The Eye-Skin Connection: Ocular Red Flags Every Dermatologist Should Know

Dermatologists frequently manage diseases with potentially vision-threatening ocular involvement yet many clinicians feel less comfortable recognizing when an eye complaint requires urgent referral. In this interview, ophthalmologist Dr Jennifer Cao discusses high-yield ophthalmic findings associated with inflammatory skin diseases, autoimmune bullous disorders, severe cutaneous adverse reactions, and systemic therapies. The goal is to help dermatology clinicians identify ocular red flags early, understand when vision is at risk, and strengthen collaboration with ophthalmology colleagues. 
 

WHY DERMATOLOGISTS NEED TO KEEP AN EYE  ON THE EYES

The Dermatologist: Many dermatologic diseases have ocular manifestations, yet eye involvement can  sometimes be overlooked. Why is it so important for dermatologists to maintain a high index of suspicion?

Dr Cao: Many dermatologic diseases are associated with ocular findings. The challenge is that there is little formal ophthalmology training in medical school. Unfortunately, we only get 1 set of eyes and there is no replacing them, so damage to the eye can be unforgiving. Early recognition is important. When patients come to me late and there is often already irreversible ocular damage, we are trying to salvage what we can from the remaining function of the eye.

The Dermatologist: What are the most common ocular complaints that should immediately raise concern in a dermatology clinic?

Dr Cao: Redness, pain, photophobia (light sensitivity), and most importantly decreased visual acuity should be taken seriously. Sometimes it can be confusing because many of these ocular symptoms can also be symptoms of dry eye. But if a patient is already using artificial tears a few times a day and the problem persists for more than a few days and has not resolved, they should probably see an ophthalmologist. There should be a low threshold to refer patients who have a dermatologic disease with a known ocular disease association, such as uveitis associated with psoriasis, ankylosing spondylitis, and inflammatory bowel disease.
 

The Dermatologist: Are there specific symptoms that should trigger a same-day ophthalmologic referral?

Dr Cao: Acute visual loss or a sudden decrease in visual acuity, whether unilateral or bilateral, warrants urgent ophthalmologic evaluation, ideally the same day. A sudden change in vision should never be treated as a routine eye complaint. 

UVEITIS: A VISION-THREATENING CONDITION

The Dermatologist: Uveitis is frequently associated with several inflammatory diseases that dermatologists treat. What is uveitis and why can delayed diagnosis be so dangerous?

Dr Cao: Strictly speaking, uveitis refers to inflammation within the eye. More broadly, however, ophthalmologists care for inflammatory disease involving the entire ocular system, including the globe, orbit, extraocular muscles, optic nerve, eyelids, and ocular surface. The term ocular inflammatory disease encompasses this broader spectrum.

The danger of delayed diagnosis is that inflammation can produce permanent structural damage. It is far easier to control inflammation before that damage occurs than to attempt to restore vision afterward.

The Dermatologist: Which dermatologic and systemic diseases most commonly present with uveitis in  your practice?

Dr Cao: Anterior uveitis is the most common type of uveitis. This refers to inflammation of the iris and/or the front part of the eye. Anterior uveitis is associated with HLA-B27 spectrum diseases, such as ankylosing spondylitis, psoriasis, and inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. Systemic diseases associated with uveitis may include lupus and sarcoidosis. I also care for a large number of patients with mucous membrane pemphigoid; when it is solely isolated to the eye, it is called ocular cicatricial pemphigoid.

HLA-B27-associated anterior uveitis deserves particular attention because it can be abrupt and severe. Patients may rapidly develop posterior synechiae, in which the inflamed iris adheres to the lens. Even a first episode may require intensive topical corticosteroid therapy. Repeated episodes can produce cumulative ocular damage. These patients should therefore be evaluated promptly and treated aggressively enough to achieve rapid control of inflammation.

Recurrent uveitis can also be a clue that the underlying systemic inflammatory disease is not adequately controlled, even when the patient’s extraocular symptoms appear relatively quiet. In those circumstances, escalation or modification of systemic immunosuppressive therapy may be necessary to achieve durable ocular control.

The Dermatologist: What symptoms and exam findings should prompt dermatologists to suspect uveitis rather than routine conjunctivitis or dry eye disease?

Dr Cao: History is often the most informative detail. Dry eye disease is extremely common in patients with autoimmune disease. These patients may awaken with red or irritated eyes that improve by midmorning, or they may have intermittent symptoms during the day that resolve with artificial tears.

Inflammatory eye disease tends to behave differently. Recurrent episodes lasting days to weeks, particularly when 1 eye is affected more than the other, should raise concern. A history of prior treatment with corticosteroid eye drops is another important clue because it may indicate a previous episode of uveitis.

There are also several examination findings that dermatologists can recognize without specialized ophthalmic equipment. Focal rather than diffuse redness may suggest scleritis. A simple penlight examination of the pupils can also be informative. Pupil asymmetry or an irregular, cloverleaf-shaped pupil may indicate posterior synechiae, which strongly suggests previous or active intraocular inflammation.

The Dermatologist: What are the long-term  consequences of undertreated or recurrent uveitis?

Dr Cao: Uveitis can produce complications from the front to the back of the eye. Although some are reversible, others can be permanent. For example, band keratopathy results from calcium deposition in the cornea. Posterior synechiae can restrict normal pupillary movement. Cataracts and glaucoma are among the most common complications of uveitis, arising either from chronic inflammation, corticosteroid therapy, or both.

Cataracts can generally be easily treated surgically. Glaucoma is more concerning because it reflects progressive, irreversible injury to the optic nerve. Elevated intraocular pressure damages optic nerve axons, which are responsible for transmission of visual information to the brain.

Macular edema is another important complication. Because the macula is responsible for detailed central vision and color, swelling in this region can cause significant central visual impairment. 
 

AUTOIMMUNE BULLOUS DISEASE: PROTECTING THE OCULAR SURFACE

The Dermatologist: Ocular involvement in pemphigus and pemphigoid can be devastating. What are the  earlier warning signs dermatologists should recognize?

Dr Cao: Ocular pemphigoid causes scarring of the conjunctiva, which is the mucous membrane that covers the inner surface of the eyelid and eyeball everywhere except the cornea. Initially, patients may have redness and irritation. Over time, however, persistent inflammation can lead to conjunctival fibrosis, contraction, and eventually adhesions between the eyelid and the globe. One of the most serious consequences is damage to the limbal stem cells. These cells are essential for maintaining a healthy, transparent corneal epithelium. When the limbal stem cell population falls below a critical threshold, patients develop limbal stem cell deficiency. Abnormal epithelium then begins to replace the normal corneal surface, producing progressive opacification and keratinization, and, ultimately, blindness.

The Dermatologist: Clinicians may think of dry eye as a nuisance symptom rather than a serious disease. How can chronic ocular surface inflammation progress to permanent vision loss in these patients?

Dr Cao: Dry eyes can be a nuisance because when your eyes are dry, it temporarily decreases clarity of vision. However, over time, drying of the eye surface increases the risk of epithelial breakdown, which increases the risk of superinfection and corneal ulceration. Complications include corneal scarring and permanent vision loss.

In a patient with ocular pemphigoid, the consequences can be even greater. Dryness and surface inflammation may accelerate conjunctival scarring, contracture, corneal ulceration, and limbal stem cell failure. In that setting, dry eye is not merely a symptom; it can contribute directly to progression of the underlying disease.

The Dermatologist: What distinguishes ocular  cicatricial pemphigoid from more routine causes of chronic ocular irritation?

Dr Cao: Ocular cicatricial pemphigoid falls within the spectrum of mucous membrane pemphigoid. Early disease can be extremely subtle, and recognition requires careful examination of the conjunctiva for evidence of scarring.

Unfortunately, not every ophthalmologist is trained to examine patients with cicatrizing conjunctival disease, so diagnosis is often delayed. If an ophthalmologist identifies subepithelial fibrosis or symblepharon, which is an adhesion between the eyelid and the globe, this should raise concern for pemphigoid, and the patient should be referred promptly to a cornea or ocular surface specialist experienced in managing the disease.

The goal is to recognize inflammation before extensive scarring has occurred and to initiate systemic immunosuppressive therapy when appropriate.
 

The Dermatologist: When should dermatologists suspect ocular involvement even if patients are not specifically complaining of eye symptoms?

Dr Cao: Visible redness or decreased visual acuity should prompt closer examination. A dermatologist can gently retract the lower eyelid and look for adhesions or conjunctival scarring that might suggest pemphigoid. If the patient mentions uveitis, your antenna should creep up quickly.

It is important to remember that not all uveitis is symptomatic. Juvenile idiopathic arthritis (JIA) is the classic example. Children with JIA may develop significant intraocular inflammation without obvious redness, pain, or initial visual complaints. The American Academy of Pediatrics and the American Academy of Ophthalmology both recommend early screening for all patients with JIA and routine screening every 3 months for highrisk groups.
 

 SJS/TEN: AN OPHTHALMIC EMERGENCY

The Dermatologist: In patients with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), what ocular findings represent an emergency?

Dr Cao: Any ocular involvement in SJS or TEN should be considered an ophthalmic emergency and evaluated immediately by an ophthalmologist.

Fluorescein staining can identify defects in the ocular surface epithelium that may not otherwise be readily apparent. We now have interventions capable of preserving the ocular surface and reducing long-term morbidity, including amniotic membrane transplantation (AMT). Timing is critical. In patients with severe ocular involvement who meet criteria for AMT, early intervention can profoundly affect the long-term outcome. For severe cases in which AMT is indicated, surgery is often recommended within the first 24 hours of arrival.
 

The Dermatologist: What long-term ocular  complications are most concerning in SJS/TEN?

Dr Cao: Long-term outcomes depend largely on the severity of the acute ocular involvement and how rapidly appropriate treatment is initiated. Some patients develop little or no ocular disease, whereas others experience extensive epithelial injury and inflammation. Published grading systems can help distinguish lower-risk from higher-risk presentations and guide management.

Patients with severe disease frequently require AMT. Whether that treatment is performed, and how early it is performed, can influence whether a patient ultimately retains good visual acuity with manageable dry eye disease or develops severe chronic dry eyes and possibly lifelong blindness.
 

 HYDROXYCHLOROQUINE TOXICITY: WHAT  DERMATOLOGISTS NEED TO KNOW IN 2026

The Dermatologist: The screening recommendations for hydroxychloroquine toxicity continue to evolve. What are the most important updates clinicians should know?

Dr Cao: Patients with classic hydroxychloroquine retinopathy typically demonstrate central defects. Plaquenil screening guidelines were most recently updated in 2026. The most important update is that we now recommend all patients be screened upon initiation of hydroxychloroquine to determine a baseline. The recommended screening includes a full dilated eye exam and spectral domain ocular coherence tomography (OCT). Another change is to include widefield imaging of the retina. The final screening component is now a 24-2C visual field test, which evaluates the central 24 degrees of visual field, instead of the previously recommended 10-2 visual field, which tests only 10 degrees of central vision.
 

The Dermatologist: Which patients are at highest risk for retinal toxicity, and how should dermatologists counsel them?

Dr Cao: Particularly high-risk groups for hydroxychloroquine toxicity include patients treated for more than 5 years, dosages of 5 mg/kg or higher, and patients with renal insufficiency. The pattern of toxicity can also vary among patients. The classic appearance of hydroxychloroquine retinopathy is a parafoveal, bull’s-eye pattern centered around the macula. In some patients, particularly East Asian individuals, toxicity may occur in the peripheral macula. That is why the recommendation was changed to widefield photography with autofluorescence to help pick up those patients with peripheral retinopathy.
 

The Dermatologist: One of the biggest concerns is that toxicity can continue to progress even after discontinuation. How does this influence screening and monitoring strategies?

Dr Cao: With OCT, the 24-2C visual field test, and a multifocal electroretinogram, which allows us to test the electrical responses of the retina, our goal is to detect hydroxychloroquine retinopathy at its earliest stages. This is because even after we discontinue the medication, hydroxychloroquine retinopathy can progress for several months, even up to a year after. Unfortunately, the retinopathy is irreversible and because it affects the central retina, this can impact fine vision, color vision, and detailed vision. Therefore, it is very important that we catch toxicity early.
 

PRACTICAL PEARLS FOR EVERYDAY DERMATOLOGY

The Dermatologist: What are the most common  ophthalmology referrals you wish dermatologists would make sooner?

Dr Cao: As a uveitis specialist, I think one of the biggest challenges is to refer patients with uveitis earlier. Unfortunately, exposure to uveitis and uveitis training can be limited in some areas of the country. So, recognizing uveitis is step 1. Step 2 is recognizing that today, we have more than just steroids for treating uveitis. We have a whole menu of immunomodulatory therapies that can be utilized for steroid-sparing and steroid-free disease control. This often requires a multidisciplinary approach coordinated by a rheumatologist, dermatologist, and gastroenterologist. There is only 1 US Food and Drug Administration-approved medication for a subset of patients with uveitis, so treatment may be either off label or we may utilize therapies garnered through other related indications, such as ulcerative colitis, rheumatoid arthritis, or psoriasis.
 

The Dermatologist: Conversely, what eye  complaints are often over-referred and can be  managed conservatively?

Dr Cao: Almost all patients with autoimmune disease have some component of dry eyes, and it is the most common reason for a referral to an ophthalmologist. For patients without alarm features, a reasonable initial approach is a consistent trial of artificial tears several times daily for a couple of weeks. If the redness, irritation, or discomfort resolves, inadequately treated dry eye becomes much more likely. If symptoms persist despite appropriate lubrication, or if there is significant pain, photophobia, visual change, asymmetry, or another concerning feature, then ophthalmologic evaluation becomes much more important.
 

The Dermatologist: If every dermatologist  remembered 3 ocular red flags that should never  be ignored, what would they be?

Dr Cao: Severe eye pain, eye symptoms that last more than a few days, and anybody who has acute vision loss should be immediately referred to an ophthalmologist. In addition, anyone who mentions the word uveitis or a history of uveitis ought to be referred to a uveitis specialist, or an ophthalmologist at minimum, ideally for a baseline examination. These patients often have underlying, undertreated uveitis.
 

 BUILDING BETTER COLLABORATION BETWEEN DERMATOLOGY AND OPHTHALMOLOGY

The Dermatologist: What information is most helpful when dermatologists refer patients with suspected ocular involvement?

Dr Cao: It would be helpful for the dermatologist to clearly list the patient’s systemic diseases, medications tried and/or failed, and the duration and character of their eye symptoms. This can really help an ophthalmologist quickly and accurately triage how urgently the patient needs to be seen.
 

The Dermatologist: How can dermatologists and  ophthalmologists work together more effectively when managing shared inflammatory disease?

Dr Cao: I think the easiest way is just to pick up the phone and talk in person. Sometimes, especially with complex patients, it is not a straightforward answer and there is a lot of nuance to treatment selection and the treatment plan. Communicating with the physician you are referring to can make treatment decisions progress quickly and efficiently.
 

The Dermatologist: Looking ahead, are there  emerging therapies or multidisciplinary approaches that you believe will improve outcomes for patients with both dermatologic and ocular disease?

Dr Cao: Traditionally in ophthalmology we have been limited to antimetabolites and then tumor necrosis factor inhibitors. But there are now new classes of exciting medications being utilized in the dermatology, gastroenterology, and rheumatology world. The most exciting to me are the Janus kinase inhibitors. I have been using them for several years and they seem to work very well for patients with uveitis. The second advancement is a growing trend toward multidisciplinary clinics where we have a uveitis specialist working in conjunction with a rheumatologist or dermatologist. This has enabled us to make treatment decisions more collaboratively and to initiate the appropriate therapies much more quickly.
 

Conclusion

A practical understanding of ocular manifestations can significantly improve outcomes for patients with inflammatory skin disease. Timely recognition of ocular red flags, such as persistent eye pain, redness, and vision changes, and a low threshold for ophthalmology referral can prevent irreversible complications. Early recognition matters because many complications of ocular inflammation are preventable but not reversible once established. Equally important is close communication between dermatologists and ophthalmologists, particularly for patients with complex immune-mediated diseases requiring coordinated systemic therapy. As newer targeted treatments and multidisciplinary care models continue to evolve, collaboration across specialties will play an increasingly important role in preserving both skin health and vision.