Rheumatoid arthritis (RA) is a chronic inflammatory disorder that primarily targets the joints, causing pain, swelling, and stiffness. RA is systemic, meaning its effects are not limited to the musculoskeletal system. The inflammation can affect various organs and systems outside of the joints, known as extra-articular manifestations. The eyes are one of the most frequently involved sites, with a significant percentage of people with RA experiencing some form of ocular complication. Understanding these eye issues is important for managing the overall condition and protecting long-term vision.
Ocular Manifestations of Rheumatoid Arthritis
The autoimmune process in RA can cause inflammation in different parts of the eye, ranging from common surface irritation to serious, sight-threatening damage. The most frequent issue is keratoconjunctivitis sicca, commonly known as dry eye syndrome. This condition results from inflammation targeting the lacrimal glands, leading to an inadequate tear film. Symptoms include a gritty sensation, burning, redness, and sometimes excessive watering due to surface irritation.
Inflammation can also affect the white layer of the eye, the sclera, and the thin tissue covering it, the episclera. Episcleritis is the milder form, causing localized redness and mild discomfort, and usually resolves without aggressive treatment. Scleritis involves deeper inflammation of the sclera, often presenting with intense pain that may radiate to the jaw or temple. This inflammation can lead to thinning and weakening of the eye wall, indicating more severe systemic disease activity.
A rare manifestation is peripheral ulcerative keratitis (PUK), which involves a crescent-shaped area of destructive inflammation and thinning at the edge of the cornea. This thinning can lead to perforation of the globe and rapid vision loss. Because PUK is frequently associated with systemic vasculitis, it requires immediate, aggressive medical management to preserve both the eye and overall health. These severe conditions result from the autoimmune response attacking collagen-rich tissues in the eye.
Eye Complications Related to RA Treatment
Eye problems can arise as side effects from the medications used to manage RA. Hydroxychloroquine, often prescribed for its disease-modifying anti-rheumatic drug (DMARD) properties, carries a risk of toxicity to the retina. This toxicity can lead to maculopathy, which is damage to the central part of the retina responsible for fine detail and color vision.
The risk of this damage is strongly related to the cumulative dose of the drug and the duration of use. Guidelines recommend a maximum daily dose not exceeding 5 milligrams per kilogram of actual body weight to minimize the danger. Retinal damage is usually asymptomatic in its early stages but can progress even after the medication is stopped, making proactive monitoring essential.
Corticosteroids, sometimes used to control flares or bridge therapy, also pose specific ocular risks. Long-term or high-dose use, whether oral or topical, can increase the risk of developing cataracts. Posterior subcapsular cataracts, which form at the back surface of the lens, are commonly associated with steroid use and can significantly impair vision. Furthermore, corticosteroids can elevate intraocular pressure, leading to secondary glaucoma, a condition that damages the optic nerve and causes progressive vision loss.
Monitoring and Prevention Strategies
Preventing severe ocular complications relies on proactive eye care, often in collaboration with the rheumatologist. Regular comprehensive eye examinations are necessary even without obvious symptoms, as some serious conditions develop silently. An eye specialist can detect subtle signs of inflammation or drug toxicity before they lead to permanent vision damage.
Patients taking hydroxychloroquine must follow a specific screening protocol to detect early signs of maculopathy.
- A baseline eye exam is required before starting the medication to establish retinal health.
- Annual screenings are recommended after five years of use, or sooner if risk factors are present.
- These specialized screenings use advanced imaging techniques.
- Spectral-domain optical coherence tomography (SD-OCT) is used to identify microscopic changes in the retina.
Patients should seek immediate care if they experience symptoms indicating a severe inflammatory flare or drug reaction. These include sudden, severe eye pain, acute changes in vision, pronounced light sensitivity, or persistent redness. Open communication between the rheumatologist managing the systemic disease and the ophthalmologist ensures that treatment plans are safely coordinated to protect both joint and visual health.