Sjogren's Syndrome: Autoimmune Dry Eye

What Sjogren's does to the eye

Immune cells infiltrate the lacrimal gland and progressively destroy its ability to produce tears. The remaining tears are concentrated and inflammatory. Without adequate tear volume the corneal and conjunctival surface dries, stains with dye in a characteristic pattern, and in severe cases develops filaments of mucus and dead cells that cause sharp pain, and, rarely, corneal ulceration. Meibomian gland dysfunction usually coexists, which compounds the evaporation.

Symptoms

Dry, gritty, burning eyes that are worse than usual dry eye and respond poorly to drops; a dry mouth with difficulty swallowing dry food and increased dental decay; and often fatigue, joint pain, dry skin and vaginal dryness. Because the eye symptoms come first for many patients, an eye doctor is often the first to suspect Sjogren's.

Diagnosis

The eye examination documents low tear production on Schirmer testing, surface staining, and an unstable tear film. Blood tests look for the SSA (Ro) and SSB (La) antibodies and other markers. A rheumatologist confirms the diagnosis, sometimes with a biopsy of the minor salivary glands in the lip, and assesses the rest of the body, because Sjogren's can affect the joints, lungs, kidneys and nerves and raises the risk of lymphoma, which the rheumatologist monitors.

Treating the eyes

• Preservative-free lubricants used frequently, with gels or ointment at night
• Anti-inflammatory drops, cyclosporine or lifitegrast, used long term to reduce the immune attack on the surface
• Punctal plugs to retain the tears that are produced, often in all four puncta in severe disease
• Autologous serum tears, made from the patient's own blood, which supply the growth factors and vitamins missing from a deficient tear film
• Scleral lenses, which hold a reservoir of fluid over the cornea all day and transform comfort and vision in severe cases
• Treatment of meibomian gland dysfunction and blepharitis alongside
• Moisture chamber glasses, humidifiers and avoidance of drying environments
• Oral secretagogues such as pilocarpine or cevimeline, prescribed by the rheumatologist, which stimulate tear and saliva production

Sjogren's and eye surgery

Laser vision correction is generally not advised, because it worsens dryness on an already deficient surface. Cataract surgery is performed when needed with the surface optimized beforehand and intensive lubrication afterward, and lens choice avoids multifocal optics that a poor tear film would degrade. Each decision is individual and discussed frankly.