Free previewYou're reading the free part of this topic. The rest is included with Clinical.See what's included
Ocular Manifestations of Rheumatoid Arthritis
Uvea
Teaching images
101. Clinical Analogy & Introduction
Teaching image
1Exam pearl
- Clinical Analogy: Think of Rheumatoid Arthritis as a chronic fire raging in synovial joints - but the same inflammatory smoke (immune complexes, cytokines, autoantibodies) drifts to the eye.
- The ocular surface is like the “synovium of the eye,” rich in connective tissue, mucin glands, and vascular networks - all vulnerable to the same tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1)/interleukin-6 (IL-6) storm.
- Peripheral ulcerative keratitis (PUK) is the ocular analogue of rheumatoid vasculitis.
- Peripheral ulcerative keratitis (PUK) may signal rheumatoid vasculitic disease and can progress to corneal melt or perforation.
- Rheumatoid Arthritis (RA) is a systemic autoimmune polyarthropathy with a 2020 age-standardized global prevalence of approximately 0.21%.
- Rheumatoid Arthritis (RA) affects women approximately 2–3 times more often than men; onset can occur at any age and is most often at 60–70 years globally.
- Reported ocular involvement prevalence varies; a meta-analysis estimated approximately 18%, while some reports describe ocular manifestations in as many as 39% of patients.
- Manifestations range from the comparatively benign dry eye to vision-threatening and potentially life-threatening necrotising scleritis and peripheral ulcerative keratitis. Rheumatoid Arthritis (RA)-associated necrotising scleritis and peripheral ulcerative keratitis are destructive, sight-threatening disease and may signal potentially lethal occult systemic vasculitis.
- The treating ophthalmologist must understand that ocular disease does not necessarily mirror systemic Rheumatoid Arthritis (RA) activity; however, worsening scleritis, especially necrotising scleritis, or peripheral ulcerative keratitis warrants urgent rheumatological reassessment after infectious causes are excluded.
2. Pathophysiology
Teaching image
1The immunopathology of rheumatoid arthritis (RA) centres on CD4-positive T-helper-cell activation → B-cell stimulation → production of rheumatoid factor (RF; autoantibodies against the Fc portion of immunoglobulin G, commonly immunoglobulin M) and anti-cyclic citrullinated peptide (anti-CCP) antibodies. In the eye, this manifests as:
| Mechanism | Ocular Target | Resultant Manifestation |
|---|---|---|
| • Immune-complex deposition • Rheumatoid factor (RF) + immunoglobulin G → complement activation | • Episcleral/scleral vessels | • Episcleritis • Scleritis |
| • T-cell-mediated inflammation • Tumour necrosis factor alpha, interleukin 1, interleukin 6, interleukin 17 | • Corneal stroma | • Peripheral ulcerative keratitis (PUK) • Keratolysis |
| • Matrix metalloproteinase (MMP) upregulation • Collagenases | • Corneal periphery | • Stromal lysis • Corneal melt |
| • Goblet-cell destruction • Lymphocytic infiltration • Mechanism affecting conjunctiva and lacrimal gland remains uncertain | • Conjunctiva / lacrimal gland | • Keratoconjunctivitis sicca (KCS) • Mucin & aqueous deficiency |
| • Vaso-occlusive necrotizing scleritis • Progressive obliteration of vascular networks | • Scleral vascular networks | • Retinal vasculitis (rare) |
| Mechanism | Ocular Target | Resultant Manifestation |
|---|---|---|
| • Immune-complex deposition • Rheumatoid factor (RF) + immunoglobulin G → complement activation | • Episcleral/scleral vessels | • Episcleritis • Scleritis |
| • T-cell-mediated inflammation • Tumour necrosis factor alpha, interleukin 1, interleukin 6, interleukin 17 | • Corneal stroma | • Peripheral ulcerative keratitis (PUK) • Keratolysis |
| • Matrix metalloproteinase (MMP) upregulation • Collagenases | • Corneal periphery | • Stromal lysis • Corneal melt |
| • Goblet-cell destruction • Lymphocytic infiltration • Mechanism affecting conjunctiva and lacrimal gland remains uncertain | • Conjunctiva / lacrimal gland | • Keratoconjunctivitis sicca (KCS) • Mucin & aqueous deficiency |
| • Vaso-occlusive necrotizing scleritis • Progressive obliteration of vascular networks | • Scleral vascular networks | • Retinal vasculitis (rare) |
Exam pearl
- PEARL: Anti-cyclic citrullinated peptide antibodies are more specific for rheumatoid arthritis (95%) than rheumatoid factor (85%). Anti-cyclic citrullinated peptide antibody positivity is associated with ocular manifestations of rheumatoid arthritis. Rheumatoid arthritis-associated scleritis is more often necrotising than idiopathic scleritis.
Free preview ends here
Keep reading Ocular Manifestations of Rheumatoid Arthritis
15 more sections are included with the Clinical plan.
- Overview of Ocular Manifestations
- Keratoconjunctivitis Sicca (KCS) / Dry Eye
- Episcleritis
- Scleritis
- Peripheral Ulcerative Keratitis (PUK)
- Management of PUK