Eye involvement ‘red flag’ in rheumatic conditions

https://isr.ie/Irish Society for Rheumatology, Spring Meeting, Sligo Park Hotel, 10-11 April 2025

Interdisciplinary collaboration between rheumatology and ophthalmology is crucial, given the high prevalence of ocular involvement in rheumatic diseases. Such collaboration supports earlier diagnosis and improves patient outcomes, attendees heard at this year’s Irish Society for Rheumatology Spring Meeting.

A presentation titled ‘Eye manifestations in inflammatory rheumatic disease’ was delivered by Prof Conor Murphy, Professor of Ophthalmology at the Royal Victoria Eye and Ear Hospital (RVEEH), Dublin. Prof Murphy, who specialises in disorders of the cornea and ocular surface, uveitis, and corneal transplant surgery, is also the clinical lead of the ocular immunology research group at the RCSI. His group focuses on research into ocular surface inflammation, corneal transplantation, and uveitis.

Patients with rheumatic disease may experience a variety of eye manifestations, he told the meeting. Rheumatic disorders commonly affect the sclera, cornea, retina, and orbit, and range from relatively mild ocular surface problems to serious threats to sight.

The most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, acute anterior uveitis (AAU), and scleritis, Prof Murphy explained.

Recurrent uveitis can indicate that a patient has underlying ankylosing spondylitis (AS), and up to 50 per cent of patients with AS develop AAU.

HLA-B27 is a strong genetic marker for AAU, which is characterised by redness, pain, and photophobia. HLA-B27 positivity is also associated with a high frequency of recurrent episodes, he noted. Posterior segment inflammation is uncommon and usually indicates iridocyclitis. Topical steroids are the first-line treatment, followed by periocular steroids, Prof Murphy told the meeting.

Some ocular manifestations of rheumatic disease can lead to rapid and irreversible vision loss, Prof Murphy warned. These include optic atrophy in giant cell arteritis (GCA), macular ischaemia in Behçet’s disease, secondary glaucoma in juvenile idiopathic arthritis-associated uveitis and anterior uveitis, as well as corneal perforation in peripheral ulcerative keratitis (PUK) and corneal melt. He stressed the importance of early recognition and prompt treatment to prevent severe outcomes.

Retinal vasculitis, which may present as painless acute or chronic vision loss, can also be associated with rheumatic diseases such as Behçet’s.

“For many patients dry eye is the most disabling component of Sjögren’s syndrome,” Prof Murphy said.

He showcased a number of clinical case studies to provide practical examples of the link between ocular pathology and rheumatic diseases and how best to treat them.

Prof Murphy noted that newer treatments are improving outcomes for many ocular manifestations of rheumatic disease, but emphasised that immunotherapy should be tailored to the individual. For example, B-cell–targeted therapies are effective in some forms of ocular inflammation, but not in others.

“Input from rheumatology to the immunosuppressive management is invaluable,” he said.

Prof Murphy also discussed the usefulness of the DUET (Dublin Uveitis Evaluation Tool) algorithm. DUET was developed to assist ophthalmologists identify patients with AAU who may have undiagnosed spondyloarthritis and help select which patients presenting with AAU to refer to rheumatology.

“It is pretty simple to use and very reliable, and we use it daily in the emergency department in the RVEEH,” he commented.

Focusing on the role of interdisciplinary collaboration, Prof Murphy stressed that it helps earlier diagnosis and optimises outcomes for patients.

Some patients may wait up to six years for a correct diagnosis of many rheumatic conditions.

“Ocular manifestations can be the first sign of systemic rheumatic disease; hence early recognition in the eye clinic is key,” he said.

Prof Murphy added that, equally, recognition in the rheumatology clinic and urgent referral are critical for sight-threatening conditions, such as GCA, PUK, scleritis, and retinal vasculitis.