Rheumatoid arthritis is a form of arthritis, so that means joints, right? Yes…but also: RA is an autoimmune disorder that “affects multiple body areas and organ systems, including the eyes,” says Rajat Bhatt, M.D., community rheumatologist at Prime Rheumatology in Richmond, Texas. Yet “eye conditions are underrecognized in RA patients, because they can have eye inflammation while still having normal vision and no symptoms.” Use this guide to help you pinpoint—and address—a potential eye issue before it becomes serious.
Eye Concern #1: Dry Eye Syndrome
Dry eye syndrome (a.k.a. keratoconjunctivitis sicca, keratitis sicca, or sicca complex) is the most common eye condition among RA patients, with research suggesting as many as 46 percent experience it. It occurs when inflammation in moisture-producing glands causes them to stop secreting fluid. “Patients have irritated, itchy eyes, or a sandy, gritty feeling in the eye,” says Howard L. Feinberg, D.O., a professor of rheumatology at Touro University California College of Osteopathic Medicine. “They think it’s a nuisance, but dry eye can cause a lot of damage, including scratches and thinning on the eye’s surface, and scar tissue that could block vision.”
Treating Dry Eye Syndrome
In good news, dry eye syndrome is relatively easy to treat with moisturizing eye drops and eye ointments at night, says Dr. Feinberg. “Mainly we use over-the-counter drops; they don’t have to be prescription.” He recommends choosing a brand that’s free from preservatives to avoid irritating the eye further. If over-the-counter fixes aren’t doing the job, there are prescription medications that stimulate the glands to produce moisture, such as Salagen (pilocarpine) or Evoxac (cevimeline).
Eye Concern #2: Sjogren’s Syndrome Dry Eye
File under More Proof That Life Isn’t Fair: About 25% of people who have one autoimmune disease go on to develop others. Sjogren’s syndrome—an autoimmune condition that damages moisture-producing glands and causes dry eye as well as dry mouth, throat, and upper airways—is particularly common in RA patients. In one study, more than 22% of people with RA had secondary Sjogren’s (primary Sjogren’s occurs alone). Fortunately, secondary Sjogren’s is often a milder form than primary, but definitely don’t ignore it or you risk permanent eyesight damage.
Treating Sjogren’s-Related Dry Eye
“We do it two ways,” says Dr. Feinberg. “First, we treat the dryness, with the same moisturizing drops or medications to stimulate fluid that we use to treat dry eye syndrome. We also treat the disease itself, to stop it from progressing and causing more damage.” Some of the medications for Sjogren’s are the same ones used to treat rheumatoid arthritis, such as Plaquenil (hydroxychloroquine), Humira (adalimumab), and Remicade (infliximab). Preliminary research on antibody-based eye drops is also showing promise as a future treatment; they seem to counteract the inflammation caused by ACPAs, autoantibodies that make dry eye worse.
Eye Concern #3: A Pink Eye From Episcleritis
Episcleritis is inflammation of the episclera, the outermost layer of the sclera (the white of the eye). It looks similar to pinkeye, says Dr. Feinberg. “But this is different: Pinkeye is due to infection; episcleritis is inflammation caused by rheumatoid arthritis.” How to distinguish between the two? Though episcleritis looks red and irritated, much like pinkeye, it doesn’t discharge or cause you to wake up with your eyes glued shut like pinkeye can. Episcleritis is relatively benign.
Clearing up episcleritis is fairly straightforward: Prescription steroid eye drops to help calm inflammation in the area, combined with treating your RA so it doesn’t continue to create problems in the eye. RA treatment can vary depending on its severity, but typically includes some combination of over-the-counter or prescription non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation; prescription steroids, also for pain and inflammation and to slow damage to the joints; disease-modifying antirheumatic drugs such as Plaquenil (hydroxychloroquine); and biological agents that target the immune system like Humira (adalimumab).
Eye Concern #4: A Red, Painful Eye From Scleritis
Another type of eye inflammation, scleritis is more concerning than episcleritis because the inflammation is more severe and involves the sclera, the next layer down in the white of the eye. People with RA, as well as other inflammatory or autoimmune diseases, are at increased risk for scleritis. “Symptoms include redness and pain, and it can lead to blindness,” says Dr. Bhatt. “The eye may also have a bluish tinge in the later stage.” Patients with scleritis usually make a doc appointment right away (as they should!) because the pain, while not severe or stabbing, is difficult to tolerate.
You’ll probably be given prescription steroids such as prednisone to reduce inflammation, along with NSAIDs (usually over the counter) to ease the pain. “We also refer patients to an ophthalmologist for close follow-up, because they are at risk of losing their vision,” says Dr. Bhatt. “If the condition worsens, even after steroids, we might add immune-suppressing medications like methotrexate to address the RA.”
Eye Concern #5: Vision Issues and Floaters From Uveitis
Below the episclera and sclera layers of the eye is another layer called the uvea, and when inflammation occurs here it’s (appropriately) known as uveitis. There are two types: Anterior uveitis, at the front of the eye, and posterior uveitis, which is at the back of the eye and very rare. “Patients with uveitis start having vision problems and seeing floaters around the eye,” says Dr. Bhatt. They may also experience redness and pain. Symptoms can have a quick onset and also worsen rapidly.
It’s important to treat uveitis promptly and properly because it can lead to loss of vision. “Inflammation in the uvea can block the drainage of fluid from the eye, causing you to develop glaucoma,” says Dr. Bhatt. Treatment can include anti-inflammatory eye drops and oral or injected steroids to reduce inflammation. “Normally, we also go to other rheumatoid arthritis medications like biologics, such as Humira, to address the underlying cause.”
Eye Concern #6: Blurred Vision From Peripheral Ulcerative Keratitis (PUK)
PUK is, fortunately, rare—but it’s a serious condition involving inflammation in the blood vessels of the eye or an ulceration in the cornea, the clear layer over the front of the eye. Symptoms of PUK are similar to those of uveitis and scleritis (it can be a late manifestation of either), including redness, pain, sensitivity to light; but PUK can also lead to blurred vision. “Sometimes patients with PUK complain that things look fuzzy because swelling can distort the lens of the eye,” says Dr. Feinberg.
Your ophthalmologist can detect PUK during a regular checkup with a slit lamp exam—which uses a microscope to find any ulcerative changes on its surface—or fluorescein dye, eye drops that coat the area that’s inflamed or damaged. A visual exam might also reveal a crescent shape on one side of the eye that indicates PUK. Treatment typically includes immunosuppressant therapy, says Dr. Feinberg. Though PUK isn’t connected to cancer, chemotherapy medicines are a more aggressive way to suppress your immune system if needed.
Eye Concern #7: Retinal Vasculitis
“Retinal vasculitis occurs when swollen, inflamed blood vessels damage the back surface of the eye where light hits and nerve endings ‘read’ what you’re seeing,” explains Dr. Feinberg. You usually don’t know anything is wrong until you experience vision loss. “Mild areas of vision loss or even complete blindness can happen suddenly, at which point it’s often too late to undo the damage,” says Dr. Feinberg.
Treating Retinal Vasculitis
This condition sounds scary, and it’s true, it can be dangerous. But! Retinal vasculitis is also rare, and caught in time, can be treated with a combo of a steroid (like Prednisone) and an immunosuppressant medicine. Just one more reason to see your ophthalmologist frequently. You’ll likely need to go more than annually, so ask your rheumatologist to recommend a schedule—and stick to it.
Eye Concern #8: Glaucoma
Caused by increased pressure inside the eye that can damage the optic nerve, glaucoma tends to be a genetic condition that strikes later in life—but it also can be a side effect of eye inflammation from RA, says Dr. Bhatt. “Often, glaucoma patients don’t have symptoms until the late stages, when they start having tunnel vision and seeing halos.”
Dr. Bhatt recommends that RA patients regularly see both an ophthalmologist and rheumatologist, who can team up to determine how to reduce pressure on the eye. Treatment can include steroid drops or injections in the eye, immune-suppressing medications, or surgery.
Eye Concern #9: Retinal Toxicity
Cruel irony: “Some of the medications that we use to treat rheumatoid arthritis can potentially cause eye problems,” says Dr. Feinberg. One top culprit? Quinolines (like Plaquenil and Chloroquine), which are classified as anti-malaria drugs but are commonly used for RA because they treat inflammation. “They can build up in the eye and affect vision or even damage the back of the eye and cause loss of vision,” Dr. Feinberg explains, a condition called retinal toxicity.
Treating Retinal Toxicity
If you’re taking Plaquenil or other quinolines, be sure to see your ophthalmologist for exams regularly. She should be able to catch any damage caused by retinal toxicity early on. If the condition goes undetected, patients start to experience a loss of extreme peripheral vision that eventually moves to the center. Fortunately, treatment is straightforward: Stop the medicine, and the symptoms stop progressing, says Dr. Feinberg.
Eye Concern #10: Cataracts and Nerve Damage From Steroids
Steroids are highly effective at treating inflammation, but using them can increase your risk of developing cataracts, a clouding of the lens of the eye, says Dr. Feinberg. Another effect of long-term steroid use is steroid-induced glaucoma. Steroids can cause changes in the eye’s drainage system that result in eye pressure and, if left untreated, lead to optic nerve damage.
Treating Cataracts and Nerve Damage
If there were any consolation about the crappy consequences of steroids, it’s this: Cataracts are reversible with surgery, a low-risk procedure that replaces the cloudy lens with a clear, artificial one, says Dr. Feinberg. In most cases, eye pressure caused by steroids returns to normal after you discontinue steroid therapy. You can’t reverse optic nerve damage, but if you’re on long-term steroid therapy, your doctor will be watching for steroid-induced glaucoma and should catch it early, before the damage occurs.