Rheumatoid Arthritis and Your Eyes: Watch Out For These Complications

PATIENT EXPERT
Feb 22, 2011

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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.


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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.

While the eyes may be windows to the soul, they may also reflect the state of your health. Rheumatoid arthritis (RA) is an inflammatory systemic disease that affects more than bones and joints, it can attack other parts of the body, such as the lungs, heart, and the eyes. Once the inflammation of RA reaches the eyes, a number of conditions may develop.

Ocular complications associated with RA affect up to 25 percent of the people living with the disease. Here are some of the more common complications:

  • Dry eyes, also known as keratoconjunctivitis sicca, which may be associated with secondary Sjögren’s Syndrome

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  • Inflammation of specific parts of the eye, such as scleritis, episcleritis, keratitis, uveitis, iritis, iridocyclitis, choroiditis, or retinal vasculitis
  • Glaucoma, cataracts, or macular edema

It’s very important to remember that people living with chronic illnesses should get regular check-ups, including annual eye exams. Please remember that new eye-related symptoms warrant prompt medical attention which might save your vision.

Dry Eyes, Sjögren’s Syndrome, and RA

Dry eye syndrome, or keratoconjunctivitis sicca (KCS), is one of the most common eye problems for people living with rheumatoid arthritis. Patients may notice irritation, a gritty feeling, painful burning, sensitivity to light, or a sensation that something is in the eye. KCS is caused by a lack of tear production, but may paradoxically be associated with “watery” eyes. Dry eye syndrome can be diagnosed with a simple test that involves inserting strips of filter paper inside the lower eyelid of each eye to measure tear production. Dangers of dry eyes include increased risks of infection and damage to the cornea.


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RA can be associated with secondary diseases such as symptom of Sjögren’s syndrome (SS) that most often affects the glands that produce tears and saliva. Eye dryness is a classic symptom of SS. Approximately 10 to 25 percent of rheumatoid arthritis patients will develop Sjögren’s syndrome. Treatment for dry eyes include artificial tears, prescription eye drops (such as Restasis), or tear duct plugs to prevent the drainage of tears from the eyes.

Scleritis and Episcleritis

Looking at the eye, we can easily identify the pupil, the iris (the color part), the sclera (the white part), and the cornea (the clear covering). With RA, the sclera can become inflamed causing the white of the eye to be red. At first glance, scleritis may be confused for a more common eye infection called conjunctivitis or “pink eye.” But the inflammation can also cause severe pain, swelling, blurred vision, tearing, 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, corticosteroids, immunomodulating therapies, and/or prescription eye drops.


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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 can also be 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.

During diagnosis, there are two important ways to distinguish scleritis from episcleritis. Gentle pressure applied to the eyeball through a closed eyelid will be much more painful with scleritis. Application of phenylephrine 2.5% — an eye drop commonly used to dilate pupils — will blanch the redness in episcleritis but not scleritis.

The Cornea and RA

With RA, the cornea can become inflamed — a condition called keratitis — which can dramatically reduce visual acuity. Potential complications of keratitis and dry eyes are corneal infection, corneal ulcers, or conjunctivitis. RA is the most common cause of peripheral ulcerative keratitis (PUK), a condition characterized by tissue necrosis of the thickest layer of the cornea. Symptoms of PUK include the sensation of something in the eye with or without pain, tearing, sensitivity to light, and loss of vision which can occur quickly when PUK progresses. Another rare but very serious complication of keratitis is corneal melt which often signals the development of systemic vasculitis in people living with RA. Corneal melt and PUK must receive early and aggressive treatment.


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Uveitis, Iritis, and Iridocyclitis

The uvea is the layer of the eye that lies between the outer layer (cornea and sclera) and the inner layer (retina). The uvea has three parts: the iris which is the colored part of the eye, the ciliary body, and the choroid. Uveitis — inflammation of the uvea — might also be named iritis, iridocyclitis, or choroiditis, depending upon which part of the eye is affected. Symptoms of uveitis include eye pain, spotty or blurred vision, redness, dark floating spots, 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 arthritis (JIA), previously termed juvenile rheumatoid arthritis (JRA). 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 each 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.


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Glaucoma, Cataracts and Retinal Damage

Certain medications commonly used in RA may contribute to the development of additional eye problems, such as glaucoma or cataracts. Glaucoma is characterized by excess pressure inside the eye. Symptoms include blurred vision, gradual vision loss, and eye pain. Treatment often involves eye drops to decrease eye pressure while some cases may require surgery. Corticosteroids can increase intraocular pressure, leading to open angle glaucoma. However, once the use of corticosteroids has been stopped, eye pressures usually go back to normal.

Inflammation from RA and long-term steroid use may contribute to the development of cataracts. Cataracts involve a clouding of the eye’s lens, a condition which becomes more common as we age. Reports published in the 1960s suggest an increased risk of posterior subcapsular cataract in patients with RA who used glucocorticoids (GC) daily for more than 1-2 years. Although the current literature suggests a possible association between GC use and the development of cataract, a recent systematic review and meta-analysis specific to published studies in RA concludes that the risk cannot be quantified from the available evidence. More well-designed research studies are required.


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Plaquenil (hydroxychloroquine sulfate), a drug commonly used to treat RA, is potentially toxic and can cause retinopathy. The retina is the part of the eye which converts light into images that are sent to the brain so you can see. The retina also controls color vision. When using Plaquenil, it is recommended to get regular eye exams every six months to catch early changes in the retina before symptoms have developed.  Plaquenil-related damage may resolve after medication is discontinued, or it may become permanent. Damage may even show up years after a person has stopped taking Plaquenil.

Retinal vasculitis (RV), a serious and potentially blinding condition, is characterized by inflammation of the tiny blood vessels of the retina. It can occur as part of systemic vasculitis or secondary to an underlying connective tissue disease, such as RA or lupus. RV is generally painless and patients may be asymptomatic or have symptoms such as blurred vision, floaters, or decreased ability to distinguish colors. Special testing with fundus fluorescein angiography, which involves injection of a dye into a vein and photographs taken of the back of the eye (retina), may be necessary for diagnosis.

Bottom Line

Visit your ophthalmologist each year for an annual eye exam and do not hesitate to contact your doctor whenever new symptoms or worsening symptoms appear. The health of your eyes is vital. Treatment for many of the ocular complications detailed above include immunomodulary therapy to reduce systemic inflammation associated with RA. Talk to your rheumatologist and ophthalmologist about what treatment approach would be most appropriate for you.


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Lisa Emrich

@LisaEmrich

Living with multiple sclerosis and rheumatoid Arthritis, Lisa Emrich is an award-winning, passionate patient advocate, health writer, classical musician, and backroad cyclist. Her stories inspire others to live better and stay active. Lisa is author of the blog Brass and Ivory: Life with MS and RA and founder of the Carnival of MS Bloggers. Lisa frequently works with organizations in support of better policies, patient-centered research, and research funding. Lisa serves on HealthCentral’s Health Advocates Advisory Board, and is a Social Ambassador for the MSHealthCentral Facebook page.

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