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. May not be reproduced in any form without permission from the publisher, except fair uses permitted under 34 Ana Maria Abreu Velez and Michael S. Howard

be very painful and is usually visible as a bright red patch on part or all of the external, white
sclera of the eye [119,120]. Treatment may require steroids or other immunosuppressive
medications once infection has been ruled out.
Other medications used to treat lupus can themselves contribute to eye problems.
Steroids, particularly if used at high doses over a long period, increase the risk of developing
cataracts at an earlier age than other people not receiving these drugs [121]. Also, patients
receiving steroids are at increased risk of optic nerve damage from glaucoma [121]. Regular
eye examinations with an optician will generally pick up on such problems at an early stage,
and treatment for these conditions can then be sought from an ophthalmologist.
As previously noted, antimalarial medications may cause a retinopathy, particularly
chloroquine [119]. Antimalarial medication retinopathy is currently not frequently
encountered, due to 1) lower dosages and 2) a preference for hydroxychloroquine over
chloroquine than in the past. However, if a patient notices a deterioration in reading vision or
in perception of color, her or she should undergo an eye examination. Notably, the most
common reasons for changes in vision in lupus patients are age related changes in focusing or
cataracts, rather than side effects from hydroxychloroquine therapy [119-121].

Mixed Connective Tissue Disease,

or Overlap Syndrome
Overlap syndrome is an entity that satisfies the criteria of at least two connective tissue
diseases (CTD). These conditions include scleroderma/systemic sclerosis (SSc),
dermatomyositis or polymyositis, Sjogren's syndrome, rheumatoid arthritis and systemic
lupus erythematosus. A combined syndrome affects the clinical features, diagnosis and
treatment of the disorder.
The classic features of an overlap syndrome include severe Raynauds phenomenon and
joint pains, often with puffy, swollen sausage fingers [122]. One recent study explored
features of scleroderma overlap syndrome [122].
The authors studied the medical records of 165 consecutive SSc patients, and reviewed
scleroderma overlap syndrome cases in depth. Specifically, an internet PubMed search was
conducted for the period 1977 to 2009 using the key words "overlap syndrome", "systemic
sclerosis", "connective tissue disease" and "biological agents." The authors found that forty of
the original 165 patients satisfied inclusion criteria for scleroderma overlap syndrome.
The incidences of additional connective tissue diseases present in 1) the original group
and 2) in the overlap syndrome group (respectively) were as follows: dermatomyositis or
polymyositis 11.5% and 47.5%, Sjogren's syndrome 10.3% and 42.5%, rheumatoid arthritis
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3.6% and 15.4%, and systemic lupus erythematosus 1.2% and 5.0%. Coexistence of SSc and
another CTD aggravated the clinical course of the disease, especially vis-a-vis lung, kidney,
digestive tract, vascular and articular involvement.
In the overlap group, coexisting non-rheumatic complications were similar to non-
overlap SSc complications. An additional rheumatic or non-rheumatic disease did affect
treatment choice [122]. A little less than 1 in 10 patients with lupus are affected with an
additional autoimmune disorder such as Graves disease, psoriasis, Hashimotos thyroiditis,
sarcoidosis, erythema nodosum, or other conditions [123].

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