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Eye health and RA

About a quarter of people with RA have eye problems, though the severity and type of eye problems varies. The most common of these eye problems are dry eye syndrome (Sjögren’s syndrome).

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Taken from NRAS magazine, Autumn 2010 

(Revised August 2017)  

By Indira M Madgula FRCOphth, Consultant Ophthalmologist Lancashire Teaching Hospital NHS Trust 

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 – the incidence and severity being worse with longer duration of the disease. Majority of the patients are women, and involvement of both eyes is common. 

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 the severity of dry eye. 

Scleritis and episcleritis 

Less commonly, about 1 in 50 people with RA may experience a painful, red eye due to inflammation of the ‘white part of the eye’ called the sclera. Inflammation of the ‘packing tissue in front of the sclera’ called the episclera is more common. This is called scleritis or episcleritis, respectively. Episcleritis causes a red, sore eye but 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 potentially sight-threatening. It requires prompt referral to the eye specialist. Treatment is with oral steroids and/or steroid-sparing agents. 

Keratitis (involvement of the cornea) 

Very occasionally, the ‘window’ or the transparent portion of the eye called the cornea might 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 potentially sight-threatening and require prompt systemic treatment.  These patients are usually monitored under the joint care of a rheumatologist. 

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

Treatments 

 The eye manifestations of RA needs to be addressed as some conditions may be irreversible or sight-threatening. 

Image of eye drops

Treatment is usually with topical or oral steroids. The long term use of 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. Glaucoma, on the other hand, is managed with eye drops and rarely needs surgical intervention 

RA may need treatment with oral steroids by the rheumatologist for prolonged periods. However, rheumatologists today try to minimise the use of oral steroids in line with the NICE & BSR RA Guidelines.