Rheumatoid Arthritis and Eye Health: Complications to Watch Out For
Can rheumatoid arthritis affect the eyes and vision? Just as RA is an inflammatory disease which attacks bones and joints, it can also attack the eyes. Complications may include dry eyes, episcleritis, scleritis, corneal problems, glaucoma, cataracts, and Sjogren’s Syndrome. As patients living with complicated medical issues, we should get regular check-ups including annual eye exams.
Dry Eyes, Sjögren's Syndrome, and RA
Dry eyes is a common problem for patients living with rheumatoid arthritis. Patients may notice irritation, a gritty feeling, painful burning, sensitivity to light, and a sensation that something is in the eye. It is caused by a lack of tear production. Patients with dry eyes are at increased risk for infections around the eye and damage to the cornea.
Eye dryness is also a symptom of Sjögren's syndrome which is an inflammatory disease that can affect many different parts of the body, but most often affects the tear and saliva glands. Approximately 10 to 25 percent of rheumatoid arthritis patients will develop Sjögren's syndrome. Treatment for dry eyes include artificial tears or prescription eye drops (ie. Restasis).
Scleritis and Episcleritis
Looking at the eye, we can easily identify the pupil, iris (the color parted), the sclera (the white part), and the cornea (the clear covering). The sclera can become inflamed causing the white of the eye to become red. The inflammation causes pain and sensitivity to light. Scleritis is a serious and painful disease which can create a hole in the eyeball if left untreated. Scleritis is treated with prescription anti-inflammatory medication, usually prednisone eye drops.
The thin membrane which covers the sclera is the episclera. Inflammation of this thin lining can also cause red eyes, pain, and irritation. While episcleritis is not as serious as scleritis, it is also treated with anti-inflammatory drugs and corticosteroid eye drops. If left untreated, episcleritis can become painful and create an environment which is more vulnerable to infection.
[I recently experienced a case of episcleritis caused by a cold virus sneaking into my eyes. The irritation and swelling became painful so I consulted my eye doctor who prescribed eye drops featuring a mild antibiotic and corticosteroid.]
The cornea can become inflamed (often from scleritis) which will dramatically reduce visual acuity. A potential complication of inflammation and dry eyes is corneal infection or conjunctivitis. A rare but serious complication of rheumatoid arthritis is corneal melt. It often signals the development of systemic vasculitis in RA patients. Corneal melt must receive early and aggressive treatment.
Please consult your ophthalmologist whenever you experience new symptoms related to the eyes. Remember to get annual eye exams also.
Uveitis, Iritis and Iridocyclitis
The uvea is the middle layer of the eye’s globe that lies underneath the sclera. The uvea has three parts, one of which is the iris (the colored part of the eye). Inflammation of the uvea is called uveitis. Uveitis might also be known as iritis or iridocyclitis, depending upon which part of the eye is affected by inflammation. Symptoms include eye pain, spotty or blurry vision, and strong sensitivity to light. Treatment with steroid or nonsteroid anti-inflammatory eye drops is usually effective.
Chronic uveitis is a serious complication of juvenile idiopathic rheumatoid (juvenile rheumatoid arthritis). Up to 80 percent of all cases of anterior uveitis in childhood are associated with juvenile arthritis. If not detected and treated early, the inflammation can cause scarring and visual problems. Glaucoma, cataracts and permanent visual damage (including blindness) are all complications which may occur from severe uveitis. Again, early and aggressive treatment is necessary to reduce the occurrence of irreversible blindness secondary to uveitis in children with rheumatoid arthritis.
Glaucoma, Cataracts and Retinal Damage
Certain medications commonly used by rheumatoid arthritis patients, including prednisone and plaquenil, can contribute to the development of additional eye problems. Glaucoma is characterized by excess pressure inside the eye. Symptoms include blurred vision, gradual vision loss, and eye pain. Treatment usually involves eye drops to decrease eye pressure while some cases require surgery. Glaucoma may also be caused by steroids which can elevate eye pressure. Fortunately, once the patient stops taking the corticosteroid, the eye pressure usually goes back to normal.
Inflammation from RA and long-term steroid use can contribute to the development of cataracts. Cataracts involve a clouding of the eye’s lens, a condition which becomes more common as we age. In “The Eye Book: A complete guide to eye disorders and health,” authors state that a particular kind of cataract (posterior subcapsular) occurs in 30 to 49 percent of people taking 10 to 15 mg of prednisone daily for one to two years.
Plaquenil, a drug commonly used to treat RA, is potentially toxic and can damage the retina of the eye. The retina is the part of the eye which converts light into images sent to the brain so you can see. It also controls color vision. It is recommended that you get regular eye exams every six months to catch changes in the retina in the early stages when no symptoms have developed. Plaquenil-related damage may resolve after a patient discontinues the medication, or may become permanent, or may even show up years after the patient stopped taking plaquenil.
Patel, SJ, Lundy, DC. Ocular Manifestations of Autoimmune Disease. Am Fam Physician. 2002 Sep 15;66(6):991-998.
Cassel, GH, Billig, MD, Randall, HG. The Eye Book: A Complete Guide to Eye Disorders and Health. The Johns Hopkins University Press, 1998.
Bucknall, RC. Arthritis and inflammatory eye disease. Rheumatology. Oct 2005;44(10): 1207-1209.
Sule, A, Balakrishnan, C. et al. Rheumatoid Corneal Melt. Rheumatology. 2002;41(6):705-706.
Nguyen, QD, Foster, S. Saving the Vision of Children with Juvenile Rheumatoid Arthritis-Associated Uveitis. JAMA. 1998;280(13):1133-1134.
How Juvenile Rheumatoid Arthritis Affects the Eyes from the Cleveland Clinic