**4. Infectious complications of the eyes in rheumatic diseases**

Viral, bacterial and fungal infectious complications occur in the organ of sight in patients with rheumatic diseases more frequently than in healthy individuals due to the immunolog‐ ical system dysfunctions, immunosuppressive therapy and chronic use of corticosteroids.

#### **4.1. Infective conjunctivitis**

**3. Characteristic changes in the organ of sight in rheumatic diseases**

the first symptom of rheumatic fever observed in approximately 4% of patients [65].

**type of symptoms and changes in the eye rheumatic disease** conjunctivitis Reactive arthritis

dryness Sjögren's syndrome

Scleritis Rheumatoid arthritis

**Table 5.** The most common ocular changes in the course of the rheumatic diseases.

Uveitis:

Panuveitis

Keratitis:

Non-necrotizing corneal melt

Diffuse vaso-occlusive disease

Necrotizing keratitis

Retinal vasculopathy Microvasculopathy

Optic nerve disaease Ischemic optic neuropathy

Acute anterior uveitis Chronic anterior uveitis

220 Common Eye Infections

The pathological changes can occur in all elements of the organ of sight in the course of rheumatic diseases. These can cause temporary or permanent damage (Table 5). Changes in the eyes are

Psoriatic arthritis

Rheumatoid vasculitis Rheumatoid arthritis Systemic vasculitis

Spondyloarthropathies Behçet disease

relapsing polychondritis

Relapsing polychondritis

Systemic Lupus erythematosus Systemic lupus erythematosus Antiphospholipid syndrome

Sjögren's syndrome Rheumatoid vasculitis Rheumatoid arthritis systemic vasculitis

Behçet disease

Changes in the eyes in course of the rheumatic diseases may also be caused by the imple‐ mented treatment. Nonsteroidal anti-inflammatory drugs are medications most commonly used in alleviating the symptoms of rheumatic diseases. Cases of keratopathy (keratopathy) after indomethacin use have been reported [66], and diplopia (double vision) and amblyopia (amblyopia) after ibuprofen and naproxen treatment [67]. Antimalaric drugs such as hy‐ droxychloroquine and more often chloroquine may aggregate in the cornea [68], in 13 - 40% of patients causing retinopathy [69,70]. Gold salts - administered parenterally over the total

Behçet disease

systemic vasculitis

colitis ulcerosa/ Leśniowski - Crohn's disease colitis ulcerosa/ Leśniowski-Crohn;s disease

Colitis ulcerosa/ Leśniewski- Crohn;s disease

Systemic vasculitis (particulary giant cell vasculitis)

#### *4.1.1. Bacterial conjunctivitis*

#### *Chlamydial conjunctivitis*

Reactive arthritis, which belongs to spondyloarthropaties, may be caused by infection with Chlamydia trachomatis and Chlamydia pneumoniae [76]. In the course of the infection with Chlamydia trachomatis (serotypes DK) chronic conjunctivitis occurs in 6-19% of patients [77, 78]. Chlamydial conjunctivitis most commonly affects sexually active adults, especially men. Chlamydia DNA is detected by PCR (polymerase chain reaction) in 96% of patients with re‐ active arthritis concomitant conjunctivitis, leakage from the urethra and inflammation of asymmetric arthritis (former name of these symptoms is Reiter's syndrome) [79]. Eye in‐ volvement probably occurs by the way of self infection from the genitourinary system, or from one eye to another. In chlamydial conjunctivitis in adults symptoms initially occur in one of the eyes. It was also found that conjunctivitis may also occur (less frequently than in Chlamydia trachomatis) in the course of Chlamydia pneumoniae infection – as was demon‐ strated by confirming the presence of bacterial DNA from conjunctival scraping [80].

Clinical symptoms of chlamydial conjunctivitis in reactive arthritis are characterized by moderate redness of a single eye or less commonly of both eyes, tearing, photophobia and decreased vision. Ocular examination shows conjunctival hyperemia, chemosis and follicu‐ lar reaction in conjunctiva and semilunar folds. Epithelial and subeopithelial infiltrates in cornea may develop.

The histopathology assessment reveals the presence of the chronic inflammation cells local‐ ized in submucosal layer, with the predominance of lymphocytes. In addition, fibrinogen deposits in the basal membrane of conjunctiva, infiltration of lymphocytes and macrophages around small blood vessels and lymphocytic infiltration of the walls of larger vessels of con‐ junctiva have been observed [81].

Diagnosis is based on the detection of IgM, IgG and IgA antibodies to these bacteria in the blood serum by ELISA method and confirmation with W-blot test. Classical method is a detection of Chlamydia basophilic intracytoplasmic inclusions in primary cells from the conjunctival swab or conjunctival scraping using DFA (direct immunofluorescence stain‐ ing) method, DNA hybridization tests or PCR (polymerase chain reaction and LCR (Ligas chain reaction).

Treatment of chlamydial conjunctivitis infection in the course of reactive arthritis consists of systemic antibiotic therapy and topical use of tetracycline, erythromycin or fluorochino‐ lones. In systemic treatment effectiveness of macrolides (azithromycin), tetracyclines and quinolones has been shown [82,83, 84]. Single dose of azithromycin (1000mg) showed effica‐ cy in eradication of C. trachomatis infection [85] It's vital to stress that chlamydia infection is still the main cause of blindness on the African Continent. In the case of trachoma present drug of choice is azithromycin [86].

Because C.trachomatis infection is sexually transsmitted, other similarly transmitted co- in‐ fections should be considered, most commonly gonococcal.

#### *4.1.2. Fungal conjunctivitis*

Significantly higher incidence of fungal conjunctivitis is observed in patients with rheumatic diseases treated with systemic glucocorticoids (eg, RA) and in patients with primary Sjögren's syndrome. The most common pathogens are Candida albicans and Candida parapsilosis [87].
