August 28, 2012

Eye Problems and Adult Rheumatoid Arthritis

By James Wymore, M.D.
Eye Surgeons Associates

Adult rheumatoid arthritis is a well known disease that is a chronic scourge of cartilage and bone in the body’s joints. A person suffering from this chronic inflammation experiences stiffness, pain, and deformity of various joints, usually symmetrically. The inflammatory process doesn’t just affect joints. Weakness and fatigue, anorexia, fever, and weight loss are common. Blood vessel inflammation (vasculitis) can lead to skin ulcers and injury to most of the major organs. Women are afflicted three times more frequently than men.

With such widespread effects, it is not surprising that the eye may also be involved. Around 20 percent of those with rheumatoid arthritis have keratoconjunctivitis sicca, the most frequent ocular complaint. This is basically a diminished amount of tears with poor tear film function, giving dry eye symptoms of burning, grittiness, blurring, mucous debris, a “sticky” sensation, and tiredness of the eyes. If this is combined with a dry mouth and other problems, such as renal and pulmonary disease, enlarged lymph nodes, and enlarged spleen, it is classified as Sjögren’s Syndrome.

More severe than simple dryness of the cornea (windows of the eyes) is direct corneal inflammation. Various inflammatory attacks can lead to significant scarring or, in severe cases, corneal “melting” and perforation. The weakened cornea is also a target for bacterial infection. An inflamed or dry cornea combined with an infectious ulcer can be very problematic to treat.

Dry eye treatment may include lubricating drops (artificial tears), lid hygiene, blocking of the tear drainage system (to retain more tears), and surgical lid alterations to decrease exposed ocular surface area. In addition to these measures, more severe inflammations of the cornea may necessitate aggressive systemic steroid or immunosuppressive medications, and rarely grafting.

Layers of the wall of the eye can become involved. The episclera, a thin layer over the white sclera, causes discomfort and sometimes pain with a reddened eye when inflamed. It usually resolves on its own over a matter of weeks, but can persist or be recurrent for months to years. Steroidal and non-steroidal anti-inflammatory agents have been used to reduce symptoms and hasten resolution.

Involvement of the sclera can take several forms, affecting both the front, visible portion and the back, unseen area. It typically gives a deep pain, light sensitivity, and a reddened eye. When the posterior part is affected, it can be much more difficult to make a diagnosis. Milder forms are generally handled well with treatment, but severe forms can dramatically thin the sclera wall, increasing the risk of traumatic perforation. Once again, anti-inflammatory drugs are the choice of treatment. Both steroidal (such as prednisone) and non-steroidal therapy are used, as well as immunosuppressives (e.g., cyclophosphamide or methotrexate). Indirect problems arising from the scleritis, like glaucoma or uveitis, may require management.

Other ocular conditions have been associated with rheumatoid arthritis, though occurring very unusually. Palsies of cranial nerves have been reported. A special retinopathy can exist when blood becomes so thickened that retinal blood flow becomes very sluggish. More customarily encountered are side effects from the medication. Steroids and immunosuppressives are powerful drugs. Steroids are well known for occasionally inducing cataract or glaucoma, and some immunosuppressives can be toxic to the retina, so regular monitoring by an eye physician for these possibilities is a must.

Like some other systemic diseases such as diabetes, rheumatoid arthritis can have minimal to drastic effects upon the eyes. Treatment can range from simple tear augmentation to surgery. Fortunately, the most common ocular difficulties from rheumatoid arthritis can be managed with a good measure of success.

Dr. Wymore, with Eye Surgeons Associates, is a board-certified general ophthalmologist. He is a member of the American Academy of Ophthalmology. Dr. Wymore practices at Eye Surgeon’s Rock Island and Silvis, Illinois offices. For more information, please see our website: