Ocular manifestations of rheumatoid arthritis
- Reza Dana, MD, MPH, MSc
Reza Dana, MD, MPH, MSc
- Claes Dohlman Professor of Ophthalmology
- Harvard Medical School
- Section Editors
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
Rheumatoid arthritis (RA) is a common and chronic systemic inflammatory disease of unknown etiology that primarily involves joints. Extraarticular manifestations are also observed, including ophthalmic involvement. The clinical course of the ocular disease may be quite variable.
The importance of the early diagnosis of ophthalmic disease in the patient with RA cannot be overemphasized, since it permits the timely management of potentially serious sight-threatening complications. The presence of ocular disease may also be an indication of ongoing systemic disease activity [1,2]. However, ocular involvement, in particular severe dry eye, may exist independently from severe articular disease and should be evaluated in all patients with RA regardless of extra-ophthalmic manifestations .
Issues relating to the ocular manifestations of RA are discussed in this review. The anatomy of the relevant structures is depicted in the figure (figure 1). The articular and other nonarticular clinical manifestations of this disorder are discussed separately. (See "Clinical manifestations of rheumatoid arthritis" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis".)
INDICATIONS FOR URGENT REFERRAL TO AN OPHTHALMOLOGIST
Urgent referral to on ophthalmologist with expertise in the management of ocular inflammation or corneal-external diseases of the eye should be carried out in patients with rheumatoid arthritis (RA) who present with any of the following:
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- McGavin DD, Williamson J, Forrester JV, et al. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol 1976; 60:192.
- Foster CS, Forstot SL, Wilson LA. Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. Effects of systemic immunosuppression. Ophthalmology 1984; 91:1253.
- Fujita M, Igarashi T, Kurai T, et al. Correlation between dry eye and rheumatoid arthritis activity. Am J Ophthalmol 2005; 140:808.
- THOMPSON M, EADIE S. Kerato-conjunctivitis sicca and rheumatoid arthritis. Ann Rheum Dis 1956; 15:21.
- Barber LD, Pflugfelder SC, Tauber J, Foulks GN. Phase III safety evaluation of cyclosporine 0.1% ophthalmic emulsion administered twice daily to dry eye disease patients for up to 3 years. Ophthalmology 2005; 112:1790.
- Dayer JM, Graham R, Russell G, Krane SM. Collagenase production by rheumatoid synovial cells: stimulation by a human lymphocyte factor. Science 1977; 195:181.
- Riley GP, Harrall RL, Watson PG, et al. Collagenase (MMP-1) and TIMP-1 in destructive corneal disease associated with rheumatoid arthritis. Eye (Lond) 1995; 9 ( Pt 6):703.
- Brown SI, Grayson M. Marginal furrows. A characteristic corneal lesion of rheumatoid arthritis. Arch Ophthalmol 1968; 79:563.
- Michels ML, Cobo LM, Caldwell DS, et al. Rheumatoid arthritis and sterile corneal ulceration. Analysis of tissue immune effector cells and ocular epithelial antigens using monoclonal antibodies. Arthritis Rheum 1984; 27:606.
- Feder RS, Krachmer JH. Conjunctival resection for the treatment of the rheumatoid corneal ulceration. Ophthalmology 1984; 91:111.
- Palay DA, Stulting RD, Waring GO 3rd, Wilson LA. Penetrating keratoplasty in patients with rheumatoid arthritis. Ophthalmology 1992; 99:622.
- Ormerod LD, Fong LP, Foster CS. Corneal infection in mucosal scarring disorders and Sjögren's syndrome. Am J Ophthalmol 1988; 105:512.
- Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol 1976; 60:163.
- McCluskey PJ, Wakefield D. Scleritis and episcleritis. In: Ocular Infection and Immunity, Pepose JS, Holland GN, Wilhelmus KR (Eds), Mosby, St. Louis 1996. p.642.
- Foster CS. Immunosuppressive therapy for external ocular inflammatory disease. Ophthalmology 1980; 87:140.
- Sainz de la Maza M, Tauber J, Foster CS. Scleral grafting for necrotizing scleritis. Ophthalmology 1989; 96:306.
- Kimura SJ, Hogan MJ, O'Connor GR, Epstein WV. Uveitis and joint diseases. Clinical findings in 191 cases. Arch Ophthalmol 1967; 77:309.
- Pinckers A, Broekhuyse RM. The EOG in rheumatoid arthritis. Acta Ophthalmol (Copenh) 1983; 61:831.
- McCormick SA, DiBartolomeo AG, Raju VK, Schwab IR. Ocular chrysiasis. Ophthalmology 1985; 92:1432.
- Roquer J, Herraiz J, Maymo J, et al. Miller-Fisher syndrome (Guillain-Barré syndrome with ophthalmoplegia) during treatment with gold salts in a patient with rheumatoid arthritis. Arthritis Rheum 1985; 28:838.
- Klingele TG, Burde RM. Optic neuropathy associated with penicillamine therapy in a patient with rheumatoid arthritis. J Clin Neuroophthalmol 1984; 4:75.
- Sarnat RL, Jampol LM. Hyperviscosity retinopathy secondary to polyclonal gammopathy in a patient with rheumatoid arthritis. Ophthalmology 1986; 93:124.
- Sigal LH. The neurologic presentation of vasculitic and rheumatologic syndromes. A review. Medicine (Baltimore) 1987; 66:157.
- Konishi T, Saida T, Nishitani H. Orbital apex syndrome caused by rheumatoid nodules. J Neurol Neurosurg Psychiatry 1986; 49:460.
- INDICATIONS FOR URGENT REFERRAL TO AN OPHTHALMOLOGIST
- CORNEAL DISEASE
- Sjögren's and sicca syndromes
- - Clinical features of ocular disease
- - Physical examination
- - Treatment recommendations
- Corneal inflammation and melting
- Corneal infection
- Treatment recommendations
- OTHER OCULAR DISORDERS
- SUMMARY AND RECOMMENDATIONS