By Bradley L. Rhinehart, O.D.
Rheumatoid Arthritis (RA) is an auto-immune disease which causes pain, loss of function and progressive joint damage. Initially, small joints in the hands and feet are affected but RA can spread to other joints and other parts of the body. Although RA primarily causes musculoskeletal complications, other considerations include mental health and so-called "extra-articular" complications in the nervous system, heart, lungs, digestive tract, kidneys, skin and eyes.1 While there is still much to learn, it is known that RA affects females more frequently than males, and that risk increases with age and with a family history of RA.2
Important considerations for RA patients include pain management, maintaining normal function and preserving quality of life. RA should be diagnosed and treated by physicians who specialize in rheumatology and auto-immune diseases. Extra-articular complications should be managed by appropriate specialty providers. For example, since both RA and RA treatment can affect the eyes, ocular complications of the disease and risks associated with treatment should be managed by an eye doctor.
Moderate to severe dry eye is often associated with RA and such patients often require aggressive dry eye treatment to help maintain healthy eyes and good vision. When RA is properly managed or is in a period of remission, it is easier to control dry eye symptoms. In addition to dry eye treatment, a detailed health history may reveal other physical symptoms in patients who have RA but have not yet been diagnosed. When undiagnosed RA is suspected, referrals should be made to a rheumatologist so patients can receive the additional testing and care they need.
Another aspect of RA management is the risk of retinopathy and vision loss in patients taking a so-called "high-risk medication" like Plaquenil (hydrxoychloroquine). This medication can be very effective in managing pain and joint stiffness in RA patients as well as in treating complications of other auto-immune diseases like Lupus. Retinopathy may be avoided or limited when patients are properly monitored. Providers and patients need to be vigilant since even though retinal complications are rare, the adverse effects are irreversible and can continue to worsen, even after a patient has discontinued the medication. Ideally, eye doctors may detect changes in the eyes before patients notice any functionally significant vision loss.
Risk factors for retinal complications with hydroxychloroquine pertain to dosage, height, weight and age as well as impaired liver or kidney function and the presence of preexisting retinal disease.3 Current guidelines established in 2011 by the American Academy of Ophthalmology recommend a complete eye examination, automated central visual field testing and one of several methods to evaluate the integrity of the central retina, (for which I usually recommend non-invasive diagnostic laser imaging of the macula), prior to or shortly after beginning treatment.4
Thereafter, patients should have an eye examination yearly. Other specialized testing does not need to be repeated within the first 5 years unless a patient has additional risk factors. After 5 years, both the eye examination and the enhanced retinal testing should be repeated yearly since complications are more likely after 5 years, which is usually around the time patients reach a cumulative dose of 1,000 grams.4
As with all medications, it is all about risk vs. benefit. Hydroxychloroquine provides significant benefits in terms of decreased pain and joint stiffness and improved dexterity, mobility, mood and overall quality of life to many patients. RA patients should work closely with their primary care and specialty providers, including their eye doctor, to manage the disease and reduce the risk of potential complications associated with treatment. Patients should remember that, while retinal complications are rare, monitoring is important because the risk is different for each person and adverse effects can be permanent. In cases of retinopathy, the eye doctor should report findings to the managing rheumatologist so an appropriate substitution can be prescribed. Retinal evaluation should then be repeated every 3 months until the condition is stable.3
1 Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD, Tanasescu R. Extra-articular manifestations in rheumatoid arthritis. Mædica. 2010;5.4:286–291. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152850. Accessed October 29, 2015.
2 Mayo Clinic Staff. Diseases and conditions, rheumatoid arthritis. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/basics/risk-factors/con-20014868. Accessed October 30, 2015.
3 Hansen MS, Schuman SG, Scott IU, ed., Fekrat S, ed., Marmor MF ed.
Ophthalmic pearls: hydroxychloroquine-induced retinal toxicity. EyeNet June 2011. http://www.aao.org/eyenet/article/hydroxychloroquine-induced-retinal-toxicity?June-2011. Accessed October 29, 2015.
4 Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler, WF. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118:415–422. http://www.ncbi.nlm.nih.gov/pubmed/21292109. Accessed October 29, 2015.
Rheumatoid Arthritis (RA) is an auto-immune disease which causes pain, loss of function and progressive joint damage. Initially, small joints in the hands and feet are affected but RA can spread to other joints and other parts of the body. Although RA primarily causes musculoskeletal complications, other considerations include mental health and so-called "extra-articular" complications in the nervous system, heart, lungs, digestive tract, kidneys, skin and eyes.1 While there is still much to learn, it is known that RA affects females more frequently than males, and that risk increases with age and with a family history of RA.2
Important considerations for RA patients include pain management, maintaining normal function and preserving quality of life. RA should be diagnosed and treated by physicians who specialize in rheumatology and auto-immune diseases. Extra-articular complications should be managed by appropriate specialty providers. For example, since both RA and RA treatment can affect the eyes, ocular complications of the disease and risks associated with treatment should be managed by an eye doctor.
Moderate to severe dry eye is often associated with RA and such patients often require aggressive dry eye treatment to help maintain healthy eyes and good vision. When RA is properly managed or is in a period of remission, it is easier to control dry eye symptoms. In addition to dry eye treatment, a detailed health history may reveal other physical symptoms in patients who have RA but have not yet been diagnosed. When undiagnosed RA is suspected, referrals should be made to a rheumatologist so patients can receive the additional testing and care they need.
Another aspect of RA management is the risk of retinopathy and vision loss in patients taking a so-called "high-risk medication" like Plaquenil (hydrxoychloroquine). This medication can be very effective in managing pain and joint stiffness in RA patients as well as in treating complications of other auto-immune diseases like Lupus. Retinopathy may be avoided or limited when patients are properly monitored. Providers and patients need to be vigilant since even though retinal complications are rare, the adverse effects are irreversible and can continue to worsen, even after a patient has discontinued the medication. Ideally, eye doctors may detect changes in the eyes before patients notice any functionally significant vision loss.
Risk factors for retinal complications with hydroxychloroquine pertain to dosage, height, weight and age as well as impaired liver or kidney function and the presence of preexisting retinal disease.3 Current guidelines established in 2011 by the American Academy of Ophthalmology recommend a complete eye examination, automated central visual field testing and one of several methods to evaluate the integrity of the central retina, (for which I usually recommend non-invasive diagnostic laser imaging of the macula), prior to or shortly after beginning treatment.4
Thereafter, patients should have an eye examination yearly. Other specialized testing does not need to be repeated within the first 5 years unless a patient has additional risk factors. After 5 years, both the eye examination and the enhanced retinal testing should be repeated yearly since complications are more likely after 5 years, which is usually around the time patients reach a cumulative dose of 1,000 grams.4
As with all medications, it is all about risk vs. benefit. Hydroxychloroquine provides significant benefits in terms of decreased pain and joint stiffness and improved dexterity, mobility, mood and overall quality of life to many patients. RA patients should work closely with their primary care and specialty providers, including their eye doctor, to manage the disease and reduce the risk of potential complications associated with treatment. Patients should remember that, while retinal complications are rare, monitoring is important because the risk is different for each person and adverse effects can be permanent. In cases of retinopathy, the eye doctor should report findings to the managing rheumatologist so an appropriate substitution can be prescribed. Retinal evaluation should then be repeated every 3 months until the condition is stable.3
1 Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD, Tanasescu R. Extra-articular manifestations in rheumatoid arthritis. Mædica. 2010;5.4:286–291. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152850. Accessed October 29, 2015.
2 Mayo Clinic Staff. Diseases and conditions, rheumatoid arthritis. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/basics/risk-factors/con-20014868. Accessed October 30, 2015.
3 Hansen MS, Schuman SG, Scott IU, ed., Fekrat S, ed., Marmor MF ed.
Ophthalmic pearls: hydroxychloroquine-induced retinal toxicity. EyeNet June 2011. http://www.aao.org/eyenet/article/hydroxychloroquine-induced-retinal-toxicity?June-2011. Accessed October 29, 2015.
4 Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler, WF. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118:415–422. http://www.ncbi.nlm.nih.gov/pubmed/21292109. Accessed October 29, 2015.