Rheumatoid arthritis (RA) is a common, chronic systemic inflammatory disease of unknown etiology that primarily involves the joints. Extra-articular manifestations are also observed including ophthalmologic involvement in approximately 25 % of RA patients. The clinical course of the ocular disease may be quite variable. The importance of early diagnosis of ophthalmic disease in the patient with RA cannot be overemphasized since it permits the timely management of potentially serious, sight-threatening complications. The presence of ocular disease may also be an indication of ongoing systemic disease activity [1, 2]. However, ocular involvement and severity of ocular disease may exist independently from articular inflammation and should be evaluated in all RA patients regardless of extra-ophthalmic manifestations [3].

RA is found worldwide and has no racial predilection; the prevalence is 0.8–1 % of the general population [4] affecting women approximately three times more often than men. Worldwide the annual incidence of RA is approximately three cases per 10,000. The disease is more commonly diagnosed after age 40 [4] but patients of any age can be afflicted. The onset of RA is most frequent during the fourth and fifth decades of life (peak between ages 35–50) [5]. The disease prevalence increases with age, and the threefold difference between the sexes diminishes in older age groups [6].

The revised criteria for the diagnosis of rheumatoid arthritis (RA) are as follows: (1) morning stiffness in and around joints lasting at least 1 h before maximal improvement; (2) soft tissue swelling (arthritis) of three or more joint areas observed by a physician; (3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; (4) symmetric swelling (arthritis); (5) rheumatoid nodules; (6) the presence of rheumatoid factor; and (7) radiographic erosions and/or peri-articular osteopenia in hand and/or wrist joints. The diagnosis of rheumatoid arthritis is established by the presence of four or more of the aforementioned criteria (Criteria 1 through 4 must have been present for at least 6 weeks to merit significance). The presence of rheumatoid factor (RF) is found in approximately 75 % of patients with RA and is not independently diagnostic of the disease. Anti-cyclic citrullinated peptide (anti CCP) antibodies are as sensitive as RF and more specific in early and established disease. Anti CCP may be detected in patients prior to the onset of clinical manifestations of RA [7–13].

The most common ocular manifestation of adult RA is keratoconjunctivitis sicca occurring in 9–31 % of patients. Other ocular manifestations include: episcleritis (0.17–5.7 % of RA patients); scleritis (0.15–6.3 % of RA patients) [5]; scleromalacia perforans, peripheral and central corneal ulceration have also been reported but are less common.

Uveitis is rare in adult RA in the absence of concomitant inflammatory disease involving the cornea or sclera (this is theorized via progression of inflammatory disease in contiguous ocular structures). In a series of 32 patients with rheumatoid scleritis, 14 (44 %) had at least one episode of anterior uveitis; of those, 7 patients (50 %) had necrotizing anterior scleritis, 5 patients had diffuse anterior scleritis, and 2 patients had nodular anterior scleritis [14]. None of the patients had isolated iritis in the absence of scleritis. Other case series have reported correlation with the degree of scleral inflammation and presence of uveitis.

Rheumatoid arthritis associated vasculitis was described in the 1960s in patients who developed severe clinical manifestations (skin rash, cutaneous ulcerations, gangrene, peripheral neuropathy, and visceral infarction) [15]. In one case series by Giordano and colleagues, 18.3 % of patients with RA had fluorescein angiographic evidence of retinal vasculitis [16] without clinical signs on fundoscopy.