The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis

doi:10.1016/j.berh.2016.10.007

Best Practice & Research Clinical Rheumatology

Volume 30, Issue 5, October 2016, Pages 802-825

https://doi.org/10.1016/j.berh.2016.10.007 Get rights and content

Abstract

Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis are associated with potentially sight-threatening inflammatory eye disease. Although the ocular manifestations associated with ankylosing spondylitis and psoriatic arthritis are similar, such as anterior uveitis, this differs from rheumatoid arthritis where dry eye, peripheral ulcerative keratitis and scleritis are the major ocular complications. Apart from causing sight loss, these conditions are painful, debilitating, often recurrent or chronic and may require long-term therapy. Treatments such as ocular lubricant, topical corticosteroid, systemic corticosteroid and systemic immunosuppression are often similar for the underlying systemic disease. Yet for the treatment of the ocular complications, the evidence base is weak. Close collaboration with a rheumatologist is often essential, particularly in the management of these patients.

Section snippets

Ocular complications of rheumatoid arthritis

The ocular complications of rheumatoid arthritis (RA) more commonly affect the front (anterior segment) than the back of the eye (posterior segment) [1]. Anterior segment disease includes dry eye, peripheral ulcerative keratitis (PUK), episcleritis and anterior scleritis [2]. Posterior segment disease includes posterior scleritis and rarely a retinal vasculitis [3].

What is the most frequent ocular manifestation of RA?

The most frequent ocular manifestation in patients with RA is dry eye disease (DED, keratoconjunctivitis sicca) with up to 45% of

What is the most common ophthalmic manifestation of AS?

The most common ophthalmic manifestation is acute anterior uveitis (AAU) that occurs in 40% of patients with AS with males more commonly affected than females, occurring typically in young adults between the ages of 20 and 40 years [44], [45]. It is estimated that up to one-third of patients with AAU have AS [46], and that 50% of patients presenting with AAU in the Western world are likely to be HLA-B27 positive [47].

Uveitis comprises a diverse group of conditions involving inflammation of the

What is the most common ophthalmic manifestation of PsA?

Ophthalmic manifestations are estimated to occur in 10% of patients with psoriasis [71], and 31% of patients with PsA [72], with the most common manifestation of PsA being uveitis, but seen at a lesser frequency (7%) than in AS [73]. Egeberg et al. performed a nationwide cohort study of the Danish population from 1 January 1997 through 31 December 2011 and included 74,129 Danish patients with psoriasis who were 18 years or older. They identified 74,129 cases of psoriasis and PsA and 13,114

Summary

RA, AS and PsA all have sight-threatening ocular complications. In RA, DED is the most common ocular manifestation with significant impact on the patient's life. Treatment options largely depend on patient preference. PUK is relatively rare but can lead to globe perforation. Underlying corneal infection must be excluded and urgent reconstructive surgery may be required. Systemic immunomodulation similar to scleritis is necessary. Scleritis causes an intense red eye with excruciating pain and

Conflict of interest/financial disclosure

Neither author has any conflict of interest nor any financial support, personal financial interest or commercial relationship relevant to the subject matter of this manuscript.

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Cited by (45)

Ophthalmic adverse events under tofacitinib and baricitinib: Case analysis of the European Pharmacovigilance Database
2023, Joint Bone Spine
Standard for treatment of visceral involvement in rheumatoid arthritis
2021, Medicine (Spain)
La afectación extraarticular en la artritis reumatoide es compleja y variada, pudiendo afectar a varios órganos y sistemas, incluyendo a nivel cutáneo, pulmonar, neurológico y oftalmológico, entre otros. La evidencia del tratamiento de estas afectaciones es escasa y de baja calidad, y se suele requerir una colaboración multidisciplinar, en muchos casos debido a su difícil manejo. En el presente protocolo terapéutico, se recogerán los tratamientos para las principales manifestaciones extraarticulares, en base a la evidencia disponible actualmente.
Non-articular and systemic manifestations in rheumatoid arthritis are very broad, and several organs and systems may be involved, including the skin, eye, lung and nervous system. High quality evidence about specific treatments is lacking, therefore the management of the extra-articular involvement in rheumatoid arthritis is complex and often requires a multidisciplinary approach. In the present treatment protocol, we will review the treatments for the main extra-articular manifestations, based on the limited evidence available.
Rheumatoid arthritis
2021, Medicine (Spain)
La artritis reumatoide es una enfermedad inflamatoria crónica de origen autoinmune que afecta a las articulaciones, causando daño a nivel de cartílago y hueso. Además, debido a su cronicidad, provoca importantes costes directos e indirectos, tanto para el individuo como para la sociedad, incluyendo discapacidad, pérdidas en la productividad laboral y disminución de la calidad de vida. De etiología desconocida y distribución universal, afecta al 1% de la población. Su patogenia, parcialmente desconocida, se ha relacionado con la exposición repetida a factores ambientales como el tabaco y la citrulinización de proteínas que provoca, asociado a una predisposición genética del individuo, una respuesta inmune. Los pacientes presentan tumefacción poliarticular simétrica con dolor inflamatorio y rigidez matutina. No obstante, existen diferentes patrones clínicos de inicio, evolución y afectación. Además, pueden desarrollar manifestaciones extraarticulares como nódulos reumatoides, afectación pulmonar, hematológica, neurológica y otras comorbilidades asociadas. Los criterios utilizados son clasificatorios. El diagnóstico se realiza en base a la presencia de artritis con datos radiológicos y analíticos característicos como son factor reumatoide y anticuerpos antipéptidos citrulinados.
Rheumatoid arthritis (RA) is a chronic inflammatory disease of autoimmune origin that affects the joints, damaging bone and cartilage. In addition, because it is chronic, it generates significant direct and indirect costs, both for the individual and for society. These costs include disability, work productivity losses and reduced quality of life. Universally distributed and of unknown aetiology, RA affects 1% of the population. The pathogenesis of RA, partially unknown, has been linked with repeated exposure to environmental factors such as tobacco and to protein citrullination, associated with a genetic predisposition to develop an immune response. Patients present symmetrical multi-joint swelling with inflammatory pain and morning stiffness. However, there are different clinical patterns of the onset, evolution and impact of RA. Patients can also develop extra-articular clinical features such as rheumatoid nodules, pulmonary, haematological or neurological involvement and other associated comorbidities. The criteria used depend on classifications. Patients are diagnosed based on the presence of arthritis, along with typical laboratory and radiology data such as rheumatoid factor and anti-citrullinated peptide antibodies.
Biologic therapy in severe and refractory peripheral ulcerative keratitis (PUK). Multicenter study of 34 patients
2020, Seminars in Arthritis and Rheumatism
Citation Excerpt :
Initial triggers of inflammatory response have been reported in some patients with PUK. The most common are surgery and activity of a systemic underlying disease [28,29]. They were searched in our patients.
We assessed the efficacy and safety of biologic therapy in severe and refractory Peripheral Ulcerative Keratitis (PUK).
Open-label multicenter study of biologic-treated patients with severe PUK refractory to conventional immunosuppressive drugs.
We studied 34 patients (44 affected eyes) (24 women/10 men; mean age, 55.26±17.4 years). PUK was associated with a well-defined condition in 29 of them (rheumatoid arthritis [n = 20], psoriatic arthritis [n = 2], inflammatory bowel disease [n = 2], Behçet disease [n = 1], granulomatosis with polyangiitis [n = 1], microscopic polyangiitis [n = 1], systemic lupus erythematosus [n = 1] and axial spondyloarthritis [n = 1]). Besides topical and oral systemic glucocorticoids, patients had received: methylprednisolone pulses [n = 9], and conventional immunosuppressive drugs, mainly methotrexate [n = 18], and leflunomide [n = 7]. Eleven patients had required ocular surgery prior to biologic therapy.
Following biologic therapy, baseline main outcomes were compared with those found at 1st week, 1st and 6th months and 1st year.
Efficacy and safety of biologic therapy. Efficacy was analyzed by the assessment of corneal inflammation (corneal thinning, central keratolysis and ocular perforation); other causes of ocular surface inflammation (scleritis, episcleritis); intraocular inflammation (uveitis); visual acuity and glucocorticoid sparing effect.
The first biologic agents used were anti-TNFα drugs (n = 25); adalimumab (n = 16), infliximab (n = 8), etanercept (n = 1), and non-TNFα agents (n = 9); rituximab (n = 7), tocilizumab (n = 1) belimumab (n = 1) and abatacept (n = 1). During the follow-up, switching to a second biologic agent was required in 12 of the 25 (48%) patients treated with anti-TNFα drugs. However, no switching was required in those undergoing biologic therapy different from anti-TNFα agents. The main outcome variables showed a rapid and maintained improvement after a mean follow-up of 23.7 ± 20 months. Major adverse effects were tachyphylaxis, relapsing respiratory infections, supraventricular tachycardia, pulmonary tuberculosis and death, one each.
Biologic therapy is effective and relatively safe in patients with severe and refractory PUK. Non-anti-TNFα agents appear to be effective in these patients.
Factors Predictive of Remission of Chronic Anterior Uveitis
2020, Ophthalmology
Citation Excerpt :
Also several other reports found that juvenile idiopathic uveitis was often accompanied by persistent disease.18–21 The diseases included in spondyloarthropathy—ankylosing spondylitis, psoriatic arthritis, and reactive arthritis—are also commonly known to be recurrent or chronic.22,23 It is interesting to note that HLA-B27 status was not associated with the incidence of remission, although HLA-B27 itself is associated with ankylosing spondylitis and psoriatic arthritis.
To estimate the incidence of medication-free remission of chronic anterior uveitis and identify predictors thereof.
Retrospective cohort study.
Patients diagnosed with anterior uveitis of longer than 3 months’ duration followed up at United States tertiary uveitis care facilities.
Estimation of remission incidence and identification of associated predictors used survival analysis.
Incidence of medication-free remission. For the primary analysis, remission was defined as inactive uveitis while off treatment at all visits spanning an interval of at least 90 days or—for patients who did not return for follow-up after 90 days—remaining inactive without receiving suppressive medications at all of the last visits. Association of factors potentially predictive of medication-free remission was also studied.
Two thousand seven hundred ninety-five eyes of 1634 patients with chronic anterior uveitis were followed up over 7936 eye-years (4676 person-years). The cumulative medication-free, person-year remission incidence within 5 years was 32.7% (95% confidence interval [CI], 30.4%–35.2%). Baseline clinical factors predictive of reduced remission incidence included longer duration of uveitis at presentation (for 2 to 5 years vs. less than 6 months: adjusted hazard ratio [aHR], 0.61; 95% CI, 0.44–0.83), bilateral uveitis (aHR, 0.75; 95% CI, 0.59–0.96), prior cataract surgery (aHR, 0.70; 95% CI 0.56–0.88), and glaucoma surgery (aHR, 0.63; 95% CI, 0.45–0.90). Two time-updated characteristics were also predictive of reduced remission incidence: keratic precipitates (aHR, 0.36; 95% CI, 0.21–0.60) and synechiae (aHR, 0.62; 95% CI, 0.41–0.93). Systemic diagnosis with juvenile idiopathic arthritis and spondyloarthropathy were also associated with reduced remission incidence. Older age at presentation was associated with higher incidence of remission (for age ≥40 years vs. <40 years: aHR, 1.29; 95% CI, 1.02–1.63).
Approximately one third of patients with chronic anterior uveitis remit within 5 years. Longer duration of uveitis, younger age, bilateral uveitis, prior cataract surgery, glaucoma surgery, presence of keratic precipitates and synechiae, and systemic diagnoses of juvenile idiopathic arthritis and spondyloarthropathy predict reduced remission incidence; patients with these factors should be managed taking into account the higher probability of a longer disease course.
The Autoimmune Rheumatic Disease Related Dry Eye and Its Association with Retinopathy
2023, Biomolecules

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2The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis

Abstract

Section snippets

Ocular complications of rheumatoid arthritis

What is the most frequent ocular manifestation of RA?

What is the most common ophthalmic manifestation of AS?

What is the most common ophthalmic manifestation of PsA?

Summary

Conflict of interest/financial disclosure

Ocular inflammatory diseases associated with rheumatoid arthritis

Nat Rev Rheumatol

Scleritis: challenges in immunopathogenesis and treatment

Discov Med

Retinal vasculitis in rheumatoid arthritis: an angiographic study

Clin Exp Rheumatol

Secondary Sjögren's syndrome in rheumatoid arthritis

J Rheumatol

The definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye WorkShop

Ocul Surf

Report of the TFOS/ARVO Symposium on global treatments for dry eye disease: an unmet need

Ocul Surf

Economic and humanistic burden of dry eye disease in Europe, North America, and Asia: a systematic literature review

Ocul Surf

Utility assessment to measure the impact of dry eye disease

Ocul Surf

Utility assessment among patients with dry eye disease

Ophthalmology

The association between dry eye disease and depression and anxiety in a large population-based study

Am J Ophthalmol

Depression and anxiety in dry eye disease: a systematic review and meta-analysis

Eye

Management and therapy of dry eye disease: report of the management and therapy subcommittee of the international dry eye WorkShop

Ocul Surf

Corneal pain without stain: is it real?

Ocul Surf

A simplified quantitative method for assessing keratoconjunctivitis sicca from the Sjögren's syndrome International Registry

Am J Ophthalmol

The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction

Invest Ophthalmol Vis Sci

Toxicity of natural tear substitutes in a fully defined culture model of human corneal epithelial cells

Invest Ophthalmol Vis Sci

Carboxymethylcellulose binds to human corneal epithelial cells and is a modulator of corneal epithelial wound healing

Invest Ophthalmol Vis Sci

Effects of punctal occlusion on clinical signs and symptoms and on tear cytokine levels in patients with dry eye

Ocul Surf

Conjunctival epithelium improvement after systemic pilocarpine in patients with Sjögren's syndrome

Br J Ophthalmol

Treatment of dry eye by autologous serum application in Sjogren's syndrome

Br J Ophthalmol

Incidence of corneal melting in association with systemic disease in the Yorkshire Region, 1995–7

Br J Ophthalmol

The eye: a window of opportunity in rheumatoid arthritis?

Nat Rev Rheumatol

Ocular manifestations of rheumatoid arthritis and their correlation with anti-cyclic citrullinated peptide antibodies

Clin Ophthalmol

Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis

Ophthalmology

Peripheral ulcerative keratitis and corneal melt: a 10-year single center review with historical comparison

Cornea

Rheumatoid keratolysis: a series of 40 eyes

Eur J Ophthalmol

Ten-year experience of pulsed intravenous cyclophosphamide and methylprednisolone protocol (PICM protocol) in severe ocular inflammatory disease

Br J Ophthalmol

Scleritis Ocul Immunol Inflamm

Evaluation of patients with scleritis for systemic disease

Ophthalmology

Rheumatic disease and scleritis

Ophthalmology

Scleritis and peripheral ulcerative keratitis

Rheum Dis Clin North Am

Scleritis and episcleritis

Br J Ophthalmol

Posterior scleritis: analysis of epidemiology, clinical factors, and risk of recurrence in a cohort of 114 patients

Ocul Immunol Inflamm

Flurbiprofen: a nonselective cyclooxygenase (COX) inhibitor for treatment of noninfectious, non-necrotizing anterior scleritis

Ocul Immunol Inflamm

Long-term, multicenter evaluation of subconjunctival injection of triamcinolone for non-necrotizing, noninfectious anterior scleritis

Ophthalmology

Mycophenolate mofetil for the treatment of scleritis

Ophthalmology

2
The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis