Eye care for the elderly arthritic patients

by Dr. Madhuri Chandorkar & Dr. Sanjay Savarkar

People with arthritis know to expect painful, swollen and tender joints. What they may not expect is the effect arthritis can have on a completely different part of the body - the eyes.

Many forms of arthritis and related diseases have an effect on the eyes. Eye problems can result from inflammation associated with arthritis or the medications used to treat it. In some cases, eye problems can indicate potentially dangerous conditions elsewhere in the body.

Arthritis is a disease of the connective tissues of the body. The layers of the eye are made up of the same tissue and each layer can be affected.

The eyes commonly have the following problems :

Dry eyes - produce a lot of discomfort & irritation, can sometimes lead to injury & corneal clouding.

Episcleritis / Scleritis - an increased incidence is seen - cause frequent redness, pain.

Corneal thinning / Sceral thinning - may lead to ulcers, pain, watering, vision loss.

Iritis - Causes severe inflammation, pain, blurring of vision. Repeated attacks reduce vision as well as cause cataracts.

Cataract - A major problem associated with arthritis. Cataract is a clouding of the normally clear lens of the eye. It is comparable to a window that is frosted or yellowed.The amount & pattern of cloudiness within the lens can vary, and you may not be aware that a cataract is present. Common symptoms are - a painless blurring of vision, glare or light sensitivity, poor night vision, double vision in one eye, fading or yellowing of colors, needing brighter light to read.

Glaucoma - Caused by a rise in the fluid pressure inside the eye. Usually does not produce any symptoms until the disease is in an advanced stage. Uncontrolled rise in the pressure (IOP) leads to a progressive, irreversible loss of vision. This rise may be due to the disease itself or as a side effect of the treatment drugs, especially steroids.

Retinal problems / retinopathy :

Here are detailed descriptions about some of the more common arthritis - related eye problems, including symptoms to watch out for.

Polymyalgia Rheumatica (PMR) :

Giant Cell Arteritis (GCA), which is an inflammation of the blood vessels that supply the head, occurs in about half of people with PMR. Inflammation can sometimes block the flow of blood to the optic nerve and cause vision problems, such as blurring, double vision and in 10 to 15 percent of people with GCA - even blindness.

Ankylosing Spondylitis (AS) :

Iritis, inflammation of the iris or colored part of the eye, affects approximately 20 to 30 percent of people with AS. The inflammation comes on suddenly, usually in one eye at a time, causing the affected eye to become red and painful. Individual incidents may last for a couple of months or more and recur a few times a year or over a period of years.

Rheumatoid Arthritis (RA) :

Scleritis, a chronic inflammation of the blood vessels in the whites of the eyes, occurs in about 1 percent of people with RA. Symptoms include eye pain and redness. If it goes untreated, scleritis may become severe, leading to a deterioration of the cornea.

People with RA are also at increased risk for Sjogren's syndrome, classified in this case as secondary Sjogren's syndrome (see below).

Sjogrens Syndrome :

Dry Eyes are a key symptom of Sjogren's syndrome, a chronic condition that occurs when the body's immune system mistakenly attacks moisture-producing glands, including the tear glands. Symptoms include a burning, gritty feeling. If not alleviated, dryness can lead to eye infections or even damage to the cornea.

Lupus :

Cotton Wool Spots :

White, puffy patches that appear on the retina and can be seen during an eye exam - occur in about 7 percent of people with lupus. The spots are caused by compromised blood supply to the retina. When this occurs, blood supply to other organs may be insufficient as well, resulting in problems as severe as a stroke. Fortunately, detecting the spots can tip doctors off to other problems, ensuring prompt or even preventive treatment. The spots themselves do not affect vision.

Juvenile Rheumatoid Arthritis (JRA) :

Iritis also occurs in about half of children with pauciarticular JRA, which begins in childhood and generally affects four or fewer joints. JRA related iritis is often asymptomatic and is known to continue into adulthood.

Eye Exams Are Important

Because detecting and treating eye problems early can, in many cases, prevent long-term complications, patients need to schedule regular appointments with an ophthalmologist (an eye surgeon) as well. Experts recommend that people who are taking anti-malarial drugs such as hydroxychloroquine (Plaquenil) should make it a priority to have their eyes checked by an ophthalmologist every year, although in some cases less frequent visits may be sufficient. Ask your doctor to help determine the frequency of eye check-ups that is best for you. Having a periodic check for a correct spectacle number is also recommended, along with eye pressure measurement, Cataract check & retinal examination.

Drugs too can do damage

In addition to the eye problems arthritis-associated inflammation can cause, some medications used to treat arthritis-related disease can create trouble of their own. Most notable are antimalarial drugs such as hydroxychloroquine and glucocorticoids such as prednisone.

Hydroxychloroquine, used to treat and slow the progression of such diseases as RA and lupus, can in rare cases damage the retina and cause blindness. Such damage can be prevented by taking low doses of the drug and by seeing an ophthalmologist regularly to detect damage before it becomes severe. Stopping the drug may reverse early harm.

Prednisone / Steroids, one of the most widely used inflammation fighting drugs, can increase risk of cataracts and glaucoma. Cataract is a cloudiness of the eye's lens resulting in blurred vision. In glaucoma, excessive fluid buildup causes pressure inside the eye. However, both problems can be treated. (See "Treating Eye Problems" below).

Treating Eye Problems

Fortunately, most eye problems related to arthritis and its treatment can be managed or corrected if detected early enough. These are some of the typical treatments for each :

Dry eyes - artificial tears, humidifiers and sunglasses; avoiding contact lenses and dry conditions.

Scleritis- local eye drops and systemic anti-inflammatory drugs.

Giant cell arteritis - prednisone / Steroids, given in high doses until inflammation subsides, can prevent blindness.

Iritis - Steroid eye drops, Dilating drops to rest the eye muscles inside the eye.

Cataracts - surgical removal of the clouded lens; replacement with an artificial lens implant (IOL) by the new method of phacoemulsification with a foldable lens, also known as "stichless cataract surgery" will restore vision.

Retinal damage from hydroxychloroquine - discontinuing drug if eye exam reveals early damage.

Cotton wool spots - no treatment is needed for the spots, however spots signal the potential presence of other health problems that may require treatment.

Glaucoma - Frequent eye pressure checks go a long way in preserving sight. If raised, eye pressure lowering eye drops or tablets are used, or surgery to drain excess fluid from eyes if there is no response to medical therapy.

In conclusion, remain alert for any eye - related problems and attend to them promptly.