Correlation between corneal hysteresis, corneal thickness and IOP in patient of Rheumatoid

arthritis and their relation to the disease activity.

Abstract
Purpose: To evaluate the corneal biomechanical properties by using Ocular Response analyzer ORA to
measure corneal hysteresis, corneal resistance factor and IOPcc and correlate them with central corneal
thickness in Rheumatoid arthritis patients and correlate it with the disease activity.
Patients and Methods: A cross sectional observational study in which rheumatoid arthritis patients
scheduled for full ophthalmic examination, measuring intraocular pressure measurement (IOP) using the
Ocular Response Analyzer (ORA) ,the Goldman applanation tonometer (GAT) and central corneal
thickness CCT by using optical coherence tomography (OCT) in the same day after assessment of the
disease activity by rheumatologist using CDAI score activity.

Results: Forty rheumatoid arthritis patients were enrolled in the study, 4 males and 36 females the mean
age of patients involved is 42.8 )± 15.4(, ranging between 30 and 70 years. Obtainability of ORA was
significantly higher than GAT in both groups (active and inactive). Strong correlations existed between
GAT and ORA measurements. Strong negative correlation between CDAI and CCT in the active group.
Significant positive correlation between CRF and CCT in the inactive group. No statistically significant
difference between ORA parameters, OCT pachymetery or IOP GAT between two groups.

Conclusion: ORA has proven to be superior to GAT in the ability to obtain reliable IOP measurements in
RA patients. Central corneal thickness was negatively correlated with CDAI activity score. Corneal
biomechanical properties could have been affected and persisted in RA in active or remission disease
phase.

Key words

Intraocular pressure – RA – Ocular Response Analyzer – Goldmann Applanation Tonometry –

OCT pachymetery -Cornea biomechanical factors.
Introduction

Rheumatoid arthritis (RA) is the most common inflammatory joint disease, affecting 1-2% of the
population world with women affected two to three times more commonly than men (Turesson et al., 2003.
Extra-articular organ involvement in RA is more frequently seen in patients with severe, active disease.
(Cimmino and Salvarani ,2000).

The most common ophthalmic manifestation of RA is dry eye occurring in about 15-25 % of patients .In
addition to dry eye, significant Inflammation may involve the sclera, the cornea, and the uvea
(Thompson,1956)

Corneal hysteresis(CH) is a characterization of the corneal ability to absorb and dissipate energy, which is a
function of visco-elastic biomechanical properties of the cornea. Corneal biomechanical properties are a
stronger predictor of IOP measurement error than thickness, it can currently only be measured by the Ocular
Response Analyzer (ORA) providing Corneal Compensated IOP (IOPcc) ) Liuand Roberts ,2010(. This is
especially important after biomechanical procedures such as refractive surgery.(Chang and Stulting ,2005).

Central corneal thickness(CCT) measurement can be measured by the frequently used ultrasound pachymetery
(USP), however, it has several possible sources of error so newer instruments such as optical coherence
tomography (OCT) instrument are currently available and have the advantage of being non-contact to the
cornea. (Quantock and Dennis ,2003).

Previous studies showed that autoimmune diseases, such as systemic lupus erythematosus and scleroderma as
well as rheumatoid arthritis, could affect the corneal biomechanical properties (Yazici AT, Kara N, Yu¨ ksel K,
et al. The biomechanical properties of the cornea in patients with systemic lupuserythematosus. Eye (Lond).
2011:25:1005–1009. 7. Emre S, Kayikcioglu O, Ates H, et al. Corneal hysteresis,corneal resistance factor, and
intraocular pressure measurement in patients with scleroderma using the reichert ocular response analyzer.
Cornea. 2010:29:628–631.

The aim of this work was to evaluate the corneal biomechanical properties by using Ocular Response analyzer
(ORA) ,central corneal thickness as measured by (OCT) pachymetery and (IOP GAT) by using Goldman
applanation tonometer in Rheumatoid arthritis patients and their correlation with the disease activity.

Patients and Methods: A Cross sectional study that was carried on from Jan. 2017 till Aug. 2017 in Kasr Al
Aini University Hospital. Forty eyes of forty patients were enrolled in this study, those subjects presented to
the ophthalmology and rheumatology outpatient clinic with diagnosis of RA. Patients were divided into two
groups by rheumatologist into: Group (A): 20 active rheumatoid arthritis patients and group (B): 20 inactive
rheumatoid arthritis patients.

Inclusion criteria: All rheumatoid arthritis patients whether active or inactive aged between 17 years to 70
years old.
Exclusion criteria: Any other autoimmune disease, ocular surgery, glaucoma or any corneal pathology. All
patients signed a written informed consent

Methodology in details: Patients were evaluated by a rheumatologist on the same day of the ophthalmic
examination. All patients underwent full medical/ocular history taking, full ophthalmological examination
including IOP by applanation tonometer, anterior segment examination excluding corneal pathology.

For assessment of RA activity: Rheumatologist calculated the disease activity by CDAI equation

CDAI = SJC + TJC + PGA + EGA

SJC = swollen joint count; TJC = tender joint count; PGA =patient global assessment; EGA = evaluator global
assessment.

A score of (≤ 2.8) was considered in remission ,(> 2.8 and ≤ 10)was considered low disease activity , (> 10 and
≤ 22 ) was considered moderate disease activity and score more than 22 was considered high disease activity.
A CDAI reduction of 6.5 represents moderate improvement.

IOP measurement:

a) Ocular Response Analyzer:

The IOP measurement using ORA, The Reichert ocular response analyzer (ORA; Reichert Ophthalmic
Instruments, Buffalo, New York, USA) was done before GAT. At least 3 measurements were taken, any
measurement with a waveform score below 5 was discarded. The software then calculates the most accurate
reading and displays it. Corneal hysteresis (CH) and corneal resistance factor (CRF) were also measured with
ORA.

b)Goldman applanation tonometry:

After a resting period of at least 30 minutes, the GAT reading was obtained.

The Haag Streit AT 900TM (Haag Streit Diagnostics, Bern, Switzerland) tonometer model mounted on
a Topcon SL – 3G TM (Topcon Corp. Tokyo, Japan) slit lamp was used to obtain the measurements. The
calibration of the tonometer was checked before the beginning of the study.

Corneal thickness (CCT):

Corneal thickness (CCT) was measured for all patients by OCT Pachymetery (Optovue USA) Scanning
at 70,000 A scans per second, after a resting period of half an hour following ORA examination. Pachymetery
Map was obtained to measure central corneal thickness within central 5mm zone where the minimum thickness
is indicated as *.

Data were statistically described in terms of mean, standard deviation (± SD), median and range when
appropriate. Comparison of numerical variables between the study groups was done using Student t test for
independent samples in comparing normally distributed data and Mann Whitney U test for independent
samples in comparing non-normal data. Correlation between various variables was done using Pearson
moment correlation equation for linear relation of normally distributed variables and Spearman rank
correlation equation for non-normal variables/non-linear monotonic relation. p values less than 0.05 was
considered statistically significant. All statistical calculations were done using computer program IBM SPSS
(Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft Windows.