Tag: optic neuritis

Autoimmune Diseases and the Eye

Autoimmune diseases can affect the eyes by causing inflammation, dry eyes, optic nerve damage, uveitis, or retinal problems, sometimes before other symptoms appear. Early diagnosis and coordinated care with an ophthalmologist can help protect vision and prevent long-term complications.

Quick Answer: Autoimmune disease can inflame almost any layer of the eye. Episcleritis is usually mild and self-limiting, scleritis is deeper, more painful, and sight-threatening if untreated, uveitis affects the inside of the eye and needs prompt steroid treatment, and Sjogren’s syndrome causes chronic dry eye through damaged tear glands. Anyone on long-term hydroxychloroquine also needs annual retinal screening regardless of symptoms, because toxicity can develop silently.

Autoimmune Disease and Your Eyes: What Rheumatoid Arthritis, Lupus and Sjogren’s Can Do to Your Vision

If you have rheumatoid arthritis, lupus, Sjogren’s syndrome, or another autoimmune condition, your eyes are not a side issue. They are often where the disease shows up first, or where it quietly does the most damage while everyone is focused on joints and skin and bloodwork.

I see this pattern often: a patient on long-term immune therapy who has never had a baseline eye check, or one who assumes a red, painful eye is just dryness when it is actually scleritis. The eye has its own version of almost every autoimmune complication your rheumatologist tracks elsewhere in the body.

In this article, I will cover the five autoimmune eye conditions I see most often: uveitis, episcleritis, scleritis, Sjogren’s-related dry eye, and the retinal toxicity risk from long-term hydroxychloroquine (HCQS) use. I will also flag two related conditions worth knowing about: peripheral ulcerative keratitis and autoimmune optic neuritis.

Dr Shibal Bhartiya is a fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator with over 25 years of experience. Her approach focuses on identifying risk before damage is irreversible, simplifying treatment decisions, and protecting vision long-term. Emphasis on early detection, risk assessment, and continuity of care. She is rated 5 stars across 1,500+ patient reviews on Google.

Uveitis

Uveitis is inflammation inside the eye, affecting the iris, ciliary body, or choroid. It is one of the most common autoimmune eye complications and can occur with ankylosing spondylitis, juvenile idiopathic arthritis, sarcoidosis, Behcet’s disease, and inflammatory bowel disease, among others.

SymptomWhat It MeansWhat To Do About It
Eye pain with redness, often around the irisActive inflammation of the front of the eye (anterior uveitis)See an ophthalmologist within 24 to 48 hours; do not wait this out
Sensitivity to light (photophobia)Inflamed iris muscle spasming in response to lightDark glasses help short term; this needs treatment, not just avoidance
Blurred vision with floatersInflammatory cells or debris in the vitreous (posterior or intermediate uveitis)Needs dilated examination to localise where the inflammation is occurring
Recurrent episodes in the same or other eyeSuggests an underlying systemic autoimmune trigger rather than an isolated eye problemWarrants referral back to rheumatology for systemic work-up if not already diagnosed
No pain but gradually worsening visionPossible chronic or posterior uveitis, which can be painless despite significant inflammationDo not assume painless means harmless; this still needs urgent assessment
Uveitis not responding to first-line steroid dropsMay need systemic immunosuppression or a biologic agentCo-management between ophthalmology and rheumatology is usually required

Episcleritis

Episcleritis is inflammation of the thin layer just under the conjunctiva. It is usually mild, often recurrent, and frequently mistaken for conjunctivitis.

SymptomWhat It MeansWhat To Do About It
Sudden patch of redness, mild discomfortLocalised inflammation of episcleral vessels, often without a clear triggerUsually self-limiting; lubricating drops and cold compresses help
Redness that blanches when you press gently with a cotton budA useful bedside sign distinguishing episcleritis from deeper scleritisIf it blanches, it is reassuring; if it does not, seek same-day assessment
Mild tenderness but no severe painEpiscleritis is typically far less painful than scleritisSevere pain is a red flag that this may be scleritis instead
Recurrent episodes over months or yearsCan be idiopathic or linked to mild autoimmune activityWorth screening for rheumatoid arthritis or other connective tissue disease if recurrent
Nodular, raised area of rednessNodular episcleritis, a slightly more persistent subtypeMay need a short course of topical steroid under supervision

Scleritis

Scleritis is deeper, more severe inflammation of the sclera itself, the white outer wall of the eye. It is strongly associated with rheumatoid arthritis, granulomatosis with polyangiitis, and lupus, and it can threaten vision if untreated.

SymptomWhat It MeansWhat To Do About It
Deep, boring eye pain, often worse at nightInflammation of the sclera, a much more severe process than episcleritisNeeds same-day ophthalmology assessment; this is not a wait-and-watch condition
Pain radiating to the jaw, brow, or faceScleral pain frequently refers along trigeminal nerve pathwaysDo not dismiss as a headache or sinus issue if accompanied by eye redness
Redness that does not blanch on pressureDeeper vessel involvement than episcleritisConfirms the need for urgent evaluation rather than home care
Thinning or a bluish discolouration of the scleraSign of necrotising scleritis, a severe and sight-threatening subtypeRequires urgent systemic immunosuppression; same-day specialist referral
Scleritis as a first presentation of joint or skin symptomsThe eye can be the first organ to show systemic autoimmune diseaseNeeds prompt rheumatology referral alongside eye treatment
Reduced vision alongside scleral painAssociated uveitis, glaucoma, or corneal involvement can occur with severe scleritisNeeds full eye examination, not just treatment of the visible redness

Dry Eye and Sjogren’s Syndrome

Sjogren’s syndrome is an autoimmune condition that attacks the tear and salivary glands directly, producing a more severe and treatment-resistant dry eye than typical age-related dryness.

SymptomWhat It MeansWhat To Do About It
Persistent gritty, burning dryness despite dropsSjogren’s-related dry eye often does not respond to standard lubricants aloneNeeds assessment for Sjogren’s if dryness is disproportionate or progressive
Dry mouth alongside dry eyesClassic combination pointing to Sjogren’s syndrome affecting both gland systemsWorth a blood test panel (anti-Ro/La) and rheumatology referral
Recurrent corneal erosions or filamentsSevere tear film instability damaging the corneal surfaceMay need punctal plugs, serum tears, or scleral lenses, not just drops
Dry eye that worsens despite treating typical MGDSuggests an aqueous-deficient, not just evaporative, dry eye componentNeeds Schirmer’s testing and systemic work-up rather than repeating MGD treatment
Joint pain, fatigue, or skin dryness alongside eye drynessSystemic features suggesting Sjogren’s rather than isolated ocular drynessRefer to rheumatology for formal diagnosis and systemic management

Hydroxychloroquine (HCQS) Retinal Toxicity

Hydroxychloroquine is a mainstay treatment for lupus, rheumatoid arthritis, and other autoimmune conditions. It is generally safe, but long-term use carries a small, dose-dependent risk of retinal toxicity that is irreversible once it progresses, which is why screening matters even without symptoms.

SymptomWhat It MeansWhat To Do About It
No symptoms at all, but on HCQS for more than 5 yearsToxicity is often silent in early stages and detected only on screeningAnnual screening is required regardless of symptoms after 5 years of use
Difficulty reading or patchy missing areas in central visionPossible bull’s eye maculopathy from established toxicityNeeds urgent retinal evaluation and discussion with rheumatology about dosing
High daily dose relative to body weightRisk rises above 5 mg/kg/day of real body weightConfirm dosing with your rheumatologist; weight-based dosing reduces risk
Pre-existing kidney disease or retinal diseaseBoth increase toxicity risk independent of dose or durationFlag these conditions before starting HCQS so screening starts earlier
Annual screening showing early paracentral changes on OCT or visual fieldsEarly, often asymptomatic, sign of toxicity preceding visible vision lossUsually prompts a dose reduction or drug change in consultation with rheumatology

Important: Screening for HCQS toxicity should start at baseline before treatment begins, then annually after 5 years of use, sooner if risk factors like high dose, kidney disease, or pre-existing retinal disease are present. This typically includes OCT, visual fields, and sometimes multifocal ERG or fundus autofluorescence.

Two More Worth Knowing About

Peripheral Ulcerative Keratitis (PUK)

PUK is a crescent-shaped thinning and ulceration at the edge of the cornea, strongly linked to rheumatoid arthritis and granulomatosis with polyangiitis. It can progress to corneal perforation if untreated and is considered an ophthalmic emergency.

Autoimmune Optic Neuritis

Optic neuritis, inflammation of the optic nerve causing pain on eye movement and vision loss, can occur in multiple sclerosis, neuromyelitis optica, and MOG antibody disease. It needs urgent neuro-ophthalmic assessment, since the underlying diagnosis changes the treatment significantly.

When To See a Doctor

  • Eye pain that wakes you at night or is described as deep and boring, not surface irritation
  • Redness that does not blanch when you press a cotton bud gently against it
  • Any vision change, however mild, alongside eye redness or pain
  • Dry eye symptoms that do not improve with standard lubricants after a few weeks
  • Known autoimmune disease with a new eye symptom of any kind
  • Long-term hydroxychloroquine use without an annual eye screening on record
  • Eye symptoms appearing before any formal autoimmune diagnosis has been made

What This Means for You

If you have an autoimmune condition, your eye care should not be separate from your rheumatology care. The two specialties need to talk to each other, especially around long-term medications like hydroxychloroquine and around any new eye symptom that could signal a flare. An annual baseline eye check, even with no symptoms, catches problems like HCQS toxicity and early scleritis before they cause permanent damage.

This article is part of the Dry Eye Hub. Please also read Basics of Dry Eye, Dry Eye Second Opinion and Dry Eye: A Chronic Disease. Why Vision Becomes Blurred After Reading or Screen Use, and Why Are Your Dry Eye Drops Not Working may also help you understand your problem better.

This page is also a part of the Neuro-Ophthalmology hub. Read about our full approach to neurological vision conditions, Some vision problems are not eye problems, and about optic nerve disease.

If you are weighing a second opinion on an autoimmune eye diagnosis, our Second Opinion Page outlines how that process works.

Frequently Asked Questions

Can autoimmune eye disease occur before other symptoms appear?

Yes. Uveitis, scleritis, and even dry eye can be the first sign of an underlying autoimmune condition, sometimes appearing years before joint or skin symptoms develop. This is one reason ophthalmologists often refer patients to rheumatology rather than the other way round.

Is hydroxychloroquine safe for long-term use?

Yes, for most people, but it requires monitoring. The risk of retinal toxicity is low at recommended doses but rises with duration of use, higher doses, and certain risk factors like kidney disease. Annual screening after 5 years of use is the standard of care, not an optional extra.

How do I tell episcleritis apart from scleritis at home?

Episcleritis usually blanches, turns paler, when you press a clean cotton bud gently against the white of the eye, and the pain is mild. Scleritis does not blanch and causes deep, often severe pain. If you are unsure, treat it as scleritis until an ophthalmologist tells you otherwise.

Why does Sjogren’s dry eye not respond to normal eye drops?

Sjogren’s syndrome damages the tear-producing glands directly, reducing the volume of tears your eye can make rather than just affecting tear quality. Standard lubricating drops can help but often are not enough on their own, which is why options like punctal plugs or serum tears are considered.

Does treating the autoimmune disease also treat the eye problem?

Often yes, particularly for uveitis and scleritis, where systemic immunosuppression treats both the eye and the underlying disease together. However, some eye complications, like HCQS toxicity or Sjogren’s dry eye, need their own dedicated monitoring and treatment regardless of how well the systemic disease is controlled.

Key Takeaways

  • Autoimmune disease can affect nearly every layer of the eye, from the surface to the optic nerve
  • Episcleritis is usually mild; scleritis is deep, painful, and sight-threatening if untreated
  • Uveitis needs prompt treatment even when painless, since delayed care risks permanent vision loss
  • Sjogren’s dry eye often needs more than standard lubricants
  • Anyone on long-term hydroxychloroquine needs annual retinal screening, with or without symptoms
  • Eye symptoms can be the first sign of autoimmune disease, before a formal diagnosis exists

Book a Consultation

If you have an autoimmune condition and have not had a baseline eye examination, or if you are on long-term hydroxychloroquine without a recent screening, it is worth getting this checked before symptoms appear. Early detection is what makes the difference between a manageable finding and irreversible vision loss in these conditions.

[Book an Appointment → contact us]

About the Author

This article was written by Dr Shibal Bhartiya, fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator, Clinical Director at Marengo Asia Hospitals, Gurugram, known for ethical, patient-centred glaucoma care and independent glaucoma second opinions. She is also the Program Director for Community Outreach & Wellness; and for the Marengo Asia International Institute of Neuro and Spine.

She has published peer-reviewed research on glaucoma management, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.

As Editor-in-Chief of Clinical and Experimental Vision and Eye Research and Executive Editor of the Journal of Current Glaucoma Practice (Pubmed Indexed, official journal of the International Society of Glaucoma Surgery), Dr Shibal Bhartiya brings editorial and research depth to every clinical decision. Her 200+ publications, including 90+ PubMed-indexed publications and 28 edited textbooks span glaucoma biology, surgical outcomes, health equity, and emerging diagnostics.

1500+ Five Star Patient Reviews Google Business Profile

If you are unable to come to Dr Bhartiya’s clinic: Read more about teleconsultation

Read her research on PubMed | Google Scholar | ResearchGate | ORCID

Upload your reports for a structured review.| www.drshibalbhartiya.com | +91 88826 38735

Leave a review on Google

Eye Pain and Brain Disease

Eye pain, especially when associated with blurred vision or reduced colour vision, may sometimes be a sign of optic neuritis, an inflammatory condition linked to multiple sclerosis. Early diagnosis can help protect both vision and neurological function.

Not all eye pain originates in the eye itself. Optic neuritis can be the first manifestation of multiple sclerosis and may present with pain on eye movement, vision loss, or colour vision changes, explains Dr Shibal Bhartiya.

Dr Shibal Bhartiya is a  neuro-ophthalmologist and glaucoma specialist (trained from Dept of Clinical Neurosciences, University of Geneva), and Mayo Clinic Research Collaborator with over 25 years of experience. Her approach focuses on identifying risk before damage is irreversible, simplifying treatment decisions, and protecting vision long-term. Emphasis on early detection, risk assessment, and continuity of care. She is rated 5 stars across 1,500+ patient reviews on Google.

Why Was This Patient’s Eye Pain Actually a Brain Disease?

Ms RM was 23 when her left eye started hurting. The pain was mild at first, a dull ache deep behind the eye. It was worse when she moved her eye to look sideways. She went to a local clinic, where she was told her eye looked structurally normal. No redness, no inflammation visible on the surface, no sign of infection. She was given lubricating drops and asked to return if it worsened. It did not improve. Three days later, she came to me.

Within two days, she said, the vision in that eye had dimmed, as if I am looking through a veil. Colours looked washed out. Reading my phone screen with that eye alone felt like reading through fog.

Her eye examination was almost entirely normal to look at. But her vision had dropped significantly in that eye, and she had pain on eye movement, which is an unusual and specific finding. When I tested her colour vision, she struggled badly with the reds and greens in that eye alone. Her pupil reacted more slowly to light in the affected eye than in the healthy one.

This pattern, pain on eye movement, reduced colour vision, and a sluggish pupil response, pointed to optic neuritis, inflammation of the nerve that carries vision from the eye to the brain. I arranged an urgent MRI of her brain and orbits.

The scan showed changes consistent with demyelination, areas where the protective coating around nerve fibres in the brain was damaged. RM’s eye was never the real problem. Her optic nerve and her brain were.

Patient details have been changed to protect privacy.

What is Optic Neuritis?

This case is one of the clearest examples of why an eye examination is sometimes a neurological examination. Optic neuritis is the first sign of multiple sclerosis in a substantial proportion of young patients who develop it, often years before any other symptom appears. It is also one of the most commonly delayed diagnoses in ophthalmology, because the eye itself looks deceptively normal. Below, I explain how optic neuritis presents, how it differs from other causes of sudden vision loss, and why an MRI is essential once it is suspected.

Quick Answer: Optic neuritis is inflammation of the optic nerve that causes vision loss, often with pain on eye movement, typically in one eye. It commonly affects young adults, especially women, and is strongly linked to multiple sclerosis. Any suspected case requires an urgent MRI of the brain to look for underlying demyelinating disease.

What Optic Neuritis Actually Is and Why the Eye Looks Normal

The optic nerve carries visual signals from the retina to the brain. In optic neuritis, this nerve becomes inflamed, usually because the body’s immune system has attacked the myelin sheath that insulates the nerve fibres. This disrupts the electrical signal travelling along the nerve, which is why vision drops even though the eye structures themselves, the cornea, lens, and retina, remain completely normal on examination.

This is the central reason optic neuritis is so often missed in its first presentation. A clinician examining the front and back of the eye with standard equipment will see nothing wrong, because nothing is wrong there. The damage is happening further back, in the nerve itself, often at a point that cannot be directly visualised without specific imaging.

Three clinical features distinguish optic neuritis from other causes of vision loss, and all three were present in Riya’s case. Pain that worsens specifically with eye movement, rather than constant pain. Reduced colour vision that is disproportionate to the reduction in visual acuity. And a relative afferent pupillary defect, where the pupil in the affected eye responds more slowly to light than the healthy eye. Any clinician trained to look for this triad will suspect optic neuritis quickly, even when the eye looks structurally normal.

The connection to multiple sclerosis matters enormously for what happens next. Studies following patients with a first episode of optic neuritis show that a meaningful proportion go on to develop MS, particularly when the MRI shows lesions in the brain’s white matter at the time of diagnosis. This is why imaging is not optional once optic neuritis is suspected. It changes the entire management plan, not just for the eye, but for the patient’s long-term neurological health.

Optic Neuritis vs Other Causes of Sudden Vision Loss

Symptom or SignWhat It SuggestsWhat To Do
Pain that worsens with eye movement, vision dimming over daysOptic neuritis, especially in a young adultUrgent ophthalmology assessment and MRI of brain and orbits
Sudden painless vision loss in one eyeRetinal vein or artery occlusion, more common in older adults with vascular risk factorsSame-day emergency eye assessment
Reduced colour vision out of proportion to blurOptic nerve pathology rather than a refractive or surface problemPupil testing and colour vision assessment by an ophthalmologist
Vision loss with headache and tenderness over the scalpGiant cell arteritis, an emergency in patients over 50Same-day assessment and urgent blood tests
Vision loss that fluctuates with body temperature or exerciseUhthoff’s phenomenon, a recognised feature in patients with prior optic neuritis or MSNeurology referral if not already under care
Eye looks completely normal but vision and colour perception are reducedOptic nerve disease is likely; the problem is not visible on the eye’s surfaceMRI brain and orbits, not just an eye examination

Why This Diagnosis Is So Often Missed

The most significant reason is that the eye examination looks normal. Clinicians and patients both tend to associate eye disease with visible signs: redness, cloudiness, swelling. Optic neuritis produces none of these. The eye looks exactly as it should, which leads many first assessments to conclude there is no eye problem at all.

The second reason is that the initial symptoms can be mild and easily attributed to eye strain, dryness, or fatigue. Riya’s earlier description, a dull ache and slightly dimmed vision, could plausibly be dismissed as tiredness or screen strain in a young, otherwise healthy woman. The specific detail that distinguishes it, pain worsening with eye movement, is easy to overlook unless directly asked about.

The third reason is that connecting an eye finding to a brain disease requires a specific kind of clinical reasoning that sits between two specialities. An eye doctor without neuro-ophthalmology training may treat the optic nerve finding in isolation. A general physician seeing eye pain may not think to examine pupil reactions or colour vision at all. The diagnosis lives precisely at the intersection of ophthalmology and neurology, which is exactly where it is most easily missed.

When To See a Specialist

Seek urgent assessment from an ophthalmologist or neuro-ophthalmologist if any of the following apply:

  • Vision loss in one eye developing over hours to days
  • Pain that is worse specifically when you move your eye
  • Reduced colour vision in one eye, even if your overall vision seems only mildly blurred
  • You are a young adult, particularly a woman between 20 and 45
  • Vision loss with no visible redness or surface change in the eye
  • Symptoms that fluctuate with heat, fever, or exercise

This presentation should be treated as urgent. An MRI arranged within days, not weeks, gives the clearest picture of what is happening and whether further neurological evaluation is needed.

This page is part of the Neuro-Ophthalmology hub. Read about our full approach to neurological vision conditions. Some vision problems are not eye problems. They are brain problems, nerve problems, or vascular problems, that show up in the eye first. Also read about optic nerve disease,  raised intracranial pressure, Vision not clear but tests normal, double vision, and conditions where no diagnosis has yet been reached.

Frequently Asked Questions

Does optic neuritis always mean I have multiple sclerosis?

No. Not everyone with optic neuritis develops MS, but it is one of the most common first presentations of the disease. An MRI helps determine individual risk.

Will my vision recover after optic neuritis?

Most patients regain significant vision within weeks to a few months, often with treatment such as corticosteroids. Some residual changes in colour vision or contrast sensitivity can persist.

Why did my eye look normal even though my vision was affected?

Optic neuritis affects the nerve carrying visual signals to the brain, not the visible structures of the eye itself. This is why a standard eye examination often shows no abnormality.

How soon should I get an MRI after a diagnosis of optic neuritis?

An MRI of the brain and orbits should be arranged urgently, ideally within days of diagnosis, as it guides both treatment and longer-term monitoring. [LINK: neuro-ophthalmology hub]

Book a Consultation

If you are experiencing vision loss with pain on eye movement, particularly alongside reduced colour vision, this needs urgent specialist assessment rather than a routine eye check. The eye may look entirely normal while the real problem lies further back along the visual pathway.

At Dr Shibal Bhartiya Eye Clinic, Gurugram, assessment for suspected optic neuritis includes detailed neuro-ophthalmic examination, pupil testing, and coordination of urgent MRI imaging. [LINK: comprehensive eye exam]

[Book an Appointment → www.drshibalbhartiya.com | +91 88826 38735]

About the Author

This article was written by Dr Shibal Bhartiya, fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator, Clinical Director at Marengo Asia Hospitals, Gurugram, known for ethical, patient-centred glaucoma care and independent glaucoma second opinions. She is also the Program Director for Community Outreach & Wellness; and for the Marengo Asia International Institute of Neuro and Spine.

She has published peer-reviewed research on glaucoma management, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.

As Editor-in-Chief of Clinical and Experimental Vision and Eye Research and Executive Editor of the Journal of Current Glaucoma Practice (Pubmed Indexed, official journal of the International Society of Glaucoma Surgery), Dr Shibal Bhartiya brings editorial and research depth to every clinical decision. Her 200+ publications, including 90+ PubMed-indexed publications and 28 edited textbooks span glaucoma biology, surgical outcomes, health equity, and emerging diagnostics.

1500+ Five Star Patient Reviews Google Business Profile

If you are unable to come to Dr Bhartiya’s clinic: Read more about teleconsultation

Read her research on PubMed | Google Scholar | ResearchGate | ORCID

Upload your reports for a structured review.| www.drshibalbhartiya.com | +91 88826 38735

Leave a review on Google

Neurological Diseases and Eyes

Posted on by Dr Shibal Bhartiya

Neurological diseases can affect vision by disrupting how the brain and nerves process visual information. They may cause symptoms like…

Optic Neuritis

Posted on by Dr Shibal Bhartiya

Optic Neuritis is because of an inflammation of the optic nerve, which connects the eye to the brain. This swelling…

Optic Neuritis

Posted on by Shibal Bhartiya

Optic Neuritis is because of an inflammation of the optic nerve, which connects the eye to the brain. This swelling causes decreased vision.
It is characterized by inflammation affecting the optic nerve. This disrupts the seamless connection between the eyes and the brain. Eventually, this causes a breakdown of the transmission of visual information from the retina to the brain.