Treatment Plan

Treat and Manage Sjögren’s

BY WILLIAM L. MILLER, OD, MS, PHD, FAAO

Recent advances in technology have allowed for an earlier diagnosis and initiation of therapy for Sjögren’s syndrome. But, the similarities to other diseases including fibromyalgia, chronic fatigue syndrome, and multiple sclerosis have increased the difficulty in diagnosis. Classified as an autoimmune disease, it has genetic as well as suspected environmental triggers, although the exact cause has not been found.

Primary Sjögren’s involves the ocular or oral mucosa; those involving associated connective tissue disorders (systemic lupus erythematosus, rheumatoid arthritis, or scleroderma) are classified as secondary Sjögren’s. The disease mostly affects female patients in the fourth to sixth decade of life.

Diagnostic criteria are typically aimed at chronicity of symptoms along with tests such as Schirmer’s and lissamine green. In addition, blood tests are frequently included for diagnosis. Two commonly used criteria systems include the European-American Consensus Criteria (Vitali et al, 2002) and the more recent SICCA criteria (Shiboski et al, 2012) proposed by the American College of Rheumatology.

Both sets of criteria have significant overlap, with the latter requiring at least two out of the three following clinical results: 1) Positive serum anti-SSA and/or anti-SSB or a positive rheumatoid factor and ANA; 2) Ocular surface staining grade ≥3; and 3) Presence of focal lymphocytic sialadenitis (≥ 1 focus/4mm²) in a biopsy taken from the labial salivary glands. Sjö (Bausch + Lomb/Nicox) uses a finger stick blood draw to test for biomarkers. An interactive interpretation tool can be found at http://sjodiagnostictool.bausch.com.

Sjögren’s Treatment Options

Our aim is to reduce symptoms and prevent secondary issues that may include ocular infections. Coordinated care will be conducted through the patient’s rheumatologist, internist, and dentist. Our first treatment step is to lubricate the ocular surface throughout a 24-hour cycle. Nonpreserved tear supplements should be our first line of treatment because patients use this form of lubrication frequently. The preservative-free tear supplements can be alternated with other supplements that may be used on a t.i.d. or q.i.d. application. Additional ocular surface coverage overnight can be achieved with ointments or gels. A preservative-free, slow-release lubricant insert can also be used before bed or during the day, although the latter may cause unpleasant blurry vision in some patients.

As the disease severity increases, other treatment modalities are added. Short-term use of topical steroids can be effective alone or when started prior to cyclosporine. An important caveat is that many of the studies used nonpreserved topical steroids. Topical cyclosporine dosed twice daily helps reduce symptoms and improve the ocular surface. Autologous serum, which contains anti-inflammatory factors, is used in these more severe forms of the disease (Petznick et al, 2013; Marsh and Pflugfelder, 1999; Hong et al, 2007; Sainz De La Maza Serra et al, 2000).

Oral adjuncts are also useful for patients who have Sjögren’s. Omega-3 essential fatty acids can be prescribed to reduce inflammation. A minimum suggested dose would start at 1,000mg per day and can augment your topical steroid application.

Lastly, scleral GP lenses have the ability to bathe the ocular surface in a tear reservoir, providing an improvement in signs and symptoms. The overall diameter should be larger than 15mm.

A comprehensive review, albeit a few years old, was published in JAMA that outlines the research results from various studies regarding the treatments used in Sjögren’s patients (Ramos-Casals et al, 2010). CLS

For references, please visit www.clspectrum.com/references and click on document #236.

Dr. Miller is an associate dean for academic affairs and professor at the Rosenberg School of Optometry, University of the Incarnate Word. He is a consultant or advisor to Alcon and Oasis Medical and has received research funding from CooperVision, Contamac, and SynergEyes and lecture or authorship honoraria from Alcon. You can reach him at wlmiller@uiwtx.edu.