Can Rheumatoid Arthritis Affect the Eyes?

People with rheumatoid arthritis often notice their eyes feel dry, gritty, and tired long before connecting it to their arthritis, and they wonder whether the two are related. Others develop a red, deeply painful eye during a flare and are alarmed by how different it feels from ordinary irritation. Because rheumatoid arthritis is known to affect joints and other organs, patients reasonably ask whether their eyes are also on the list.

Rheumatoid arthritis is a systemic autoimmune disease, so its inflammation is not confined to joints. On the eye's surface, the immune process reduces tear production and quality, producing the burning, gritty, watery-then-dry discomfort of significant dry eye; over time this can roughen and damage the cornea. Deeper down, the same disease can inflame the sclera, the tough white shell of the eye, and this scleritis is genuinely painful and potentially damaging.

The distinction between layers matters. Episcleritis inflames the thin tissue just over the sclera and is usually mild, uncomfortable rather than truly painful, and self-limited. Scleritis inflames the sclera itself, causing severe, deep, boring pain that can radiate to the face and wake a person at night; the sclera can thin, and in rare severe cases the wall or cornea can perforate. Because these deeper problems can permanently harm the eye and tend to track with active arthritis, they are treated seriously.

The eye conditions linked to rheumatoid arthritis span the surface to the deep wall. Keratoconjunctivitis sicca (dry eye), often as secondary Sjogren's syndrome, is the most frequent and results from immune damage to the tear-producing glands. Episcleritis is a common, benign inflammation of the superficial layer over the sclera. Scleritis, though less common, is the most important, because rheumatoid arthritis is its leading systemic cause; it can be diffuse, nodular, or, in the worst form, necrotizing, where the sclera breaks down. Peripheral ulcerative keratitis, a thinning at the edge of the cornea, can accompany severe disease and can lead to perforation.

Eye involvement often reflects disease activity and duration, and scleritis in particular can mark more aggressive rheumatoid arthritis or associated vasculitis. Some medications also intersect with the eyes: long-term hydroxychloroquine requires periodic retinal screening, and steroids can promote cataract and raised eye pressure. Managing the eyes therefore goes hand in hand with managing the systemic disease.

Dry eye from rheumatoid arthritis is usually a comfort and surface-health issue, but deeper involvement is serious. Seek prompt evaluation for:

• Deep, severe, boring eye pain, particularly pain that radiates to the brow or wakes you from sleep (possible scleritis).
• A red eye with pain that does not fit ordinary irritation or allergy, or with light sensitivity and blurred vision.
• A localized area of the white of the eye that looks bluish or thinned, or new decreased vision.

Necrotizing scleritis and corneal thinning can threaten the eye and require urgent, aggressive treatment.

The doctor examines the surface for dry eye using tear-film assessment and dye staining to grade damage. Distinguishing episcleritis from scleritis is a key step: a drop of phenylephrine blanches the superficial vessels of episcleritis but not the deep vessels of scleritis, and scleritis shows deeper, violaceous injection with exquisite tenderness. A slit-lamp and dilated exam check the cornea for thinning and the inside of the eye for inflammation. Because scleritis signals systemic disease, evaluation is coordinated with rheumatology and may include markers of disease activity and vasculitis, and patients on hydroxychloroquine receive scheduled retinal screening.

Dry eye is managed with artificial tears and ointment and, when needed, prescription anti-inflammatory drops (such as cyclosporine or lifitegrast), punctal plugs to conserve tears, and lid care. Episcleritis often needs only lubrication or a short course of a mild anti-inflammatory, since it typically settles on its own. Scleritis is treated far more aggressively, usually with oral nonsteroidal anti-inflammatory medication or systemic steroids, and necrotizing or resistant scleritis requires steroid-sparing immunosuppressive or biologic therapy managed with a rheumatologist. Corneal thinning may need intensive treatment and sometimes surgical repair. Across all of these, controlling the rheumatoid arthritis itself is central to controlling the eye disease.

• Do not brush off deep, severe eye pain as a bad case of dry eye; that pattern suggests scleritis and needs prompt care.
• Do not use over-the-counter redness-removing drops to mask a red, painful eye.
• Do not skip scheduled retinal screening if you take hydroxychloroquine.
• Do not treat a rheumatoid flare and an eye flare as unrelated; tell both your eye doctor and rheumatologist so treatment can be coordinated.

Call for an evaluation if you have rheumatoid arthritis and develop persistent dry, gritty eyes, and seek prompt care for a red eye with deep, severe pain, light sensitivity, or reduced vision, which can mean scleritis. May Eye Care Center, serving the Hanover, Pennsylvania area, can examine the surface and wall of the eye, distinguish benign from serious inflammation, and coordinate with your rheumatologist.

Rheumatoid arthritis commonly causes significant dry eye and is the leading systemic cause of scleritis, so a deeply painful, red eye in a rheumatoid patient should be examined promptly rather than treated as ordinary irritation.