|Year : 1977 | Volume
| Issue : 3 | Page : 20-26
Ocular manifestations of rheumatoid arthritis
SC Reddy, SD Gupta, IS Jain, SD Deodhar
Postgraduate Institute of Medical Education and Research, Chandigarh, India
S C Reddy
Civil Assistant Surgeon & Eye Specialist, Government Headquarters Hospital, Ongole-523002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Reddy S C, Gupta S D, Jain I S, Deodhar S D. Ocular manifestations of rheumatoid arthritis. Indian J Ophthalmol 1977;25:20-6
|How to cite this URL:|
Reddy S C, Gupta S D, Jain I S, Deodhar S D. Ocular manifestations of rheumatoid arthritis. Indian J Ophthalmol [serial online] 1977 [cited 2020 Jun 5];25:20-6. Available from: http://www.ijo.in/text.asp?1977/25/3/20/31264
Although considerable attempts have been made to elucidate the aetiopathogenesis presently, rheumatoid arthritis is considered to be auto-immune in nature, principally producing a progressively crippling polyarthritis. Ocular involvement is an important nonarticular manifestation.
The association of ocular lesions with rheumatoid arthritis has long been recognised. The well documented ocular complications of this disease are keratoconjunctivitis sicca, anterior uveitis, episcleritis, scleritis, scleromalacia perforans and massive granuloma of sclera. The rare ocular lesions reported in the literature are granular opacities with peripheral vascularisation of corneal stroma, marginal furrows of cornea, choroiditis, optic neuritis, and bilateral choroidal nodules and secondary retinal detachment. Watson has described marginal thinning and opacification of cornea, keratolysis and descemetocele accompanying severe €necrotising scleritis, sclerosing keratitis causing diffuse opacification and "candy floss" opacity of cornea in patients with rheumatoid arthritis.
Since the clinical profile of rheumatoid arthritis in India seems to be different from that observed in West and the ocular involvement is relatively uncommon in India, it was felt worthwhile to study the ocular manifestations of rheumatoid arthritis. Moreover, there is paucity of literature from India on this subject. Therefore the present study was undertaken to find out the prevalence of various ocular lesions in patients with rheumatoid arthritis in the North-West region of India.
| Materials and method|| |
One hundred consecutive patients of rheumatoid arthritis, irrespective of their age and sex, attending Rheumatology clinic of Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, from August, 1971 to January, 1974, were studied for various ocular lesions. A detailed clinical examination of the patients was done to assess the clinical status of arthritis. The following investigations were done in every patient viz., erythrocyte sedimentation rate, Rosewaaler test/latex fixation test for rheumatoid factor, serum proteins for hyperglobulinemia and X-Rays of the affected joints. The diagnosis of rheumatoid arthritis was made as per the criteria of American Rheumatism Association and all the patients were grouped into classical, definite and probable rheumatoid arthritis.
A detailed history of eye symptoms with their duration was obtained and a complete ocular examination was done in every patient with torch light and slit lamp biomicroscope. The lacrimal secretion was measured in all patients by Schirmer I test using Whatman No. 41 filter paper strips. Schirmer II test was done in those who showed impaired lacrimal secretion i.e., less than 15 mm. by Schirmer I test. All the patients were subjected to Rose Bengal Staining of eyes and the corneal involvement was assessed by slit lamp examination. Ophthalmoscopic examination of fundus was done in every patient. The diagnosis of definite or possible keroto-conjunctivitis sicca was made as per the criteria of Williamson et a1. The statistical analysis of the data was done by using group comparison `t' test and chisquare (x2) test.
| Observations|| |
Out of 100 patients studied 36 were males and 64 were females. The distribution of eye changes in different groups of rheumatoid arthritis is shown in [Table - 1]. Thirty nine patients (11 males and 28 females) showed evidence of ocular lesions. Some of them had more than one ocular manifestation. The various ocular lesions observed in these 39 patients are shown in [Table - 2]. Ocular involvement was found to be bilateral in 26 and unilateral in 13 patients. Nine patients were suffering from juvenile rheumatoid arthritis and three of them showed eye changes viz., disseminated choroiditis and chronic iridocyclitis in one, unilateral edema of optic disc in another and posterior subcapsular cataracts in the third.
The corneal damage, as shown by rose bengal staining, in relation to the amount of lacrimal secretion is shown in [Table - 3]. In the present series a significant correlation (p <0.01) was found between postive rose bengal staining and the impairement of lacrimal secretion.
The clinical and laboratory findings of all patients of rheumatoid arthritis are shown in [Table - 4]. At the time of examination the mean age of patients and duration of arthritis were significantly higher in patients with eye changes (p < 0.01) as compared to those without eye changes. Erythrocyte sedimentation rate (an index of disease severity), presence of rheumatoid factor in serum (1:16 or higher titre of Rose Waaler test or positive latex fixation test), hyperglobulinemia (more than 3.5 G% globulins in serum) and the presence of radiological changes in the affected joints, were not significantly related (p > 0.05) to the presence or absence of ocular diseases in patients of rheumatoid arthritis.
It is worthwhile mentioning the following interesting observations in some of our cases:
1. A thirteen year old boy suffering from Juvenile rheumatoid arthritis developed sudden, painless, blurring of vision in right eye during his stay in the hospital. Ocular examination revealed edema of optic disc in right eye [Figure - 1] and normal optic disc in left eye. Visual acuity and colour vision were normal in both eyes. There was no central scotoma.
There were no symptoms of raised intracranial pressure. So the edema of optic disc in right eye was considered to be neither due to optic neuritis nor raised intracranial pressure, though the exact pathogenesis was obscure.
2. Bilateral disseminated choroiditis was observed in a twenty two year old woman who was suffering from Juvenile rheumatoid arthritis of fifteen years duration. [Figure - 2] This patient also had chronic iridocyclitis in both eyes. She was taking oral corticosteroids for the past five years and slit lamp examination revealed posterior subcapsular cataracts in both eyes. All the investigations for other causes of uveitis were negative, so it was assumed that choroidits was related to rheumatoid disease in this patient.
3. A twenty two year old man with definite rheumatoid arthritis of four years duration had normal eyes in his first visit. After one year, he developed acute iridocyclitis in left eye following arthrodesis of right knee joint. There was exacerbation of iridocyclitis after six weeks following patellectomy on the same side. Inspite of intensive local and systemic steroid therapy there was no improvement of vision. Right eye was normal. Finally complicated cataract developed in left eye three months after the attack of acute iridocyclitis. As all the investigations for other causes of anterior uveitis were negative, the iridocyclitis was considered to be of rheumatoid origin in this patient.
4. A recurrent, chronic tender episcleral nodule, few millimeters away from the limbus, in the upper temporal quadrant of left eye was observed in a forty year old women suffering from probable rheumatoid arthritis of two and half years duration.
5. A forty two year old woman suffering from definite rheumatoid arthritis of three years duration had keratoconjunctivitis sicca in both eyes. A small retinal haemorrhage was observed below the macular area in her left eye. In the absence of any other factor to account for the cause of retinal haemorrahage it was considered to be of rheumatoid origin, though the exact pathogenesis remains obscure.
| Discussion|| |
The incidence of ocular lesions in the present study (39%) is much higher than the earlier reports i.e., 6.2% by Smith and 20.8% Williamson et a1. The former of the two studies is not comparable to the present series since it was a retrospective study of case histories of rheumatoid arthritis patients and the tests for keratoconjunctivitis sicca were not done in those patients.
| Keratoconjunctivitis Sicca|| |
Keratoconjunctivitis sicca is the commonest ocular manifestation of rheumatoid arthritis. The incidence of keratoconjunctivitis sicca in the present series is 29% whereas it has been reported in 10% to 40°/ of patients of rheumatoid arthritis by different authors [Table - 5]. Rheumatoid process has been considered to be aetiologically related to keratoconjunctivitis sicca by Stenstam, Holm, and Thompson and Eadie. However Henderson and Stoltze et a1 regarded rheumatoid arthritis as an incidental finding without aetiological importance for Sjogren's syndrome. It is possible that both these diseases might have autoimmune aetiological basis as suggested by Doniach and Rott.
In the present study 18 patients had definite rheumatoid arthritis and keratoconjunctivitis sicca and thus could be labelled as Sjogren's syndrome, which is characterised by the triad of Polyarthritis, Keratoconjunctivitis sicca and Xerostomia or atleast two of the three features (Sjogren). Five out of these 18 patients had subjective dryness of mouth and findings suggestive of moderate xerostomia.
Two of our patients presented with pain, redness, diminution of vision and marked photopobia. They had superficial corneal ulcers, but the lacrimation was markedly diminished as evidenced by Schirmer test. So, this suggests that the lack of lacrimation in the presence of photophobia and redness in cases of corneal ulcers should arouse the suspicion of keratoconjunctivitis sicca.
The findings of negative rose bengal staining of cornea in 9 eyes with grossly impaired lacrimation and positive staining of cornea in 10 eyes with adequate secretion [Table - 3] are consistent with the observation of Holm This phenomenon could be due to alteration in the quality rather than the quantity of tears (Henderson)
An interesting observation in our study was that 40 patients did not have any eye symptoms, however on detailed examination 3 of them showed definite keratoconjunctivitis sicca. This emphasizes the need of routine and complete Ophthalmological examination of all patients of rheumatoid arthritis in order to detect the ocular involvement early in the course of disease.
| Anterior uveitis|| |
Incidence is shown in [Table - 6] though Foresteir et all did not find any case of iritis in their study of 100 cases of rheumatoid arthritis.
| Posterior uveitis|| |
Choroiditis is rare in rheumatoid arthritis. Kimura et al found one case of choroiditis among sixteen adults with rheumatoid arthritis. Hogan et al pointed out that choroiditis practically never occurs in rheumatoid arthritis and the selective involvement of iris or iris and ciliary body is remarkable. However, in the present study bilateral diseminated choroiditis along with chronic iridocyclitis was seen in a case of Juvenile rheumatoid arthritis [Figure - 2],[Figure 4] and the association of posteior and anterior uveitis itself is a rare occurence. The infrequent involvement of choroid in uveitis has been attributed to the presence of hyaluronidase or hyaluronic acid in the aqueous which might predispose the iris vessels to more damage (Maumenee).
| Scleral lesions|| |
The scleral lesions seem to be rare in rheumatoid arthritis. Jayson and Jones reported 6.3% incidence of scleritis in rheumatoid arthritis and concluded that scleritis was significantly associated with rheumatoid nodules and other systemic complications of rheumatoid arthritis. They did not find any case of episcleritis in their study of 142 patients. However in the present series one case of episcleritis and another case of healed scleritis were observed in probable and definite rheumatoid arthritis patients respectively. Subcutaneous nodules and rheumatoid factor in serum were absent in both these patients.
| Optic Nerve Lesions|| |
Primary involvement of optic nerve in rheumatoid arthiritis has been earlier reported by Jain et al  and Chadwick and Rosen. In the present series, one patient of Juvenile rheumatoid arthritis was found to have unilateral edema of optic disc [Figure - 1]. The exact mechanism of edema of optic disc is not clear. However, the involvement of collagen tissue of optic nerve sheaths and septa of optic nerve by rheumatoid process, as postulated by Jain et al could be a possible mechanism in pathogenesis of edema of optic disc in this patient.
| Retinal Lesions|| |
Primary involvement of retina in rheumatoid arthritis is very rare. However, one case of bilateral choroidal nodules and secondary retinal detachment in a patient with rheumatoid arthritis and a history of severe vascular abnormalities, iritis and scleremalacia performans was reported by Hurd et al. sub In the present study one patient showed retinal haemorrhage in left eye. She had keratoconjunctivitis sicca in her both eyes. In the absence of any other factor to account for retinal haemorrhage it was considered to be rheumatoid origin, though the exact pathogenesis remains obscure.
| Lenticular Changes|| |
The observation of posterior subcapsular cataracts in patients of rheumatoid arthritis who were on long term oral steroids has been well documented by Oglesby et a1 and Williamson et a1. In the present series 15 patients were receiving long term oral corticosteroids and 9 of them showed bilateral posterior subcapsular cataracts. These cataracts were not present in the rest 85 patients who were not on steroid therapy. The mean duration of steroid therapy was 3.83 years, the range being 5 month to 12 years and the average dose of steroids was 10-15 mg. per day. The intra ocular pressure was normal in all of them. The presence of posterior subcapsular cataracts in patients who were on long term oral steroid therapy and their absence in those who were not taking steroids shows clearly the cause and relationship between the cataracts and drug therapy, rather than the disease process.
In 18 out of 39 patients with ocular lesions the following systemic manifestations were observed viz: anaemia in ten patients, hepatosplenomegaly in three, nodular goitre in two, hepatomegaly in one, hypogenadism and gynaecomastia in one, secondary amyloidosis of kidney and right parotid abscess in one patient. None of the ocular lesions were significantly associated with systemic complication of rheumatoid arthritis.
| Summary|| |
In a study of 100 cases of rheumatoid arthiritis 39 patients showed various ocular lesions viz., keratoconjunctivitis sicca in twenty nine patients, anterior uveitis in four, disseminated choroiditis in one, episcleritis in one, healed scleritis in one, retinal haemorrhage in one, unilateral edema of optic disc in one and posterior subcapsular cataracts in nine patients. In 7 patients more than one ocular manifestation was present.
The following conclusions were drawn from this study.
1. Ocular involvemeul in rheumatoid arthritis is not uncommon in India.
2. Age of patients and duration of arthriits are directly related to the frequency of ocular lesions.
3. Presence of rheumatoid factor, hyperglobulinaemia, radiological changes in joints and erythrocyte sedimentation rate do not have any relation with the prevalence of ocular lesions in rheumatoid arthiritis.
4. There is no correlation between the severity of arthritis and scleral lesions.
5. Routine Schirmer test and Rose Bengal staining help to detect the early onset of keratoconjunctivitis sicca in patients of rheumatoid arthritis.
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[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]