Rheumatoid Arthritis
Autoimmune disorder causing inflammation and scarring of joints Principal ophthalmic manifestation in adults: dry eye syndrome ("keratitis sicca"), as tear-producing glands become damaged Principal ophthalmic manifestation in children: anterior uveitis
Photophobia "It feels like there is sand in my eyes" ("foreign body" sensation) Corneal surface dry and without usual shine Areas of absent epithelium stain green with instilled fluorescein dye Paper strip placed in anesthetized conjunctival cul-de-sac (Schirmer test) shows less than 10mm of wetting after 5 minutes In severe rheumatoid arthritis, junction of cornea and sclera ulcerates ("sclerokeratitis ") Children often report no symptoms Slit lamp examination of children shows low-grade anterior chamber inflammation, iris margin adhering to anterior lens capsule (posterior synechia ), cataract, elevated intraocular pressure
Corneal inflammation, trauma, dystrophy, radiation, and exposure may cause epithelial fluorescein staining (superficial punctate keratopathy), but Schirmer test normal Dry eye syndrome common feature of graft versus host disease, erythema multiforme, cicatricial pemphigoid, vitamin A deficiency Anterior uveitis and sclerokeratitis may occur in isolation or in other connective tissue diseases; see Connective Tissue Diseases
Refer patients suspected of rheumatoid arthritis or other connective tissue diseases to ophthalmologist because... Findings may help with systemic diagnosis and... Ophthalmic manifestations may require attention
Dry eye syndrome may lead to corneal scarring if not treated adequately Dry eye syndrome is treated with tear substitutes, topical corticosteroids and cyclosporine, punctal occlusion, moisture chambers, tarsorrhaphy Sclerokeratitis may lead to corneal perforation, endophthalmitis, loss of eye Anterior uveitis may lead to glaucoma and cataract
