Rheumatoid Arthritis: Eye Symptoms, Complications, and Management

What are the eye symptoms with Ra?

Rheumatoid Arthritis (RA) is a systemic autoimmune disease primarily known for affecting the joints, but its inflammatory nature can impact various organ systems, including the eyes. Ocular manifestations of RA range from common, mild discomforts like dry eyes to rare, severe conditions that can threaten vision.

Understanding Rheumatoid Arthritis and Systemic Impact

Rheumatoid Arthritis is a chronic inflammatory disorder where the body's immune system mistakenly attacks its own tissues. While it predominantly targets the lining of the joints (synovium), leading to pain, swelling, and eventual joint deformity, RA is a systemic disease. This means it can affect non-joint tissues and organs, including the skin, lungs, heart, blood vessels, and notably, the eyes. The inflammatory processes that cause joint damage can also lead to inflammation and damage in ocular structures, necessitating a comprehensive understanding for affected individuals and their healthcare providers.

Common Ocular Manifestations of RA

The eye symptoms associated with RA are diverse, reflecting the various structures within the eye that can be affected by systemic inflammation.

Dry Eye Syndrome (Sicca Syndrome / Secondary Sjögren's Syndrome)

• Description: This is the most common ocular complication in individuals with RA, affecting up to 25% of patients. It occurs when the immune system attacks the tear-producing glands (lacrimal glands), leading to insufficient tear production or poor tear quality. When dry eye syndrome occurs in conjunction with RA, it is often referred to as Secondary Sjögren's Syndrome.
• Symptoms: Patients typically experience a gritty or sandy sensation, burning, stinging, redness, excessive tearing (paradoxically, as the eye tries to compensate for dryness), light sensitivity (photophobia), and blurred vision, especially after prolonged visual tasks.

Scleritis and Episcleritis

• Description: These conditions involve inflammation of the sclera, the white outer protective layer of the eye.
  • Episcleritis is inflammation of the episclera, the thin layer of tissue between the conjunctiva and the sclera. It is generally less severe and self-limiting.
  • Scleritis is a more serious and painful inflammation of the deeper sclera. It is less common but can be a significant indicator of active systemic RA and may lead to serious complications if untreated.
• Symptoms:
  • Episcleritis: Localized redness (often a bright red or pink hue), mild discomfort or tenderness, and usually no significant pain or vision changes.
  • Scleritis: Severe, deep, boring eye pain that may radiate to the head or face, intense redness (often a violaceous or bluish-red hue), tenderness to touch, and potential for vision changes or even vision loss if the inflammation is severe or spreads.

Uveitis

• Description: Uveitis is inflammation of the uvea, the middle layer of the eye that contains the iris, ciliary body, and choroid. While less common in RA compared to other inflammatory conditions like ankylosing spondylitis, it can occur and is a serious condition requiring prompt treatment to prevent vision loss.
• Symptoms: Eye pain, redness, sensitivity to light (photophobia), blurred vision, and floaters.

Peripheral Ulcerative Keratitis (PUK)

• Description: This is a rare but severe and vision-threatening complication where the cornea (the clear front window of the eye) thins and ulcerates, often at its periphery, due to immune-mediated inflammation. It is a direct manifestation of active systemic RA.
• Symptoms: Severe eye pain, redness, light sensitivity, tearing, and significant vision changes. Without prompt treatment, PUK can lead to corneal perforation and permanent vision loss.

Retinal Vasculitis and Retinal Involvement

• Description: While less common, RA can cause inflammation of the blood vessels in the retina (retinal vasculitis) or other parts of the retina. This is a serious complication that can impair blood flow to the retina.
• Symptoms: Blurred vision, visual field defects, or sudden vision loss.

Secondary Effects: Glaucoma and Cataracts

• Description: These conditions are not direct inflammatory manifestations of RA but can be secondary effects.
  • Cataracts: Prolonged use of corticosteroids, a common treatment for RA, can increase the risk of cataract formation.
  • Glaucoma: Chronic ocular inflammation (e.g., from scleritis or uveitis) or long-term corticosteroid use can lead to increased intraocular pressure, potentially causing glaucoma and optic nerve damage.
• Symptoms:
  • Cataracts: Gradual blurring or clouding of vision, halos around lights, decreased night vision.
  • Glaucoma: Often asymptomatic in early stages; later symptoms may include peripheral vision loss, eye pain, or headaches.

Importance of Early Detection and Management

Given the potential for serious vision-threatening complications, individuals with Rheumatoid Arthritis should be vigilant about their eye health. Regular, comprehensive eye examinations by an ophthalmologist are crucial, even in the absence of obvious symptoms. Early detection allows for timely intervention, which can prevent irreversible damage and preserve vision. Communication between the rheumatologist managing RA and the ophthalmologist is vital for coordinated care.

When to Seek Medical Attention

It is imperative for individuals with RA to seek immediate medical attention from an ophthalmologist if they experience any of the following symptoms:

• Sudden onset of new or worsening eye pain
• Significant or persistent eye redness
• Changes in vision, such as blurring, dimming, or loss of vision
• Severe light sensitivity (photophobia)
• New floaters or flashes of light
• Any sensation of something being in the eye that doesn't resolve

Conclusion

Rheumatoid Arthritis is a systemic disease with the potential to affect various parts of the eye, from the tear glands to the deepest layers of the sclera and retina. While dry eyes are the most common ocular complaint, more severe inflammatory conditions like scleritis, uveitis, and peripheral ulcerative keratitis can pose significant threats to vision. A proactive approach to eye health, including regular ophthalmological evaluations and prompt reporting of any new or concerning symptoms, is an essential component of comprehensive RA management. This vigilance ensures that potential ocular complications are identified and treated early, safeguarding long-term vision and overall quality of life.