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If you have rheumatoid arthritis, lupus or another autoimmune disease, your eyes may also be dry, burning or sensitive. This is no coincidence: the same inflammation that damages the joints or the skin can also damage the lacrimal glands and the surface of the eye. On this page we explain the link, which signs need urgent attention, and how the eye doctor and the rheumatologist work together.
Why rheumatic diseases affect the eyes
Many rheumatic diseases are autoimmune diseases, meaning that the immune system mistakenly attacks the body's own tissues. The lacrimal gland, the conjunctiva (the clear membrane that covers the white of the eye) and the cornea (the clear window at the front of the eye) are tissues that the immune system can damage. The inflammation reduces tear production and harms tear quality, and the dry eye surface in turn increases the inflammation. This creates a cycle that is hard to break with lubricating drops alone.
Major reviews of dry eye list autoimmune diseases among the known causes of dryness. In addition, some of the medicines taken for these diseases, and at an older age hormonal changes too, can add to the dryness. You will find information on medicines linked to dryness on the medicines that cause dry eyes page.
Rheumatoid arthritis
Rheumatoid arthritis is a chronic inflammatory disease of the joints. Dry eyes are its most common eye manifestation. It usually causes burning, a gritty, sandy feeling and tired eyes, and is treated like ordinary dry eye, but it is often more stubborn.
Alongside dryness, rheumatoid arthritis can, rarely, cause more serious inflammation in the eye: inflammation of the sclera (scleritis, inflammation of the tough white wall of the eye) and ulcerative inflammation at the edge of the cornea (PUK, peripheral ulcerative keratitis, thinning and an ulcer at the periphery of the cornea). These conditions need prompt treatment and coordination with the rheumatologist, and we describe them in more detail below.
Lupus
Lupus (SLE) is an autoimmune disease that can affect the skin, the joints, the kidneys and other organs. In lupus too, dry eyes are the most common eye manifestation. Sometimes there is also inflammation of the eyelid margins or a rash on the skin of the eyelids. Rarely, lupus also affects the retina or the optic nerve, so any drop in vision needs to be examined.
Secondary Sjögren's
Sjögren's syndrome is an autoimmune disease that mainly attacks the lacrimal and salivary glands. When it appears alongside another rheumatic disease, such as rheumatoid arthritis or lupus, it is called secondary Sjögren's. Dry eye in Sjögren's tends to be particularly severe, because the main problem is a shortage of tears. If you also have a dry mouth, difficulty swallowing dry food or swollen salivary glands, tell your rheumatologist. More on the Sjögren's syndrome page.
Other autoimmune diseases
Scleroderma (systemic sclerosis), inflammation of the blood vessels (vasculitis) and other inflammatory diseases can also cause dryness or inflammation in the eye. In scleroderma, for example, the skin of the eyelids can harden, so that they close less well. The principle is the same: when you have an autoimmune disease and symptoms in your eyes, it is worth having an eye doctor examine you.
Dryness or serious inflammation: how to tell them apart
Most eye symptoms in people with a rheumatic disease come from dryness. Dryness usually causes burning, a gritty, sandy feeling, itching and vision that changes during the day. The symptoms tend to get worse at a screen, in air conditioning and at the end of the day, and to improve a little after drops.
Scleritis feels different. The pain is deep and intense, sometimes spreading to the forehead or jaw, wakes you from sleep and gets worse when you move the eye. The white of the eye looks dark red or purplish, and the redness does not go away with drops. In peripheral ulcerative keratitis (PUK) the cornea thins at its periphery, sometimes with pain and sensitivity to light. Both conditions are rare, but they can put the eye at risk, and they are sometimes a sign that the general disease is active. So it is important to know about them and not to put every pain down to dryness.
What the eye doctor checks
When dryness continues despite lubricating drops, a thorough assessment helps to understand whether the main problem is a shortage of tears, rapid evaporation, inflammation, or a combination of these. Usually the following are checked:
- Examination with a slit lamp (a microscope for examining the eye) of the cornea, the conjunctiva, the sclera and the eyelid margins.
- Staining of the eye surface with fluorescein (a harmless yellow-orange dye), which shows damaged areas and measures the stability of the tears.
- The Schirmer test, which measures the amount of tears using a thin paper strip.
- Assessment of the meibomian glands and the eyelid margins, because in rheumatic diseases too there is often an evaporative component.
Details are on the dry eye testing page. The eye findings can also help the rheumatologist, for example when considering a diagnosis of Sjögren's.
Treatment: from home to the clinic
The basis is preservative-free lubricating drops, a gel or ointment before sleep, keeping away from air conditioning and fan draughts, and eyelid care when needed. The eye doctor may also prescribe anti-inflammatory drops. When this is not enough, these are the treatments given at the clinic, as needed and after an examination:
- Punctal plugs: they keep the few tears on the eye for longer. Significant inflammation of the eye surface is usually calmed first.
- Autologous serum eye drops: drops prepared from the patient's own blood, for severe dryness that does not respond to usual treatment.
- Bandage contact lens: a soft lens that protects the cornea like a bandage, in selected cases and under close follow-up.
- Meibomian gland expression and IPL treatment (broad-spectrum pulsed light, not a laser), when there is also blockage of the meibomian glands.
- BlephEx treatment: cleaning of the eyelid margins when there is blepharitis or Demodex.
Hydroxychloroquine and retina checks
Hydroxychloroquine (a common medicine in lupus, arthritis and Sjögren's) is an important and relatively safe medicine, but with long-term use it can, rarely, damage the retina. So people who take it need retinal screening tests at intervals set by their doctors, according to the accepted guidelines. These tests are separate from dryness treatment. Do not stop the medicine by yourself.
Working together with the rheumatologist
The rheumatologist treats the general disease, and the eye doctor treats the surface of the eye. Treatment works better when they keep each other informed. Tell your eye doctor about the diagnosis and all your medicines, including biological medicines and steroids. Tell your rheumatologist about symptoms in your eyes and about the test findings. When serious inflammation appears in the eye, such as scleritis, the general treatment sometimes needs adjusting, and that decision is the rheumatologist's.
Rheumatic diseases change over the years, with quiet periods and periods of flare-up. Eye dryness may change accordingly too, so regular follow-up with an eye doctor is important even when you feel well. This makes it possible to adjust treatment in time, and to spot damage to the cornea or signs of inflammation early.
When to see a doctor straight away: deep, intense pain in the eye, especially pain that wakes you from sleep or gets worse with eye movements; an eye that is very red or has a purplish tinge; strong sensitivity to light; a white spot or a thin area at the edge of the cornea; or a sudden drop in vision. These can be signs of scleritis or of peripheral ulcerative keratitis, which need urgent treatment.
Want a basic explanation first?For a basic guide to dry eye: the guide on the Mitzmutz site
Frequently asked questions
I have rheumatoid arthritis and dry eyes. Does that mean I also have Sjögren's?
Not necessarily. Dry eyes are common in rheumatic diseases even without Sjögren's. When the dryness is severe, especially together with a dry mouth, the rheumatologist may check whether there is secondary Sjögren's.
How can I tell ordinary dryness from dangerous inflammation in the eye?
Dryness usually causes burning, a gritty, sandy feeling and vision that changes during the day. Deep, intense pain that wakes you from sleep or gets worse with eye movements, a very red eye or a drop in vision are not typical of ordinary dryness, and need an urgent examination.
I take hydroxychloroquine. Is a dry eye examination enough?
No. Retinal screening tests during hydroxychloroquine treatment are separate, and include imaging of the retina and a visual field test. Arrange them with your rheumatologist and eye doctor.
Do dry eye treatments clash with rheumatology treatment?
Most local eye treatments do not affect your general (whole-body) treatment. However, it is important that the eye doctor knows which medicines you take, especially medicines that suppress the immune system, because they affect the risk of infection and the choice of treatment.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Shiboski CH, Shiboski SC, Seror R, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren's syndrome. Arthritis Rheumatol. 2017;69(1):35-45.
- Foulks GN, Forstot SL, Donshik PC, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Ocul Surf. 2015;13(2):118-132.
- Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF. Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision). Ophthalmology. 2016;123(6):1386-1394.
- Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334-365.
- Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.