safety of prolonged use of autologous serum eye drops at various concentrations should also be included in future investigations. As tear components are fully elucidated, we believe artiÞcial tear substitutes that include all essential tear components will eventually replace autologous serum eye drops in the future.

24.8Conclusion

This review has described the unique treatment of SjogrenÕs syndrome dry eye by autologous serum eye drops. As I have described in the introduction, autologous serum treatment can be replaced by the punctal plug or secretagogues in certain types of patients. Punctal plug insertion is more convenient for most of the patients and may be the method of Þrst choice to supply essential tear components. However, autologous serum is most beneÞcial and necessary for patients who do not have enough tearing even with a punctal plug or when there has been no response to the secretagogues. It was been my pleasure to report to you, the reader, this unique treatment initially described by Fox, who is the editor of this book.

24.9Late-Breaking Update

Recently, P2Y2 receptor agonist (Diquafosol tetrasodium, Santen Pharmaceutical Co., Ltd.) was approved as the Þrst drug for the treatment of dry eye in the world. We are expecting the improvement of dry eye symptoms in the management of SjogrenÕs syndrome with this drug.

References

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pp. 283Ð286.

2.Tsubota K, Nakamori K. Dry eyes and video display terminals. N Engl J Med. 1993 Feb 25;328(8):584.

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10.Kojima T, Higuchi A, Goto E, Matsumoto Y, Dogru M, Tsubota K. Autologous serum eye drops for the treatment of dry eye diseases. Cornea 2008;27: S25Ð30.

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S.Diseases associated with ocular surface abnormalities: the importance of reßex tearing. Br J Ophthalmol. 1999 Jan;83(1):89Ð91.

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There have been no formal studies on the incidence and prevalence of primary and secondary SjšgrenÕs syndrome in Australia. Notwithstanding this, SjšgrenÕs syndrome is encountered commonly in clinical practice; indeed most rheumatologists and clinical immunologists would see more patients with primary SjšgrenÕs syndrome than with systemic lupus erythematosus. Patients treated for rheumatoid arthritis and systemic sclerosis frequently have sicca symptoms. A recent South Australian study reported a 50% prevalence of secondary SjšgrenÕs syndrome in patients with systemic sclerosis [1].

T. Gordon ( )

Department of Immunology, Flinders Medical Center, Flinders, Australia

e-mail: t.gordon@ßinders.edu.au

The clinical features observed in Australian patients with primary SjšgrenÕs syndrome are comparable to reports from North America and Europe. As expected, the dominant symptoms are dry eyes and xerostomia with signs relating to salivary and lacrimal gland involvement. In our experience with a cohort of more than 200 patients, 50% or more have RaynaudÕs phenomenon and about one-third of patients have extraglandular complications involving the skin, lungs, kidneys, muscles, peripheral sensory nerves, or central nervous system. A small number of patients (2Ð3%) have developed non-HodgkinÕs lymphomas of the salivary/lacrimal glands and/or gastrointestinal tract that have generally responded well to conventional chemotherapy. Overall, the clinical patterns seen in Australia are similar to the overseas experience. A particular area of interest has been the study of autonomic complications involving

A decade earlier, primary SjšgrenÕs syndrome (SS) had been rarely reported from India. Even a population-based study [1] of rheumatic diseases in India, by a rheumatology center, makes no mention of this disease. Contrary to Western data, the reported occurrence of disease has been low. Even in dedicated clinics for rheumatic diseases, only about 0.5% of all patients seen are diagnosed to have SS. We had reported a series of 26

R. Misra ( )

Department of Immunology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India e-mail: rnmisra2000@gmail.com

North Indian patients with SS [2]. Subsequently, two series of patients were presented in the annual national rheumatology meeting from the Western and the Southern regions of India. The California criteria were used for diagnosis in our series whereas the latter two used the AmericanÐ European Consensus criteria for diagnosis. There is thus an increasing awareness to diagnose SS at rheumatology centers. This brief write up will attempt to summarize the clinical picture of the disease and similarities and dissimilarities with patients reported from Western countries.

One of the striking features is the younger age at the time of diagnosis. The mean age of our

patients is 10 years younger than that reported from Europe. Though we cannot explain this earlier occurrence, we have observed this Òshift to the leftÓ phenomenon in other diseases such as multiple myeloma, which normally has been described in the sixth decade. Due to lack of awareness and availability of appropriate diagnostic facility, there is a delay in diagnosis by an average of 4 years. There was some variation in the sex ratio among the three series, but the female predominance was similar to that reported elsewhere. The series from North India has less number of females, which is a referral bias and could reßect that less number of females do seek specialistÕs attention for apparently milder and innocuous symptoms like dry eyes and dry mouth. The occurrence of xerostomia, dry eyes, parotid gland enlargement, purpura, hypergammaglobulinemia, and presence of autoantibodies are comparable to that seen in Western countries (Table 26.1) [7]. Some delayed complications of the disease such as renal tubular acidosis and even glomerulonephritis was observed by us. The retrospective series from South India had a biopsy done in all patients who had dry mouth along with polyarthralgia/arthritis or chronic Þbromyalgialike pain. Hence, the number of patients with

arthritis was higher. Besides, it observed dental problem (193, 83.5%), neurological features (25, 11%), respiratory (26, 11%), and lymphoma (2, 0.01%).

Diagnosis was based on both the presence of antibodies to Ro and antibodies to La and/or the biopsy of minor salivary gland. The prevalence of various autoantibodies in present series is similar to that reported in other series.

Many of the patients with SS are labeled as rheumatoid arthritis or systemic lupus erythematosus (SLE) due to overlapping features and it is only after extensive investigations for the dry eyes and dry mouth that proper diagnosis is reached. Documenting a reduction or absolute lack in salivation by objective tests is an issue as investigational facilities like salivary scintigraphy, parotid sialography, and measurement of salivary ßow are not available at all centers. Antibodies to Ro and La are still not widely available. Though minor salivary gland biopsy remains a simple and deÞnitive diagnostic test, there are reservations in getting their biopsies done by both patients and physicians. It also helps in excluding diagnosis like tuberculosis, sarcoidosis, and lymphoma, which may mimic the clinic picture of SS. We encountered