Ocular manifestations of common pulmonary diseases: a narrative review

Submitted: January 27, 2023
Accepted: February 22, 2023
Published: March 3, 2023
Abstract Views: 1520
PDF: 472
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Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.



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Michailopoulos P, Almaliotis D, Georgiadou I, et al. Allergic conjunctivitis in patients with respiratory allergic symptoms; a retrospective study in Greece. Med Hypothesis Discov Innov Ophthalmol 2017;6:3-9.
Gradman J, Wolthers OD. Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic. Pediatr Allergy Immunol 2006;17:524-6. Erratum in: Pediatr Allergy Immunol 2007;18:90.
Neto HJC, Rosário NA, Westphal GLC, et al. Allergic conjunctivitis in asthmatic children: as common as underreported. Ann Allergy Asthma Immunol 2010;105:399-400.
Dupuis P, Prokopich C, Hynes A, et al. A contemporary look at allergic conjunctivitis. Allergy Asthma Clin Immunol 2020;16:5.
Huang Q, Zheng Y, Zhang C, et al. Association between asthma and dry eye disease: a meta-analysis based on observational studies. BMJ Open 2021;11:e045275.
Cumming RG, Mitchell P, Leeder SR. Use of inhaled corticosteroids and the risk of cataracts. N Engl J Med 1997;337:8-14.
Bielory L. Ocular toxicity of systemic asthma and allergy treatments. Curr Allergy Asthma Rep 2006;6:299-305.
Sheffer AL, Silverman M, Woolcock AJ, et al. Long-term safety of once-daily budesonide in patients with early-onset mild persistent asthma: results of the Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) study. Ann Allergy Asthma Immunol 2005;94:48-54.
Weatherall M, Clay J, James K, et al. Dose-response relationship of inhaled corticosteroids and cataracts: A systematic review and meta-analysis. Respirology 2009;14:983-90.
Garbe E, LeLorier J, Boivin JF, Suissa S. Inhaled and nasal glucocorticoids and the risks of ocular hypertension or open-angle glaucoma. JAMA 1997;277:722-7.
Ishii M, Horita N, Takeuchi M, et al. Inhaled corticosteroid and secondary glaucoma: a meta-analysis of 18 studies. Allergy Asthma Immunol Res 2021;13:435-49.
Kalra L, Bone MF. The effect of nebulized bronchodilator therapy on intraocular pressures in patients with glaucoma. Chest 1988;93:739-41.
Mulpeter KM, Walsh JB, O'Connor M, et al. Ocular hazards of nebulized bronchodilators. Postgrad Med J 1992;68:132-3.
Amerasinghe N, Aung T. Angle-closure: risk factors, diagnosis and treatment. Prog Brain Res 2008;173:31-45.
Wenzel S, Castro M, Corren J, et al. Dupilumab efficacy and safety in adults with uncontrolled persistent asthma despite use of medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist: a randomised double-blind placebo-controlled pivotal phase 2b dose-ranging trial. Lancet 2016;388:31-44.
Simpson EL, Bieber T, Guttman-Yassky E, et al. Two phase 3 trials of dupilumab versus placebo in atopic dermatitis. N Engl J Med 2016;375:2335-48.
Blauvelt A, de Bruin-Weller M, Gooderham M, et al. Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a 1-year, randomised, double-blinded, placebo-controlled, phase 3 trial. Lancet 2017;389:2287-303.
Busse WW, Maspero JF, Rabe KF, et al. Liberty asthma QUEST: phase 3 randomized, double-blind, placebo-controlled, parallel-group study to evaluate dupilumab efficacy/safety in patients with uncontrolled, moderate-to-severe asthma. Adv Ther 2018;35:737-48.
Rabe KF, Nair P, Brusselle G, et al. Efficacy and safety of dupilumab in glucocorticoid-dependent severe asthma. N Engl J Med 2018;378:2475-85.
Tukler Henriksson J, Coursey TG, Corry DB, et al. IL-13 stimulates proliferation and expression of mucin and immunomodulatory genes in cultured conjunctival goblet cells. Invest Ophthalmol Vis Sci 2015;56:4186-97.
Akinlade B, Guttman-Yassky E, de Bruin-Weller M, et al. Conjunctivitis in dupilumab clinical trials. Br J Dermatol 2019;181:459-73.
Avorn J, Glynn R, Gurwitz J, et al. Adverse pulmonary effects of topical beta blockers used in the treatment of glaucoma. J Glaucoma 1993;2:158-65.
Hedner J, Everts B, Möller CS. Latanoprost and respiratory function in asthmatic patients: randomized, double-masked, placebo-controlled crossover Evaluation. Arch Ophthalmol 1999;117:1305-9.
Alim S, Demir HD, Yilmaz A, et al. To evaluate the effect of chronic obstructive pulmonary disease on retinal and choroidal thicknesses measured by optical coherence tomography. J Ophthalmol 2019;2019:7463815.
Ugurlu E, Pekel G, Altinisik G, et al. New aspect for systemic effects of COPD: eye findings. Clin Respir J 2018;12:247-52.
Vaes AW, Spruit MA, Theunis J, et al. Looking into the eye of patients with chronic obstructive pulmonary disease: an opportunity for better microvascular profiling of these complex patients. Acta Ophthalmol 2018;96:539-49.
Longo D, Fauci A, Kasper D, et al. Harrison's principles of internal medicine. New York: McGraw-Hill Professional; 2011.
Pasadhika S, Rosenbaum JT. Ocular sarcoidosis. Clin Chest Med 2015;36:669-83.
Obenauf CD, Shaw HE, Sydnor CF, Klintworth GK. Sarcoidosis, and its ophthalmic manifestations. Am J Ophthalmol 1978;86:648-55.
Rothova A. Ocular involvement in sarcoidosis. Br J Ophthalmol 2000;84:110-6.
Mavrikakis I, Rootman J. Diverse clinical presentations of orbital sarcoid. Am J Ophthalmol 2007;144:769-75.
Obenauf CD, Shaw HE, Sydnor CF, Klintworth GK. Sarcoidosis and its ophthalmic manifestations. Am J Ophthalmol 1978;86:648-55.
Chapman KL, Bartley GB, Garrity JA, Gonnering RS. Lacrimal bypass surgery in patients with sarcoidosis. Am J Ophthalmol 1999;127:443-6.
Prabhakaran VC, Saeed P, Esmaeli B, et al. Orbital and adnexal sarcoidosis. Arch Ophthalmol 2007;125:1657-62.
Yaosaka M, Abe R, Ujiie H, et al. Unilateral periorbital oedema due to sarcoid infiltration of the eyelid: an unusual presentation of sarcoidosis with facial nerve palsy and parotid gland enlargement. Br J Dermatol 2007;157:200-2.
Henkind P. Sarcoidosis: an expanding ophthalmic horizon. J R Soc Med 1982;75:153-9.
Moin M, Kersten RC, Bernardini F, Kulwin DR. Destructive eyelid lesions in sarcoidosis. Ophthalmic Plast Reconstr Surg 2001;17:123-5.
Kim DS, Korgavkar K, Zahid S, et al. Vision loss after central retinal artery occlusion secondary to orbital sarcoid mass. Ophthalmic Plast Reconstr Surg 2016;32:e37-40.
Papadopoulos KI, Hörnblad Y, Liljebladh H, Hallengren B. High frequency of endocrine autoimmunity in patients with sarcoidosis. Eur J Endocrinol 1996;134:331-6.
Dithmar S, Waring GO 3rd, Goldblum TA, Grossniklaus HE. Conjunctival deposits as an initial manifestation of sarcoidosis. Am J Ophthalmol 1999;128:361-2.
Manrique Lipa RK, de los Bueis AB, De los Ríos JJ, Manrique Lipa RD. Sarcoidosis presenting as acute bulbar follicular conjunctivitis. Clin Exp Optom 2010;93:363-5.
Geggel HS, Mensher JH. Cicatricial conjunctivitis in sarcoidosis: recognition and treatment. Ann Ophthalmol 1989;21:92-4.
Bui KM, Garcia-Gonzalez JM, Patel SS, et al. Directed conjunctival biopsy and impact of histologic sectioning methodology on the diagnosis of ocular sarcoidosis. J Ophthalmic Inflamm Infect 2014;4:8.
Lennarson P, Barney NP. Interstitial keratitis as presenting ophthalmic sign of sarcoidosis in a child. J Pediatr Ophthalmol Strabismus 1995;32:194-6.
Siracuse-Lee D, Saffra N. Peripheral ulcerative keratitis in sarcoidosis: a case report. Cornea 2006;25:618-20.
Jabs DA, Johns CJ. Ocular involvement in chronic sarcoidosis. Am J Ophthalmol 1986;102:297-301.
Rodriguez A, Calonge M, Pedroza-Seres M, et al. Referral patterns of uveitis in a tertiary eye care center. Arch Ophthalmol 1996;114:593-9.
Baughman R, Lower E, Kaufman A. Ocular sarcoidosis. Semin Respir Crit Care Med 2010;31:452-62.
Rothova A. Ocular involvement in sarcoidosis. Br J Ophthalmol 2000;84:110-6.
Crouser ED, Maier LA, Wilson KC, et al. Diagnosis and detection of sarcoidosis. An official american thoracic society clinical practice guideline. Am J Respir Crit Care Med 2020;201:e26-e51.
Krishna Y, Christou L, Khzouz J, et al. Optic nerve head sarcoidosis mimicking an intraocular tumour and occurring as the first manifestation of neuro-ocular sarcoidosis. Am J Ophthalmol Case Rep 2020;20:100988.
Heuser K, Kerty E. Neuro-ophthalmological findings in sarcoidosis. Acta Ophthalmol Scand 2004;82:723-9.
Kidd D, Burton B, Graham E, Plant G. Optic neuropathy associated with systemic sarcoidosis. Neurol Neuroimmunol Neuroinflamm 2016;3:e270.
Frohman LP, Guirgis M, Turbin RE, Bielory L. Sarcoidosis of the anterior visual pathway: 24 new cases. J Neuroophthalmol 2003;23:190-7.
Kefella H, Luther D, Hainline C. Ophthalmic and neuro-ophthalmic manifestations of sarcoidosis. Curr Opin Ophthalmol 2017;28:587-94.
Mochizuki M, Smith JR, Takase H, et al. Revised criteria of international workshop on ocular sarcoidosis (IWOS) for the diagnosis of ocular sarcoidosis. Br J Ophthalmol 2019;103:1418-22.
LaMattina KC, Goldstein DA. Adalimumab for the treatment of uveitis. Expert Rev Clin Immunol 2017;13:181-8.
Salinas R, Puig M, Fry CL, et al. Floppy eyelid syndrome: a comprehensive review. Ocul Surf 2020;18:31-9.
Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthalmic Plast Reconstr Surg 1987;3:99-103.
Santos M, Hofmann RJ. Ocular manifestations of obstructive sleep apnea. J Clin Sleep Med 2017;13:1345-8.
McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalmic Plast Reconstr Surg 1997;13:98-114.
Culbertson WW, Tseng SCG. Corneal disorders in floppy eyelid syndrome. Cornea 1994;13:33-42.
Kadyan A, Asghar J, Dowson L, Sandramouli S. Ocular findings in sleep apnoea patients using continuous positive airway pressure. Eye 2010;24:843-50.
Acar M, Firat H, Yuceege M, Ardic S. Long-term effects of PAP on ocular surface in obstructive sleep apnea syndrome. Can J Ophthalmol 2014;49:217-21.
Balbay EG, Balbay O, Annakkaya AN, et al. Obstructive sleep apnoea syndrome in patients with primary open-angle glaucoma. Hong Kong Med J 2014;20:379-85.
Huon LK, Liu SYC, Camacho M, Guilleminault C. The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath 2016;20:1145-54.
Liu PK, Chiu TY, Wang NK, et al. Ocular complications of obstructive sleep apnea. J Clin Med 2021;10:3422.
Chaitanya A, Pai VH, Mohapatra AK, Ve RS. Glaucoma and its association with obstructive sleep apnea: a narrative review. Oman J Ophthalmol 2016;9:125-34.
Teberik K, Eski MT, Balbay EG, Kaya M. Evaluation of intraocular pressure, corneal thickness, and retinal nerve fiber layer thickness in patients with obstructive sleep apnea syndrome. Pak J Med Sci 2018;34:817-22.
Koseoglu HI, Kanbay A, Ortak H, et al. Effect of obstructive sleep apnea syndrome on corneal thickness. Int Ophthalmol 2016;36:327-33.
Zengin MO, Tuncer I, Karahan E. Retinal nerve fiber layer thickness changes in obstructive sleep apnea syndrome: one year follow- up results. Int J Ophthalmol 2014;7:704-8.
Shiba T, Takahashi M, Sato Y, et al. Relationship between severity of obstructive sleep apnea syndrome and retinal nerve fiber layer thickness. Am J Ophthalmol 2014;157:1202-8.
Ulusoy S, Erden M, Dinc ME, et al. Effects of use of a continuous positive airway pressure device on glaucoma. Med Sci Monit 2015;21:3415-9.
Pépin JL, Chiquet C, Tamisier R, et al. Frequent loss of nyctohemeral rhythm of intraocular pressure restored by nCPAP treatment in patients with severe apnea. Arch Ophthalmol 2010;128:1257-63.
Kiekens S, Veva DG, Coeckelbergh T, et al. Continuous positive airway pressure therapy is associated with an increase in intraocular pressure in obstructive sleep apnea. Invest Ophthalmol Vis Sci 2008;49:934-40.
Cohen Y, Ben-Mair E, Rosenzweig E, et al. The effect of nocturnal CPAP therapy on the intraocular pressure of patients with sleep apnea syndrome. Graefes Arch Clin Exp Ophthalmol 2015;253:2263-71.
Pellegrini M, Bernabei F, Friehmann A, Giannaccare G. Obstructive sleep apnea and keratoconus: a systematic review and meta-analysis. Optom Vis Sci 2020;97:9-14.
Karaca EE, Akçam HT, Uzun F, et al. Evaluation of ocular surface health in patients with obstructive sleep apnea syndrome. Turk J Ophthalmol 2016;46:104-8.
Wu Y, Zhou LM, Lou H, et al. The association between obstructive sleep apnea and nonarteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis. Curr Eye Res 2016;41:987-92.
Sun MH, Lee CY, Liao YJ, Sun CC. Nonarteritic anterior ischaemic optic neuropathy and its association with obstructive sleep apnoea: a health insurance database study. Acta Ophthalmol 2019;97:e64-70.
Liguori C, Placidi F, Palmieri MG, et al. Continuous positive airway pressure treatment may improve optic nerve function in obstructive sleep apnea: an electrophysiological study. J Clin Sleep Med 2018;14:953-8.
Zhu Z, Zhang F, Liu Y, et al. Relationship of obstructive sleep apnoea with diabetic retinopathy: a meta-analysis. Biomed Res Int 2017;2017:4737064.
Nishimura A, Kasai T, Kikuno S, et al. Apnea hypopnea index during rapid eye movement sleep with diabetic retinopathy in patients with type 2 diabetes. J Clin Endocrinol Metab 2019;104:2075-82.
D’Souza H, Kapoor KG. Retinal vascular manifestations of obstructive sleep apnea. Curr Opin Ophthalmol 2020;31:508-13.
Vié AL, Kodjikian L, Agard E, et al. Evaluation of obstructive sleep apnea syndrome as a risk factor for diabetic macular edema in patients with type II diabetes. Retina 2019;39:274-80.
Nesmith BL, Ihnen M, Schaal S. Poor responders to bevacizumab pharmacotherapy in age-related macular degeneration and in diabetic macular edema demonstrate increased risk for obstructive sleep apnea. Retina 2014;34:2423-30.
Altaf QA, Dodson P, Ali A, et al. Obstructive sleep apnea and retinopathy in patients with type 2 diabetes. A longitudinal study. Am J Respir Crit Care Med 2017;196:892-900.
Lin P-W, Lin H-C, Friedman M, et al. Effects of CPAP for patients with OSA on visual sensitivity and retinal thickness. Sleep Med 2020;67:156-63.
Chou KT, Huang CC, Tsai DC, et al. Sleep apnea and risk of retinal vein occlusion: a nationwide population-based study of Taiwanese. Am J Ophthalmol 2012;154:200-5.e1.
Wan W, Wu Z, Lu J, et al. Obstructive sleep apnea is related with the risk of retinal vein occlusion. Nat Sci Sleep 2021;13:273-81.
Wang D, Barash A. Association of obstructive sleep apnea with retinal vein occlusion: a systematic review and meta-analysis. Invest Ophthalmol Visual Sci 2020;61:1315.
Liu PK, Chang YC, Tai MH, et al. The association between central serous chorioretinopathy and sleep apnea: a nationwide population-based study. Retina 2020;40:2034-44.
Brill KA. How to avoid interface problems in acute noninvasive ventilation. Breathe 2014;10:230-42.
Matossian C, Song X, Chopra I, et al. The prevalence and incidence of dry eye disease among patients using continuous positive airway pressure or other nasal mask therapy devices to treat sleep apnea. Clin Ophthalmol 2020;14:3371-9.
Brzecka A, Ejma M, Misiuk-Hojlo M. Ocular manifestations of lung cancer. J Oncol 2003;53:428-31.
Qu Z, Liu J, Zhu L, Zhou Q. A comprehensive understanding of choroidal metastasis from lung cancer. Onco Targets Ther 2021;14:445165.
Lampaki S, Kioumis I, Pitsiou G, et al. Lung cancer and eye metastases. Med Hypothesis Discov Innov Ophthalmol 2014;3:40-4.
Villgran VD, Chakraborty RK, Cherian SV. Pancoast syndrome. Treasure Island: StatPearls Publishing; 2022.
Heinemann S, Zabel P, Hauber HP. Paraneoplastic syndromes in lung cancer. Cancer Ther 2008;6:687-98.
Thirkill CE, Roth AM, Keltner JL. Cancer-associated retinopathy. Arch Ophthalmol 1987;105:372-5.
Ohguro H, Yokoi Y, Ohguro I, et al. Clinical and immunologic aspects of cancer-associated retinopathy. Am J Ophthalmol 2004;137:1117-9.
Goldstein SM. Cancer-associated retinopathy. Arch Ophthalmol 1999;117:1641-5.

How to Cite

Singh, Mamta, Kunal Deokar, Bibhuti Prassan Sinha, Monika Keena, and Govind Desai. 2023. “Ocular Manifestations of Common Pulmonary Diseases: A Narrative Review”. Monaldi Archives for Chest Disease 94 (1). https://doi.org/10.4081/monaldi.2023.2535.