RHEUMATIC DISEASES AND THE EYE CARE AND PROBLEMS IN RA PATIENTS

Dr Udayan Dixit 
Consultant Ophthalmologist
dudayan@hotmail.com
 98220 57734.

Aches and pains, limitations in movements , prolonged and relentless course of the disease  and restrictions in so many day to day activities is how everyone knows the Rheumatic Diseases [RD]. Mostly seen in adults and  the elderly but this enigma of a disorder unfortunately can affect even young children  although thankfully on relatively  lesser occasions .

Affection of the eye and that too sometimes with grave possible consequences is not something which the patients of RD are aware of . Conditions like Rheumatoid Arthritis, Systemic Lupus Erythematosus, Psoriatic Arthritis, Juvenile Idiopathic Arthritis [JIA] , Juvenile Seropositive Arthritis , Ankylosing Spondylitis  are some of the Rheumatic Diseases which affect the eyes.

Many parts of the eye can be affected by RD . In fact sometimes the eye is an important indicator of the onset and progression of the disease . It is not necessary that an attack of Arthritis will match an attack of an Inflammatory Episode of the eye . From the front or the anterior segment to the backmost part of the eye or posterior segment , all the layers can get affected by RD.

1] A patient starts complaining of pain, redness, watering , mild reduction in vision ,sensitivity to bright light These are  the symptoms of the commonest disorder of the eye related to RD . It is called Iritis or Iridocyclitis.

The more precise name for the same is “ Acute Anterior Uveitis” . It is important for the eye doctor to have high index of suspicion in patients presenting with these symptoms , specially in case of someone with a known history of RD .A simple but careful clinical examination on the Slit Lamp Bio Microscope can clinch the diagnosis

The doctor can see presence of cells and fogginess in the front compartment of the eye called “ Anterior Chamber”.

The treatment has to commence immediately . It is usually in the form of eye drops . Anterior Uveitis can occur repeatedly . Each episode can leave behind a legacy like adhesions between the pupil and anterior lens capsule called “Anterior Synechiae.”

Schematic diagram of the eye.

Local steroid drops and pupil dilating or mydriatic drops is the mainstay of treatment for Iritis and Iridocyclitis [ Acute Anterior Uveitis ] .On occasions , patient who show a serological test called HLA B27 positive , the course of anterior Uveitis is more severe . A pus like level is seen in the area between cornea and iris . This is called Hypopyon . This requires intense local medication and help of oral medication may be required . In children Anterior Uveitis is noted in cases of Juvenile Idiopathic Arthritis [ JIA] . In these patients , the eye can be quiet unlike adult Acute Anterior Uveitis and hence a diagnosis can be missed unless one is vigilant during eye examination.

Pupil adhesions or Synechiae.

Hypopyon

On rare occasions , when Anterior Uveitis is non responsive to steroid regimen , immunosuppressants like Methotrexate, Azathioprine on TNF inhibitors like Infliximab or Adalimumab are used . 

2] Sometimes the back portion of the eye called posterior segment gets affected by a few varieties of Rhematic Diseases . This disorder is called Choroiditis  wherein the layer behind the retina gets  inflamed . Retina itself can get affected too  when it is called Retinitis . Patients with posterior segment disease can complain of Floating particles in front of the eye and  reduction of vision . Diagnosis is made by careful examination of the back of the eye called Fundoscopy examination . Ancillary tests like Photography of the back portion of the eye after injecting a dye into the vein of the hand ,called Fundus Fluorescein Angiography [ FFA] ,ICG dye Angiography and retinal scan called OCT are done.

In some patients , the anterior , intermediate and posterior segment of the eye, all get inflamed . This condition is called “ Pan uveitis”.

The posterior segment inflammations require oral medication . It is in the form of anti inflammatory  drugs , mainly oral steroids . On some occasions the disease does not come under control with steroids or keeps relapsing as soon as the dose of steroids is lowered to safe levels . I this situation , drugs called Immunosuppressants  or anti metabolites are used . Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Rituximab are some of the drugs used for severe posterior uveitis .  Modern drugs called Biologics are now used more effectively for the posterior segment affection of  the  eye caused by RD . Long term steroid treatment has to be carefully monitored . Weight gain, puffiness of face , rise of blood sugar and blood pressure , acidity or gastritis, bone density lowering or Osteoporosis are known untoward effects of long term oral steroids . If one considers treatment with Antimetabolites or Biologics , it is advisable  for eye doctors to work as a team with Rheumatologists. These new drugs can have detrimental effects on Kidney , Liver  and  immunity of the patients.

3] On occasions  the central part of retina called as Macula gets swollen [ Macular Edema ] in patients with RD . . This is commonly seen in “ Intermediate Uveitis” where the part between anterior and posterior segment of the eyeball called Pars Plana gets inflammation . Macular Edema causes rapid reduction of central vision . Diagnosis can be made  by simple clinical  examination with special lenses in front of the Slit Lamp Biomicroscope . Confirmation and grading of Macular Edema is done by doing Retinal Scan called OCT   [ Optical Coherence Tomography ] .  The most effective treatment of Macular Edema is in the form of injection of steroid given in the jelly that is present in  front of retina called  “ Vitreous Humor”. This intra vitreal injection is given under topical anesthesia or by instillation of eye drops , under the microscope and takes only two minutes to administer it .

FFA showing Macular Edema.

OCT showing Macular Edema.

4] The white coat of the front of the eye, which lies behind the transparent conjunctiva , called sclera can get affected in RD . The milder variety is called episcleritis . It makes the eye blood shot red . There can be mild pain or discomfort . Vision is usually  not affected . The disease can be self limiting but treatment is commenced in the form of Non steroid anti inflammatory drops like Nepafenac or proper steroid drops Prednisolone or Dexamethasone.

Episcleritis.

5] A more serious form of inflammation is called Scleritis . In 50% of these cases auto immune pathology is notedinflammation is more deep seated. Patient can complain of significant pain or dull ache . Uncontrolled inflammation can lead to thinning of this important protective coat of the eye. This condition called “ Scleromalacia Perforans” can have grave consequences on the integrity of the eye.

The scleritis can be either diffuse as in the left photo or Nodular as in the right photo.

Treatment  is given in a stepwise fashion starting from  Non Steroid anti inflammatory drops to steroid drops . In 60% of cases of Scleritis one needs to  resort to Oral Steroids or even Immunosuppressives or Biologics .Rarely local injection of depot steroids is given in the sclera with utmost care.

A rare variety of Scleritis is called “ Posterior Scleritis”. The portion at the back of the eyeball which is not visible in the routine eye examination gets inflamed . This condition is difficult to diagnose . Careful examination of the Retina and Choroid and  B scan Ultrasonography can clinch the diagnosis . The treatment is along the same lines as that of anterior scleritis mentioned before.

6] One of the most commonly encountered consequences of Rheumatic Disease spectrum is formation of Dry Eyes. Dryness can be of a mild variety or a very severe and incapacitating variety like Sjogren’s Syndrome.Dryness is caused by reduced tear secretion as a result of inflammation of the tear producing gland called the “ Lacrimal Gland”.Examination under microscope with instillation of fluorescent dye called Fluorescein Sodium can diagnose and grade the dryness.The reduction of tear production can be measured by using a millimeter marked thin strip simply put on the edge of the eyelids.This is called “ Schirmer Test”.There are other sophisticated imaging tests available for grading the amount of dryness.Treatment of dry eyes is in the form of local lubricant drops of different varieties and grades. The same medication in the form of a gel is also used.There are eye drops like Cyclosporin which stimulate teat production to some extent.In addition to the lubricants , anti inflammatory drops are used to boost the effectivity of the lubricant drops.The tiny openings at the lid margins which drain tears every minute can be plugged or blocked to preserve the precious little tears that are formed.This procedure is called “ Punctal Plug”.Transplantation of the tube producing Saliva into the front of the eye can be done in very  incapacitating dry eyes. 

Fluorescein staining of dry cornea

7] Rare consequence of RD is the inflammation of the front most transparent portion of the eyeball called Cornea . It is called “ Peripheral Ulcerative Keratitis”. The periphery of the cornea is thinned out . Treatment is in the form of local steroid drops, Lubricants , oral steroids, oral antibiotics and on rare occasions surgical procedure.

It is a very important thing to know that as the Rheumatic Diseases affect various structures of the eye , the strong treatments needed to control this group of recalcitrant ailment can also cause untoward effects on the eye. Local steroid drops if used for a prolonged period and oral steroids themselves to a lesser extent , can cause cataract formation as well as Glaucoma . Immunosuppressive medicines can have untoward effects on general health Drugs like Chloroquine used for RD can cause adverse effects on  Macula and requires routine screening.

The key to getting around these inflammatory diseases affecting various parts of the eye is being aware of consequences of Rheumatic Diseases on the eye . A high degree of suspicion must be observed  while examining and counselling patients of RD .Seeing an eye doctor , preferably a Uveitis Specialist if possible, is beneficial. Commencing treatment on time , showing compliance in regular treatment and meticulous follow up is the Mantra to manage Ophthalmic consequences of RD . Patients should be made well aware that getting repeated episodes or attacks of eye inflammation is a natural course of this disease and hence repeated treatment is a rule and not  an exception.

If there is one disease of the eye where patient education and counselling play a precious role , it is eye inflammation related to Rheumatological Diseases.