תענית כד, א
״וְהָיָה אִם מֵעֵינֵי הָעֵדָה נֶעֶשְׂתָה לִשְׁגָגָה״: מָשָׁל לְכַלָּה שֶׁהִיא בְּבֵית אָבִיהָ. כל זְמַן שֶׁעֵינֶיהָ יָפוֹת — אֵין כל גּוּפָהּ צְרִיכָה בְּדִיקָה. עֵינֶיהָ טְרוּטוֹת — כָּל גּוּפָהּ צְרִיכָה בְּדִיקָה
“Then it shall be, if it shall be committed in error by the congregation, it being hidden from their eyes” (Numbers 15:24). This verse indicates that the leaders are considered the eyes of the congregation. There is a parable that illustrates this, involving a bride who is in her father’s home and has not yet been seen by her bridegroom. As long as her eyes are beautiful, her body need not be examined, as certainly she is beautiful. However, if her eyes are bleary [terutot], her entire body requires examination. So too, if the leaders of the generation are flawed, it is a sign that the entire generation is unworthy.
In this parable, which is told by the talmudic sage Oshaya, the leaders of the Jewish people - its eyes - are a barometer of their spiritual health. If the leaders are flawed, then we can assume the people themselves are similarly flawed. Today, we will take this parable one step further, and examine in what ways the eyes do, in fact, reveal much about the health of the rest of the body.
The Eyes and Systemic Diseases
As any medical student can attest, there is a long list of ocular manifestations of systemic diseases, or in non-medical language, of how changes in the eyes reflect illness elsewhere in the body. Here are a few, taken from a useful paper published several years ago by a former colleague.
Eyelid Abnormalities
A number of dermatological problems can show up on the eyelids, which are, after all, also made up from skin. These include eczema, psoriasis, rosacea, and infections like cellulitis. Tumors that effect the eyelids include Kaposi’s sarcoma, which is found in patients with AIDS.
Dry Eyes
The list of conditions that cause dry eyes is enormous, and dry eyes may be a manifestation of many autoimmune and collagen vascular diseases. But before you self-diagnose any of these, remember also that dry eyes can also be idiopathic, meaning it is a condition that arises spontaneously, or for which the cause is unknown.
From Rothenhaus, T. Polis, A. Ocular Manifestations of Systemic Disease. Emer. Med. Clin. N. Am. 1995; 13 (8). 608.
Conjunctivitis
We have all had conjunctivitis at one time or another. It is simply an inflammation of the mucous membranes lining the inner eyelids and anterior sclera - the white part of the eyeball. It is usually caused by a viral infection and goes away after a few days. But it can also be a manifestation of systemic diseases, such as Reiter's syndrome, Wegener's granulomatosis, erythema multiforme, Stevens-Johnson syndrome, psoriatic arthritis, Kawasaki's disease, Crohn's disease and gout. As if that’s not enough, it can also be caused by systemic infections, such as Lyme disease, mononucleosis, measles, or gonorrhea. It turns out that simple conjunctivitis is a hypochondriac’s best friend.
Optic Neuritis
Optic neuritis is an inflammation of the optic nerve, and results in a rapid deterioration of vision. Causes include multiple sclerosis, sarcoidosis, syphilis, toxoplasmosis, Lyme disease (again), cat-scratch disease (it’s a real thing, look it up), and diseases related to human immunodeficiency virus (HIV), especially cytomegalovirus (CMV) and Cryptococcus. Drugs, such as ethambutol and tamoxifen, can also cause an optic neuritis.
Ptosis
Ptosis, a drooping of the eyelids, can be on one (unilateral) or both sides (bilateral). It can be a sign of neurologic disease causing a third nerve palsy (botulism, tumor, aneurysm), or a primary neuromuscular disorder, such as myasthenia gravis.
Infectious Diseases
There are many systemic infectious diseases that cause eye problems. Diphtheria (which is no-longer commonly seen since we have a vaccine against it) commonly results in a minimally purulent conjunctivitis. Botulism (which can kill you) can cause a droopy eye, an inability to focus, double vision and decreased tear formation. Farmers who are in contact with livestock might catch Brucellosis, which will cause fever, sweats, weight loss, weakness, headache, and body aches. It also causes visual field changes and a decreased visual acuity, as well as corneal lesions, conjunctivitis, and lid edema. A visit to the emergency department is recommended. The sexually transmitted disease syphilis can cause iritis, an inflammation of the colored ring around the center of the eye as well as conjunctivitis. Lyme disease, transmitted by deer ticks and increasingly common in the US can cause conjunctivitis, as well as Bell’s palsy, in which one side of the face together with the eyelid, droop.
And on and on
The list continues. Other infectious diseases that cause ocular problems are herpes, chlamydia, tuberculosis, and leprosy, as well as fungal infections and HIV. Autoimmune diseases, in which the body’s own immune system turns against itself also cause eye problems. The list of these diseases includes systemic lupus erythematosus, sarcoidosis, Sjogren's Syndrome, Behcet's Disease, polyarteritis nodosa and giant cell arteritis. And diabetes, hyperthyroidism and gout can cause a number of different eye problems, as will sickle cell disease.
“Knowledge of the characteristic ophthalmologic manifestations of systemic disease can aid the physician in diagnosing a particular disorder, limit the progression of more common diseases, and prevent further visual loss or blindness in patients with serious ophthalmologic complications.”
So Oshaya’s parable was, medically speaking, spot on. Let us hope that the leaders of the Jewish people have fewer ocular problems than these.
Want more about talmudic eye diseases? The read our post on the Cohen with eye problems.
