Overview of Management of Dry |
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Eye Associated with Sjögren’s |
Syndrome
Paul E. Michelson and Robert I. Fox
Abstract
This initial discussion of dry eye in the patient with primary Sjögren’s syndrome (SS) is provided primarily for the non-ophthalmologist who will, hopefully, Þnd useful the explanations of common diagnostic tests and therapeutic interventions employed in treating dry eye patients. A more detailed description of lacrimal gland and tear Þlm physiology is presented in the chapter by Stern and Pßugfellder. In particular, the authors of this chapter have collaborated during the past 25 years on patients with dry eyes referred for evaluation and treatment of their SS. This chapter summarizes many of the common problems that the primary physician may refer to the rheumatologist and the Òdaily practicalÓ questions from the SS patient that are not generally covered in academic reviews of dry eye care.
Keywords
SjšgrenÕs syndrome ¥ Keratoconjunctivitis sicca ¥ Blepharitis ¥ Herpetic keratitis ¥ Uveitis ¥ Aqueous tear deÞciency ¥ Neuroparalytic or neurotrophic keratitis ¥ SchirmerÕs test ¥ Rose Bengal ¥ Lissamine Green ¥ ArtiÞcial tear ¥ ArtiÞcial lubricant ¥ Ocular ointment ¥ Ocular gel ¥ corneal topography ¥ Punctal occlusion ¥ Punctal plugs ¥ Moisture shields ¥ Lacrimal gland pathology ¥ Tear surface physiology
12.1Background
Patients seeking relief for their dry eyes associated with SjšgrenÕs syndrome (SS) often see a variety of specialists and use both prescription
P.E. Michelson ( )
Eye Care of La Jolla, Scripps Memorial Hospital,
La Jolla, CA, USA; UCSD School of Medicine, La Jolla, CA, USA
e-mail: pmichel2@san.rr.com
and over-the-counter medications. Many of the medications used for other medical conditions (i.e., antihistamines, antihypertensives, antidepressants, hypnotics, and analgesics) may exacerbate ocular and oral dryness. Although evaluation and treatment of dry eyes is truly in the domain of the ophthalmologist, it is common for the SS patient to direct their questions to their rheumatologist.
It is important to emphasize that a rheumatologist, armed with an ophthalmoscope and a bottle
R.I. Fox, C.M. Fox (eds.), Sjögren’s Syndrome, DOI 10.1007/978-1-60327-957-4_12, |
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of Rose Bengal, Fluorescein, or Lissamine Green diagnostic agents, is not a substitute for an ophthalmologist who is highly skilled in the use of a slit lamp and experienced in treating dry eyes.
In this chapter, we will present some of the more common questions that may be directed to the rheumatologist by the patient including
¥How should I choose one or more artiÞcial tear products from the great variety of branded and generic (preserved and non-preserved) tears that are available?
¥How should I compare the components of generic and brand name tears?
¥What are guidelines to use of mixing and matching different types of artiÞcial tears?
¥What are some suggestions and hints to preserve eye moisture?
¥What are most prominent environmental and lifestyle factors that contribute to dryness, and how can they be minimized?
¥What incidental iatrogenic factors, including prescription medicines and over-the-counter remedies, contribute to dryness?
¥What are surgical iatrogenic factors, including cosmetic surgery or LASIK surgery, that may contribute to dryness and subsequent corneal erosions?
¥What are the precautions for the patient undergoing surgery to prevent exacerbation of the eye symptoms?
¥Are cosmetic eye procedures such as LASIK and blepharoplasty therapeutically contraindicated for the patient with dry eye?
In a world of managed care, medicalÐlegal
considerations, and Þxed resources, rheumatologists must decide if the patient needs to be seen and evaluated the same day, the same week, or at the next available scheduled appointment that may be weeks or months away.
12.2Incidence, Symptomatic Presentation, and Impact on Quality of Life
There is a generally high level of dissatisfaction on the part of both the treating physician as well as the patient with respect to the medical care and
management for dry eyes [1, 2], largely due to three factors:
1.The complex difÞculty in managing a chronic, variable, and problematic condition;
2.The inadequate appreciation by clinicians of the true impact on patientsÕ lifestyles; and
3.The extensive time and resources required to educate and treat patients appropriate to their individual needs [3].
The International Task Force and Delphi panel [4], among others, were assembled to address these issues, and their recommendations have been addressed elsewhere in this chapter and incorporated in this discussion [5Ð7].
While dry eye associated with SS represents a very small subset of the increasingly better recognized large group of our general population suffering from dry eyes, the SjšgrenÕs population is disproportionately skewed to the more severe and problematic.
Estimates of the incidence of dry eye syndrome in general depend on selection and diagnostic criteria.
Reports vary from:
¥17% of females and 11% males, increasing with age, to a more recent study suggesting
¥7% in females and 3% in males in their sixth to seventh decade of life, increasing to
¥10–12% of females and 4–5% of males in the eighth decade [8, 9].
There are a minimum of several million people
in the United States alone who, by any reasonable diagnostic criteria, suffer from signiÞcant dry eye disorders.
Of course, it is also reasonable to say that virtually 100% of us experience some symptoms of dry eyes under extreme conditions, endogenous and exogenous, such as
¥dehydration,
¥profound illness and debility,
¥a dry, windy day outdoors, and
¥a long airplane ride where the humidity is
notoriously low.
It is important to be mindful as treating physicians of the extent to which even mild-to- moderate dry eyes affect the lifestyle and visual functioning of our patients. When patients do
12 Overview of Management of Dry Eye Associated with Sjögren’s Syndrome |
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not present in the most extreme and obvious dis- |
suspect, given other systemic features of possi- |
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tress, it is too easy to dismiss even moderate dry |
ble SjšgrenÕs syndrome, the array of signs and |
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eyes as a relatively minor inconvenience, reme- |
symptoms must be considered. |
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died quite easily with over-the-counter artiÞcial |
It has long been a great frustration to those |
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tears [10]. |
of us attempting to investigate various diag- |
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A fairly recent study attempting to assess |
nostic and treatment approaches to note the |
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the actual impact of this condition on the |
often profound disconnect between patientsÕ |
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patientÕs lifestyle and activities of daily liv- |
signs and symptoms. Recent basic science |
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ing, the so-called utility value, found that |
and clinical studies have led to an epiphany, |
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patients with moderate dry eyes literally equate |
suggesting an explanation for this seeming |
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their dry eyes with the effects of moderate |
disconnect. |
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angina [11]. |
We now better understand that the chronic |
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Reinforcing this surprising assessment, other |
inßammation attending the vicious cycle of dry |
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studies and industry surveys have shown that |
eye disease, also called Òdysfunctional tear dis- |
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close to half the patients said mild-to-moderate |
order,Ó causes the release of cytokines and other |
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dry eyes affect their life Òa lot,Ó with more than |
inßammatory by-products that are neurotoxic and |
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40% relating a detrimental effect on their read- |
desensitizing. |
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ing ability, and about a third on their use of |
Also, the role of mucins in maintaining the |
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computers [5]Ñindeed, intently staring at mon- |
viscosity of the tear Þlm is increasingly impor- |
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itors can unknowingly reduce blink rate by up to |
tant. When the patient describes increased dis- |
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90%, thereby dramatically exacerbating dry eye |
comfort in their eyes, they may be referring to |
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problems. |
an increased friction as the upper lid traverses the |
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Thus, we suggest that the SjšgrenÕs patient |
orbit. |
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select a dependable means of reminding him- |
On the other hand, the patientÕs symptoms |
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self/herself to consciously blink while at the |
may be much less severe than the observation |
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computer. |
of disrupted tear Þlm and corneal surface. Thus, |
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In clinical practice, we must remain receptive |
a neuroparalytic or neurotrophic keratitis (a rare |
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to our patientsÕ concerns and appraisals of the dis- |
degenerative corneal disease caused by an impair- |
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ease impact as well as our own knowledge of its |
ment of trigeminal corneal innervation, leading |
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threat to the patientÕs well-being. |
to a decrease or absence of corneal sensation) |
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The diagnosis of dry eyes in association with |
can reduce, if not eliminate, corneal sensitivity. |
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SjšgrenÕs syndrome may literally be painfully |
This adaptation may allow a remarkable degree of |
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apparent to both patient and clinician. Indeed, |
corneal disruption in patients otherwise expected |
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patients are often sent to an ophthalmologist with |
to be quite symptomatic. |
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the established diagnosis of autoimmune disease, |
The possibility of signiÞcantly diminished |
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dry mouth, and obvious ocular inßammation. The |
corneal sensitivity in the presence of chronic dry |
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eyes often look dry, and the patient may even |
eye disease is important to keep in mind when |
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complain of dryness. Of course, other more com- |
trying to assess the range of signs and symptoms. |
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mon and less obvious presentations require some |
For example, chronic contact lens wear may lead |
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diagnostic acumen. |
to corneal desensitization, and thus, the normal |
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While patients with SjšgrenÕs syndrome often |
pain mechanism may not alert the patient in time |
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exhibit more severe disease, they do include the |
to prevent corneal damage. |
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entire spectrum from subclinical to extreme/acute |
Another basic concept to keep in mind is the |
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threat to vision. |
distinction between: |
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When asked to assess a patient with mild- |
¥ Basal tear production (the more or less steady- |
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to-moderate symptoms suggesting dry eyes or a |
state lubrication produced largely by tear |
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patient who has not articulated symptoms but is |
glands located in the cul-de-sacs), and |
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P.E. Michelson and R.I. Fox |
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¥Reflex tear production (largely from the lacrimal gland seated in the upper outer portion of the orbit; more responsive to external irritation, neuro-endocrine stimuli, and emotion).
Basal tear production is largely the result of small glands that reside in the inner portion of the lids.
Medications with anticholinergic/drying side effects, including antihistamines (including Tylenol PM), tricyclic antidepressants (TCAs), also selective serotonin reuptake inhibitor (SSRI) antidepressants, birth control pills (due to hormone changes), antihypertensives, diuretics, angiotensin-converting enzyme (ACE) inhibitors, isotretinoin-type drugs (for acne), and opiates taken at bedtime will have much more drying effect than if taken at other times when tearing stimulation is higher.
While patients may complain of chronic or episodic redness, signs of ocular inßammation are neither not always present nor not always obvious to the patient in mild-to-moderate cases.
The Þve most common complaints voiced by the patient related to dry eye include
1.ÒThere seems to be something foreign or ÔgrittyÕ in my eye that keeps my eye irritated most all the time.Ó
Probably the most common and characteristic complaint of dry eye patients is chronic foreign body sensation, or grittiness, which, along with other symptoms of dry eyes, tend to increase as the day progresses, as demanding visual tasks are undertaken, and as potentially drying environmental conditions are encountered for long periods.
Some patients describe burning, stinging, and varying degrees of pain.
While many practitioners believe the sensation of itching to be almost pathognomonic of allergy, it is occasionally related as a symptom of dry eye. Of course, the reduced tear volume and ßow, allowing irritants and allergens for more prolonged contact with the ocular surface, may initiate or exacerbate coexisting allergy.
2.ÒMy eye seems to keep tearing up for no (apparent) reason.Ó One of the seemingly
paradoxical symptoms of dry eye disease is excessive tearing (epiphora).
Generally, this excess tearing will occur under conditions of increased ocular exposure and drying; for example, prolonged computer use or reading (when the blink rate is usually unknowingly signiÞcantly reduced), or outdoors during windy and/or dry conditions. Typically, golfers will complain of annoying and exuberant tearing while out on the course. While some of these complaints may be within normal limits, they may reßect underlying mild-to-moderate dry eye in which the basal tear secretion is deÞcient, stimulating excessive reßex tearing, that can result in signiÞcant overßow.
3.ÒI seem to be losing visual acuity in one or both eyes.ÓAnother frequent symptom of dry eye disease is episodic and sometimes persistent, loss of best-corrected vision. Disruption of the normally regular and clear optical surface of the eye can result in very annoying, if not disabling, visual disturbances.
Even without visible surface disruption when examined by slit-lamp biomicroscopy, the reduced ßow of abnormally constituted tears alternating with excessive reßex tearing can be the explanation of patientsÕ vague visual complaints. Of course, more severe dry eye syndrome results in obvious surface disruption and irregularity with reduction in visual acuity.
4.Ò(Bright) light seems to be intolerable to my eyes, requiring me to lower the lights or keep sunglasses on.Ó Photophobia—abnormal light sensitivityÑis also a result of the abnormal ocular surface, causing optical light scattering. SigniÞcant changes in the ocular surface can cause disabling light sensitivity and pain.
5.ÒI seem to be waking up most mornings with lots of sticky ÔgunkÕ in my eyes.Ó Another subtle, sometimes chief, complaint of patients with mild-to-moderate dry eyes is tenacious mucus found in the eyes upon awakening. In the absence of infection, one explanation for this uniquely stringy mucus secretion may be that the goblet cell mucus production is undiluted by the aqueous component of the normal tear Þlm.