated in psoriasis are also deeply involved in the pathogenesis of uveitis. The activation cascade of plasmacytoid dendritic cells → myeloid dendritic cells → IL-23 → Th17 cells triggers inflammation in both the skin and eyes.

IL-17 produced by Th17 cells promotes keratinocyte proliferation and chemokine production, recruiting more immune cells. IL-22 causes differentiation disorders of keratinocytes. TNF-α increases the expression of adhesion molecules on vascular endothelium, promoting tissue infiltration of inflammatory cells.

Overlap in Pathophysiology of Dry Eye and Uveitis

According to a review by Rojas-Carabali et al. (2023), dry eye and uveitis share multiple molecular signaling pathways, including involvement of Th1 lymphocytes, IL-17/Th17 expression, activation of matrix metalloproteinases, and infiltration of macrophages and dendritic cells¹⁾.

In the tear fluid of uveitis patients, concentrations of IL-1β and IL-23 are significantly higher than in healthy controls. IL-23 plays an important role in the long-term memory of Th17 cells and mediates chronic inflammation in autoimmune diseases including dry eye¹⁾.

Epithelial cells produce and release TNF-α, IL-1, IL-6, and IL-8, amplifying immune responses and attracting inflammatory cells. This mechanism is centrally involved in the pathogenesis of dry eye¹⁾.

Inflammasomes, including NLRP3, are also suggested to be involved in the pathogenesis of both dry eye and uveitis¹⁾.

Mechanisms of Cataract Formation

Cataracts associated with psoriasis arise through multiple mechanisms. Inflammatory cytokines such as TNF-α and IL-6 increase oxidative stress and promote degeneration of lens proteins. In addition, posterior subcapsular cataracts due to long-term systemic steroid use and lens damage from UV exposure in PUVA therapy are also involved.

7. Latest Research and Future Perspectives

For patients: Please be sure to read

The following content is currently under research or in clinical trials and is not standard treatment available at general hospitals. It is reference information for professionals regarding future medical developments.

Biomarker Research

Serum osteopontin has been reported to be potentially associated with ocular complications in psoriasis. Whether it can serve as a biomarker for early detection or severity prediction of ocular complications awaits future validation.

Retinal Vascular Imaging

Studies using optical coherence tomography angiography (OCTA) have shown that retinal vascular changes may be detected even in psoriasis patients without clinical eye disease. It is expected to become a tool for disease severity classification in the future.

Coexistence of Dry Eye and Uveitis

Rojas-Carabali et al. (2023) pointed out that the coexistence of dry eye and uveitis may be more frequent than previously assumed, and recommended that ophthalmologists actively search for dry eye (both aqueous-deficient and evaporative types) in patients with anterior uveitis. They also emphasized the need for longitudinal studies to clarify which disease precedes the other ¹⁾.

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8. References

1. Rojas-Carabali W, et al. Association between uveitis and dry eye disease: a systematic review of observational studies. J Ophthalmic Inflamm Infect. 2023;13:2.