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  • Review Article
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Ocular inflammatory diseases associated with rheumatoid arthritis

Nature Reviews Rheumatology volume 10, pages 108–116 (2014)Cite this article

Subjects

Key Points

  • Extra-articular complications of rheumatoid arthritis (RA) can include ophthalmological manifestations

  • Episcleritis is a benign self-limited disease associated with RA that frequently warrants topical corticosteroids for rapid control of the condition

  • Necrotizing scleritis and peripheral ulcerative keratitis (PUK) can rapidly threaten ocular prognosis in RA and can cause excess mortality because of their association with systemic vasculitis

  • Once infection has been excluded, necrotizing scleritis and PUK are treated with high-dose systemic corticosteroids and cyclophosphamide

  • In less severe forms of scleritis, methotrexate, azathioprine and mycophenolate mofetil are prescribed in cases of corticosteroid-dependence, corticosteroid-resistance or severe adverse effects

  • Infliximab, or even rituximab, might also have a place in the treatment arsenal, but etanercept is not effective; rare cases of uveitis have been reported during treatment with anti-TNF drugs, principally with etanercept

Abstract

The extra-articular complications of rheumatoid arthritis (RA) include ophthalmological manifestations, which can, in some cases, be the first signs of the disease. These inflammatory ophthalmological conditions include episcleritis, scleritis and peripheral ulcerative keratitis (PUK). RA is the leading cause of necrotizing scleritis and of PUK, which are the two most severe ocular conditions associated with the disease. These conditions can rapidly threaten ocular prognosis and are associated with excess mortality in patients with RA owing to their association with systemic vasculitis. Close collaboration between the ophthalmologist and the rheumatologist or internal medicine expert is required for the diagnosis and therapeutic management of these patients. In this Review, we provide an overview of ocular inflammatory diseases in patients with RA with particular focus on the diagnosis and current available therapies (including biologic agents) for these conditions. Furthermore, we propose a decision tree to assist clinicians in their choice of treatment for patients with RA who also have ocular inflammatory disease.

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Figure 1: Episcleritis.
Figure 2: Different features of scleritis.
Figure 3: Necrotizing anterior scleritis complicated by perforation.
Figure 4: Scleromalacia perforans.
Figure 5: Peripheral ulcerative keratitis.
Figure 6: Proposed decision tree for treatment of scleritis and PUK associated with RA.

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Authors and Affiliations

  1. National Referral Centre for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, Paris, 75014, France

    Mathieu Artifoni, Loïc Guillevin & Xavier Puéchal

  2. Department of Opthalmology, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, Paris, 75014, France

    Pierre-Raphaël Rothschild & Antoine Brézin

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All authors contributed to substantial discussion of content, writing and reviewing and/or editing the manuscript before submission. M. Artifoni and X. Puéchal researched data for the article.

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Correspondence to Xavier Puéchal.

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Artifoni, M., Rothschild, PR., Brézin, A. et al. Ocular inflammatory diseases associated with rheumatoid arthritis. Nat Rev Rheumatol 10, 108–116 (2014). https://doi.org/10.1038/nrrheum.2013.185

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