Eyes and Vision

It is common for rheumatoid arthritis (RA) to affect the eyes. Studies have found that 30 to 40 percent of people with RA will develop some eye problems related to their condition. Most people are affected in both eyes.1,2

Additionally, vision problems are a rare but serious complication of hydroxychloroquine (Plaquenil), a drug that is commonly used to treat RA. For these reasons, people with RA should have regular eye exams.3,4

The most common eye and vision problems in people with RA include:1,5

  • Dry eye disease
  • Episcleritis
  • Scleritis
  • Peripheral ulcerative keratitis
  • Anterior uveitis

Dry eye disease

Dry eye disease (keratoconjunctivitis sicca) is the most common eye problem for people with RA. Studies have found that anywhere from 18 to 90 percent of people with RA have dry eye disease, with up to 50 percent of them experiencing moderate to severe symptoms.1

Dry eye disease happens when the eyes do not produce enough tears and/or the eyes excessively leak fluid. This causes symptoms such as burning, pain, dryness, and a gritty sensation. The symptoms might be worse at the end of the day. Dry eye syndrome is linked to Sjögren’s syndrome, an immune system disorder often tied to RA.1,5

The test used to diagnose dry eye disease is called the Schirmer’s test. The test is done by putting a small paper strip inside the bottom lid of each eye. A few minutes later, your doctor will check how wet the strip is. The results indicate whether your tear glands are working properly.1

To treat dry eye disease, your doctor might prescribe you ointment, artificial tear drops, or eye-drop medicine. In some cases, people have tiny plugs inserted into the tear ducts to help keep tears on the surface of the eye. If left untreated, dry eye disease can lead to infections and corneal (the clear covering of the eye) scarring.5

Episcleritis

Episcleritis is inflammation of the episclera, the clear layer on top of the white part of the eye (sclera). It affects between 1 and 5 percent of people with RA. It occurs when some of the blood vessels in the eyes become blocked by inflammation.

It causes tearing, pain, irritation, and redness that is limited to 1 area of the eye. It is usually diagnosed during an exam. In most cases, episcleritis is best controlled by treating RA symptoms. Topical NSAIDs, artificial tear drops, and steroids may help treat severe cases.1,5

Scleritis

Scleritis is severe inflammation of the episclera and sclera. It affects between 1 and 6 percent of people with RA. Doctors are not exactly sure what causes scleritis in people with RA, but research suggests it may be a combination of inflammation and TNF, a protein involved in inflammation.

Scleritis causes red eyes, tearing, sensitivity to light, and sharp, severe pain. Severe cases can cause perforation of the eye globe, resulting in loss of the eye. It is diagnosed during an eye exam. In most cases, scleritis is treated with steroids and immunosuppressant drugs.1,6

Peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is described as inflammation and open sores on the cornea (the clear outer layer at the front of the eye). It is uncommon, though most cases are in people with RA. It develops when inflammatory cells gather in the cornea, and it may lead to perforation (breaking) of the cornea, resulting in blindness.

Symptoms include pain, redness, tearing, and blurry vision. It is diagnosed during an eye exam. Treatment includes steroids, sometimes along with immunosuppressants.1

Anterior uveitis

Anterior uveitis is inflammation of the uvea, which is the pigmented (colored) middle layer of the eye, located between the sclera and the retina. It is not common, though about 40 percent of people with anterior uveitis also have RA. Researchers are still trying to determine how RA plays a role in anterior uveitis.

Symptoms include pain, decreased vision, iris adhesions, tearing, sensitivity to light, and redness. It is diagnosed during an eye exam. Treatment usually includes topical steroids, though topical NSAIDs and immunosuppressants may also be used.1

Hydroxychloroquine and risk of vision problems

Hydroxychloroquine (Plaquenil) is an antimalarial drug that is approved to treat RA. It reduces symptoms such as pain, swelling, and joint tenderness. Hydroxychloroquine improves physical function and reduces the frequency of RA flares.3

Vision problems are a possible side effect of hydroxychloroquine if it is used for a long time or at high doses. One study found that 7.5 percent of people who used this drug for at least 5 years had retina damage. In people who took lower doses, 2 percent had retina damage in the first 10 years of use. After 20 years of use, nearly 20 percent had retina damage. These results are higher than what has been seen in other studies. Nevertheless, studies generally have shown that the risk increases with duration and dose.4

A vision test is recommended when starting hydroxychloroquine and while taking this drug. The test may evaluate:3,4

  • How sharp your vision is (visual acuity)
  • The scope or total area that you can see objects
  • Your ability to tell different colors apart
  • Any signs of damage to your retina or other eye structures (fundoscopy)

The American Academy of Ophthalmology recommends that you begin having annual eye exams after 5 years of taking hydroxychloroquine. You may need more frequent eye exams if:3,4

  • You are on a high dose of hydroxychloroquine
  • You have kidney or liver disease
  • You are over the age of 65
  • You have certain vision problems

Visiting an eye care specialist

People with RA who experience any change in vision should be evaluated right away. Even if you do not have symptoms of eye problems, regular eye exams may be recommended to monitor for changes in your vision.

There are several different types of eye care professionals. The training and expertise of each type of professional is different, so it is important that you see the right doctor for your needs:7,8

  • Ophthalmologist – These are doctors who are licensed to practice medicine and surgery. An ophthalmologist can diagnose and treat all eye diseases, perform eye surgery, and prescribe/fit corrective lenses. Many ophthalmologists often conduct research on the causes and cures for eye disease and disorders. Some ophthalmologists also specialize in specific areas of eye care, allowing them to treat more complex or specific conditions of the eye. In many cases, people with RA are referred to an ophthalmologist to manage eye problems.
  • Optometrist – An optometrist provides primary vision care. This involves performing eye exams, diagnosing certain eye abnormalities, prescribing drugs for eye disease, and prescribing/fitting corrective lenses. An optometrist is not a medical doctor, but has received a doctor of optometry (OD) degree from a 4-year optometry school.
  • Neuro-ophthalmologist – These doctors treat vision problems that are related to the nervous system rather than the eyes. They are ophthalmologists with specialized training in problems that involve the eye, brain, nerves, and muscles. A neuro-ophthalmologist has completed at least 5 years of clinical training after medical school and is board-certified in neurology, ophthalmology, or both.

Some people with RA may be referred to a neuro-ophthalmologist.

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Written by: Jonathan Simmons & Heather Morse | Last reviewed: January 2021.