Rheumatoid arthritis (RA) is an autoimmune disorder primarily known for causing inflammation in the joints, leading to pain, swelling, and stiffness. However, this condition is systemic, meaning the same immune system malfunction that attacks the joint lining can affect other organs throughout the body, including the eyes. RA can definitively affect the eyes, causing ocular manifestations that can range from common discomfort to severe, sight-threatening complications. The underlying systemic inflammation can directly damage various eye structures, necessitating close monitoring by both a rheumatologist and an eye care specialist.
Inflammatory Eye Conditions Driven by RA
The inflammation characteristic of RA can directly target the delicate tissues of the eye, leading to a spectrum of conditions. The most frequently reported ocular issue is Keratoconjunctivitis Sicca, often referred to as severe dry eye. This condition arises when RA-related inflammation damages the lacrimal glands, which are responsible for tear production, resulting in insufficient lubrication. This lack of moisture can cause a gritty sensation, burning, light sensitivity, and blurred vision.
Beyond dry eye, RA can cause inflammation in the outer layers of the eye, specifically the sclera and episclera. Episcleritis involves the superficial layer of tissue covering the white of the eye (the episclera) and usually presents as a localized or diffuse patch of redness and mild discomfort. It is typically a self-limiting condition that resolves on its own.
Scleritis, however, is a much more serious condition involving the deeper, thicker white layer of the eye, the sclera. Scleritis is often associated with intense, deep, boring eye pain that can sometimes radiate to the head or face. This inflammation can be a sign of worsening systemic disease and may lead to thinning and destruction of the scleral tissue, which can threaten the structural integrity of the eye. A rarer but severe manifestation is Peripheral Ulcerative Keratitis (PUK), which involves a crescent-shaped thinning and ulceration of the cornea. PUK is a vision-threatening condition that signifies highly active, uncontrolled systemic disease and requires urgent, aggressive treatment to prevent corneal perforation.
Ocular Health and RA Treatment
Patients managing RA must also be aware of potential eye complications that can arise as a side effect of necessary medications. One of the most significant concerns is the risk of retinopathy associated with Hydroxychloroquine (Plaquenil), a common disease-modifying antirheumatic drug (DMARD). This medication can cause irreversible damage to the retina at the back of the eye, which is known as hydroxychloroquine retinopathy.
The risk of toxicity is low, less than 1%, within the first five years of use but increases significantly with longer duration and higher daily doses relative to a patient’s weight. Current guidelines recommend that annual eye screening, using specialized tests like Spectral-Domain Optical Coherence Tomography (SD-OCT), should begin after five years of Plaquenil use for patients without additional risk factors. Patients who are at higher risk due to pre-existing retinal disease, kidney impairment, or concomitant use of Tamoxifen may require earlier and more frequent monitoring.
Corticosteroids, such as Prednisone, which are often used to quickly control RA flares, also present a risk to ocular health, particularly with long-term, high-dose use. These drugs are known to increase the risk of developing two common conditions: glaucoma and cataracts. Glaucoma occurs when pressure builds up inside the eye, potentially damaging the optic nerve, while cataracts involve the clouding of the eye’s lens, leading to blurred vision. Any new visual symptoms should always be reported to the prescribing rheumatologist and eye doctor.
Recognizing Signs of Eye Involvement
Recognizing symptoms of eye involvement early is important for preventing permanent vision damage in people with RA. Specific warning signs that should prompt an immediate visit to an eye care specialist include:
- Persistent, deep eye pain that is not relieved by over-the-counter pain relievers and may wake a person from sleep.
- Sudden, significant changes in vision, new onset of blurry vision, or a severe increase in light sensitivity (photophobia).
- A red eye that does not improve with simple lubricating drops, or one accompanied by a gritty sensation or foreign body feeling.
Patients should communicate their RA diagnosis, the duration of the disease, and a complete list of all current medications, especially Plaquenil and corticosteroids, to their eye care professional. This information helps the ophthalmologist determine if the symptoms are related to RA activity or medication side effects. Routine, comprehensive eye exams are recommended for all RA patients, even those who are not experiencing symptoms. Early detection of subtle changes through specialized screening, such as for Plaquenil retinopathy, is the only way to intervene before irreversible vision loss occurs.