Rheumatoid Arthritis (RA) is a chronic autoimmune disease causing inflammation in the joints, leading to pain and swelling. Because RA is systemic, the immune system’s misdirected attack can affect organs throughout the body beyond the joints. RA can significantly impact eye health, leading to a range of ocular complications. Approximately one in five people with RA experience some form of eye problem, making proactive care important.
Why RA Targets Eye Tissue
The underlying mechanism for eye involvement stems from the widespread inflammatory process characteristic of RA. Ocular structures, such as the sclera (the white outer layer) and the cornea (the clear front dome), contain connective tissues structurally similar to those found in the joints. These similarities make the eyes secondary targets for circulating inflammatory agents and immune cells.
Inflammation, driven by cytokines and immune complexes, travels throughout the body via the bloodstream. This systemic inflammation leads to the infiltration of immune cells and the breakdown of collagen in the eye tissue. Damage to the sclera and cornea is a direct manifestation of the autoimmune response. This process is sometimes associated with systemic vasculitis, which can lead to severe ocular complications.
Specific Ocular Conditions Linked to RA
The most common eye issue associated with RA is dry eye syndrome, medically known as keratoconjunctivitis sicca, affecting up to 40% of RA patients. This condition results from inflammation damaging the lacrimal glands, reducing tear production. Reduced and poor-quality tears lead to a gritty, burning, or foreign body sensation. Severe dry eye is often classified as secondary Sjögren’s Syndrome when it occurs alongside RA.
More serious complications involve inflammation of the outer layers of the eye, specifically the episclera and sclera. Episcleritis is inflammation of the thin layer between the conjunctiva and the sclera, typically presenting with salmon-pink redness, and is often mild and self-limiting. Scleritis, inflammation of the deeper, white outer layer, is a more severe condition associated with RA, occurring in about 2% of patients.
Scleritis can present in various forms, but the most concerning is necrotizing scleritis, which involves the destruction of scleral tissue and can lead to thinning or perforation of the globe. This condition is intensely painful, often radiating to the head and waking the patient at night. Another severe, rare complication is Peripheral Ulcerative Keratitis (PUK), where the cornea thins and develops a crescent-shaped ulcer. PUK is a sight-threatening emergency that can rapidly lead to corneal melt and perforation, often signaling poorly controlled systemic RA.
Recognizing Urgent Warning Signs
Patients with RA must monitor for specific symptoms indicating eye involvement. Persistent foreign body sensation, burning, or grittiness that does not resolve with simple lubricating drops should be noted, as this is often the first sign of severe dry eye.
A symptom requiring immediate attention is severe, deep, aching eye pain that often worsens with eye movement and may radiate around the orbit. This intense pain is characteristic of scleritis, a condition needing prompt medical intervention. Persistent redness in the white of the eye that does not improve with over-the-counter drops is also a significant warning sign.
Patients should also watch for sudden changes in vision, such as blurring or distortion, and increased sensitivity to light (photophobia). Any new onset of these symptoms, especially when combined with eye pain, suggests a potentially vision-compromising inflammatory process. Reporting these symptoms right away is necessary to prevent permanent damage.
Management and Collaborative Care
Effective management of RA-related eye conditions centers on controlling underlying systemic inflammation. Treatment for the joints, often involving Disease-Modifying Antirheumatic Drugs (DMARDs) or biologic therapies, serves as the primary defense for ocular health. Reducing the overall activity of RA mitigates the autoimmune attack on eye tissues.
The best outcomes are achieved through a collaborative care approach involving the patient’s rheumatologist and an ophthalmologist. The rheumatologist focuses on systemic control of the disease, while the ophthalmologist diagnoses and manages specific eye manifestations. This multidisciplinary team determines the necessity of targeted eye treatments, such as lubricating drops for dry eye or topical steroids and immunosuppressants for active scleritis.
Routine eye examinations are highly recommended for all individuals with RA, even when symptoms are absent. An eye specialist can detect early signs of ocular inflammation before the patient notices symptoms, particularly those associated with aggressive conditions like scleritis or PUK. Early detection allows for timely adjustment of systemic medication or initiation of localized treatments, significantly improving the chances of preserving vision.