What are the risks and management of eye involvement in patients with rheumatoid arthritis (RA)?

Eye Involvement in Rheumatoid Arthritis

Adult rheumatoid arthritis patients are at risk for keratoconjunctivitis sicca (most common), episcleritis, scleritis, and peripheral ulcerative keratitis, with scleritis and peripheral ulcerative keratitis being vision-threatening emergencies that require immediate systemic immunosuppression and close ophthalmology-rheumatology collaboration. 1, 2, 3

Types of Ocular Manifestations and Their Risks

Keratoconjunctivitis Sicca (Dry Eye)

• Most common ocular manifestation affecting the majority of RA patients, more severe than idiopathic dry eye 2, 4, 5
• Autoimmune-mediated tissue damage on the ocular surface involving defects in innate immunity, cytokines, and T-cell subsets 4
• Can occur at different times from articular disease 4

Episcleritis

• Occurs in approximately 5% of RA patients 5
• Benign condition treated with oral NSAIDs and/or topical corticosteroids 1
• Does not typically threaten vision 2

Scleritis

• Present in 2-8% of RA patients, with RA accounting for 8-15% of all scleritis cases 1, 5
• RA is the leading cause of necrotizing scleritis, the most severe form 3
• Patients with RA are more likely to present with diffuse or necrotizing forms and have increased risk of ocular complications and refractory inflammation 1
• Associated with systemic vasculitis and excess mortality 3
• Can be the first indicator of underlying rheumatoid vasculitis 1

Peripheral Ulcerative Keratitis (PUK)

• RA is the leading cause of PUK 3
• One of the two most severe ocular conditions associated with RA (along with necrotizing scleritis) 3
• Rapidly threatens ocular prognosis and requires urgent intervention 3

Management Algorithm

For Keratoconjunctivitis Sicca

• Depending on severity: ciclosporin, topical corticosteroids, tacrolimus, autologous serum, or systemic immunosuppression 4
• Matrix metalloproteinase inhibitors for tissue damage 4

For Episcleritis

• First-line: Oral NSAIDs and/or topical corticosteroids 1
• Usually resolves without complications 1

For Scleritis

• Initial treatment: Oral NSAIDs and oral corticosteroids 1, 3
• If inadequate response: Add disease-modifying anti-rheumatic drugs (DMARDs) 1
• For refractory cases: Anti-TNF biologic agents (infliximab and adalimumab) are now recommended 1
• Alternative biologics with evidence: Rituximab may be effective; tocilizumab, abatacept, tofacitinib, and ACTH gel require further study 1

For Peripheral Ulcerative Keratitis

• Requires immediate systemic immunosuppression similar to scleritis management 3
• Matrix metalloproteinase inhibitors for corneal tissue damage 4
• Close monitoring for systemic vasculitis 3

Critical Clinical Pitfalls

Monitoring Requirements

• Close collaboration between ophthalmology and rheumatology is essential, especially when scleritis or PUK may be the first indicator of systemic vasculitis 1, 2, 3
• Regular ophthalmologic screening should be performed even in asymptomatic patients 2

Prognostic Indicators

• Necrotizing scleritis and PUK are associated with excess mortality due to their association with systemic vasculitis 3
• These conditions can rapidly threaten both ocular prognosis and systemic health 3

Treatment Escalation

• Do not delay escalation to biologics in refractory scleritis or PUK, as vision loss can be rapid and irreversible 1, 3
• Systemic corticosteroids should be used as bridging therapy only, with early addition of steroid-sparing agents 1

Important Distinctions from Juvenile Arthritis

The evidence provided includes extensive guidelines for juvenile idiopathic arthritis-associated uveitis 6, 7, 8, 9, which presents differently from adult RA. In children with JIA, chronic anterior uveitis is the primary concern and is often asymptomatic, requiring regular screening. In contrast, adult RA patients primarily develop keratoconjunctivitis sicca, episcleritis, scleritis, and PUK rather than uveitis 1, 2, 3, 5.