In addition, about 10% of patients may complain of local discomfort at the plug site or excessive tearing (especially if both upper and lower puncta are blocked), and the punctal plug may need to be removed in these patients. Patients who have lost the initial plug are twice as likely to lose the replacement plug.

12.8Oral Medications and Supplements

12.8.1Dietary Fatty acids (Flaxseed Oil) and Dry Eyes

Our diet contains two types of fat (saturated and unsaturated). Recent research has shown that oral therapy with polyunsaturated fatty acids reduces ocular surface inflammation and improves dry eye symptoms.

Americans obtain an excess of linoleic acid (omega-6 fatty acid) through their consumption of beef, dairy, vegetable cooking oils, and vegetable shortenings (i.e., cookies, potato chips, and snacks). However, the American diet is deÞcient in gamma-linolenic acid (omega-3 fatty acid). The two best sources of omega-3 fatty acid are Þsh oil and ßaxseed oil. Although supplements containing omega-6 fatty acid may help dry eye patients, there is a possibility that they may not be good for patients with macular degeneration.

12.8.2 Oral Medications

Systemic secretagogues (such as pilocarpine or cevimeline) have been shown to increase tear ßow slightly but not to a level sufÞcient for them to gain FDA approval as therapy for dry eyes.

Preparations of time-release pilocarpine or cevimeline have been proposed to yield a more linear pharmacokinetic release of drug, resulting in improved patient tolerance, reduced the systemic side effects and may prove useful in the future for both tear and saliva production [24, 25]. Although discussed for the last decade, they are not yet currently available or listed as currently in clinical trial.

Past reports of bromhexine, a mucolytic agent used in the past in many parts of the world, were reported to have proved helpful in improving dry eye [26Ð28]. However, this medication was relatively expensive at the doses required, was never available in the United States, and has disappeared from the market in most countries.

A role of androgens, either topically or orally, has been suggested based on animal studies [29]. Although a series of trials have been conducted, clear recommendations have not yet been made. Research reports have suggested that patients may prefer artiÞcial tears supplemented with DHEA, while oral administration of DHEA showed less impressive results [30].

Other reports have suggested beneÞt from non-preserved steroid (methylprednisolone hemisuccinate) [31, 32], although there is a risk of glaucoma and ocular hypertension after a short duration of use [33].

Obviously, dry eye in general, and certainly the dry eyes accompanying Sjögren’s syndrome, represents a chronic and potentially serious, debilitating, even vision-threatening disorder. Satisfactory management requires a partnership between an educated patient, empowered to alter his or her management within reasonable parameters, and a patient and dedicated clinician.

12.9Complications Associated with Ophthalmologic Cosmetic Procedures

Cosmetic surgery such as blepharoplasty may disrupt the function of tear glands. Another side effect of cosmetic surgery (or thyroid exophthalmia) is that the lids may not have adequate closure at night and result in an area of increased corneal exposure with resulting evaporative loss. The problem of tear loss at night is particularly important since basal tear rates show important diurnal variation with the lowest rate being during sleep.

Many patients seeking LASIK and refractive surgery are contact lens intolerant as a result of dry eyes. Contact lens wear can be an excellent

provocative test for otherwise subclinical dry eyes!

LASIK refractive surgery is therapeutically and categorically controversial and potentially dangerousfor a dry eye patient!

These patients must be extremely cautious when considering this cosmetic surgery [34], which results in actual cutting of about 90% of the corneal sensory nerves.

A signiÞcant percentage of normal eyes suffer from dryness for months after LASIK surgery, until the corneal nerves regenerate; others, who may have had a pre-existing mild or asymptomatic dry eye, may develop a signiÞcant and persistent dry eye.

LASIK vision-corrective surgery may lead to a relative denervation of the corneal surface, as this procedure uses a microtome to create a ßap, i.e., cut across the corneal surface and also cuts across some of the sensory nerves that innervate the cornea.

We thus feel patients with Sjögren’s syndrome and other immune disorders or vasculitis should probably not consider themselves candidates for LASIK surgery.

Other refractive surgeries that spare the corneal nerves may be considered, but socalled photorefractive keratectomy (PRK) (which avoids creating the ßap that severs the nerves) removes the surface epithelium, which depends upon an adequate tear Þlm for recovery and sustenance.

Aggressive pre-treatment and post-treatment in some mild-to-moderate dry eyes may allow a successful result.

12.10 Summary

It is essential for the rheumatologist, ophthalmologist, and patient to establish good working relationships to optimize continuity of care.

Additionally, if the rheumatologist provides written information to the patient as well as referring physician (and/or ophthalmologist), it will aid in effective management of dry eye and help minimize its negative effects on patient quality of life.

Therapy of dry eye in SjšgrenÕs syndrome (aqueous tear deÞciency or lacrimal keratoconjunctivitis siccaÑKCS) requires a multi-pronged approach aimed at

¥Eliminating exacerbating factors,

¥Supporting tear-producing glands,

¥Hydrating the ocular surface,

◦Restoring normal tear Þlm osmolarity,

◦Stabilizing the tear Þlm, and

¥Inhibiting the production of inßammatory mediators and proteases.

Take home points for tear selection include

1. Be prepared to mix and match different tear preparations. This includes recognition of mild (i.e., hypotonic and less viscous) to moderate and more extreme higher severe/intensive concentration polymers (more viscous and consequently longer action tears).

2.Do not use preserved tears more than four times a day.

3.There is no basic incompatibility in the various lubricants. For example, for patients concerned about cost but are using drops more than four times per day, they can still use less expensive preserved drops more or less equally spaced and then supplement with the non-preserved tears in-between.

4.Patients who really need the more viscous but transiently blurring drops should use less viscous, non-blurring drops while driving or doing other visually demanding activities. Then use the more viscous drops at other times where safety and critical vision is not at issue.

5.Read the ingredient label content on packages of generic (as well as branded) tears carefully, as some still contain older more toxic preservatives, including benzalkonium chloride or thimerosal.

6.The judicious use of ointments and/or gels may be very effective in breaking the cycle of periodic surface disruption.

7.Involve the patient in the treatment planning and decision-making process and recognize the role of medications and environments that increase dryness.

8.Rheumatologists are not ophthalmologists and should not oversee or try to take over the

management of dry eyes. Treatment of these special patients should always be a joint/ collaborative effort on the part of both the rheumatologist and ophthalmologist.

However, patients will ask their rheumatologist about the initial choice of artiÞcial tears and expect some knowledge about the choice of tears (more than simply reaching into the sample cabinet to see what is available).

Successful treatment with artiÞcial tears is a lot more than just Òadd water (and stir)Ó and there is more to the successful management of dry eye disorders than artiÞcial tears.

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