oa Editorial [Hot Topic: The Eye in Rheumatological Disease (Guest Editors: Sue Lightman and Simon Taylor)]

The eye can be involved in many different rheumatological and vasculitic disorders. Most rheumatological diseases have ocular complications, many of which are specific to the particular disease and the occurrence of which may help in diagnosis. Indeed, ocular involvement may be the presenting feature of systemic disease, or the involvement of the eye may help to bring together a variety of symptoms and signs and thus make the diagnosis. It is therefore of prime importance that both physicians and ophthalmologists are aware of the ocular symptoms and signs involved in this group of disorders. The first aim of this series of articles is to assist physicians in understanding the range of ocular complications that can be associated with systemic disease and to indicate when urgent referral to an ophthalmologist is necessary. To this end, various ocular complications are discussed. Dry eye disease, synonymous with keratoconjunctivitis sicca, is the commonest ocular manifestation of rheumatological disease, and varies enormously in severity. In its milder forms, topical lubricants may be sufficient, but severe disease may require corticosteroid or immunosuppressive therapy in addition to aggressive lubrication and measures such as lacrimal punctual plugging. Episcleritis and scleritis are common manifestations, particularly in association with rheumatoid arthritis, but require different treatment and have different prognoses, so their differentiation is useful. Necrotising scleritis is a complication that occurs most commonly in association with Wegener's granulomatosis and constitutes an ophthalmological emergency; prompt diagnosis and treatment are of the essence. Uveitis and retinal vasculitis also occur in association with rheumatological disease, and can form a major cause of morbidity, as occurs in Behcet's disease. Anterior uveitis generally responds to topical corticosteroids, but treatment can cause complications in the form of raised intraocular pressure and cataract, and requires regular review by an ophthalmologist. Juvenile idiopathic arthritis is a special case, as ‘silent’ anterior uveitis can occur, necessitating regular screening if complications are to be avoided. Posterior uveitis is more serious and generally requires systemic corticosteroids and immunosuppression, although the biological agents are increasingly being used in refractory cases. A similar approach is required for the management of orbital disease causing proptosis or optic nerve compression, as also occurs in Wegener's granulomatosis. One often neglected area in which rheumatological disease can lead to ophthalmic complications is related to the sideeffects of drug therapy. Hydroxychloroquine is well-known to cause a potentially irreversible maculopathy, but other drugs can also have ocular complications, including opportunistic infection in patients immunocompromised for the management of systemic rheumatological disease. The last article in this series addresses the complications of drug therapy in rheumatological and vasculitic disease, and suggests when screening may be appropriate.