How Does Rheumatoid Arthritis Affect Your Eyes?

Eye Inflammation

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Eye complications are not uncommon in people with rheumatoid arthritis (RA), an inflammatory autoimmune disease where your immune system mistakenly attacks your joints. These attacks cause inflammation, which leads to painful, swollen, and stiff joints. Chronic inflammation might eventually cause joint damage and disability. 

RA is a systemic disease, which means it can have whole-body effects. Systemic symptoms occur in people who have a more severe form of the disease. This could mean more inflammation to other parts of your body, including your skin, blood vessels, and eyes. Keep reading to learn about how RA can affect your eyes. 

Eye Complications of RA

RA can affect your eyes in many different ways, some of which might be more serious than others. Eye complications of RA include keratoconjunctivitis sicca, episcleritis, scleritis, and uveitis.

Keratoconjunctivitis Sicca

Also known as dry eye syndrome, keratoconjunctivitis sicca is a common eye complication connected to RA. It occurs when the eyes cannot produce tears, or enough tears. While there are a number of conditions that may cause dry eyes, RA and a condition called Sjogren’s syndrome are the most common causes.

Dry eye syndrome can cause mild or severe symptoms. Symptoms include:

  • Eye irritation
  • A feeling of grittiness in the eyes
  • Dry eyes
  • Redness
  • Blurred vision

It is important to treat dry eye syndrome to avoid the risk of eye infection or damage to the cornea. Dry eye syndrome can be managed effectively, and treatment is usually dependent on the underlying cause, symptoms, and severity.

Mild cases can respond well to over-the-counter eye drops, while severe cases might require prescription eye drops, anti-inflammatory medicines, or surgery.

Episcleritis

Episcleritis refers to inflammation of the episcleral, the clear layer on the top of the white part of the eye called the sclera. This inflammation causes the eyes to appear red and irritated.

Episcleritis is the second most common eye complication of RA and is believed to affect up to 5% of people with RA. It may occur at any stage of RA, although it is common during times when a person with RA is experiencing high levels of inflammation. Most cases of episcleritis are limited to one eye.

Episcleritis might resemble pink eye, but it doesn’t cause any discharge. This inflammatory eye symptom tends to clear up on its own without treatment.

There are two types of episcleritis: diffuse and nodular. They appear slightly different from each other. Diffuse type episcleritis affects 70% of people with episcleritis, and nodular episcleritis affects the remaining people with episcleritis.

  • Diffuse episcleritis causes redness in one part of the eye or throughout the eye with minimal discomfort.
  • Nodular episcleritis causes slightly raised bumps surrounded by dilated blood vessels, usually in one part of the eye.

Both types of episcleritis cause similar symptoms, including:

  • Sensitivity to bright light
  • Tearing or watery eyes
  • A hot, prickly, gritty feeling in the affected eye

Symptoms of episcleritis don’t usually affect vision. Most cases of episcleritis are mild and will resolve with 21 days. Recurrent episodes are treated with refrigerated artificial tears, mild topical corticosteroid eye drops, or oral nonsteroidal anti-inflammatory drugs (NSAIDs).

For most people, episcleritis is a harmless condition that doesn’t cause any long-term problems. Most of the time, it resolves on its on, and artificial tears help most people with RA manage symptoms. Corticosteroid eye drops and oral NSAIDs are also effective in controlling eye inflammation.

Scleritis 

Scleritis is an eye disorder in which the sclera becomes severely inflamed. The sclera is the white part of the eye and is connected to the muscles that help the eye to move.

Scleritis can be a painful condition that may lead to partial or complete vision loss if not properly treated. This inflammatory eye condition affects up to 6% of people with RA.

There are two main types of scleritis: anterior scleritis, which occurs at the front of the eye, and posterior scleritis, which occurs at the back part of the eye.

The anterior type has three subtypes, with the most common causing redness and irritation to the whole sclera. This type is the most treatable. Another type causes tender nodules (bumps) on the sclera, and the most severe is very painful and may damage the sclera.

The posterior type is much rarer than the anterior type. People with the posterior type have pain and tenderness. This type can lead to detachment of the retina (retinal detachment) and angle-closure glaucoma. The retina is the thin, light-sensitive layer of tissue that lines the back of the eye on the inside.

Most people with RA who have scleritis only have one type, but others might have it on both the front and back of the eye.

Symptoms of scleritis include:

  • Pain and tenderness of the affected eye
  • Redness and swelling in the white part of the eye
  • Blurry vision
  • Tearing
  • Extreme light sensitivity
  • Vision loss in severe cases

Treatment for scleritis may include:

  • NSAIDs to reduce inflammation and provide pain relief
  • Oral corticosteroids when NSAIDs don’t help with reducing inflammation
  • Immunosuppressive drugs for severe cases
  • Antibiotics and antifungal medicines to treat and prevent infections
  • Surgery to repair eye tissue, improve muscle function, and prevent vision loss

Scleritis treatment also involves treating its underlying cause. In people with RA, this means effectively managing the condition and getting inflammation under control.

Uveitis 

Uveitis is a type of inflammation affecting the middle layer of the tissue in the eyewall (the uvea). It causes eye redness, pain, and blurred vision. It can affect one or both eyes.

Uveitis affects up to 42% of people with RA who have eye involvement. There is some evidence that etanercept, a TNF blocker used in the treatment of RA, may be associated with an increased risk of uveitis in this population. 

Uveitis can be serious and lead to permanent vision loss. Early diagnosis and treatment are vital to prevent complications and preserve vision. Symptoms include: 

  • Eye redness
  • Eye pain
  • Sensitivity to light
  • Blurry vision
  • Dark, floating spots in the field of vision—called floaters
  • Decreased vision

There are four different types of uveitis, based on which parts of the eye are affected:

  • Anterior uveitis affects the inside of the front part of the eye. It is also called iritis, and is the most common type of uveitis.
  • Intermediate uveitis affects the retina, the blood vessels behind the lens, the pars plana, and the gel in the center of the eye (vitreous).
  • Posterior uveitis, also called choroiditis, refers to inflammation of the choroid, or the back part of the uvea. It may also affect the retina and optic nerve and could lead to permanent vision loss.
  • Panuveitis refers to inflammation of all of the layers of the uvea. It may also affect the lens, retina, optic nerve, and vitreous, eventually leading to vision loss or blindness.

When uveitis is caused by RA or another autoimmune disease, treatment will focus on getting all-over inflammation under control.

Treatment for uveitis may include the following.

  • Medicines to reduce inflammation: This might include prescription eye drops and inflammatory medications, such as oral corticosteroids. Corticosteroid injections in or around the eye are another way to reduce eye inflammation.
  • Medicines to manage spasms: Eye drops that dilate (widen) the pupils can relieve eye spasms and reduce eye pain.
  • Medicines to fight off infections: When uveitis is caused by infection, it might be treated with antibiotics or antiviral medicines.
  • Medicines to reduce the effects of the immune system: If uveitis affects both eyes or doesn’t resolve with other treatments, immunosuppressive drugs reduce the effects of your overactive immune system and stop inflammation before it starts.
  • Surgery: Two types of surgery can be done to manage uveitis. The first involves removing some of the vitreous from the affected eye. The second involves a medication-releasing implant that releases small amounts of corticosteroids into the eye for two or three years.

How RA Treatment Might Affect Your Eyes

Some of the medicines that treat RA can trigger eye problems. Two medications in particular—corticosteroids and Plaquenil (hydroxychloroquine), an immunosuppressive drug—might affect your eye health.

Corticosteroids

Taking corticosteroids can raise eye pressure, and this is true of many types of steroids, including prednisone. Both eyedrop corticosteroids and oral corticosteroids can lead to eye issues.

Eye pressure increases can occur as early as three to six weeks using eye drops. Corticosteroid injections can cause an increase in eye pressure after several months.

Corticosteroid use has also been linked to steroid-induced glaucoma. While doctors don't know exactly why this happens, many think steroid medicines stop cells that clear debris in eye cells. This causes a buildup of debris, which increases eye pressure.

If you have RA and take corticosteroids to manage RA and its effects, you should visit your eye doctor regularly. They can check for eye pressure and diagnose any eye problems early.

Plaquenil

Long-term use of Plaquenil has been found to damage the retina, which might lead to serious vision loss. If you experience retina damage, it might take some time to notice vision loss. And, unfortunately, vision loss associated with retina damage is permanent.

If you are taking Plaquenil to treat RA, you should also be seeing an ophthalmologist regularly. This way you can be checked for retina problems before there is any serious damage.

A Word From Verywell

Everyone living with rheumatoid arthritis should see an ophthalmologist yearly. They can diagnose, rule out, or treat any eye problems early on in people with RA. You should also make an appointment with an ophthalmologist if you experience ongoing eye symptoms, including itching, feeling like something is in your eye, eye redness. eye pain, or vision loss. 

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