Rheumatoid Arthritis and Your Eyes: Be 'Clear' About These Facts

M.A., Health Writer
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If you have rheumatoid arthritis (RA), you know that your inflammatory disease typically involves your joints. As an ophthalmologist, Anat Galor, M.D., associate professor of ophthalmology at Bascom Palmer Eye Institute of the University of Miami Health System, sees many RA patients with ocular or eye issues. "Sometimes patients describe an eye issue —something common to an RA diagnosis — when they haven't told me they have RA. They'll say, 'I didn't realize RA can show up in the eye.'"


Dry eye syndrome or keratitis sicca (Part 1)

This umbrella term generally refers to varied dry eye symptoms and signs, Dr. Galor. said in a telephone interview. These can include sensations of dryness, burning, aching, and tenderness. People may have dry eye symptoms because of not making enough tears to properly lubricate the eye (aqueous tear deficiency) or not having tears stay on the eye long enough (evaporative dry eye).


Dry eye syndrome or keratitis sicca (Part 2)

People may also have dry eye symptoms due to anatomic issues, such as loose tissue of the eyelid or conjunctiva — the thin layer covering the white part of the eye — or due to nerve issues, such as dysfunctional nerve that causes neuropathic pain.


How dry eye is diagnosed

To diagnose dry eye, ophthalmologists consider many factors and evaluate tear production, evaporation, anatomy, and health of the corneal nerves. Many people with RA have the dry eye sub-type of not having enough tears to lubricate the eye, says Dr. Galor. This subtype is often associated with inflammation on the ocular surface. This can indicate the presence of Sjögrens, another immune disorder often occurring with RA. Dry eye occurs more often in women and the elderly.


Treating dry eye syndrome

Inflammation is involved in many dry eye sub-types and must be considered in people with RA, Dr. Galor says. Systemic therapies for treating RA aren't usually effective for dry eye. Anti-inflammatory eye drops administered locally are usually recommended — usually, topical cyclosporine (Restasis) or lifitegrast (Xiidra). Not everyone responds to these two federally approved agents. Topical corticosteroids can be used for acute treatment, but ongoing use increases risk of cataracts and glaucoma.


Newer treatments for dry eye syndrome (Part 1)

Dr. Galor says that other therapies considered for people with severe dry eye, especially those who don't make enough tears, include eye drops made from a person's own serum, which is a component of human blood. To prepare, blood is drawn from the patient and "spun down" to separate the cellular component from the serum. The serum is diluted and given as an eye drop. In uncontrolled trials, autologous serum eye drops have improved ocular surface health and reduced symptoms.


Newer treatments for dry eye syndrome (Part 2)

Autologous serum tears can be made at various concentrations, typically from 20 to 50 percent. Serum tears remain on the eye longer than "regular" eye drops and also contain growth factors that help the skin and nerves of the eye become healthier. Patients must commit to blood draw appointments — sometimes far from home — safe storage and use, plus this treatment can be expensive.


Scleritis and RA (Part 1)

The eye's sclera makes up 90 percent of the eye's outer coating. Think of this "wall" as the "white of your eye." There are five subtypes of scleritis, inflammation of the deep episcleral vessels — as opposed to superficial vessels, which would be episcleritis, Dr. Galor says. These include anterior scleritis, nodular scleritis, necrotizing scleritis with inflammation, necrotizing scleritis without inflammation, and posterior scleritis.


Scleritis and RA (Part 2)

Symptoms can include blurred vision, severe eye pain, red patches, tearing, and light sensitivity. Treatments depend on the type of scleritis and systemic RA findings for the particular patient. They may include oral corticosteroids or other immunosuppressive agents, she says.


Peripheral ulcerative keratitis (PUK) and RA

This ocular damage from inflammation occurs in the cornea, the eye's clear layer over the front of the iris and the pupil, and manifests as peripheral ulceration, says Dr. Galor. Symptoms include blurry vision, light sensitivity, and pain that can range from severe to a feeling that "something's in my eye." As in scleritis, oral therapies are usually needed to control the disease, including corticosteroids and other immunosuppressive agents.


Episcleritis and RA

The episclera, the outermost layer of the sclera, can develop episcleritis. Just like scleritis, this condition can be associated with RA, with less-severe symptoms and visual consequences. The condition is usually asymptomatic, meaning patients don't really have symptoms, unless they complain of redness. Treatments are geared to addressing local abnormalities including dry eye and blepharitis. Anterior blepharitis signs include oily flakes at the eyelashes' base, says Dr. Galor.


Uveitis and RA (Part 1)

Uveitis is not a common feature in RA — scleritis and PUK are more common, Dr. Galor says. However, ophthalmologists look for evidence of inflammation inside the eye in all patients with systemic auto-immune conditions. Uveitis can involve inflammation in several compartments of the eye. Anterior uveitis presents with white blood cells in the space between the cornea and iris, the colored part of the eye. Symptoms include pain, blurry vision, redness, and light sensitivity.


Uveitis and RA (Part 2)

Intermediate uveitis presents with cells in the vitreous cavity, the cavity in the eye behind the lens that contains the vitreous gel. Symptoms include floaters and blurry vision. Posterior uveitis can involve inflammation of the retina, choroid or vascular layer, or the optic nerve, Dr. Galor says. Anterior uveitis is treated with topical corticosteroids, while intermediate, posterior, and pan-uveitis usually require injections of medications into the eye, or systemic (oral) therapy.


You may have heard cataracts referred to as a "cloudy lens," which in people with RA, can occur due to inflammation or as a side effect of prolonged corticosteroid use. Ask your ophthalmologist about use of corticosteroids and about the most effective dose and duration for your therapy, she says.


Glaucoma and RA (Part 1)

This group of diseases can damage your eye's optic nerve, and may ultimately then cause vision loss and blindness, says Dr. Galor. Unusually high pressure in your eye is a main risk factor for glaucoma, which is divided into "open-angle" or glaucoma with a normal eye anatomy — the most common type — or “narrow-angle” glaucoma, when fluid can't drain out of the eye normally.


Glaucoma and RA (Part 2)

Unless the intraocular pressure — the pressure within your eye — goes up suddenly, glaucoma is generally painless and symptoms only occur after significant vision loss. This is because the vision loss involves peripheral and not central vision. Open-angle glaucoma is treated with topical intraocular pressure-lowering medications — eye drops such as beta blockers and prostaglandins — lasers, surgery, or a combination of these treatments.


Risks of Plaquenil (hydroxychloroquine) with RA

Retinal toxicity is a real risk for patients who take hydroxychloroquine, according to the American Academy of Ophthalmology (AAO), even though this side effect is "rare." The older, disease-modifying, anti-rheumatic drugs (DMARDs) reduce arthritis pain and swelling and may also prevent joint damage. The AAO issued revised recommendations for dosing in 2016. Toxicity can result from high dose and long duration of use. Talk to your doctor about whether this medication is the best choice for you.