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:
- Rheumatologic
- Dermatologic
- Endocrine
- Vascular
This is part one of a four-part series in which we discuss autoimmune rheumatologic diseases and the eye including:
- Rheumatoid arthritis
- Sjögren's syndrome
- 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
- Symmetrical inflammatory polyarthritis
- 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
- Dysfunction of
- 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.

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.

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