A Rheumatologist’s Warning About The Disease Behind Dry Eyes

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As a pediatric ophthalmologist and mom of three, I spend a lot of time looking at eyes.

And what I have learned over almost twenty years of practice is this: the eye is not just an organ of vision.

It is a window.

Sometimes what I see looking into someone's eye tells me something is happening in their body that has nothing to do with their eyes at all.

Why are your dry eyes not responding to any treatment?

Why is this inflammation coming back again and again?

Why does a young woman with no prior eye history suddenly walk in with both eyes completely red?

The answer — more often than patients expect — begins not in the eye, but in the immune system.

In this episode of In Focus: Vision, Clarity and Eye Health for the Whole Family, I sit down with Dr. Hillary Norton, board certified rheumatologist, clinical trial investigator, and director of Santa Fe Rheumatology — who also happens to be living with ankylosing spondylitis herself.

What makes this episode different is simple.

This is not just a clinical overview.

This is a conversation between two specialists who work in the same overlapping territory — and a physician who knows firsthand what it feels like to be a patient navigating the very diseases she treats.

Why This Conversation Matters Right Now

Autoimmune diseases are notoriously difficult to diagnose.

They are heterogeneous — meaning they show up differently in every person. They involve multiple body systems. The symptoms are often nonspecific: fatigue, joint pain, rashes, dryness.

And women — who are disproportionately affected by rheumatologic conditions — are still far too often dismissed. Told they are depressed. Told they are anxious. Asked if their marriage is okay.

The delay between first symptoms and correct diagnosis is often measured in years.

This episode is about shortening that delay — by helping you recognize what the eyes can reveal, and knowing when to push for answers.

Meet Dr. Hillary Norton: The Rheumatologist Who Has Been the Patient

Dr. Hillary Norton was on the first day of her medical internship — thirty hours into an ICU shift — when she developed a severe case of uveitis.

The ICU fellow told her she was fine. She was tired. She was on call.

By morning, her eye was entirely red. A rheumatologist friend happened to look at her before she even sat down in the exam chair and said: do you have back pain? You need to see a rheumatologist.

That was her diagnosis.

She has been treating autoimmune disease from both sides of the exam table ever since.

What Is an Autoimmune Disease, Really?

At its core, an autoimmune disease is what happens when the body loses tolerance to itself.

The immune system is designed to surveil for infections, foreign invaders, and cancer. When it begins to identify the body's own tissue as foreign, it attacks. And because the immune system can target virtually any part of the body, the resulting diseases are enormously varied.

Dr. Norton sees rheumatoid arthritis, lupus, Sjögren's disease, psoriatic arthritis, and inflammatory bowel disease — among others. Each one involves inflammation attacking different systems: joints, skin, kidneys, nerves, lungs, and yes, the eyes.

The Eye Conditions That Signal Something Systemic

Dry eyes that won't respond to treatment.

This is often the first clue I see in my own clinic. When a patient comes back repeatedly and nothing is working — not artificial tears, not the newer prescription drops designed to stimulate tear production — that is a red flag. Something systemic may be driving the dryness.

The condition most associated with this is Sjögren's disease, where the immune system attacks the exocrine glands — including the lacrimal glands that produce tears and the salivary glands that produce saliva. The result is profound dryness: dry eyes, dry mouth, and often vaginal dryness as well. Fatigue is nearly universal in Sjögren's. Joint pain, swollen salivary glands that create a chipmunk-cheek appearance, and rashes are also common.

What makes diagnosis complicated is that some patients have all the hallmark symptoms of Sjögren's but test negative for the specific antibodies. In those cases, Dr. Norton begins investigating for a primary autoimmune disease that may be causing secondary dryness — asking about back pain, rashes, other symptoms that could point to an underlying condition.

Uveitis.

This is the other major eye presentation I see in autoimmune patients — and it is one of the true emergencies in rheumatology.

Uveitis is inflammation inside the eye. Patients come in with redness, light sensitivity, floaters, and blurred vision. It can affect one or both eyes. It can cause cataracts, macular edema, pupil distortion, and blindness if not treated promptly and properly.

The diseases most associated with uveitis include HLA-B27-related conditions like ankylosing spondylitis, sarcoidosis, Behçet's disease, lupus, and juvenile idiopathic arthritis. When I see a patient with uveitis — especially bilateral uveitis — I run a comprehensive lab panel: HLA-B27, ANA, rheumatoid factor, TB test, sarcoidosis markers, and viral labs including syphilis and herpes, because infections can also cause uveitis and must be ruled out first.

The key message for patients: if I send you to a rheumatologist after an eye visit, do not be surprised. The real treatment for your eye may begin with treating what is happening in your immune system.

How Biologics Changed Everything

When I trained, a child with uveitis from juvenile idiopathic arthritis often ended up with cataracts. With scarred, distorted pupils. With retinal swelling. With permanent vision loss. Our tools were steroid eye drops and dilating drops, and they were not enough.

I no longer see those outcomes.

That is almost entirely due to biologics.

Dr. Norton described it beautifully: biologics have been called one of the top three advances in medical science of the last century. When the early clinical trials were running, patients were leaving their wheelchairs and crutches in the office and walking out.

What makes biologics so remarkable is their precision. Traditional immunosuppressants — steroids, methotrexate — suppress inflammation broadly throughout the body, affecting all cell lines. Biologics like HUMIRA and Remicade are TNF inhibitors: they target only tumor necrosis factor, a single inflammatory cytokine that is out of control in these diseases. The rest of the immune system is left intact.

The result is dramatically better safety, dramatically better tolerability, and for my uveitis patients — dramatically better eyes.

The risk of untreated autoimmune disease, as Dr. Norton tells her patients, is 100 percent. Down the road, something will go wrong. The risk of the medication is very, very low. When patients think about it in those terms, the decision often becomes much clearer.

Recognizing the Red Flags

Not every tired, achy woman has an autoimmune condition. But Dr. Norton outlined the specific warning signs worth taking seriously:

For inflammatory joint pain — the kind that suggests autoimmune disease rather than wear-and-tear osteoarthritis — look for morning stiffness that lasts two or more hours. Night pain that wakes you up. Bilateral, symmetrical symptoms — both hands, both feet. These are hallmarks of rheumatoid arthritis.

For lupus — watch for low-grade fevers, joint pain, rashes, mouth sores, and hair loss in patches or bald spots (not the diffuse thinning that often comes with perimenopause). The butterfly rash — spanning both cheeks and the nose, sparing the nasolabial folds — is still a meaningful clinical sign. Lupus is highly heterogeneous; some patients present mostly with fatigue and joint pain, while others present with organ involvement.

For Sjögren's — persistent dry eyes and dry mouth that don't have another explanation, combined with fatigue that is new and pronounced, are the starting point.

A general red flag across conditions: a sudden change that has no life circumstance to explain it. New fatigue. Low-grade fevers. New rashes. When something shifts in your body without an obvious cause, that is worth investigating.

On Being Dismissed — And What to Do About It

Dr. Norton was told, in her own medical training, that she could not have ankylosing spondylitis because only men get it. She was told her SI joints would probably fuse and the pain would lessen once they did.

Her patients — mostly women — regularly arrive after being told they are depressed, anxious, or simply stressed. Asked if their marriages are okay.

Her advice to anyone navigating this:

Be specific. The more detail you can provide about what is new and different in your body, the more useful it is. If the fatigue is new — if you are sleeping well and still hitting a wall — say exactly that.

And if you are not being listened to, that may simply not be the right fit. Find someone who will listen. You are not obligated to accept a dismissal as a diagnosis.

Final Thoughts

Almost twenty years ago, I used to see children with cataracts from untreated uveitis. I do not see that anymore.

That progress happened because of better medications, better collaboration between specialties, and better awareness — on the part of both physicians and patients — that the eye does not exist in isolation from the rest of the body.

If your dry eyes are not getting better, ask why.

If you have uveitis, ask what else might be going on.

If you have been told your symptoms are anxiety or stress and something in you says that is not the whole story, trust that instinct and find someone willing to investigate further.

The eye is a window into the whole body.

And sometimes the most important thing I can do as your eye doctor is point you in the direction of the door you actually need to walk through.

Want to Learn More?

You can find Dr. Hillary Norton at inspiresantafe.com and on Instagram at @HillaryNortonMD.

You can subscribe to my podcast, In Focus, anywhere you listen — or follow along on Instagram for updates and tips.

Watch this episode on YouTube right now!

Thanks for reading — and for doing what you can to protect your family's vision, one step at a time.

– Dr. Rupa Wong Pediatric Ophthalmologist | Surgeon | Mom of 3

This episode is brought to you by The Pinnacle Podcast Network! Learn more about Pinnacle at learnatpinnacle.com