Ocular manifestations of

rheumatoid arthritis

Taken from NRAS magazine, Autumn 2010

By Indira M Madgula MRCOphth, Registrar Ophthalmology and Colin Jones FRCOphth, Consultant Ophthalmologist at the Norfolk and Norwich University Hospital
 
Rheumatoid arthritis (RA) affects not only the joints but has extra articular (outside the joints) manifestations as well. About a quarter of people affected by RA have eye problems as a result.

Dry eye syndrome (Sjögren’s syndrome)

The most common of the eye problems is dry eye syndrome. About 15% of the normal population have dry eyes but in people who have RA the percentage is much higher – some studies quote 40 %. The most common symptom is a gritty sensation in the eye or a feeling of ‘sand in the eye’ or paradoxically a ‘watery eye’. The symptoms are worse during the evening, after sleep, prolonged reading or watching a VDU screen.  Symptoms are also exacerbated in dry air conditioned rooms or on a cold windy day. Treatment is symptomatic with tear substitutes that are available over the counter or may be available on prescription, wearing sunglasses, using room humidifiers and avoiding dry environments. If the symptoms persist, then referral to the ophthalmologist may be necessary.  The severity of RA has no correlation with severity of dry eye.

Scleritis and episcleritis

Less commonly, about 1 in 10 people with RA may experience a painful, red eye due to inflammation of the ‘white part of the eye’ called the sclera or the layer of packing tissue in front of the sclera called the episclera. This is called scleritis or episcleritis respectively. Episcleritis is more common than scleritis and although causes a red, sore eye, it is less painful than scleritis. Episcleritis is recurrent and self limiting; it is also treated with lubricants or in more severe cases with non steroidal drops or weak steroid drops.  Scleritis is more painful, often waking up the patient at night and requires referral to the eye specialist. Treatment is with oral steroids.

Affects on the cornea

Occasionally, the ‘window’ or the transparent portion of the eye called the cornea may be involved either in association with the dry eye syndrome or with scleritis. This may lead to inflammation followed by scarring. Sometimes the cornea may thin in the centre or in the periphery which may be sight threatening and require prompt treatment with steroids or steroid sparing (immunosuppressive agents) that are usually commenced and monitored by the rheumatologist.

Uveitis

One of the other eye problems associated with RA is uveitis.  This can occur alone or in conjunction with keratitis (inflammation of the cornea) or scleritis. It is an inflammation of the uvea or the middle layer of the eye. It presents as a painful red eye. Sometimes vision may be reduced in the more severe cases. This condition is treated with steroid drops over weeks. As with the other manifestations of RA, it may recur.

Very rarely, RA can cause inflammation of the blood vessels inside the eye (vasculitis) or a swelling of the central portion of the eye (macular oedema).

Treatments

The eye manifestations of RA may warrant steroid use, whether oral or steroid drops.  The long term use of steroids, particularly steroid drops may lead to the development of a cataract (an opacity in the lens of the eye) or raised pressure inside the eye (glaucoma).  A cataract is treated surgically by removal of the opaque lens and replacing it with an acrylic one. It is a very successful operation and the most commonly performed surgery in the country. RA may need treatment with oral steroids by the rheumatologist for prolonged periods, although rheumatologists today try to minimise use of oral steroids in line with the NICE & BSR RA Guidelines.

Glaucoma on the other hand is managed with eye drops and rarely needs surgical intervention.