Treatment Plan

RA and Its Ocular Complications

BY WILLIAM L. MILLER, OD, PHD, FAAO

Ocular conditions secondary to systemic diseases pose unique challenges for our practice. They require careful review of systems as well as treatment and management of the ocular condition with keen coordination with another healthcare specialist concerning the systemic disease itself.

Rheumatoid arthritis (RA) is one such disease that falls into this category, with about 1.5 million patients affected in the United States (Centers for Disease Control). While it is true that keratoconjunctivitis sicca is likely the most common associated ocular disease in RA patients, it is not the only one. K. sicca and other ocular and systemic conditions other than joint disease are typically referred to as extra-articular manifestations of the disease. This column will focus on the other ocular extra-articular manifestations of RA.

Treatment and Management

Ocular structures affected by RA include the sclera, episclera, cornea, and retina. The manifestation of any ocular extra-articular complication should be communicated to the patients’ rheumatologist or internist because an occurrence may speak to the increasing severity or exacerbation of the RA condition.

Treatment and management of RA-related conditions such as scleritis and episcleritis may be similar to other non-RA derived cases; however, precise management strategies may vary due to the disease’s pathogenicity and mechanisms of inflammation.

Ocular sequelae are the result of the overall systemic inflammation, which in the management scheme are also controlled by the systemic medication the patient is taking. Depending on the severity and history, many RA patients will be treated by their physician with the following classes of drugs: disease modifying antirheumatic drugs (DMARDs, e.g. Methotrexate), non-steroidal anti-inflammatory drugs (NSAIDs), immunosuppressants/biological response modifiers (e.g. Rituxan, Humira, Remicade, and Enbrel), and corticosteroids.

Scleritis and Episcleritis

Scleritis and episcleritis are the second most common associated ocular conditions and are typically treated and managed with anti-inflammatory medications.

Episcleritis can be self-limiting and may require topical lubrication and tear supplements. However, given the systemic nature causing the episcleritis, many patients will benefit from topical steroid or NSAID treatment because the timeframe for these induced episcleritis episodes may last longer compared to the idiopathic variety.

The more serious extra-articular ocular complication, scleritis, is present in 1 percent to 6 percent of your RA patients (Thorne and Jabs, 2001; Matsuo et al, 1997). The lack of penetration to scleral tissue makes topical application of steroids and NSAIDs a less useful option for ocular treatment. An injectable steroid (triamcinolone) can be beneficial, but is contraindicated in cases of necrotizing scleritis. Side effects can include cataract formation and intraocular pressure elevation; the latter can be managed with anti-glaucoma medication.

Several reports explain the benefit of ocular steroid injections (sub-conjunctival or sub-tenons), with success rates between 92 percent and 96 percent (Albini et al, 2005; Roufas et al, 2010). Roufas (2010) reported a mean time between scleritis episodes of 112 months after steroid injections.

Other therapy regarding scleritis in your RA patients includes systemic medications and are best coordinated with the patient’s rheumatologist, internist, or ophthalmologist specializing in systemic inflammatory disease treatment. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #208.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Academy of Optometry and the AOA where he serves on its Journal Review Board. He is a consultant or advisor to Alcon and Vistakon and has received research funding from Alcon and CooperVision and lecture or authorship honoraria from Alcon and B+L. You can reach him at wmiller@uh.edu.