Painful Red Eye in Arthritis

  • Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthropathy, Wegener’s, Polyarterirtis Nodosa, Lupus etc  are various auto immune diseases, where the immune system also targets the ocular tissues and other organs like the lungs and kidneys , besides  causing   destruction of the joints due to inflammation of the cartilages and synovial tissues.
    Autoimmune reactions and inflammation mediated via Interleukins and T cell mediated antigen antibody reactions. HLA B-27 is known to be associated with tendency to recurrence of the disease, as it presents the altered antigen to the T cells. The ocular collagen is often misrecognised a s the ‘target’ organ and immune mediated lesions occur in the various structures of the eye.
    Ocular involvement in immune mediated arthritis may preceded or follow the manifestation of the systemic disease. Hence a painful red eye in a patient may be the presenting feature of a systemic disease.

    The eyes can be affected in many ways. Conjunctival congestion, Secondary Sjogren’s syndrome or dry eyes, peripheral ulcerative keratitis or Mooren’s ulcer, marginal keratitis, sclero keratitis, episcleritis, scleritis and iridocyclitis are known manifestations of eye disease in  immune mediated arthritis. Sterile melting of the cornea is another sinister complication of rheumatoid eye disease and can occur quite unsuspectingly.
    Dry Eyes Disease affects almost 50 % of patients of RA. It is more common in women  The patient experiences irritation, foreign body sensation, mucoid discharge, redness and blurry vision. Examination of the eyes shows a reduced tear secretion, increased tear film break up time, staining of the cornea and conjunctiva. The pathogenesis of dry eye in RA (like other forms of Sjogren’s) involves immune destruction of the goblet cells and lacrimal glands. The main stay of treatment is tear substitutes, lubricating gels or ointments and punctual plugs. Topical cyclosporine 0.05 or 0.1 % is recommended to increase the tear secretion. Systemic steroids and immunosuppression, as part of the therapy adds value to controlling the disease.
    Episcleritis is a painless congestion of the episcleral tissues. It blanches with the instillation of epinephrine. The patient himself may not notice the redness and is often pointed out by other observers. This responds well to topical NSAIDs and may rarely need local steroid drops to be instilled.
    Scleritits on the other hand is a painful mauve or violaceous congestion of the sclera.  The patient complains of pain that may wake him up from his sleep. The area of congestion is tender and may extend under the lids and is hence more extensive that the seen lesion. Necrotising scleritis is an extremely painful avascular necrosis of the sclera. The affected tissues show thinning and may become staphylomatous.  Scleromalacia perforans, on the other hand is a painless necrosis and sloughing off of the sclera tissues. In all these conditions the vision remains unaffected unless it is accompanied by iridocyclitis or posterior uveitis. Posterior uveitis is often missed as the loss of vision is painless. Retinal detachment,  subretinal exudates and retinal haemorrhages are noted. When accompanied by panuveitis, the eye may become phthisical.
    Iridocyclitis, can be acute (sudden) or chronic. The patient complains of haziness of vision along with pain and redness. There may be accompanying headache due to the secondary rise in Intraocular pressure. The cornea shows keratic precipitates, edema , anterior chamber flare and cells. The pupil is miosed and there may be posterior synechiae suggestive of previous episodes of uveitis. Subcapsular cataract may follow recurrent uveitis.
    Marginal  keratitis  affects the peripheral cornea just within the limbus. There is congestion around the affected limbus. The peripheral cornea shows melting and thinning and may even perforate (more often following the instillation of topical steroids without systemic immunosuppression). Sclerokeratitis occurs when the peripheral limbus and adjacent sclera is involved. Focal or diffuse keratitis is also noted .  Somtimes there may occur an asymptomatic thinning of the cornea all around the limbus resulting in a ‘Contact lens’ cornea.
    Investigation of a patient with arthritis and a red eye include all causes of uveitis / arthritis and few secondary causes.
    Ocular lesions may be the first manifestation of the major systemic disease. Hence any patient with unexplained redness, corneal melts, marginal kerattitis or peripheral ulcerative keratitits or uveitis must be investigated for a systemic disease. Haemogram, RA factor, C Reactive Protein, cANCA for Wegener’s and other vasculitic causes , pANCA for nonvasculitic causes like Ankylosing Spondylitis , ACE  I level for Sarcoidosis,   ANA and DsDNA for Lupus related arthritis. Dermatological opinion for psoriatic arthroathy , form the battery of tests that need to be done. An Xray of the lumbosacral joint to rule out sacroilitis and/or ankylosing spondylosis. Renal and liver function tests must be done before starting the immune suppressive agents as these are known to be hepato and nephrotoxic.
    Treatment includes systemic steroids, Immunosuppressives, oral analgesics, topical steroids, NSAIDs, cyclosporine and cycloplegics. Additional therapeutic measures like tissue adhesives, patch grafts may be necessary.
    Systemic steroids and Immunosuppression are essential in controlling the disease and so it’s ocular manifestations. After detailed investigations oral prednisolone is started at the dose of 1 mg/ kg to be tapered over two to three weeks. A low dose maintenance dose may be continued, ensuring the blood sugars as normal and calcium supplements given. Oral Methotrexate weekly 7.5 to 15 mg, or Azathioprine 100 mg daily. Anti TNF alpha agents like eternacept, infliximab have been used with good results.
    Systemic therapy needs to be continued on a long term basis and hence monitoring under the care of a physician to be sure the disease process is under control and at the same time no toxicity involving bone marrow depression, renal or liver dysfunction occurs.
    Local therapy in ocular lesions like Episcleritis, scleritis, iridocyclitis and keratitis are all treated with steroid eye drops. Prednisolone acetate 1% penetrates the best and has to be administered under close supervision. The dosage has to be titrated according to the local response. Any associated corneal thinning or melting must be treated with application of tissue glue, bandage contact lenses or patch graft with preserved cornea or sclera. Scleral thinning would require sclera patch grafts in areas of extensive thinning. Anti glaucoma drops and oral medication are required to control raised intraocular pressure resulting from the accompanying inflammation or the steroid response. Cycloplegics and antibiotics must also be prescribed.  Artificial tears, lubricants and prophylactic antibiotic drops are adjuvents in the treatment.
    Preservation of the ocular morbidity, by treating the active disease and preventing recurrences and preserving the vision and so the quality of life of the patient form the main aim of therapy of patients with ocular involvement  in Arthritis.


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