Autoimmune Rheumatologic Disorders and the Eye: Study Guide

Maxwell A. Levi's Avatar Maxwell A. Levi Alanna Nattis, DO, FAAO's Avatar Alanna Nattis, DO, FAAO
Jul 8, 2021
6 min read
756 views

The eye is frequently involved in numerous autoimmune and rheumatologic disorders. In part one of this four-part study guide, we discuss rheumatoid arthritis, Sjögren's syndrome, and seronegative spondyloarthropathies.

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Introduction

Autoimmune diseases have a variety of systemic manifestations; the eye is frequently involved in numerous autoimmune and rheumatologic disorders. Ocular manifestations are frequently nonspecific and different diseases may affect different parts of the eye, but early recognition of symptoms can help avoid or delay both systemic and ocular sequelae.

The most common autoimmune diseases that affect the eyes can be separated into four categories:

  1. Rheumatologic
  2. Dermatologic
  3. Endocrine
  4. Vascular

This is part one of a four-part series in which we discuss autoimmune rheumatologic diseases and the eye including:

  1. Rheumatoid arthritis
  2. Sjögren's syndrome
  3. Seronegative spondyloarthropathies

Rheumatoid arthritis 1-5

Rheumatoid arthritis - epidemiology

  • Disease
    • Incidence in USA:40 per 100,000 persons
    • Prevalence
      • .024-1% of population
    • 2:1 (women: men)
    • Age: 30-50
  • Eye manifestations
    • 27.2% of patients with RA

Rheumatoid arthritis - mechanism

  • Vasculitis
    • Vascular occlusion
    • Infiltration
    • Fibrinoid necrosis
  • Immune complex deposition
  • Complement activation
  • Autoantibodies
  • Secretion of collagenases by macrophages and neutrophils
  • Cytokine production

Rheumatoid arthritis - presentation

  • General
    • Symmetrical inflammatory polyarthritis
      • Joint deformities
      • Nodules (Proximal interphalangeal joints (PIP)>Distal interphalangeal joints (DIP))
    • Constitutional symptoms
    • Joint stiffness
    • Fever
    • Weight loss
  • Anterior segment more commonly affected than posterior segment

Rheumatoid arthritis presenting with keratoconjunctivitis sicca (most common)

  • Mechanism
    • Dysfunction of
      • Meibomian gland
      • Lacrimal gland
      • Accessory lacrimal gland
      • Goblet cells
  • Characteristics
    • Foreign body sensation
    • Burning
    • Decreased visual acuity
    • Photophobia
    • Pruritis
  • Complications
    • Superficial punctate keratitis
    • Filamentary keratitis
    • Corneal ulcer
    • Corneal melt
  • Diagnosis
    • 25% meet criteria for secondary Sjögren's Syndrome (SS)
    • Schirmer’s Test
      • < 5mm tear extension
    • Tear break up time
      • < 5 seconds
    • Decreased lacrimal lake
    • Staining
      • Fluorescein
      • Rose Bengal
      • Lissamine green
  • Treatment
    • Lubricating drops/ointment
    • Topical cyclosporine
    • Oral pilocarpine
    • Topical Lifitegrast
    • Punctal occlusion
    • Amniotic membrane
    • Tarsorrhaphy

Rheumatoid arthritis presenting with episcleritis

  • Mechanism
    • Inflammation of episclera
  • Characteristics
    • 40% bilateral
    • Salmon-pink eyes
    • Mild pain
    • Occurs in a sectoral or radial distribution
  • Diagnosis
    • Clinical

Below, in Figure 1, you will find an image of a patient with episcleritis.

Episcleritis .jpeg

Figure 1: episcleritis

  • Treatment
    • Self-limiting
    • Symptom relief
      • Topical corticosteroids
      • Oral NSAID

Rheumatoid arthritis presenting with scleritis

  • Mechanism
    • Inflammation of sclera
    • Vasodilation of superficial and deep episcleral vessels
  • Characteristics
    • Most common cause of scleritis
    • Can present before onset of joint symptoms
    • Bilateral in 40-50% of patients
    • Anterior Scleritis

Figure 2 shows a non-necrotizing scleritis.

non-necrotizing scleritis .jpeg

Figure 2: non-necrotizing scleritis

  • Pain made worse with eye movement
  • Blurry vision
  • Photophobia
  • Tearing
  • Posterior Scleritis
    • T-sign on B-scan

In Figure 3, you will find an example of T-sign with fluid in Tenon space on B-scan