It’s not widely known, but eye problems, visual impairment and even blindness are not uncommon features of many forms of arthritis and rheumatic disease. Dr Badal Pal and Dr Sathianathan Panthakalam, of Withington Hospital, Manchester, explain.
Common, inflammatory joint disease
The three main problems in rheumatoid arthritis are dry eyes, which affects one quarter of RA patients; keratitis (inflammation of the cornea); and scleritis (inflammation of the sclera, the white outer layer of the eyeball) of which RA is one of the most common causes. Patients may also develop secondary SjÃ¶gren’s Syndrome due to salivary gland abnormality which also causes a dry mouth. In scleritis, the sclera can become thin leading to perforation.
Juvenile chronic arthritis:-
Rare form of inflammatory arthritis affecting children from six months upwards
In most cases of JCA, the eyes are unaffected for up to three years, when complications may occur, so it is important for children at risk to have their eyes checked regularly. Up to 18 per cent of youngsters with JCA have a form of uveitis after having JCA for five years. Uveitis is inflammation of the uvea â€“ a layer of tissues made up of the iris and choroid membrane and the middle of the three layers of the eyeball â€“ which causes irritation, reddening of the eye, and blurred or loss of vision. It can be treated by steroid drops and immuno-suppresives. Children at the highest risk are those aged under nine, with a few affected joints. They need screening every three months at the age of two, then regularly until they reach ten. Youngsters with many affected joints, or with systemic onset disease, and all children over the age of nine, are considered low risk.
Systemic lupus erythematosus:-…………
Autoimmune disease affecting many organs in the body
Eye damage in patients with lupus vary from minor problems to severe retinopathy (inflammation of the iris or choroid which can lead to visual impairment, even blindness). Five per cent of patients develop scleritis. Retinal vasculitis (inflammation of the arteries) can occur, and patients can develop cotton wool spots at the back of the eyeball, retinal bleeding and swelling of the optic disc. Double vision can also occur,
Systemic sclerosis (scleroderma):-………….
Rare, serious condition affecting the skin, joints and internal organs
The most common complaint is dryness in the eyes. A minority of patients develop retinopathy with cotton wool spots at the back of the eyeball, retinal haemorrhages and blockage of retinal arteries.
Polymyositis and dermatomyositis:-……………
Similar automimmune diseases causing inflammation of the muscles. Dermatomyositis also affects the skin
The typical lilac discolouration (heliotropic) rashes on the eyelids are seen in 40 per cent of patients. Ocular myopathy (muscle wasting) can occur in a small proportion of patients, leading to double vision, and a few people develop retinopathy.
A group of non-rheumatoid inflammatory diseases
Acute uveitis is the most important disease in this group of patients:
Rheumatic disease affecting the spine, resulting in stiffness in the back
Uveitis occurs in 20 per cent of patients. Only one eye is usually affected at one time, but both eyes may become affected during the course of the disease.
Also known as reactive arthritis; affects tendons and tissues as well as joints
Conjunctivitis is the most common symptom, seen in 30â€“60 per cent of patients. Uveitis is less frequent in early disease, but can occur in up to 40 per cent of patients.
A form of inflammatory arthritis, similar to RA
Uveitis occurs in up to 15 per cent of patients, and is frequently accompanied by conjunctivitis, dry eyes or keratitis. It can be chronic or acute.
Arthritis associated with inflammatory bowel disease
Arthritis occurs in association with Crohn’s disease, ulcerative colitis and Whipple’s disease.
Uveitis is seen in 10 per cent of these patients. Crohn’s disease seems to be frequently associated with uveitis (less often with ulcerative colitis).
Other eye lesions seen occasionally in this group of patients are episcleritis â€“ inflammation of the superficial vessels of the sclera â€“ or peripheral corneal ulceration. The likelihood of eye lesions increase in those with arthritis, spondylitis and skin symptoms.
A rare disorder of oral and genital ulcers, inflammatory eye disease and skin lesions
Eye involvement is the most serious symptom in Beh§et’s patients. It occurs in 70 per cent of patients, and 25 per cent will go blind. Those most at risk are men, particularly those who developed the condition at a young age. Women are less severely affected. Patients develop eye disease within two to three years of developing the condition. Anterior uveitis is fairly easy to treat, but postererior uveitis and retinal vasculitis are more serious. After four years of eye disease, up to 85 per cent of patients have some form of visual impairment.
A form of vasculitis
Eye problems develop in about 50 per cent of patients. The eye socket is infiltrated with granulomatous tissue; the eyes become prominent, and become reddened because of scleritis. Patients sometimes have visual impairment because of the compression of the optic nerve by granulomatous tissue.
Rare skin condition also affecting the lungs, eyes and the musculoskeletal system
Between 30 and 40 per cent of patients will develop eye problems. The most common problem is acute or chronic relapsing uveitis leading to dry eyes. Five per cent of patients develop optic nerve neuropathy (a disease of the peripheral nerves causing weakness or numbness) with a significant loss of sight.
Giant cell arteritis:-
Inflammation of blood vessels commonly in the head
Giant cell arteritis is an emergency condition, and an important cause of preventable blindness in old people. Twenty five per cent of patients develop eye disease and suddenly lose the sight in one eye. Blindness is usually due to loss of blood supply, and subsequent damage to the optic nerve. Treatment is immediate, high dose steroids, to prevent blindness in the other eye, as recovery is unusual.
Ocular side effects of anti-rheumatic therapy:-
Most of these drugs cause no significant side effects, but cortisteroids and antimalarial drugs can have toxic effects.
Antimalarial drugs, hydroxychoroquine and chloroquine, which are used in RA, lupus and other related disorders, can lead to irreversible retinal damage and corneal opacity. Patients on these drugs have their eyes examined once a year.
Corticosteroids can lead to corneal and scleral thinning, and cataracts are common after higher doses of steroids. Raised intra ocular pressure is another common side e
*Sclera…. white outer layer of the eye Retina inner most light-sensitive layer of the eye
*Conjunctiva…. transparent membrane on the front part of the sciera iris pigmented tissue surrounding the pupil â€“ in front of the lens â€“ allowing light to enter the eye.
*Cornia……... front part of the eye overlying the pupil, iris and lens. it is part of the sclera
*Choroid….… middle layer of the eye, alsocalled the uvea. it contains blood vessels and a pigment that absorbs excess light â€“ this prevents blurring
*Optic nerve…… main nerve travelling from the back of the eye carrying signals to the brain for the eye to see
*Vitreous body.… jelly-like substance separating the front part of the eye and the back part where the retina and optic nerve are located.
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Inflammatory conditions of the eye associated with rheumatic diseases.
EYE INVOLVEMENT IN THE SPONDYLOARTHROPATHIES
Ophthalmologic manifestations of rheumatic diseases