Manifestation of Ocular Involvement in Rheumatoid Arthritis

Aim: To find the ocular manifestation in rheumatoid arthritis.
Material and Method: A cross sectional study was conducted in Bahria Hospital Lahore, 200 patients were examined
in I or II stage of rheumatoid disorders. Consecutive sampling technique was used. All patients were sero-positive.
Ophthalmological exam, visual acuity by Snellen’s visual acuity, biomicroscopy of anterior segment, Schirmer test, tear
break-up time (BUT), applanation tonometry and indirect ophthalmoscopy.
Result: The result showed Ocular manifestations were in 41% patients. Most common ocular manifestation were
keratoconjunctivitis and 33% other ocular manifestation were scleritis including uveitis, keratitis, episcleritis.
Conclusion: Ocular man and festations involved with RA are significant. The most common manifestation of ocular
involvement was KCS, these were more common amongst patients with longer disease duration and the persons mostly
steroids for longer duration.
Keywords: episcleritis, keratoconjunctivitis sicca, rheumatoid arthritis, scleritis including uveitis.

INTRODUCTION:
 

Rheumatoid arthritis (RA) is a systemic inflammatory disease, which is associated with a number of extra-articular organ manifestations, such as pericarditis,pleuritis, major cutaneous vasculitis, Felty’s syndrome, neuropathy, ocular manifestations, glomerulonephritis, and other types of vasculitis [1] Extra-articular manifestations in RA are present in 10–40% of patients and are more frequently seen in sero-positive patients [2]. Ocular manifestations involved with RA are mainly keratoconjunctivitis sicca (KCS), episcleritis, scleritis, corneal changes, and retinal vasculitis [3] KCS is common in individuals with RA and is often the initial manifestation. KCS appears as a result of the decreased secretion of tears from the main and accessory lacrimal glands. [4][5]The interruption of lacrimal secretion is caused by the atrophic and cirrhotic changes in the lacrimal glands and leads to the reduction of the middle layer of the precorneal lacrimal film, which becomes viscous in later stages. In KCS, conjunctival goblet cells are stimulated to increase the secretion of the mucus. [6]Very often, fibrous coverings of mucin tied down to the cornea or laid in the lower fornix are seen. It rarely appears as a form of filamentous keratitis − for example, twisted filaments tied up to the cornea by one part. This is a particularly painful condition because blinking moves the filaments, tugging the epithelial attachments and tending to strip off further epithelium [7]


1.Medical officer at DHQ Hospital Okara2. Medical officer BHU 40/3-R
Okara.3. House Officer Jinnah Hospital Lahore.


Correspondence: Dr. Tahira Sadaf, Medical officer at DHQ Hospital
Okara Tahirasadaf34@gmail.com, 03355592817


Received April’2019 Accepted: May’2019
 


Ocular manifestations involved with RA are significant. The most common ocular involvement is KCS and more common among patients with longer disease duration with steroids.


Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between the conjunctiva and the sclera. Usually, episcleritis is a mild, self-limiting, recurrent disease; although most cases are of unknown etiology; up to one-third of patients have an underlying systemic condition [8]. Scleritis is a chronic, painful, and potentially blinding inflammatory disease that is characterized by edema and cellular infiltration of the scleral and episcleral tissues. It may be classified into anterior and posterior. Anterior scleritis can be diffuse, nodular, necrotizing with inflammation (necrotizing), and necrotizing without inflammation (scleromalacia perforans) [9]. The most common clinical forms are diffuse scleritis and nodular scleritis. Necrotizing scleritis with or without inflammation is much less frequent, more ominous, and frequently associated with systemic autoimmune disorders. Posterior scleritis is characterized by flattening of the posterior aspect of the globe, thickening of the posterior coats of the eye (choroid and sclera), and retrobulbar edema; however, it is rarely seen in patients with RA. [10]

MATERIAL AND METHOD:

A total of 200 patients with RA were selected through consecutive sampling to participate in this cross-sectional study during the period between October 2016 and August 2017. Patients were selected according to strict eligibility criteria, with rheumatoid arthritis of stage I and II. On the other hand other types of retinopathy due to other reasons such as diabetic retinopathy, retinitis pigmentosa, and retinopathy due to blood disorders were excluded. Ophthalmological exam contained visual acuity by Snellen ‘s biomicroscopy of anterior segment, Schirmer test, tear break-up time (BUT), applanation tonometry and indirect ophthalmoscopy. The study was approved by the Ethical Committee of Bahria University. The participants were informed about the purpose of the study, and confidentiality of data was maintained. Informed consent was obtained from all participants. Data were analyzed using the software statistical package for the social science (SPSS version 20. Frequency distribution with its percentage and descriptive statistics with mean and SD were calculated. Chi-square, t-test ,and correlations were done whenever needed. P values of less than 0.05 were considered significant.

RESULTS:

Of the 200 patients who were recruited for the study, 84% were female and 16% were male. The age of the patients ranged between 20 and 72 years with a mean of 44.97±11.75 years. The duration of RA since it was diagnosed for the first time ranged between 1 and 18 years with a mean of 5.73±4.13 years; 81 (45%) patients had a history of RA more than 5 years and 99 (55%) patients had a duration less than 5 years. The mean erythrocyte sedimentation rate of the patients was 45.13±12.05 mm. Throughout the study, 101 (56.1%) patients were on monotherapy, and the rest of the patients were taking more than one medication, with 165 (91.7%) patients being on methotrexate, 75 (41.7%) patients on steroids, and 48 (26.7%) patients on antimalarial drugs. 33% patients had ocular manifestations (3 male and 58 female). 4% had episcleritis (all were female); 3.2% had scleritis (all were female); and three patients 2 patients had keratitis (1 male and 1 female). There was no statistically significant difference between the two sexes as regards the form of ocular manifestations (P>0.05).Patients with scleritis were found to have anterior diffuse scleritis including iridocyclitis.







DISCUSSION:

The result showed that the ocular manifestations were present among 41% patients. Most common ocular manifestation was keratoconjunctivitis which was 33% other ocular manifestation were scleritis, keratitis, episcleritis. A study was conducted in Egypt in 2017 by Safaa. F in which Of the 180 examined patients, 61 (33.9%) patients had ocular manifestations. There were 52 (85.3%) patients with KCS, three (4.9%) patients with episcleritis, three (4.9%) patients with scleritis, and three (4.9%) patients with keratitis. Patients with longer disease duration were much more likely to have ocular manifestations (odds ratio=7.13, P<0.001). [18] Another study was in addition, patients with positive history of steroid manifestations of rheumatoid arthritis may affect various components of the eye. There are a lot of signs and symptoms concerning the eye tissue like keratoconjunctivitis sicca, episcleritis, scleritis, keratitis and uveitis. Our study represents a first step in understanding the consequences of rheumatoid arthritis in the eye involvement. Moreover, the purpose of this article is to clarify to clinicians the possible manifestations of the aforementioned disease, as well as their specific management and treatment options. (odds ratio=1.88, P<0.001).[19] Similarly a study was conducted in Saudi Arabia by Khalid. A Tabbara according to him Thirty nine (65%) patients had ocular manifestations of rheumatoid arthritis. The most frequent manifestation was dry eyes 30 (50.0%). There was no relation between severity of the rheumatoid arthritis disease and ocular manifestation (P = 0.529). There was a relationship between the Anti-CCP antibodies titer and presence of ocular manifestations in rheumatoid arthritis patients (P = 0.006). There were no curable effects of the disease modifying anti-rheumatic drugs, biological agents on ocular manifestations
in rheumatoid arthritis patients.[20]

CONCLUSION:

Ocular manifestations involved with RA are significant. The most common manifestation of ocular involvement was KCS. Ocular manifestations were more common among patients with longer disease duration specially with the persons who used steroids for longer duration.

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