IP International Journal of Ocular Oncology and Oculoplasty

Rheumatoid arthritis is a risk factor for dry eye in south Indian population

Full Text PDF

Article Type : Null

Author Details: Syed Ali Nasar Waris,Rubina Huda*,S V. Swamy Raj,C Panchapakesa Rajendran

Volume : 5

Issue : 1

Online ISSN : 2581-5016

Print ISSN : 2581-5024

Article First Page : 31

Article End Page : 33

Abstract

Abstract

Aim: The objective of this study was to screen the patients with rheumatoid arthritis for dry eye and to find out prevalence of dry eye disease in these patients. We also studied the association of rheumatoid arthritis with severity of dry eye disease.

Materials and Methods: This cross section study was carried out in SRM medical college ophthalmology department. Duration of this hospital based study was from november2013 to October 2014. Forty four patients with rheumatoid arthritis from rheumatology department were taken and forty four age and sex matched patients were taken from SRM ophthalmology department as control for study. Detailed history and eye examination was done. SPSS 16 and Mann-Whitney U test was used for statistical analysis.

Results: Overall prevalence of dry eye disease in rheumatoid arthritis patients was15/44(34.09%) in our rheumatoid arthritis patients, as compared to5/44(11.36%) control. In our study 17/44(38.63%) of rheumatoid arthritis patients had TBUT<10>

Conclusion: There is a high prevalence of dry eye disease in rheumatoid arthritis patients in South India. Severity of dry eye disease is also more in rheumatoid arthritis patients as compared to normal population. There is a statistically significant difference of tear quantity and tear quality between two groups. We recommend early diagnosis and prompt treatment of dry eye disease in rheumatoid arthritis patients because greater percentage of patients had signs of dry eye disease as compared to symptoms of dry eye disease. Therefore it is very important to screen all rheumatoid arthritis patients for dry eye disease irrespective of duration and severity of rheumatoid arthritis.

Keywords: Rheumatoid arthritis, Dry eye disease, Tear break up time (TBUT), Schirmers test, Prevalence.

Introduction

An overall of 1% general population,^[1],^[2] is affected by rheumatoid arthritis. Rheumatoid arthritis has been described as a symmetric deforming polyarthritis. It is diagnosed clinically and serologically. The criteria used for diagnosis of rheumatoid arthritis was taken from ARC revised criteria. Extra articular findings are commonly seen in rheumatoid arthritis patients.^[2] They are rheumatoid nodules, pulmonary lesions, cardiac involvement vasculitis and also ocular manifestation.^[2] Common ocular manifestation in rheumatoid arthritis patients are Keratoconjunctivitis sicca, scleritis^[3],^[4]corneal melts.^[5],^[3] Other ocular findings are episcleritis, peripheral ulcerative keratitis,^[5].^[6],^[7],^[8]Brown syndrome^[9] orbital myositis^[10] and hydroxycholoroquine toxicity.^[11][12],^[13],^[14] Rheumatoid arthritis has been regarded as an important risk factor for causing dry eye disease.^[15][16],^[17],^[18]Dry eye has a harmful effect on the ocular surface^[19].It causes grittiness, dryness, burning sensation, stickiness, watery eye, and even redness of eyes.^[19],^[20],^[21]A number of studies has been done earlier in an attempt to find out the prevalence of dry eye^[15],^[22],^[23]Various risk factors associated with dry eye are rheumatoid arthritis^[15],^[16],^[24]drugs ^[15],^[22],^[25],^[26],^[27]pterygium,^[28]and meibomian gland dysfunction.^[29][30]

Materials and Methods

This cross sectional study was done in SRM medical college and hospital ophthalmology department. For this study, forty four rheumatoid arthritis diagnosed patients were taken from rheumatology department and forty four age and sex matched patients were taken from ophthalmology department. Patients suffering from thyroid eye disease, post LASIK patients, chronic blepharitis, meibomian gland dysfunction, proptosis, patients on medications known to cause dry eye were excluded from this study. Standard Questionnaires was used to diagnose dry eye.^[31]Mann-Whitney U formula was used for analysis of data. The eye which had more severe dry eye was taken into consideration. We used Schirmers test, tear breakup time, as our diagnostic tests. The presence of dry eye was indicated by a Schirmers reading of less than 10 mm. Schirmers test indicates tear film quantity. In order to access tear film stability in our patients, we used tear break up time. Any reading of less than 10 second was taken as abnormal. Grading of severity of dry eye was done by taking into account symptoms and Schirmers test. Approval for this study was taken from ethical committee.

Results

In our study, rheumatoid arthritis patients has a mean age 49.95+/-1.37 Standard Error (SE). Non rheumatoid patients had mean age 49.61+/-1.62 SE. We had 5 males and 39 females in our rheumatoid arthritis study group. We used Mann-Whitney U test to analyze our results. Since our data was not normally distributed, t test was not used. As shown in table 1, on the basis of evaluation of symptoms of dry eye disease 22.72% of rheumatoid arthritis patients showed symptoms of dry eye disease whereas only 9.09% of non-rheumatoid group (age and sex matched) were symptomatic. Table 2 shows 34.09% of rheumatoid arthritis patients having positive Schirmer test whereas non rheumatoid arthritis group had only 11.36% reduced tear quantity. Readings from table 3 shows that reduced TBUT was found in 38.36% of rheumatoid arthritis patients whereas it was 11.36% in non-rheumatoid arthritis patients. Therefore rheumatoid arthritis patients showed poor tear stability. There is a statistically significant difference between the mean TBUT of both the groups (p=0.000).Table4 shows greater percentage of rheumatoid arthritis patients having reduced tear quantity. We had ten moderate dry eye and one severe dry eye out of fifteen rheumatoid arthritis patients suffering from dry eye disease. Out of five non-rheumatoid arthritis patients suffering from dry eye disease, only one had moderate dry eye. Thereby we can make an inference that there are more chance of getting severe form of dry eye disease in rheumatoid arthritis patients as compared to non-rheumatoid arthritis patients

Discussion

We observed in our study that although a greater percentage of rheumatoid arthritis patients had no symptoms yet had poor tear quality (TBUT) and reduced tear quantity (Schirmers). In our study of forty four rheumatoid arthritis patients, 22.72 % patients had symptoms of dry eye disease while in control age and sex matched of forty four non rheumatoid patients, only 9.09% had dry eye disease symptoms (table-1). In Beavers Dam study by Moss et al, using patients symptoms, diagnosis of dry eye was made.^[15]A statistically significant relation was seen between dry eye and a history of arthritis. We used Schirmers test to estimate tear quantity in our patients. A reading of less than 10 mm was taken as marker for the presence of dry eye. In our study out of forty four rheumatoid arthritis patients fifteen (34.09%) had reduced tear quantity. Whereas the non-rheumatoid arthritis group, 11.36% had reduced Schirmer value (table 2). Since our data was found to be not normally distributed, we used Man-Whitney U test for statistical analysis and found that there was statistically significant difference in tear quantity between the two groups P value (p value <0 p=0.003).>^[16] For the assessment of tear film stability, Tear film break up time (TBUT) was taken. A TBUT of less than 10 second was taken as abnormal, showing the presence of dry eye. Table 3 shows a greater number of rheumatoid arthritis patients(38.63%) had poor tear stability, that is TBUT less than 10, as compared to non-rheumatoid arthritis patients (11.36%). We used Mann-Whitney U test for statistical analysis of data. P value was statistically significant in our study. A similar observation was made in Punjabi et al study^[16] where 22.6% rheumatoid arthritis subjects had TBUT less than 10 as compared to control group (9.52). Their result was also found to be statistically significant.

Table 1: Symptoms of dry eyes

Groups	Subject with symptomatic dry eye	Subjects without symptomatic dry eye
Subjects	No           %	No                   %
Rheumatoid arthritis	10            22.72%	34              77.27%
Non rheumatoid patients	4            9.09%	40             90.90%

Table 2: Schirmers test result

Groups	Subjects with redued schirmers value	Subjects with normal schirmers value	mean schirmers value (+ - SE in mm)
Subjects	No            %	No            %
Rheumatoid arthritis	15          34.09%	29        65.90%	9.68+/-0.65 SE
Non rheumatoid arthritis	5            11.36%	39      88.63%	17.34+/-0.65SE

Table 3: tear break up time result (TBUT) in seconds

Groups	Subjects with reduced tbut	Subjects with normal tbut	Mean Tbut Value + -SE
Subjects	No            %	No           %
Rheumatoid arthritis	17          38.26%	27           61.36%	9.89+/-0.58 S.E
Non rheumatoid patients	5           11.36	39           88.65%	13.45+/- 0.47S.E

Table 4: Severity of dry eyes

Group	Mild	Moderate	Severe
Rheumatoid arthritis	04	10	01
Non rheumatoid patients	04	01	0

Table 5: Grading of severity of dry eye disease

Severity	Symptoms	Irritant or emotional tears	Schirmers test
Mild	Mild	Present	5-10
Moderate	Moderate	Absent	1-5
Severe	Severe	Absent	<1>

Conclusion

From this study we conclude that there is a high prevalence of dry eye disease in rheumatoid arthritis patients in south Indian population. A greater percentage of rheumatoid arthritis patients had a more severe form of dry eye disease than normal population. There is a statistically significant difference of tear quantity and tear quality between two groups. We recommend early diagnosis and prompt treatment of dry eye disease in rheumatoid arthritis patients because greater percentage of patients had signs of dry eye disease as compared to symptoms of dry eye disease. Therefore it is very important to screen all rheumatoid arthritis patients for dry eye disease irrespective of duration and severity of rheumatoid arthritis.

Conflict of Interest: None.

References

1. ^ Hochberg MC. Adult and juvenile rheumatoid arthritis. Current epidemiologic concepts. Epidemiol.1981; 3:27.
2. a, b, c  Ruddy S, Harris ED, Sledge CB. Clinical features of rheumatoid arthritis. Kelly's Textbook of Rheumatology. 2012; 967–1000.
3. a, b Watson PG, Hazelman BL. The Sclera and Systemic Disorders. 1976
4. ^ Jabs DA, Mudun A, Dunn JP. Clinical features and treatment results of scleritis and episcleritis. Am J Ophthalmol 2000;130:469
5. a, b Jabs DA. Rheumatic diseases. Ryan S.2012; 1410–1433
6. ^ Foster CS, Forstot SL, Wilson LA. Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. Ophthalmol 1984;91:1253.
7. ^ Thorne JE, Jabs DA. Ocular manifestations of vasculitis. Rheum Dis Clin North Am 2001; 27:761.
8. ^ Sainz de la Maza M, Foster CS, Jabbur NS: Scleritis associated with rheumatoid arthritis and with other systemic immune-mediated diseases. Ophthalmol 1994;101:128
9. ^ Wright KW, Silverstein D, Marrone AC. Acquired inflammatory superior oblique tendon sheath syndrome. Arch Ophthalmol 1982; 100:1752.
10. ^ Nabili S, McCarey DW, Browne B. A case of orbital myositis associated with rheumatoid arthritis. Ann Rheum Dis 2002; 61:938.
11. ^ Tobin DR, Krohel GB, Rynes RI. Hydroxychloroquine, Seven year experience. Arch Ophthalmol 1982;100:81.
12. ^ Johnson MW, Vine AK. Hydroxychloroquine therapy in massive doses without retinal toxicity. Am J Ophthalmol 1987;104:139.
13. ^ Thorne JE, Maguire AM. Resolution of hydroxychloroquine maculopathy. Br J Ophthalmol 1999;83:1201.
14. ^ Mazzuca SA, Yung R, Brandt KD. Current practices for monitoring ocular toxicity related to hydroxychloroquine therapy. J Rheumatol 1994; 21:59.
15. a, b, c, d, e Moss SE, Klein R, Klein BEK. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000;118:1264-1268
16. a, b, c, d Punjabi OS, Adyanthaya RS, Mhatre AD, Jehangir RP. Rheumatoid arthritis is a risk factor for dry eye in the Indian population. Ophthalmic Epidemiol 2006;13:379-384.
17. ^ Agarwal S, Agarwal A, Apple DJ, Burato L, Alió JL, Pandy SK, Textbook of Ophthalmology. 2002;2997.
18. ^ Haper SL, Foster CS. The ocular manifestations of rheumatoid disease. Int Ophthalmol Clin 1998;38(1):1-19.
19. a, b The definition and classification of dry eye disease. Report of the definition and classification subcommittee of the International Dry Eye Workshop. Ocul Surf 2007; 5: 75-92
20. ^  Lemp MA. Report of the National Eye Institute/Industry Workshop on Clinical Trials In Dry Eyes. CLAO J 1995;21:221-232.
21. ^ Perry HD. Dry eye disease: pathophysiology, classification and diagnosis. Am J Manag Care 2008;14:79-87.
22. a, b  Schein OD, Tielsch JM, Mufloz MS, Bandeen-Roche K, West S. Relation between signs and symptoms of dry eye in the elderly. Cornea 1997;104:1395-1401
23. ^ Doughty MI, Fonn D, Richter D. A patient questionnaire approach to estimating the prevalence of dry eye symptoms in patients presenting to optometric practices across Canada. Optom Vis Sci 1997;74:624-631.
24. ^ Fujita M, Igarashi T, Kurai T, Sakane M, Yoshino S, Takahashi H et al. Correlation between dry eye and rheumatoid arthritis activity. Am J Ophthalmol 2005;140:808-813.
25. ^ Sahai A, Malik P. Dry eye: Prevalence and attributable risk factors in a hospital based population. Indian J Ophthalmol 2005;53:87-91.
26. ^ Srihari NB, William LM, Thomas CP, Julie A, Jackson RN, Norman EL et al. The Diagnosis and Characteristics of moderate dry eye in non-contact lens wearers. Eye & Contact Lens. 2005; 31: 96-104.
27. ^ Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone replacement therapy and dry eye syndrome. JAMA 2001;286:2114-2119.
28. ^ Guo B, Lu P, Chen X, Zhang W, Chen R. Prevalence of dry eye disease in Mongolians at high altitude in China: the Henan Eye Study. Ophthalmic Epidemiol 2010;17:234-241.
29. ^ Nien CJ, Massei S, Lin G, Nabavi G, Toa J, Brown DJ et al. Effects of age and dysfunction on human meibomian glands. Arch Ophthalmol 2011;129:462-469.
30. ^ Nichols KK, Foulks GN, Bron NJ, Glasgow BJ, Dogru M, Tsubota K. The International Workshop on Meibomian Gland Dysfunction: Executive summary. Invest Ophthalmol Vis Sci 2011;52:1922-1929.
31. ^ Mc Monnies CW, Ho A. Patient history in screening for dry eye conditions. J Am Optom Assoc 1987;58:296-301

Doi No:-10.18231/2581-5016.2019.0008