Dry Eye in Rheumatoid Arthritis

Autoimmune Disease-Related Dry Eye Diseases and Their Placement Under the Revised Classification Systems: An Update

Dry eye disease (DED) is a chronic and progressive disorder involving the ocular surface, characterized by disturbances in tear film composition, instability of the tear film, and inflammation of the ocular surface. There are two forms of DED: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). Autoimmune diseases are systemic disorders involving multiple organs, including the eyes, and have a significant impact on DED. There have been multiple studies demonstrating the relation between autoimmune diseases and DED. This article reviews the current knowledge regarding the epidemiological characteristics, pathogenesis, and treatments of autoimmune disease-related DED.

Non-contact meibography changes according to disease activity in rheumatoid arthritis cases

PURPOSE

To measure dry eye disease (DED) activity in rheumatoid arthritis (RA) patients, correlate it with the activity and duration of RA, and objectively measure the degree extent of DED in RA active cases.

METHODS

The paper studied the meibomian gland of 30 RA cases referred by the Rheumatology Department, Sohag University Hospitals to Sohag Cornea and Refractive Center, Sohag, Egypt, by infrared non-contact meibography in the Scheimpflug topographer (Sirius, CSO, Italy) from July 2021 to July 2022. The cases fulfilled the RA classification criteria according to the 2010 American College of Rheumatology and European League and underwent full lab investigations. They were distributed to two groups based on the DAS-28 questionnaire. The patients were distributed into low to moderate activity (3.2 < score <  = 5.1) and high activity groups (score > 5.1).

RESULTS

This study included 60 eyes of 30 RA patients. They scored a mean age of (44 ± 10 years), number of swollen joints (3 ± 3), number of tender joints (5 ± 3), duration of disease (8 ± 4), activity of the disease measured by DAS-28 (4.4 ± 0.9), and sex (males were 9.7% vs females 90.3%). The number of swollen joints, tender joints, ESR and DAS-28 were more in the high activity group with the p-value of (0.018, 0.001, < 0.003 and < 0.004), respectively. There are no statistically significant differences between both groups as regards disease duration (p-value of 3.8). The high activity group showed significant affection regarding the mebioscore of the lower and upper lids, total mebioscore, percentage of meibomian glands in upper and lower lids, first non-invasive break-up time test (NIV-BUT) of the tear film, as well as average non-invasive break-up time test (NIavg-BUT). There were moderate correlations between the activity of the disease represented by (DAS-28) and different parameters evaluating eye dryness (meiboscore of the lower and upper lids, total meiboscore, percentage of meibomian glands in upper and lower lids, NIV-BUT of the tear film, and NIavg-BUT of the tear film).

CONCLUSION

There was no correlation with duration of RA but moderate correlations between the activity of the disease represented by (DAS-28) and different parameters evaluating eye dryness in RA patients with valuable use of noncontact Meibography to evaluate eye dryness in RA cases. Both Meiboscore and Meiboscale of Non-contact Meibography were found to be useful tools in grading of dry eye disease in different activity grades of Rheumatoid Arthritis.

Diagnostic Performance of the Tear Meniscus Osmolarity Measurement for Dry Eye Disease in Rheumatoid Arthritis Patients

BACKGROUND

The aim of our study was to evaluate the diagnostic capacity of the tear meniscus osmolarity measurement for dry eye disease (DED) in patients with rheumatoid arthritis (RA), using a portable osmometer based on electrical impedance and an integrated circuit technology (TearLab® (Escondido, CA, USA)).

METHODS

We included 101 RA patients, 81 patients with DED and 20 without DED (controls). We measured tear osmolarity and assessed other clinical diagnostic tests as suggested by the TFOS DEWS II composite reference standard diagnostic criteria for DED using Ocular Surface Disease Index (OSDI), Five-item Dry Eye Questionnaire (DEQ-5), fluorescein tear break-up time (F-TUBT), ocular surface staining (SICCA score), and other clinical parameters to classify DED subtypes. We analyzed the agreement between osmolarity and the TFOS DEWS II composite reference standard for DED diagnosis. We conducted receiver operating characteristic (ROC) curve analyses using the DED variable and its subtypes as dependent variables and the continuous variable for osmolarity or the inter-eye difference in osmolarity as independent variable. Sensitivity, specificity, and area under the curve for all potential cut-off points were obtained and reported from ROC curves.

RESULTS

We found that tear meniscus osmolarity had a low diagnostic capacity for DED (AUC = 0.57). Tear meniscus osmolarity measurement had a sensitivity of 35% and a specificity of 80% with a kappa level of agreement of 0.08 compared to the TFOS DEWS II composite reference standard. The low diagnostic capacity of the tear meniscus osmolarity was similar for aqueous-deficient DED and for evaporative DED, being only fair for severe DED with a 57% sensitivity and 80% specificity and a kappa level of agreement of 0.36.

CONCLUSIONS

Our findings suggest that in patients with RA, tear meniscus osmolarity measured by the TearLab® showed low sensitivity, low specificity, and limited agreement with the TFOS DEWS II composite reference standard for DED diagnosis.

Hydroxychloroquine is neutral on incidental cataracts in patients with rheumatoid arthritis

To study whether hydroxychloroquine (HCQ) therapy increases the risks of cataracts in patients with rheumatoid arthritis (RA). In this retrospective cohort study, 2821 treatment-naive RA patients, collected from the Longitudinal Health Insurance Database, were enrolled from 2000 to 2012 and followed up monthly until secondary cataracts were detected but no later than Dec 31, 2013. All participants were split into two groups according to the usage of HCQ in one year: the HCQ group (465 patients), with a usage duration higher than 90 days, and the non-HCQ group (465 patients), with a usage duration less than 30 days. The HCQ and non-HCQ groups were age-, sex-, complication- and drug combination-matched. There was no significant difference in survival rate between the two groups (p > 0.05). A multivariate logistic regression model was applied. Of all participants, 173 were diagnosed with secondary cataracts in both the HCQ and non-HCQ groups, with 28.8/1000 and 36.5/1000 person-years, respectively. After adjustments for other predictors, patients in the HCQ group had no increased (or decreased/equal) hazard of secondary cataract (hazard ratio (HR): 1.17; confidence interval (CI): 0.86-1.59; p > 0.05). HR analysis of HCQ usage duration, age, sex and corticosteroids showed that the CI of the adjusted HR was not statistically significant. This study showed that HCQ usage was not associated with the risk of cataracts in RA patients.

Moxibustion with Walnut Shell Spectacles Could Improve the Objective Symptoms and Tear Film Stability of Patients with Dry Eye Disease: A Randomized Controlled Trial

Objectives

This study aims to evaluate the efficacy and acceptability of moxibustion with walnut shell spectacles in treating dry eye disease (DED) patients and to provide treatment options.

Methods

126 DED patients were randomly allocated into the moxibustion group (treated by moxibustion with walnut shell spectacles, 64 cases) and the artificial tears group (treated with sodium hyaluronate eye drops, 62 cases). Evaluate the changes in the ocular surface disease index (OSDI), the visual analogue scale (VAS) of ocular discomfort, the tear film break-up time (TBUT), corneal fluorescein staining (CFS), and the Schirmer I test during the trial at baseline and after 1-week, 2-week, 3-week, and 4-week treatment. Evaluate the OSDI scale and the ocular symptom VAS scale one month after the end of treatment.

Results

There were no significant differences in baseline characteristics between the two groups. For OSDI scores, the results showed that the efficacy of the moxibustion group was no less than that of the artificial tear group. For VAS of ocular discomfort, both groups significantly reduced their score compared with baseline, and for the moxibustion group, the decrease was more significant. For TBUT, FAS, and PPS, results showed that the efficacy of the moxibustion group was significant in both eyes after 4 weeks of treatment, but the right eye was in the artificial tear group. For CFS and Schirmer I test scores, there was no significant effect for both groups.

Conclusion

Moxibustion with walnut shell spectacles could improve the clinical symptoms and tear film stability of DED patients; however, it has no significant efficacy on improving corneal injury and tear secretion, just the same as sodium hyaluronate eye drops. Nevertheless, moxibustion with walnut shell spectacles may have better effects on the self-assessment of ocular discomfort than sodium hyaluronate eye drops.

Study of Factors Influencing Dry Eye in Rheumatoid Arthritis

Purpose

The present study investigated the relationship between dry eye and the disease activity in patients with rheumatoid arthritis (RA).

Methods

Patients with RA were divided by the Ocular Surface Disease Index (OSDI) into the symptomatic group (score ≥ 12) and the asymptomatic group (score < 12). By using the Disease Activity Score (DAS-28) questionnaire, they were divided into the active group (score > 2.6) and the stable group (score ≤ 2.6). In the control group, 20 healthy adults with matched sex and age were selected. RA patients and healthy adults were inspected for the tear film break time (TBUT), tear meniscus height (TMH), corneal fluorescein staining (CFS), meibomian scan (MS), meibomian gland secretion score (MSS), and eyelid margin assessment (EMS).

Results

The TBUT of the RA group was significantly less than that of the control group, while the CFS, MS, EMS, and MSS were higher. The TBUT of the symptomatic RA group was significantly less than that of the asymptomatic group, and the CFS was higher. In the active RA group, only the CFS was higher than that of the stable group, and there was no significant difference between the two groups for other parameters. Furthermore, there was no significant correlation between the course of RA and the dry eye (P > 0.05).

Conclusion

The rheumatoid activity does not necessarily lead to an aggravation of dry eye. Regardless of the duration, RA was not found to exhibit relation with the severity of dry eye. Translational Relevance. RA patients with disease active period cannot be ignored for the existence of dry eye, since patients with dry eye often lack the signs and symptoms.

Dry eye in rheumatoid arthritis: relation to disease activity

The aim of this study was to find the correlation between severity of dry eye and rheumatoid arthritis (RA) disease activity. Forty- two RA patients with dry eye were recruited from Rheumatology Outpatient Clinic in Minia University Hospital. Assessment of RA disease activity was performed using disease activity score (DAS-28). Ocular tests include Schirmer test I, tear film break up time (TBUT) and ocular staining score (OSS) was performed by ophthalmologist to find evidence of ocular dryness. Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anti SSA/Ro and anti SSB/La was also tested. Patients with severe dry (OSS ≥ 3) underwent minor salivary gland biopsy (MSGB) as suspected to have secondary Sjögren's syndrome (SS). Of 42 RA patients, 30 had definite dry eye. DAS-28 did not show significant correlation with any of ocular tests for dryness while the duration of RA was significantly positively correlated with Schirmer test and OSS. The biopsy results of RA patients with severe dry eye show no evidence of SS. The severity of dry eye is not correlated with activity of RA but with its duration.

The impact of ocular manifestations of rheumatoid arthritis on the health-related quality of life and the functional ability of black Africans

Objectives To determine the patterns, predictors and overall impact of ocular manifestations of rheumatoid arthritis (RA) on the health-related quality of life and disability index.

METHODS

A total of 50 Nigerian patients with RA were studied. Full ocular evaluation was done to determine the presence of each defined ocular manifestation of RA. All patients completed the Medical Outcome Study 36-Item Short Form Health Survey (SF-36) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) questionnaires.

RESULTS

The mean ± SD age of the patients was 47.2 ± 12.5 years. A total of 42 cases of ocular diseases were found in 23 (46%) patients. Keratoconjunctivitis sicca was found in 15 (30%) patients; cataract, 13 (26%); scleritis/episcleritis, 4 (8%); disk edema, 4 (8%); glaucoma, 3 (6%); ulcerative keratitis, 1 (2%); vitreitis, 1 (2%); and macula edema, 1 (2%) patient. There is an association of the presence of ocular manifestations with the physical component summary (PCS) [T = - 3.398, P = 0.001] and the mental component summary (MCS) [T = - 2.616, 0.012] of the SF-36 but not with the HAQ-DI (T = 1.685, 0.099). Following multiple regression analysis, the predictors of the presence of ocular manifestations were age greater than 45 years and positive anti-citrullinated protein antibody. Following linear regression analyses, Steinbrocker's functional class independently predicted the PCS while both Steinbrocker's functional class and female sex predicted the MCS.

CONCLUSIONS

The development of ocular disorders associated with RA is associated with a significant negative impact on the quality of life of the patients.