News|Articles|October 26, 2026

Women’s Health: Identifying dry eye in rheumatoid arthritis can make all the difference

Fact checked by: Meghan K. Berkenstock, MD

Key Takeaways

Rheumatoid arthritis (RA) is an autoimmune disorder that develops much more frequently in women than men, with a female-to-male ratio of 3 to 1.
A careful patient history is paramount to arrive at a correct diagnosis. Patients may mention morning stiffness, which can be a factor in the diagnosis of RA.
Dry eye in RA results from aqueous tear deficiency due to immune-mediated destruction of the lacrimal glands. Symptoms include burning, redness, photophobia, a foreign body sensation, and fluctuating vision.

Rheumatoid arthritis, is an autoimmune disorder, develops more often in women than men in a 3:1 ratio.

Rheumatoid arthritis (RA) is an autoimmune disorder that develops much more frequently in women than men, with a female-to-male ratio of 3 to 1.

“Most autoimmune diseases have a female predominance and they usually disproportionately affect younger individuals, although they can occur in later middle-aged people,” according to Meghan K. Berkenstock, MD, associate professor of ophthalmology, Wilmer Eye Institute, Division of Ocular Immunology, Baltimore.

No definitive reason has been uncovered for why women are impacted to a greater degree, but hormonal issues or other susceptibility factors have been suggested. While the specific causes for the disease are still unknown, the World Health Organization¹ mentioned several modifiable lifestyle-associated risk factors, such as smoking, and obesity and non-modifiable risk factor such as genetics, female gender, and age.

There also has been speculation that autoimmune diseases are linked to the X chromosome in women. A molecular coating found on the X chromosome might explain why women account for about 80% of all cases of autoimmune disease. Women have two X chromosomes, while men have one. Women’s X chromosomes are coated with RNA and proteins that muzzle the genes inside and are targeted by misguided immune molecules. Experiments in male mice with a lupus-like disease showed that those with a form of this coating had higher autoantibody levels and more extensive tissue damage, according to a Nature report.²

RA generally damages synovial-lined joints in the hands, feet, wrists and knees. Extra-articular effects have been described in multiple organ systems including the lungs, kidney, cardiovascular system, and eyes. Subcutaneous nodules are the most common extra-articular manifestation and are present in from 20% to 30% of patients, although the frequency of nodules may be decreasing. Clinical observations suggest severe complications such as corneal “melts” and perforations in RA are decreasing with advances in modern biologic treatments.³

RA and the eye

During an ophthalmic examination, the most common ocular manifestations in RA and other rheumatic diseases are dry eye and secondary Sjögren’s syndrome, Dr. Berkenstock explained.

Dry eye in RA results from aqueous tear deficiency due to immune-mediated destruction of the lacrimal glands. Symptoms include burning, redness, photophobia, a foreign body sensation, and fluctuating vision,⁴ according to the Arthritis Foundation.

Scleritis, the next most common manifestation after dry eye, can affect the front of the eye (anterior scleritis), and because the sclera is a dense connective tissue that extends to the back of the eye and abuts the optic nerve, the development of posterior scleritis is also possible, she explained. Importantly, scleritis affects the retinal vasculature causing fluid accumulation and can potentially cause blindness.

Impaired vision in RA is strongly associated with a significant decline in quality of life and can also exacerbate problems related to physical functioning. Consequently, it can lead to serious complications in the treatment of the underlying disease.⁵

It is also important to note that ocular diseases may precede the occurrence of inflammatory joint and spinal diseases, as well as organ involvement in systemic connective tissue disorders. Therefore, paying attention to ocular symptoms can help in early diagnosis and thus improve patient prognosis. For the aforementioned reasons, ocular diseases should be carefully considered in routine rheumatologic practice.⁵

Like the joints, the sclera and cornea contain proteoglycans and collagen. This histologic similarity likely accounts for many of the ocular manifestations of RA. The ocular conditions associated with RA have pathological features in common with vasculitis, which may include vascular occlusion, infiltration, and fibrinoid necrosis. Processes at play include immune complex deposition, secretion of collagenases, e.g., matrix metalloproteinases, by macrophages and neutrophils, cytokine production, complement activation, and formation of autoantibodies.⁶

In addition to dry eye and scleritis, other common ocular manifestations of RA are episcleritis,⁷ uveitis,^8,9 keratitis,⁷ retinal vasculitis,¹⁰ lacrimal gland inflammation (rare),¹¹ and optic neuritis.¹²

Differentiating between dry eye and dry eye in RA in clinical practice

A careful patient history is paramount to arrive at a correct diagnosis. Patients may mention morning stiffness, which can be a factor in the diagnosis of RA. “Rheumatoid arthritis is a clinical diagnosis that is supported by laboratory values and radiology results, the latter of which may show joint erosion. An RA diagnosis must meet a minimum set of diagnostic criteria in the clinical examination and history,” Dr. Berkenstock explained.

During an examination she asks specific questions about the bilaterality of the joint pain and swelling, the severity of the stiffness in the morning compared to later in the day with activity, the presence of an approximately 45-minute duration of stiffness in the morning, and the presence of stiffness for longer than 6 weeks. If the patient responds positively to these inquiries, the next step is laboratory testing following a rheumatologic evaluation and x-rays, Dr. Berkenstock explained.

In her practice, when patients respond positively, she then looks for the previously mentioned signs of ocular involvement.

A notable bit of information for clinicians is that not all patients with dry eye have RA. Those who do have RA may have inflamed lacrimal glands or the accessory tear glands in the conjunctiva. “Tear production issues occur in RA as opposed to evaporative dry eye,” she said.

Conversely, RA can develop without the eyes becoming involved in the disease process.

Treatment

In patients with dry eye associated with RA, Dr. Berkenstock prescribes a topical corticosteroid, such as Lotemax (loteprednol etabonate, Bausch & Lomb) with tapering for 1 month, and Restasis (cyclosporine, AbbVie, Inc.) or Xiidra (lifitegrast, Bausch & Lomb) that can be used over the long term to address the ocular surface and for tear production.

She may also prescribe systemic immunosuppressant drugs to treat scleritis or retinal vasculitis.

Case report

Dr. Berkenstock described the case of a woman who presented with scleritis, which indicated clearly uncontrolled RA. She walked with a cane because of the status of her joints, and her hands were severely gnarled. Such patients have an increased risk of cardiovascular death and complications. The patient was referred to a rheumatologist with the suggestion of treatment with rituximab (Rituxan, Biogen and Genentech) to address the scleritis and the RA. The drug works by depleting B cells, which are part of the immune system. The patient had an immediate response and did not require a cane to walk by the time of the next appointment.

Patients have educational opportunities available to them on the website of Dr. Berkenstock’s practice (https://www.hopkinsmedicine.org/wilmer/services/ocular-immunology). She also partners with a rheumatologist, who may refer RA patients before the development of frank ocular involvement.

She emphasized the importance of seeking medical help. “If patients have RA or any autoimmune or rheumatologic issue, and they notice any changes in vision, pain, or redness, they need to find an ophthalmologist or rheumatologist. In many cases, they will be diagnosed with dry eye, but in other cases a more complex scenario could lead to blindness,” she stated.