Clinical PracticeClinical Guidelines for Management of Dry Eye Associated with Sjögren Disease
Introduction
The Sjögren’s Syndrome Foundation initiated development of clinical guideline recommendations for medical practitioners in 2010. Representatives from rheumatology, oral medicine/dentistry, and eye care providers were enlisted to evaluate recent literature and develop recommendations for those guidelines. This preliminary perspective from the eye care subcommittee is provided prior to the ultimate publication of the entire committee and is based upon agreement of the subcommittee members, all of whom contributed to the guidelines and agreed upon the recommendations.
The definition of dry eye provided by the 2007 International Dry Eye Workshop (DEWS) report is: “Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.”1
An alternative description of the disease is “dysfunctional tear syndrome” to emphasize that the tear film dysfunction can occur in the presence of normal tear secretion.2 The discomfort is often described in various ways, such as burning, stinging, grittiness or sensation of something in the eye (foreign body sensation), itching, and, occasionally, pain. A recent survey of the members of the Sjögren’s Syndrome Foundation revealed that the symptoms of dry eye were the most annoying and activity-limiting aspect of Sjögren disease. Sjögren disease is an autoimmune disease affecting primarily the exocrine glands of mucous membranes, resulting in dry eye and dry mouth, but often with additional musculoskeletal disturbance and damage to other body systems.3 Visual disturbance is often noted as fluctuation of vision, particularly during reading or working at a computer, and blinking often clears the vision.
Dry eye is usually classified into two major categories: aqueous-deficient dry eye, in which tear production is reduced, and evaporative dry eye, in which the evaporation of the tear film is abnormally high.1 Both categories have increased concentration of tear film constituents, as manifested by elevated osmolarity and rapid tear film breakup time (TFBUT).4, 5, 6, 7 Although the mechanisms of production of dry eye are easily separated, both conditions often occur simultaneously.
Inflammation of the lacrimal gland and ocular surface occur both as an inciting event in many cases and as a secondary effect as the dry eye disease worsens, prompting the name as keratoconjunctivitis sicca (KCS). Further classification of aqueous-deficient dry eye specifies dry eye that is associated with Sjögren disease versus dry eye not associated with Sjögren disease; this is done in recognition of the greater severity of aqueous-deficient dry eye as well as the greater inflammation associated with Sjögren disease.1, 8 It should be noted, however, that aqueous-deficient dry eye and evaporative dry eye have both been associated with Sjögren disease.9, 10
An additional approach to categorizing dry eye, which has become more frequently used in determining the management strategy, involves the gradation of severity of the dry eye based upon level of discomfort, interference with activities of daily living, degree of clinically observable inflammation, and response to previous therapy.11
The literature evaluating the management of dry eye specifically in Sjögren disease is limited, and the options for therapy most often are evaluated in non-Sjögren patients. In this review, the studies that specifically included Sjögren disease patients are identified, although the management options evaluated in non-Sjögren patients are presented when considered essential or helpful in management of Sjögren dry eye disease. Publications were graded according to the American Academy of Ophthalmology Preferred Practice Pattern guidelines for level of evidence (Table 1).
Eye care practitioners frequently encounter patients with dry eye symptoms, as there are more than an estimated 20 million people with dry eye in the United States.1 Although most patients complaining of dry eye disease do not have Sjögren disease, it is incumbent upon the practitioner to consider Sjögren disease when features of the dry eye suggest it as a possible etiology. More severe disease and more severe inflammation or difficulty in controlling the dry eye should prompt questions about concurrent dry mouth, arthritis, or other systemic evidence of inflammation or autoimmune disease. Patients with these associations should be referred to a dentist and rheumatologist for oral and systemic disease diagnosis and management.
Section snippets
Symptoms
Dry eye is usually symptomatic, although recent studies demonstrate that more than 40% of subjects with clear objective evidence of dry eye disease are asymptomatic.12 The first diagnostic clue is often the patient’s report of either eye discomfort and/or fluctuating vision. Many questionnaires have been developed to assess symptoms of dry eye, but few have been validated as accurate for diagnosis or response to therapy.
Dry eye surveys have been used in a variety of ways in both clinical care
Management of Dry Eye
The management approach to dry eye disease has changed over the past 10 years, but several principles persist. Communication between the practitioner and the patient is critical to assure that the patient understands the disease, the aggravating factors, and the management strategy. Given the multiple contributing causes of dry eye and the expansion of therapy to include nutritional support and management of lid margin disease, in addition to topical therapy, the patient should consider therapy
Summary and Recommendations
Dry eye disease is one of the most quality-of-life and activity-limiting features of Sjögren disease. In a given patient, the clinician must determine whether the dry eye is due to inadequate production of tears, excess evaporation, or a combination of both mechanisms; success of treatment depends upon proper recognition and approach to therapy.
Evaluation of symptoms can be accomplished by use of a number of questionnaires to grade severity of symptoms. Practical considerations recommend use of
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Funding support: The Sjogren’s Syndrome Foundation organized site meetings of the Committee for Ocular Clinical Guidelines in the Management of Dry Eye Associated with Sjogren Syndrome. No compensation was paid to any author.
Financial disclosures: All participating authors completed Conflict of Interest forms of the American College of Rheumatology, a co-sponsor of the Sjogren Syndrome Clinical Guidelines project, and the ICMJE-AJO forms. Consultant or advisory positions (SLF, GNF, MG, MAL, KKN, JDN, SCP, PA); speaker bureaus or lecture fees (SLF, PCD, MAL, KKN, SCP, JF, JMT, PA); grant support (MG, KKN, SCP, PA); equity payments (GNF, MG, MAL, KKM, SCP); and expert witness testimony (JDN).
Contributions of authors: Design and conduct of the panel (SLF, GNF, KH); collection, management, analysis, and interpretation of the data (SLF, GNF, PCD, MG, MAL, KKN, JDN, SCP, PA, DJ); and preparation, review, or approval of the manuscript (SLF, GNF, JF, PCD, MG, MAL, KKN, JDN, SCP, JMT, PA, DJ).
Single-copy reprint requests to Gary N. Foulks, MD, FACS (address below).