Jeepers Peepers!

There’s a lot more to rheumatoid disease than meets the eye. When I first started learning more about this disease about ten years ago, thanks to an increasingly useful Internet, I was a little stunned to learn just how much.

It was an eye-opener (forgive me--these puns! They just keep coming!) when I learned, for instance, that RD could cause eye damage. Now, I don’t know about you, but I like my peepers. They’ve seen a lot, filling my visual memory with such smash hits as: freaking out on the car ride at Disneyland as an eight-year-old because I didn’t know how to steer and the cars were on an elevated road, and it was going to be a long fall if I screwed up. Or how about the first time I saw my new Boston terrier puppy when I was 10; or that time when, as a 32-year-old, I gazed at the breathtakingly steep drop-off between the tips of my skis on a mountainside in the Austrian Alps? Holy... well... you know.

These were good times all, and I can see them in my mind’s eye right now just as clearly as I saw them with my real eyes all those decades ago. I treasure those memories, and I want more of them. The idea that RD might screw up my eyesight along with my joints just steams me.

So, how does RD affect the eyes?

First, a quick primer. Rheumatoid disease (arthritis) is an autoimmune disease that causes the body’s immune system to mistake its own tissues for foreign invaders, like viruses and bacteria. The immune system mobilizes warrior antibodies with a vengeance to seek out and destroy these enemies.

Except in this case, what it’s destroying is synovial tissues--which include the linings of the joints; the cartilage, ligaments and tendons that cushion and attach them to the bone; the linings of the heart, lungs, and vascular system; and the eyes. What they all these have in common is collagen, one of their main components. RD inflames collagen.

In the eye, the white part (the sclera) and the cornea (the lens) are made mostly of collagen, so those are the parts that most often become inflamed and endure the most potential damage from RD.

RD is responsible for many different comorbidities—the diseases and conditions it may trigger. Some of these concern the eyes. The most common is

• Keratitis sicca (sicca syndrome), or dry eye syndrome. This mild inflammation causes the eyes to be red, dry, scratchy, and irritated, and sometimes it feels like there’s something in the eye. Eye drops and/or artificial tears usually do the trick to keep the eyes comfortable, but this condition bears watching. It’s the precursor to keratoconjunctivitis sicca, or
• Sjögren's syndrome (keratoconjuntivitis sicca). Sjögren's, which is also an autoimmune disease, affects as many as 3.1 million people in the U.S. About half of those also have another autoimmune disease, like RD or lupus. Sjögren's affects the body’s mucus membranes, causing them to dry out and lose flexibility. It most often affect the eyes, where it inhibits tear production, and the mouth, where it inhibits the production of saliva. Symptoms include dry, red, gritty-feeling, irritated eyes that may burn painfully and are often sensitive to light. Vision may be blurry. Left untreated, the complications may include infections around the eye and corneal damage. Like RD, Sjögren's is incurable.
• Scleritis, or inflammation of the sclera. That’s the white of the eye--the eye wall--to thin. That can be dangerous, as it means the eye may be more easily injured. Symptoms include redness that doesn’t go away when you use over-the-counter eye drops, and pain that can be severe. You may also be sensitive to light or notice reduced vision. Treatment includes corticosteroid eye drops, but since getting this disease indicates that inflammation in the body is out of control, treatment may also involve getting it back under control.
• Uveitis. This one involves the uvea, the vascular layer of the eye that lies between the sclera and the retina, and if it’s left untreated, may cause blindness. The uvea becomes inflamed, causing pain, redness, sensitivity to light, and blurred vision. Treatment includes corticosteroids in the form of drops, pills, or injections, and further treatment to get the inflammation in the body under control. Antibiotics may also be used. Uveitis can be chronic.
• Glaucoma. It’s usually caused by high pressure inside the eye that damages the optic nerve, causing vision loss. Inflammation from RD may cause the pressure to rise, although there are other causes as well, such as corticosteroid treatment. Symptoms include eye pain, blurry and/or blank spots in the vision, and perhaps seeing rainbow-colored auras around lights. Treatment involves eye drops that lower the pressure inside the eyes or, if necessary, surgery.
• Cataracts. Lots of people, as they age, get cataracts--a cloudy film that forms on the cornea (lens). Inflammation from RD may cause it, as can corticosteroids. Symptoms include cloudy or blurry vision, poor night-time vision, and colors that seem dull or faded. The only treatment for cataracts is surgery. The surgeon replaces the clouded lens with a clear, artificial one.
• Plaquenil. As if diseases of the eye weren’t enough, you should also be aware that some medications can damage the eyes. Although it’s very rare, Plaquenil (hydroxychloroquine), a disease-modifying anti-rheumatic drug (DMARD), can cause retinal/macular toxicity. There are rarely any noticeable symptoms, particularly early in the damage process. Your rheumatologist will send you to an ophthalmologist before you start taking Plaquenil to establish a baseline exam of your eyes. After that, you should see an ophthalmologist once a year or as often as your rheumatologist recommends for screening. According to the American Academy of Ophthalmology, the damage to the retina/macula may be permanent and can continue even after you stop taking the drug.

I take Plaquenil, so I’m a yearly visitor to the eye doctor. I also have dry eye syndrome that I hope won’t progress. As I said, I like my eyes. I want them to stay as healthy and sharp as possible.