Effects of RA on Eyes and Vision

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It is common for RA to affect the eyes. About 30% to 40% of people with RA will have some eye symptoms.1, 2 Most people are affected in both eyes.2 Additionally, vision problems are a rare but serious complication of hydroxychloroquine, a medication commonly used to treat RA. For these reasons, people with RA may require regular eye examinations.

Dry Eyes and Other Symptoms

Dry eye syndrome is the most common eye problem for people with RA.2 The medical term for this condition is “keratoconjunctivitis sicca.” Dry eye happens when they eyes produce too few tears or the right quality of tears to keep the eyes moist.3 This causes symptoms such as burning, pain, or blurry vision.4 You might feel like there is something stuck in your eye. The symptoms might be worse at the end of the day. Dry eye syndrome is associated with secondary Sjögren’s syndrome.

The test used to diagnose dry eye syndrome is called Schirmer’s test.4 The test is done by putting a small paper strip inside the bottom lid of each eye. Five minutes later, your health care provider will check how wet the strip is. The results indicate whether your lacrimal (tear) glands are working properly.

Simple steps like wearing sunglasses, using a humidifier, and avoiding dry environments might help.4 If your symptoms are severe, your health care provider might recommend tear substitutes.

RA can cause inflammation in other parts of the eye, including:

  • Scleritis: inflammation of the whites of the eyes.
  • Episcleritis: inflammation of the layer that covers the sclera (the white of the eye).
  • Keratitis: inflammation of the cornea. The cornea is the clear layer that covers the colored part of your eye (iris).

Some symptoms of these conditions include:4

  • Pain that spreads into your cheek, eyebrows, and temples.
  • Sensitivity to light.
  • Blurred or decreased vision.
  • Tearing.
  • Red eyes.

Hydroxychloroquine and Risk of Vision Problems

Hydroxychloroquine (brand name: Plaquenil) is an antimalarial drug that is approved to treat RA.5 It reduces symptoms such as pain, swelling, and joint tenderness. Hydroxychloroquine improves physical function and reduces the frequency of RA flares.

Vision problems are a possible side effect of hydroxychloroquine if it is used for a long time or at high doses. People who used this medication for at least 5 years underwent sensitive vision tests in one study.6 Overall, 7.5% of people had retina damage. For people who used lower doses (4-5 mg/kg), 2% of people had retina damage in the first 10 years of use. After 20 years of use, nearly 20% 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.7

A vision test is recommended when starting hydroxychloroquine and while taking this medication.5 The test may evaluate:

  • 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 after five years of taking hydroxychloroquine, you begin having annual eye exams.7 The prescribing information for hydroxychloroquine suggests annual eye exams while taking the medication.5 You may need more frequent eye exams if:5,7

  • You are on a high dose of hydroxychloroquine.
  • You have kidney or liver disease.
  • You are elderly.
  • You have certain vision problems.

Visiting an Eye Care Specialist

In a person with RA, any change in vision should be evaluated right away. Even in the absence of eye symptoms, 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 quite different, so it is important that you see the right doctor for your needs.8,9

Optometrist. An optometrist provides primary vision care. This involves performing eye exams and diagnosing certain eye abnormalities. An optometrist can prescribe corrective lenses and medications for eye disease. An optometrist has not attended medical school and is not a medical doctor. An optometrist has completed college and has received a doctor of optometry (OD) from a four-year optometry school.

Ophthalmologist. An ophthalmologist is a medical or osteopathic doctor (MD or DO) who is licensed to practice medicine and surgery. An ophthalmologist can diagnose and treat all eye diseases. An ophthalmologist has completed college and medical school, plus at least four years of clinical training. In many cases, people with RA are referred to an ophthalmologist to manage eye problems.4

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 college and medical school, plus at least five years of clinical training.

view references
  1. Prete M, Racanelli V, Digiglio L, et al. Extra-articular manifestations of rheumatoid arthritis: An update. Autoimmun Rev. 2011;11:123-31.
  2. Vignesh AP, Srinivasan R. Ocular manifestations of rheumatoid arthritis and their correlation with anti-cyclic citrullinated peptide antibodies. Clin Ophthalmol. 2015;9:393-397.
  3. American Academy of Ophthalmology. What is dry eye? Accessed May 7, 2016 at: http://www.aao.org/eye-health/diseases/what-is-dry-eye.
  4. Patel SJ, Lundy DC. Ocular manifestations of autoimmune disease. Am Fam Physician. 2002;66:991-998.
  5. Plaquenil [package insert]. St. Michael, Barbados: Concordia Pharmaceuticals, Inc.
  6. Melles RB, Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014;132:1453-1460.
  7. American Academy of Ophthalmology. Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy – 2011. Accessed April 26, 2016 at: http://www.aao.org/clinical-statement/revised-recommendations-on-screening-chloroquine-h#ScreeningRecommendations
  8. American Association for Pediatric Ophthalmology and Strabismus. Difference between an ophthalmologist, optometrist, and optician. Accessed April 26, 2016 at: http://www.aapos.org/terms/conditions/132.
  9. North American Neuro-Ophthalmology Society. What is a neuro-ophthalmologist? Accessed April 26, 2016 at: http://www.nanosweb.org/i4a/pages/index.cfm?pageid=3279
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