DicLE TIP DERGISi (JOURNAL OF MEDICAL SCHOOL) C:28 S:3-4. ROMATiD ARTRiTLi HASTALARDA GOZ TUTULUMU

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1 DicLE TIP DERGISi (JOURNAL OF MEDICAL SCHOOL) C:28 S:3-4 ROMATiD ARTRiTLi HASTALARDA GOZ TUTULUMU Remzi f;evik1 AIi GOR1 SeYim SOKER f;akmak 2 Kemal NAS 1 Dr. Suat EM 4 Mehmet KARAKOf; 4 Ferda ERDoGAN DZET Bu 9S1/~mada, romatoid artritte ortaya r;/kan goz bulgulannt ve r;e~itli durumlarla ili$kisini ara~t/rmay/ amar;lad/k. 29 romatoid artritli hasta (23 bayan, 6 erkek ve ya~ ortalamas/: 42.45%10.08) 9S1/~ma kapsamtna almd/. Hastal/k suresi(ay) 86.93%82.83 olarak belirlendi. Hastalarm % 52'sinde goz patolojisi saptand/. Hastalarm 0/o24.1'inde gorme alanmda santral skotom, %34.5'inde goz ya~/ yetersizligi ( schirmer testi); hastalarm %6.9'unda komeal apasite, keratit ve pterjium (ayrt ayn); %3.4'unde ise katarakt, makula dejenerasyonu ve bletarit (ayrt ayrt) saptand/. Olgulartm/zda schirmer pozititligi ile keratit arasmda pozitit; cinsiyet ile katarakt ve bletarit arasmda ise negatit anlaml/ bir korelasyon belirlendi (pdj05). Hastalanmlzm ya$, hastal/k sureleri ve iiar; ku/lamm/ ile goz bulgular/ arasmda anjaml1 korelasyon bulunmadl(p>(j05). Sonur; olarak, romatoid artritte goz tutulumu olduk9s s/k olup, gozun duzenli ve aynnt/i/ degerlendirilmesinin hastal/gm morbiditesini azaltacag/ kanaatindeyiz. Anahtar kelime#er: Romatoid artrit, goz. GiRi$ Romatoid artrit (RA), etyolojisi belli olmayan; sistemik tutulumlar gosteren, ozellikle kronikeklem tutulumu ye deformasyonlar ile seyreden enflamatuyar otoimmonbir hastal!ktlr. Eklemlerdl~mda plorit, perikardit, kas atrofisi, lenfadenopati, splenomegali, cilt altl nodolleri ye goz tutulumuna ait bulgular ortaya Clkar.RA'I!hastalarda %20-50 dolaymda okuler tutulum olabilecegi bildirilmektedir(1,2,3).en slk ortaya Clkabilen goz bulgulan kuru goz (keratokonjunktiyitissikka), sklerit ye periferik korneal Olser geli~imidir(4). Bunun dl~lnda episklerit, periferal korneal incelme ye retinal yaskolitsayllabilir(5). Hastallgm slk olarak gozo etkilemesi yanmda tedayide kullamlan glukokortikoidler. altm ye antimalaryal gibi ilaclann goz Ozerine olan olumsuz etkileri (6) nedeniyle RA'l! hastalarda gozon degerlendirilmesi onem kazanmaktadlr. Biz bu cah~mamlzda romatoid artritli hastalarda ortaya Clkan goz bulgulanm ye bu bulgulann ce~itlidurumlarla iii~kisini degerlendirmeyi amacladlk. (1.3.4) D.O. Tip FakOnesi Fiziksel Tip ve RehabHhasyon Anablllm Dah Vard.mcl D~nll (7) D.O. Tip FakOnesl Flzlksel Tip ve Rehabililasyon Anabilim Dah Vardlmcl Do~nll. (4) D.O. Tip FakOnesi Fiziksel Tip ve Rehabllltasyon Anabllim Dah Ar~.GOr.. (2) D.O. Tip FakOllesl GOz Hastahklar. Anabllim Dah Vardlmc. ~ntl.

2 36 MATERYAL VE METOD Amerika Romatizma Dernegi kriterlerine (7) gore RA tamsl alan ye Dicle Oniyersitesi Tip FakOltesi Fiziksel Tip ye Rehabilitasyon ile Goz Anabilim Dallan taraflndan takip edilen 29 hasta cah~ma kapsamma ahndl. TOm hastalann aynntllt anamnez, klinik muayene, radyolojik ye rutin laboratuar tetkikleri yaplldl. TOm olgular goz bulgulan aclsmdan degerlendirildi. Hastalann refraksiyon ye biomikroskopik muayeneleri yaplldl. Schirmer ye Fluorescein klnlma zamam (FKZ) testleri uygulandl. Schiermer testinde total sekresyon 5 dakikada 5 mm'den az ise; FKZ 10 saniyeden az ise patolojik olarak kabul edildi. Aplanasyon tonometresi ile goz ici basmclan oicoldo.fundus direkt ye indirekt oftalomoskopla incelendi. Goldmann Ocaynalt lensi ile periferik retina ve iridokorneal aci degerlendirildi. Gorme ala m muayeneleri yaplldj. istatiksel degerlendirmede "Pearson korelasyon testi" kullanlldl. BULGULAR Hastalarm 23'0 (%79,3) kadm, 6'sl (20,7) erkek olup Ya~ ortalamasl: 42.45:1:10.8 (22-60) olarak belirlendi. Hastallk soresi ortalamasl ise (ay) 86,93:t82,83 (2-300) idi. Olgulanmlzm ya~, cinsiyet ve hastahk soreleritablo-1'de gosterilmi~tir. TabIo-1: HastaJannya~. cinsiyet Yehastahk soreleri n % Ye, artai8ma8i Hastellk soresi ortaiamasl( ay) Kadln :1: :t87.18 Erkek :1: :1:63.75 Gene! :1: :1:82.83 Hastalanmlzda en fazla saptadlglmlz bulgu goz ya~mda azalmayi (gozde kuruma) gosteren Schirmer testi pozitifligiydi (%34,5). Bunun yanmda %24,1 hastada gorme alamnda santral skotom saptandl. % 6,9 hastada ise ayn ayn olarak komeal opasite (nefelyone), pterjium ve keratit bulundu. Hastalanmlzda saptadlglmlz goz bulgulan tablo-2'de gosterilmi~tir.

3 37 Tablo-2: Romatoid artritli 29 olguda saptanan goz bulgulart. GOz bulgusu Olgu saylsl Ok Schirmer GA'da santral skotom Korneal opasite Pteium Katarakt Keratit Komeal mukus plak Blefarit Makula dejenerasyonu Konjunktivit TARTI$MA Romatoid artritte ortaya elkan tom okoler goronomler gercekte hastaltgm bir komplikasyonu olarak degerlendirilebilir (8). RA'nm temel goz komplikasyonlanmn Sjogren's sendromu, episklerit ye sklerit oldugu bildirilmi~tir (9). RA'II olgulanmlzda en fazla saptadlglmlz bulgu(%34.5) kuru goz (Schirmer pozitifligi) idi. literatorde de romatoid artritin seyrinde en slk saptanan goz patolojisinin keratokonjiktiyitis sikka(kks) oldugu bildirilmi~tir (10,11,12). KKS slkllglm Karaka~ ye ark (1) %32.25, Albach ye ark(11) % 37.64, Celikel ye ark(10) %39.47, Boztok ye ark (13) ise %55.8 olarak bildirmi~lerdir. Reddy ye Rao(2) yaptlklan prospektif bir eall~mada hastalarm %22,4'Onde goz komplikasyonu saptaml~lar ye keratokonjiktiyitis sikkanm en yaygm okoler lezyon oldugunu bildirmi~lerdir. Diger lezyonlarm ise episklerit, sklerit, keratolizis ile birlikte marjinal kornea incelmesi, periferal yaskolarizasyonla birlikte stromal komea opasiteleri ye iridosiklit oldugu belirlenmi~tir. Hastalanmlzda saptadlglmlz ikinci slkllktaki bulgu, gorme alanmda santral skotomdu (%24.1). Retina dejenerasyonunun erken belirtisi olarak degerlendirilen gorme alanmda santral skotomun Yarhglmn klorokin kullammlna bagh olarak geli~tigi bildirilmi~tir (14). Biz eah~mamlzda herhangi bir ilae kullamml ile santral skotom arasmda anlamll bir korelasyon saptayamadlk. Bununla birlikte cah~mamlzda santral skotomun azlm- sanmayacak oranda saptanmasl, hem romatoid

4 38 artritli hastalarm hem de gorme alanmda santral skotom saptanan hastalarm daha aynntlh degerlendirilmesinin geregini do~ondormektedir. Sklerit ve periferal korneal Olsergeli~iminin RA'da en slk saptanan bulgulardan oldugu bildirilmi~tir (2). Buna kar~lllk Karaka~ ve ark. <;all~malannda periferal korneal Olser geli~imine rastlamazken, bir vakada nodoler sklerit saptaml~lardlr (1). Biz <;ah~mamlzdasklerit ve periferal korneal Olser geli~imine rastlamadlk. Ancak olgulanmlzm %6.9'unda keratit ve korneal opasite artl~1 (nefelyon) mevcuttu (ayn ayn). Bir hastada (%3,4) ise korneal mukus plak mevcuttu. Aynca schirmer patolojikligi (gozde kuruma) ite keratit geli~imi arasmda pozitif anlamll bir korelasyon soz konusuydu. Bunun da gozde olu~an kurumaya sekonder olarak geli~ebilen keratitle iii~kili olmasl muhtemeldir. RA'I! hastalarda uzun sore steroid kullammma bagll olarak ozellikle subkapsoler katarakt riskinin arttlgl bildirilmi~tir (15). Biz vakalanmlzm sadece birinde ba~langl«;kataraktl saptadlk. Bogliolo ve ark.(16) 23 hastadan birinde steroid kullammma bagll posterior subkapsuler katarakt saptadlklanm bildirmi~lerdir. Aynca birer olgumuzda ya~a bagh makula dejenerasyonu ve blefarit saptadlk. Hastalanmlzda katarakt ve blefarit geli~imi ile cinsiyet arasmda negatif anlamh bir korelasyon mevcuttu. Sonu«;olarak, romatoid artritte ekstraartikoler tutulum olarak goz, geli~bilecek patolojiler a«;lsmdan zengin bir spektruma sahiptir. Bu nedenle romatoid artritli hastalarda gozon dozenli ve aynntlll muayenelerle izlenmesi hastahgm morbiditesini azaltacaktlr. SUMMARY OCULAR INVOL VEIlENT IN RHEUMA TOlD ARTHRITIS We aimed to evaluate ocular findings and relationship with some conditions at rheumatoid arthritis(ra). 29 patients (23 female, 6 male and mean age 42.45:1:10.08) with RA were evaluated in our study. Disease duration(month) was 86,93:1:82,83.Ocular pathology was detected 52 % of patients % of patients had central scotoma in the visual field, 34.5 % had deficiency in tear production(schirmer's test positive), 6.9 % had keratitis, and corneal apacity, and pterygium, 3.4% had cataract, and macular degeneration, and blepharitis There were significant correlation positive between positivity of the Schirmer's test and keratitis; significant negative correlation between sex, cataract, and blepharitis (p<0.05). There weren't significant correlation between ocular findingsand age, disease durationand drug using (p>o.05). In conclusion we think that there is frequently ocular involvement in RA, and ophthalmic evaluationregularlyand in detail willdecrease disease morbidity. Key words: Rheumatoid arthritis,eye.

5 KAYNAKLAR 1. Karaka~ N, Sara~ J, Erdo~an F, $enerkek E, Ata~lu S, unlu MK: Romatoid artritli hastalarda goz bulgulan. Fizik Ted. ve Rehabil Derg; 19: , Reddy SC, Rao UR: Ocular complications of adult rheumatoid arthritis. Rheumatol Int; 16(2):49-52, Blocy KJ, Buchanon WW, WohlMJ, BunimJJ: Sjogren's syndrome, a clinical pathological and serological study of sixtytwo cases. Medicine,44:187, Reddy CV, Foster CS: Adultrheumatoid arthritis. In: AlbertDM,Jacobiec FA ed. Principles and Practice of Ophtalmology. W. B. Saunders Company, Philadelphia: , Matsuo I, Kono R, Matsuo R, Ezewa K: Incidence of ocular complications in rheumatoid arthritis and the relation of keratoconjunktivitis sicca with its systemic activity.scand J Rheumatol; 26: 113-6, Matteson EL,Cohen MD,Conn DL:Rheumatoid Arthritis,ClinicalFeatures and Systemic Involvement. KlippelJH, Dieppe PA ed. Rheumatology 2nd edition Voll, Mosby, London: : Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatizm Association 1987 revised criteria for the classification of rheumatoid arhritis. ArthritisRheum; 31: , Harris ED: ClinicalFeatures of Rheumatoid Arthritis.In: KellyWN, Ruddy S, Harris EO, Sledge CB eds. Textbook of Rheumatology, 5th ed. Vol I, WB Saunders Company, Philadelphia: , AkilM, Amos RS: Rheumatoid Arthritis:ClinicalFeatures and Diagnosis. British MedicalJournal, 310(6979):587(4), QelikelM, GundClzK, Okudan S, Zengin N, Ozka~nlcl A : Romatoid artritli hastalarda gozincelemesi. T KlinOft; 2: 124-7, Albach KA,Lauer M,Stolze HH: Diagnosis keratoconjunctivitissicca in rheumatoid arthritis. The value of various tests. Ophthalmology;91: , Gumu~i~ G: Romatoid Artrit.Gumu~i~ G, ~anav~argil E ed. KlinikRomatoloji. istanbul, Deniz Matbaasl; , Boztok Y, Anda~ K, Yagcl A, AkkmC: Romatoid artritlihastalarda goz bulgulanmn degerlendirilmesi. TOD 24. Ulusal Kong. BUIt.,Ankara; 297-9, Cursiefen C, Grunert U, Junemann A: Chloroquine-induced bull's eye maculopathy withoutelectrophysiologic changes. KlinMonatsblAugenheilkd;210: 400-1, Black RL, Oplesby RB, Von Salmon L, BunimmJJ: Posterior subcapsuler cataracts induced by corticosteroids in patients with rheumatoid arthritis. JAMA; 174: , Bogliolo A, Mela a, Perpignano L, Demontis L, Hellies L, Tanda A, Serra A, Perpignano G: Ocular involvement in rheumatoid Arthritis.Clin Ter ;142(1):41-46, 1993.

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