These double-blind studies are based on the numerous encouraging smaller studies from single-center or multi-center trials. However, it is likely that the same complexities in evaluating patient response in SS will be encountered that were seen when these agents were recently studied in double-blind studies of SLE to fulÞll FDA requirements for drug approval. Both the global and patient overall evaluations are strongly inßuenced by symptoms of Þbromyalgia that show response to both the active and placebo treatments and the Þnal results did not fulÞll their endpoints at longer endpoints of disease activity [25]. Therefore, objective damage and activity endpoints may need to be considered in a category distinct from overall global evaluation.

4.6Ocular Treatment

Although treatment of ocular signs and symptoms is best left to the ophthalmologist, the rheumatologist will often be asked questions by the patient at the time of the ofÞce revisit (or by phone or by email) about treatment options

or changes in their status. There are several key points for the rheumatologist:

¥Whether the SS patient needs to see the ophthalmologist and how soon. In the managed care environment of medicine today, simply checking ophthalmology revisit does not specify ÒtodayÓ (urgent) or Ònext availableÓ which may be in 6 weeks.

◦Issues such as corneal abrasions or perforations, herpetic lesions of the eye, and vasculitic lesions including uveitis or retinal vasculitis need immediate attention.

◦Issues such as blepharitis or choice of artiÞcial tears may be more electively handled.

4.6.1 Choice of Artificial Tears

Many patients are told to go to the pharmacy and get a selection of artiÞcial tears (Table 4.7). Most rheumatologists are not aware of the staggering array of choices that the patient sees available when they arrive at the pharmacy or grocery store. We are including Table 4.7 to help guide the choice of artiÞcial tears that have also been discussed in more detail in the chapter by Michelson et al. [27].