discovering dry eye

Dry Eye and Systemic Disease

BY BARBARA CAFFERY, OD, MS
April 1999

The majority of patients who present with dry eye symptoms suffer from mild to moderate dry eye disease or contact lens related dry eye syndrome. The origin of their symptoms is not well understood. Their symptoms are usually manageable with education and the use of lubricants.

There's another group of dry eye patients who suffer from well-documented autoimmune related dry eye disease. These are the patients with primary or secondary Sjogren's syndrome. As with all diseases, Sjogren's syndrome begins with mild and infrequent symptoms of dry eye. Therefore, in the early stages of the disease, patients may appear to have the mild to moderate dry eye that we commonly see. Sjogren's patients often say that the first symptom of their disease was a slow loss of tolerance to contact lens wear. Therefore, practitioners must be mindful of the possibility that patients who present with dryness symptoms may indeed have the earliest manifestations of a systemic autoimmune disease.

The diagnosis of Sjogren's syndrome is difficult, and the average patient consults nine doctors before the diagnosis is made. The history and ocular findings are very helpful in making the diagnosis and should be used often by eyecare practitioners.

Only one out of every 10 Sjogren's patients are male, and these patients almost always present with enlarged parotid glands. The more common presentation is that of a female over the age of 30 years who has symptoms of dryness, foreign body sensation and intolerance to contact lenses. These patients admit to dry mouth and a reduced ability to swallow dry food without drinking fluids (the cracker sign). Often they report an increase in dental carries over the past few years. These patients may have fatigue, erythema nodosum, joint pain and enlarged parotid glands, and they often have a family history of autoimmune disease, such as rheumatoid arthritis or lupus.

Ocular signs that suggest the diagnosis include Shirmer test results of less than 5mm wetting in five minutes and significant rose bengal staining of the exposed bulbar conjunctiva and cornea. These two findings, which may not be as severe in the early stages, are essential for the diagnostic criteria set out by the San Diego criteria. These patients have other characteristics of the ocular surface, including reduced tear film break-up time, debris in the tear film, meibomian gland dysfunction and blepharitis.

Patients with these characteristics deserve a complete workup for autoimmune disease. Rheumatologists who specialize in this area do a complete systemic assessment and serum analysis. Patients with Sjogren's syndrome demonstrate multiple serum antibodies. Antibodies to Ro and La (the designations for the antibodies that show up in the blood of Sjogren's patients) are pathoneumonic if lupus has been ruled out.

Dental evaluation includes a history of altered taste and intolerance to spicy foods. The salivary gland flow is also assessed, and a full evaluation for carries is also required. The final diagnostic component is the biopsy of the minor salivary glands, which are taken from the lower lip and in Sjogren's syndrome show periductal lymphocytic infiltrates and focal aggregates that replace acini. The type of lymphocytes that are most often seen are CD4 cells. Definitive diagnosis using the Chisolm and Mason criteria requires more than one foci of lymphocytic cells in one 4mm squared area of tissue.

Patients diagnosed with Sjogren's syndrome require careful management by a team of healthcare providers. Treatment of the disease is based on the relief of symptoms, since no curative medications exist.

Dr. Caffery has practiced optometry in Toronto, Canada, in a group setting dedicated to contact lens and tear film research since 1977.