Rheumatoid Arthritis and the Effect on the Eye
Rheumatoid arthritis can affect the eye in a variety of ways. It can range from mild dry eyes, severe inflammation, and loss of vision. Fortunately, it is rare for the complications from rheumatoid arthritis to cause someone to go blind.
What is Arthritis or Rheumatoid Arthritis?
Rheumatoid arthritis is an auto-immune disease which classically consists of symmetrical inflammatory polyarthritis (inflammation of multiple joints). It is typically associated with joint stiffness, fever, swelling of joints, weight loss and malaise. Other manifestations may include joint deformities, nodules, periarticular bony erosions. Rheumatoid arthritis typically spares the distal interphalangeal joints.
Rheumatoid arthritis can have effects on other parts of the body including the heart, lungs, kidneys, circulation, nervous system, and the eyes. Females are affected more commonly.
Diagnosing Rheumatoid Arthritis
The diagnosis of rheumatoid arthritis is made on the presence of multi-joint involvement and blood tests.
Rheumatoid factor (RF) — The RF is designed to detect and measure the blood level of an antibody that acts against gamma globulin.
Anti-cyclic citrullinated peptide (anti-CCP) — This test is also known as anti-citrullinated protein antibodies (ACPA). This is a test for the presence of a particular autoantibody that can be found in 60 to 80 percent of patients with rheumatoid arthritis. This test is more specific for rheumatoid arthritis than (RF).
Antinuclear antibody (ANA) — This test is positive in people with rheumatoid arthritis but is not specific for rheumatoid arthritis. It can also be positive in people with scleroderma, polymyositis, Sjogren’s syndrome, and other mixed connective tissue diseases.
C-reactive protein (CRP) — This test measures the presence of inflammation in the body. This measures a substance secreted by the liver when there is inflammation in the body.
Erythrocyte sedimentation rate (ESR or sed rate) — This test measures how fast the red blood cells settle to the bottom of a tube in one hour of time. The higher the sed rate, the more there is inflammation in the body. This is not specific for any particular disease. Anything that causes inflammation in the body can increase the sed rate. It is a good indicator of the amount of inflammation present in the body.
Common Tests for Following Treatments for RA
- Liver enzyme tests
- White blood cell count
- Platelet count
- Hematocrit (HCT) and hemoglobin (Hgb)
Why is Rheumatoid Arthritis Associated with Eye Disease?
The joints contain collagen and proteoglycans and the cornea (clear portion of the front of the eye) and sclera (white portion of the eye) contain similar collagen and proteoglycans. This similarity of structure accounts for eye diseases related to rheumatoid arthritis. Common conditions to both include vasculitis, vascular occlusion, fibrinoid necrosis, and infiltration. Disease processes include macrophages secreting collagenases, cytokine secretion, formation of antibodies, and deposition of immune complexes.
Eye Diseases Related to Rheumatoid Arthritis
Scleritis is the inflammation of the white portion of the eye. There is vasodilation of the blood vessels in the sclera. Scleritis occurs in both eyes nearly 50 percent of the time. It may occur before there are any symptoms of joint pain. The scleritis can be anterior or posterior based on the portion of the eye involved. It can be nodular, necrotizing, or diffuse. Symptoms include intense pain especially with eye movements, redness, photophobia, blurred vision, and epiphora (tearing).
Posterior scleritis can cause cataracts, glaucoma, uveitis, retinal detachment, and/or fluid under the choroid. Scleromalacia perforans is a very severe manifestation of scleritis where the sclera thins and/or is absent exposing the underlying choroid portion of the eye. It can often occur without pain or inflammation. Surgery may be needed to protect the integrity of the eye with a patch graft applied over the area of disease.
Treatment of Scleritis
Many times, topical medications are not effective but good control of the underlying rheumatoid arthritis is the best treatment. The most common form of treatment is oral corticosteroids or prednisone. Other medicines include methotrexate, cyclosporine, infliximab, rituximab, azathioprine, anakinra, and adalimumab.
Episcleritis is inflammation of the tissue that lies over the sclera. This inflammation is usually idiopathic but can be associated with rheumatoid arthritis. It can be bilateral in nearly half the cases. There are two types of episcleritis which are simple and nodular. The symptoms are redness in portion of the eye, watering, sensitivity to light or photophobia, and mild pain. Episcleritis is usually self-limiting. Treatment is usually with topical corticosteroids and in some cases, oral corticosteroids may be used.
Peripheral Ulcerative Keratitis (PUK)
Peripheral keratitis is a corneal disease characterized by inflammation and corneal ulceration and/or thinning of the cornea. PUK is most likely caused by an autoimmune reaction. Rheumatoid arthritis may be related in approximately one third of the cases. It is usually unilateral is more than half of the time. Symptoms include pain, foreign body sensation, sensitivity to light, and blurred vision. The ulceration is located in the peripheral portion of the cornea (clear portion of the front of the eye) near the sclera. There is a crescent-shaped infiltrate of immune complexes, neovascularization or new blood vessels, and thinning of the corneal tissue.
The mainstay of treatment is to control the systemic autoimmune disease. Systemic corticosteroids are used initially but other immunologic drugs may be needed as well. Support for the eye may include oral tetracycline, acetylcysteine, and medroxyprogesterone. If there is significant thinning of the cornea, the eye doctor may apply a tissue adhesive and cover it with a contact lens and/or amniotic membrane placement. Surgical procedures may be needed in severe cases with the application of grafts.
Sjogren’s syndrome is associated with rheumatoid arthritis and dry eye disease. Sjogren’s syndrome has been classically described in the past as the triad of rheumatoid arthritis, dry eyes, and dry mouth. Sjogren’s syndrome is actually a systemic autoimmune disease the causes inflammation throughout the body. The symptoms include excessive dryness especially of the mouth and eyes. Other symptoms include joint pain, fatigue, central nervous system disease, kidney disease, gastrointestinal diseases, lungs, liver, pancreas, and blood vessels. People with Sjogren’s have a higher risk of developing lymphoma. There are approximately 4 million Americans with Sjogren’s syndrome with ninety percent being women. About fifty percent of the time it occurs with another autoimmune disease such as rheumatoid arthritis, scleroderma, and lupus. While many cases may have mild symptoms, some people have severe complications secondary to their Sjogren’s syndrome.
Sjogren’s can be difficult to diagnose and it usually takes about three years before someone is diagnosed with the disease after the beginning of symptoms. The symptoms are similar to other diseases such as rheumatoid arthritis, fibromyalgia, lupus, multiple sclerosis, and chronic fatigue syndrome. Early diagnosis and treatment are essential in minimizing the complications. Blood tests are similar to those for rheumatoid arthritis plus more specific tests, called SS-A and SS-B. These are marker antibodies for Sjogren’s syndrome. Seventy percent of Sjogren’s patients are positive for SS-A and forty percent for SS-B. A salivary gland biopsy showing lymphocytic infiltration of the glands may be done to confirm the diagnosis.
Treatment includes the treatment for the dry eyes with a variety of the treatments available for dry eyes. Other treatments include pilocarpine and NuetraSal®. Immunosuppressive agents may be prescribed for more severe cases.
Dry Eye Disease
Dry eye disease is a very common disease associated with rheumatoid arthritis. The glands that produce the tear film can be damaged from the inflammation related to the arthritis. The dry eye disease may be mild to severe depending on the damage from the arthritis. There are many different treatments for dry eyes at this time. The treatment should be based on the type of dry disease present and the severity of the dry eye disease. The beginning mainstay of treatment for dry eyes is using the proper type of artificial tears.
If you have rheumatoid arthritis, you may develop an associated eye disease. The most common eye disease is dry eye syndrome. In less common instances, you may develop a more severe form of one of the eye diseases discussed. If you have rheumatoid arthritis and have any of the eye symptoms discussed, see an eye doctor immediately.