Aishwarya Jha, B. Optometry

Fellow Optometrist, Dr shroff’s charity eye hospital, Delhi, India.


When the immune system attacks  the body and damages healthy cells, vision is subsequently affected. In many cases, the eyes indicate to both the patient and their consultant that an autoimmune disease may be developing and affecting the eye along with other organs of the body. These autoimmune disorders can have devastating ocular manifestations.

Mostly, ocular complications involve the cornea but may also include the conjunctiva, uvea, sclera, retina, and surrounding structures. Dry or red eyes, foreign-body sensation, pruritus, photophobia, pain, visual changes, and even complete loss of vision are the main symptoms.

The purpose of this blog, is to discuss the most common autoimmune diseases and their ocular manifestations :-

Rheumatoid Arthritis:- Approximately 25% individual with (RA) have ocular manifestations like keratoconjunctivitis sicca, scleritis and episcleritis (fig 1 and 2) keratitis, peripheral corneal ulceration. Entities like choroiditis, retinal vasculitis, episcleral nodules, retinal detachments, and macular oedema less common.(1,2)

RA is the most common cause of scleritis, accounting for approximately 18 to 33%of cases.(1-3)


Figure 1 – Scleritis (Left Panel)

Figure 2 – Episcleritis (Right Panel)


Sjögren’s syndrome:- The primary ocular manifestation of Sjögren’s syndrome is keratoconjunctivitis sicca. In addition to the treatment 5 mg of oral pilocarpine (Salagen) four times daily may improve the symptoms of dry eyes and dry mouth. (4,5)

Graves’ Disease:- Exophthalmos occurs in approximately 50% of patients with thyroid disease.(6) It is found in patients who are having euthyroid or hypothyroid and strongly with chain smokers. In the case  of optic nerve compression, there will be decreased visual acuity, reduced visual fields, relative afferent pupillary defect, and loss of colour vision. Computed tomography or MRI of the orbit is recommended.(7,8)

Giant cell arteritis:- Up to 50% of patients with giant cell arteritis will present  ocular symptoms like pain, diplopia, visual loss, and amaurosis fugax, also in addition to headache, jaw claudication, and neck pain will be seen.(7)  It is important to note that ocular involvement is common in the absence of systemic signs and symptoms.

Systemic Lupus Erythematosus:- Ocular disease occurs in 20% of patients with systemic lupus erythematosus (SLE). External ocular manifestations include keratoconjunctivitis sicca, conjunctivitis, uveitis, episcleritis, scleritis, keratitis.(8,9)

Neuroophthalmic involvement in SLE is primarily caused by microinfarction, haemorrhage, or vasculitis in various locations of the eye (fig 3) and along the visual pathway. Typical complications include optic neuritis, ischemic optic neuropathy, hemianopia, amaurosis, internuclear ophthalmoplegia, pupillary abnormalities, oculomotor abnormalities, pseudotumor cerebri, and visual hallucinations.(9)


Figure 3:- Cotton-wool spots in a patient with systemic lupus erythematosus


Multiple Sclerosis:- The ocular manifestations of multiple sclerosis (MS) can be divided into afferent and efferent disorders. Optic neuritis is diagnosed in 75% of patients with MS and is the presenting symptom in 14-25% of cases¹¹. Visual field defects in patients with MS occurs due to demyelination along the visual pathway. Dysmetria, nystagmus, and cranial nerve palsies, especially involving the sixth and third nerves, may result from lesions of the brain stem and cerebellum.(12)



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  2. Harper SL, Foster CS. The ocular manifestations of rheumatoid disease
  3. McGavin DD, Williamson J, Forrester JV, Foulds WS, Buchanan WW, Dick WC, et al. Episcleritis and scleritis. A study of their clinical manifestations and association with rheumatoid arthritis. Br J Ophthalmol. 1976;60:192–226. Int Ophthalmol Clin. 1998;38:1–19.
  4. Vivino FB, Al-Hashimi I, Khan Z, LeVeque FG, Salisbury PL 3d, Tran-Johnson TK, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicentre trial. Arch Intern Med. 1999;159:174–81.
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  9. Nguyen QD, Foster CS. Systemic lupus erythematosus and the eye. Int Ophthalmol Clin. 1998;38:33–60.
  10. Soo MP, Chow SK, Tan CT, Nadior N, Yeap SS, Hoh HB. The spectrum of ocular involvement in patients with systemic lupus erythematosus without ocular symptoms. Lupus. 2000;9:511–4
  11. Kidd D. Presentations of multiple sclerosis. Practitioner. 1999;243:24–6,28–30.
  12.  Davis EA, Rizzo JF. Ocular manifestations of multiple sclerosis. Int Ophthalmol Clin. 1998;38:129–39.