What is Dry Mouth ? Many individuals complain of mouth dryness. Dry mouth or xerostomia can be caused by decreased salivary flow or may be due to a sensation of dryness without decreased flow. Most Sjögren’s syndrome patients experience dry mouth because of decreased salivary flow. The only way to determine the degree of dry mouth with any degreeof certainty is by objective testing.
Some causes of dry mouth includes:
- Mouth breathing
- Dehydratation which can be caused by excess caffeine consumption
- Prescription medications, such as: analgesics, anti-cholinergics, stomach acid pump inhibitors, cholesterol-lowering drugs, anti-hypertensives, antidepressants, antihistamines, sleep aids, anti-Parkinson’s medication.
- Medical treatments: Head and neck radiation therapy or bone marrow transplantation
- Chronic conditions: Amyloidosis, Diabetes, Depression, Sarcoidosis, Hepatitis C, HIV, Sjögren’ syndrome
Saliva has a number of functions which are easily overlooked when saliva production is not an issue, including:
- Saliva keeps your mouth wet during sleep so that the tissues stay moist, hydrated and infection free.
- Saliva contains enzymes that begin the first phase of digestion.
- Saliva helps food form into a bolus so that it can be easily swallowed.
- Saliva produces the stickiness or sliminess needed to allow dentures to adhere to the mucosal tissue.
- Saliva is necessary to moisten the tongue, teeth and the mucosal tissues so that food can slip over these tissues.
- Saliva is necessary for proper speech and to keep normally wet tissues, such as lips, from feeling burnt, dry and chapped.
Salivais is necessary to dissolve food so that food can be tasted. In the absence of saliva, as in the case of Sjögren’ syndrome, most individuals find themselves drinking fluids with meals in order to enhance taste and to aid in swallowing safely.
Indications of Dry mouth
Saliva is a key component in oral health. Dry mouth symptoms include:
- Frequently sipping liquids
- Pain or discomfort when swallowing
- Speech difficulties
- Mouth dryness and discomfort
- Altered sense of taste
- Mouth and salivary gland infections
- Increased tooth decay
- Discomfort wearing dentures / appliances
- Absence or frotty thick saliva
- Cracking at the corners of the lips (angular chelitis)
Diagnosing Dry mouth
Dry mouth is uncomfortable and can be painful, and importantly , it can lead to other problems or indicate more serious disease such as Sjögren’s syndrome. If you suspect dry mouth, it is important to be tested.
Research has shown that it requires about a 50% loss of saliva for individuals to become aware of having dry mouth. Thus, there may or may not be signs of dry mouth in its early stages. In its milder form, the tissues may appear normal. Individuals are able to eat and speak without difficulty and usually do not have problems with tooth decay. The oral ecological balance is usually maintained and there is often no issue with secondary bacterial or viral infections. Mild oral dryness often occurs in individuals using long-term medication for medical issues such as high blood pressure. It can also be seen in individuals with fibromyalgia.
The more severe forms of dry mouth are usually seen in individuals who are using large doses of psychotropic medication, large doses of analgesics including opioids and in individuals with Primary Sjögren’s syndrome where salivary flow can sometimes reduce to zero.
When salivary flows lessen, the tongue and other mucosal tissues are often infected with yeast (candidiasis), causing baldness of the surface of the tongue and redness of the mucosal tissue. These areas can ulcerate and become very painful. When there is infection on the tongue, taste can diminish and eating can become very difficult and less enjoyable because of pain and loss of taste. Individuals tend to avoid spicy or scratchy foods, which can irritate the mucosal tissue. These changes are reversible with treatment.
Much less reversible are the changes that occur to the teeth. With the loss of saliva, including both its mechanical cleaning and its antibacterial, antiviral, and antifungal properties and with the subsequent increase in bacterial load and decrease in oral pH, the teeth can begin to demineralize and decay quickly. There may come a time when the teeth are non-restorable when decay affects large area of the tops, bottoms, or sides of the teeth. When extensive teeth may fracture, leaving decayed roots and fragments of decayed teeth resulting in infection and pain. Sometimes the only choice is extraction and replacement with implants or a dental prosthesis, which may be implant-supported.
Connective Tissue Disorders
Sjögren’s syndrome can occur alone (Primary Sjögren’s syndrome) or as a complication in connective tissue disorders such as Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosis (SLE). Although this with Secondary Sjögren’s syndrome also experience dry mouth, the dryness is not usually as severe as it is in Primary Sjögren’s syndrome. In Primary Sjögren’s syndrome, specific antibodies are produced against salivary gland tissue and other exocrine glands, including the lacrimal or tear glands. As a result of the loss of salivary gland tissue, mouth dryness becomes severe.
What should you do if dry mouth is suspected ?
If you think you have dry mouth, it is important to see your dentist or physician and inform them of your concern. You must remember that even if your mouth does not look dry, it may still be dry. You should ask your physician to run blood tests to look for evidence of a connective tissue disorder, blood loss, or nutritional deficiency. A salivary uptake scan can be helpful in the investigation.
You might also discuss a referral to rheumatologist for a workup if Sjögren’s syndrome or other connective tissue disorder is suspected. A minor salivary gland lip biopsy may be ordered to assist in diagnosing Sjögren’s syndrome.
Salivary flows: Testing starts with very simple measures including measuring oral acidity (oral pH); salivary buffering capacity and measuring salivary flow. Salivary flow is measured by assessing the flow of saliva from the patient’s mouth in a set amount of time. Unstimulated whole salivary flows tests use no stimulus while stimulated salivary flow is measured while you chew a piece of paraffin or gum. A low oral pH, low salivary buffering capacity and low instimulated or stimulated flows are objective evidence of dry mouth. Low unstimulated or resting flow usually means dry mouth at night; low stimulated flow usually suggest difficulty eating without supplemental fluid.
Blood tests: Blood testing can be done to look for evidence of systemic disease, including Sjögren’s syndrome.
Salivary scans: Following a finding of low clinical salivary flows, low pH or low salivary buffering capacity, a salivary uptake scan can be done. During this test, Tc99m (Technium 99) is injected and its uptake measured in the major three salivary glands (parotid, submandibular, sublingual glands). Discharge of saliva can be determined after stimulation with lemon juice.
Other imaging: A finding of an abnormal salivary scan may be followed by MRI or CT scan investigation of the glands to look for stones, cysts or infection, or other problems if suspected.
Dry mouth management
Simple measures include using sugarless candy or gum to stimulate salivary flow. Medications such as sialogogues, including pilocarpine and bethanechol may be prescribed for stimulation of the salivary glands, however, they may not be effective if there is not sufficient salivary gland tissue remaining or if side effects are experienced with these medications. Many over-the-counter products may also be helpful, including artificial saliva and newer products which claim to bind to the tissues increasing their wetness.
Products for dry mouth may include:
- Limited use of chlorhexadine rinse to reduce bacterial load in the mouth and increase oral pH.
- High fluoride containing toothpaste which can substitute at least once a day for regular toothpaste.
- Recalcifying products, such as MI Paste and X-PUR help to re-mineralize teeth that are at risk because of low pH. Sometimes these may be used with soft bleaching type trays during the night to stimulate saliva. The trays may also provide protection against tooth wear during bruxism (tooth grinding) and against tooth erosion due to acid reflux and low oral pH.
- A small amount of medication to increase salivary flow during sleep, such as pilocarpine or bethanechol.
- Using 100% xylitol containing products (granulated, gum, mints or discs) to reduce caries producing bacterial activity.
- Avoid burning or irritating toothpastes or mouthwashes. Use non-irritating products sush as PreviDent5000 plus, Control Rx, Biotene products or xylitol toothpastes.
Visiting the dentist
If you do have a problem with mouth dryness, especially if it is associated with a lowered pH and risk of increased decay, you should see your dentist and / or dental hygienist every three to four months for examination and restoration of early caries (cavities). Professional fluoride treatment including fluoride varnish can be done at these times. In addition, if there are signs of dental erosion or tooth wear, review of nutrition and oral hygiene practices may be helpful.
How you can help yourself
- Avoid caffeine
- Limit the frequency of sugar and soda consumption since caries risk increases with frequency of sugar exposures.
- Avoid acidic foods and beverages
- Keep mouth hydrated
- Take extra care and particular attention to good oral hygiene habits
- Stimulate natural saliva by chewing sugar-free gum, sucking sugar-free candies
- Use an electric toothbrush
- Treat acid reflux
- Humidify the house and office with a cool mist humidifier
The best way to help yourself is by joining an organization such as Sjögren’s Society of Canada so that you can be kept up to date about ongoing trials and new medications and products. The Sjögren’s Society of Canada can provide support and resource materials that will be helpful for you dentists / physicians.
To learn more about Sjögren’s syndrome, please contact the:
304-31 Mechanic Street
Paris, Ontario, N3L 1K1
Dry eye disease is a common medical condition that occurs when the eyes do not make enough tears or the tears evaporate too quickly. This leads to inflammation of the ocular surface, causing the eyes to become dry, red, and irritated. Symptoms include dryness, grittiness, soreness, burning and temporarily blurred vision.
There are many reasons our eyes become dry, for example, wearing contact lenses, working at a computer screen for long periods, poor diet, air conditioning and heating, inflammatory skin disease (rosacea), inflammatory eyelid disease (blepharitis) or simply growing older.
The latest advice from global dry eye experts recommends Omega 3 dietary supplementation.
Essential fatty acids, especially Omega 3, have been shown to improve dry eye symptoms due to their anti-inflammatory capabilities.
Reduce inflammation in dry eyes. Help rebuild damaged cells on the surface of the eye. Strong anti-inflammatory to help soothe dry eyes. Reduce ocular inflammation and increase tear film.
Eye Nutrients Dry Eye Omega contains three Omega 3 essential fatty acids such as EPA (help reduce inflammation in dry eyes), DHA (helps rebuild damaged cells on the surface of the eye), DPA (a very strong anti-inflammatory to help soothe dry eyes). It also contains Omega 7 essential fatty acids that will help to retain moisture in the membrane of the eye and vitamin D3 that helps reduce ocular inflammation and increase tear film.
Natural solutions to reduce dry eyes
Meibomian Gland Disease (MGD) is possibly the most frequent cause of Dry Eye Disease. Omega 3 fatty acids contain powerful anti-inflammatory antioxidants and studies have shown the benefits of Omega 3 n improving the symptoms of dry eye, mainly by increasing tear stability. Dietary supplementaton with essential fatty acids provides an additional strategy for relieving the inflammation and symptoms that dry eye disease presents.
Dry eyes and dry mouth are the two most common symptoms of one of the most prevalent autoimmune diseases affecting mostly women. Sjögren’s syndrome is a serious autoimmune disease that preferentially attacks and damages the salivary, tear and mucous-secreting glands, resulting in dry eyes, dry mouth, or swollen salivary glands.
Recognized as one of the most prevalent autoimmune diseases, it was first identified by a Swedish physician, Henrik Sjögren, in 1933.
Sjögren’s is a chronic, systemic disease
Sjögren’s is a chronic, systemic disease that can cause arthritis, painful weak muscles, neuropathy and debilitating fatigue. It can result in inflammation of the lungs, kidneys, GI system, blood vessels, liver, brain or thyroid gland.
Sjögren’s syndrome is often under-diagnosed, misunderstood and under-treated
Symptoms may wax and wane and are often unpredictable. While some people experience mild discomfort, others suffer debilitating symptoms that greatly impair their quality of life. Early diagnosis and proper treatment can prevent serious complications and greatly improve the quality of life for those with Sjögren’s syndrome.
Who does Sjögren’s syndrome affect ?
- 1 of 70 Canadians, up to an estimated 430,000.
- 9 out of 10 patients are women
- People between 35-65 years of age, but children can also suffer from Sjögren’s
- Often the disease occurs alone (Primary Sjögren’s syndrome)
- It can also occur as a complication in rheumatoid arthritis, lupus, scleroderma, primary biliary cirrhosis or other connective tissue diseases (Secondary Sjögren’s syndrome)
What are the most common Sjögren’s symptoms ?
- Dry, gritty, sore or burning eyes
- Eyes may be sensitive to sun, tear excessively
- Dry or burning mouth, yeast infections
- Difficulty speaking, chewing or swallowing
- Frequently using liquids to help swallow dry foods
- Increased dental decay
- Swollen salivary glands
- Difficulty wearing dental apparatus
- Altered sense of taste or smell
- Sore weak muscles
- Dry cough
- Sore or cracked tongue
- Dry skin and rashes
- Digestive problems
- Joint pain
- Dry nose
- Mouth sores
- Vaginal dryness
What should I do if I suspect Sjögren’s syndrome ?
Talk to your health care provider if you have had dry eyes and / or dry mouth for more than three months and other commonly associated Sjögren’s-types symptoms. Fatigue and joint pain are common complaints of Sjögren’s because this is a systemic inflammatory disease.
Is Sjögren’s easily diagnosed ?
NO: It can often be difficult to diagnose due to the complexities of the disease and diversity of symptoms. All symptoms may not be present at the same time. On average, it can take 5-9 years to be diagnosed. Depending on their symptoms, an undiagnosed person may seek treatment from different specialists who will treat each symptom individually.
Sjögren’s can mimic other diseases such as rheumatoid arthritis, lupus, multiple sclerosis or fibromyalgia, further complicating diagnosis. One of the difficulties with diagnosing Sjögren’s syndrome is that patients frequently have no obvious clinical findings and, unless the physician is particularly astute, they will not be diagnosed appropriately. The invisibility of the disease may add to the delay in diagnosis or not to be taken seriously by professionals. The general lack of awareness about this complicated syndrome may also be a factor in the delay of diagnosis.
Ways Sjögren’s syndrome can affect your body
- Dry eye causes considerable discomfort and can lead to corneal ulcerations if left untreated. Eyes are more sensitive to irritants and susceptible to infection.
- Dry mouth can affect diet and nutrition, speech, taste, tolerance to dental prostheses, and dental decay leading to poor oral health.
- Skin disorders such as cutaneous vasculitis, Raynaud’s phenomenon, and digital ulceration can occur.
- Some people with Sjögren’s have liver abnormalities, including primary biliary cirrhosis and chronic active hepatitis.
- A small percentage of Sjögren’s patients develop pancreatitis.
- People with Sjögren’s may have neurological problems including impaired memory and concentration. Peripheral neuropathy is seen.
- Severe oral dryness may lead to dysphagia, with food “sticking” in esophagus, or reflux esophagitis.
- Sjögren’s can be complicated by recurrent upper respiratory infections including sinusitis and, less frequently, by obstructive or interstitial lung disease.
- Nutritional malabsorption may occur due to damage to the mucus of the stomach lining. Malabsorption can occur for a variety of reasons including adult onset Celiac disease.
- Vaginal dryness is common.
How is Sjögren’s syndrome diagnosed ?
Once Sjögren’s syndrome is suspected, you may have a series of blood tests, including:
- ANA (Anti-Nuclear Antibody): About 70% of Sjögren’s patients have elevated antibodies that react against normal components of a cell’s nucleus.
- SS-A (or Ro) and SS-B (or La): 70% of patients are positive for SS-A and 40% positive for SS-B.
- RF (Rheumatoid Factor): 60-70% of patients have a positive RF.
- ESR (Erythrocyte Sedimentation Rate): Measures inflammation. An elevated ESR can indicate an inflammatory disorder, including Sjögren’s syndrome.
- IGs (immunoglobulins): Normal blood proteins, sometimes elevated in Sjögren’s.
The ophthalmologic tests include:
- Schirmer Test: Measures tear production.
- Rose Bengal or Lissamine Green and Fluoresceine: Uses dyes to observe abnormal cells on the surface of the eye, a consequence of the dryness of the eye.
- Slit-Lamp Exam: Observation of lids to rule out the presence of lid inflamation which is often associated with a dry eye. The slit lamp examination is also used to examine the ocular tear film and the overall health of the ocular surface.
The salivary gland tests include:
- Parotid Gland Flow: Measures the amount of saliva produced over a certain period of time.
- Salivary Scintigraphy: Measures salivary gland function.
- Sialography: An x-ray of the salivary duct system.
- Lip Biopsy: Confirms lymphocytic infiltration of the minor salivary glands.
What kind of doctor treats Sjögren’s patients ?
Rheumatologists usually have primary responsabilities for managing Sjögren’s patients. Ophthalmologists, dentists, ear nose and throat doctors and other specialists can treat related Sjögren’s symptoms.
How is Sjögren’s syndrome treated ?
There are several over-the-counter products that can provide symptomatic relief for various aspects of the disease. There are a few prescription medications that may be helpful in treating dry eye, dry mouth and other symptoms depending on the type and severity.
What else can I do ?
It is important to seek expert eye and dental care. There are strategies and products that can help manage or relieve symptoms such as the use of electric toothbrushes, humidifiers, moisture chamber glasses or goggles. Often people are better able to cope with a chronic condition like Sjögren’s when they educate themselves and connect and learn from each other in support groups.
What will happen to me ?
Sjögren’s syndrome is a serious disease but is generally not fatal. One study reported non-Hodgkins lymphoma (lymph node cancer) occurred at a rate 44 times greater in Sjögren’s patients as compared to the general population. Lymphoma may occur in up to 10% of patients with Sjögren’s syndrome, but it is generally a low grade tumour and easily treated with the new drugs we now have available. It is important for Sjögren’s patients to be monitored closely for the possible complications, development of related autoimmune phenomena and lymphoma.
Is there a cure for Sjögren’s syndrome ?
Not yet; but with your help there will be. Please join with and make your voice heard ! Join the Sjögren’s Society of Canada and help conquer one of the most prevalent autoimmune diseases !
What is blepharitis and meibomian gland dysfunction ?
You have probably never heard of blepharitis unless you have it or know someone who has blepharitis.
But what is blepharitis?
It is a chronic inflammation of the eyelid margin that contains the meibomian glands. These small glands on the spinal margin produce the meibum, an essential lipid that enters into the composition of your tears. This lipid, which happens to be the last layer of your tear film plays a crucial role in the stability of it. Indeed, it helps stabilize the tear film to delay evaporation.
When the meibomian glands do not work!
Thus, when the meibomian glands do not work well or are clogged, the quality of your tears is inevitably diminished. This has the consequence of causing an evaporative dry eye. Your eyes are red, sensitive, irritated and uncomfortable. In general, blepharitis can not be cured. It tends to be chronic but fortunately it can be treated by controlling the symptoms with simple means but must be done every day to reduce the symptoms and have the best quality of life possible.
When the meibomian glands do not work properly, the lipid they produce tends to be thicker than normal or absent. It is then enough to apply hot compresses on the eyes every day in order to liquefy the meibomian secretions and to return them their normal fluidity.
Heat application and eyelid massage
After applying a warm compress on the eyes for about ten minutes, gently massage the eyelids to purge the glands and release the lipid that has been made more fluid by heat. Be careful not to massage your eyelids too vigorously; remember, the eyelid massage must be firm but delicate.
Subsequently, it is recommended to clean your eyelids with a product such as Ocusoft Lid Scrub Cleansing Foam. Finally, we finish with artificial tears. Remember that it is best to use artificial tears without preservatives.
Follow this treatment every day to prevent relapse. You should continue even in the absence of symptoms or if you feel better.
So here’s how I treat my evaporative dry eye, which by the way is the most common type of dry eye.
- Waking up in the morning, as soon as I open my eyes I put artificial tears without preservatives.
- Subsequently, I put a hot compress on my eyes for about ten minutes.
- Then I proceed with the massage of the eyelids delicately.
- Immediately after, I clean my eyes with Ocusoft Lid Scrub foam.
- I put artificial tears specifically made for meibomian gland dysfunction.
- Before bedtime, I clean my eyes with Ocusoft Lid Scrub.
- Thereafter, I use my sleeping eye mask to shield my eyes during my sleep. You can use artificial tears without preservative right before wearing your night mask.
Since I have been on this diet rigorously, I have noticed a marked improvement in my condition and quality of life. Of course, it’s not perfect, I have good days and not so good days but in general it’s much better. Of course, there are prescription treatments that you should discuss with your doctor such as tetracyclines, cyclosporin A, and corticosteroids. But I do not want to address the issue of prescription drugs because I think it needs to be discussed with your health care provider. By the way, you will not find any prescription products on this site.
When you have sensitive eyes, it is not always easy to find a makeup that does not irritate the eyes or the eyelid. At the Dry Eyes Store, we have makeup designed for people with sensitive eyes. But how to make a successful makeup when you have sensitive eyes?
To make a success of my makeup
Successful makeup depends first and foremost on perfectly cleansed and well hydrated skin. Then, it is necessary to wait about ten minutes between the application of your care cream and the make-up to assure a better holding.
Makeup of the complexion
To obtain a perfect make-up of the complexion imposes to respect a strict order of application of the products:
- First, the tinted cream that you stretch (without spreading) with your fingertips going to the outside of the face to unify your complexion,
- then, the eye contour that you use with the foam applicator and you fade gently tapping lightly, to hide imperfections (signs of fatigue, redness, dark circles, …)
- then, the loose powder that you apply generously with a large brush on the entire face to obtain a matte and silky finish. During the day, you can touch up with the compact powder,
- finally, the blush that you affix on the protruding parts of the cheekbones to accentuate the relief of your face.
Highlighting the beauty of your eyes and the intensity of your eyes is an essential step in makeup. Each product has a distinct function:
- Attract light with makeup or eye shadow,
- enlarge your eyes thanks to the pencil or eyeliner, to deposit at the base of the upper lashes,
- accentuate and brighten the look with the mascara that thickens the lashes and gives the impression of lengthening them.
Illuminating your complexion, modeling your face, attracting light, these are the qualities that will bring you lipstick, pencil lip contour and lipgloss.
The varnish protects the nails and ensures shine and color in harmony with the makeup of the face. For a better hold, it is recommended to apply the clear lacquer in make-up base.
Makeup for sensitive skin and eyes
The skin is today more and more sensitive and fragile. All women, including those who wear contact lenses, need skincare and make-up products that guarantee perfect safety. To respond to this new dermocosmetic environment, Laboratoires Contapharm has developed the High Tolerance Eye Care Cosmetics range of skincare products, recognized by dermatologists, ophthalmologists, allergists, as the reference in the field of ocular sensitivity. cutaneous thanks to a completely new concept: the bio-inertia formulations.
With Eye Care Cosmetics makeup, women are more than ever sure of their beauty.
When you suffer from dry eye, we look for all the possible means at our disposal to put a little moisture in our dry eyes. Although artificial tears do a good job, they are often not enough to counter the symptoms of dry eyes and provide lasting relief.
How to relieve my dry eye symptoms?
If you are one of those who use artificial tears several times a day, know that there are other solutions, sometimes more effective to relieve your symptoms of dry eyes. Artificial tears have a limit and sometimes you have to turn to other means.
Glasses for dry eyes
Wearing glasses specifically designed to relieve dry eyes is unavoidable when you have a moderate to severe dry eye. The principle of these glasses is simple. They block the wind and dust while trapping moisture naturally released by your body inside the telescope. The humidity in the air around your eyes is therefore higher, which allows your tear film to evaporate less quickly. There are several types of glasses, all colors and for all tastes. If you have dry eyes and have not tried our glasses yet, it is high time for you to offer yourself a real chance to find a quality of life.
Little trick: Put artificial tears in your eyes just before wearing these glasses … The effect will be increased tenfold!
During the night, the eyes tend to dry out for a variety of reasons. When you suffer from dryness at night or in the early morning when you wake up, just make sure to protect them during the night. Some will use a night mask to simply reduce the flow of air around the eyes while others will prefer a mask or a night bezel. Although these are more effective than a night mask, you will need to take the time to get used to sleeping with these protections. The protective effect for your eyes is magic! The next day, you will feel your eyes much less dry and more rested.
Hot compresses are necessary to ensure proper functioning of the glands responsible for the production of tears. For this, use a quality compress that will keep its heat between 45 and 50 degrees Celcius for about 15 minutes. Those who use a washcloth under hot water will never achieve the therapeutic effect of a hot compress designed for this purpose since the washcloth is cooled much too easily.
It is necessary to massage the eyelids regularly. You can use your fingers or use the Eyepeace device. Massage the eyelids also allows the meibomian glands to function properly and ensures that the lipid secreted by these glands is expelled from the glands.
If you still clean your eyelids with baby shampoo diluted in hot water … STOP! Personally, this way of doing things has always irritated my eyes even more. It is much better to use a specially designed solution for this purpose. These products are sold in several formats and are very practical.
Routine for dry eyes
If you follow these basic tips, you should see an improvement in your dry eye symptoms. Of course, sometimes you have to wait several days or even a few weeks before you notice a significant improvement in your symptoms. Your dry eye has taken months, maybe years to settle. You will not be able to reverse this in a few days.
Chat with others who live with dry eyes
Finally, consult your doctor and follow his recommendations. There are several prescription treatments that your doctor may suggest such as Restasis, Xiidra and other topical anti-inflammatories.
You walk into a party reception room and are greeted with trays of delicious hors d’oeuvres. Everyone is encouraging you to try them, but you can’t. First you need to get to the bar on the opposite side of the room so you can get a glass of water to thelp the food go down. […]
Sjögren’s Syndrome and Dry Eye. Many Canadians suffer from dry eye. There are two major causes of dry eye: decreased lacrimal tear secretion and loss of tears due to evaporation which can result in symptoms of irritation, blurring, grittiness, burning and dryness.
Dry eye is a hallmark symptom of Sjögren’s syndrome. Sjögren’s is a serious autoimmune disease that results in inflammation that damages the salivary, tear and mucous-secreting glands, resulting in dry eyes and dry mouth. The disease affects 1 in 70 Canadians, up to an estimated 430,000. 9 out 10 patients are women. On average, Sjögren’s affects people between 35 and 65 years of age, but children can also suffer. Sjögren’s can occur alone (Primary Sjögren’s syndrome) or as a compilation in rheumatoid arthritis, lupus, scleroderma or other connective tissue diseases (Secondary Sjögren’s syndrome).
The Role of Tears
The tear film is a complex structure that receives molecules from the lacrimal glands, the mucus secreting globet cells, conjunctival and corneal cells of the ocular surface as well as the oil secreting meibomian glands of the lids. In the normal eye, there is a steady stream of tears that is replenished regularly during the day with the blink.
Composition of the Tear Film
- The watery portion of the tears that come from the lacrimal glands and contain lubricants and special proteins that fight off infection and maintain the health of the surface cells.
- The mucus portion thickens the tear film and helps maintain a slippery surface so that the lids can move over the surface easily.
- The oils from the meibomian glands sit on the surface of the tear film to prevent evaporation.
Maintaining a normal tear film is hard work. When any of the glands or cells that supply the tears become compromised, the ocular surface sends signals of dryness, discomfort, grittiness and burning to the brain. This is the basis of dry eye disease. In Sjögren’s syndrome, most of these systems fail.
Diagnosing Dry Eye
Dry Eye is the most common presentation in eye care offices. Like many diseases, there is no one test that can determine the presence and the extent of this disease. However, optometrists and ophthalmologists can get a very good idea of what is going on by doing few tests:
Symptoms of Dry Eye
- It is important that your eye care practitioner know how your eyes feel and you should discuss your symptoms during your examination.
Tear Flow Tests
- Using Schirmer strips or phenol red threads to measure the flow of tears over a specified period of time allows some estimate of the function of the lacrimal gland. In Sjögren’s syndrome Schirmer testing is most often done without anaesthetic and for 5 minutes. A score of less than or equal to 5mm in at least one eye is characteristic of dry eye Sjögren’s syndrome related dry eye disease. A score of less than 10mm is characteristic of aqueous deficient dry eye.
- Using fluorescein dye in the eye, a practitioner can measure the amount of time it takes for your tear film to breakup or evaporate. A break up time of less than 10 seconds is considered indicative of an unstable tear film.
Status of the Ocular Surface
- Your eye doctor will use dyes on the surface of your eye to determine the level of dryness. Yellow fluorescein dye is used to observe dry spots on the cornea and rose bengal or lissamine green dye highlight the dry spots on the conjunctiva. Your practitioners will grade the level of staining from a score of 9. Sjögren’s syndrome is suspected when the staining in at least one eye is 4/9 or greater.
Status of the Lids and Meibomian Glands
- Your lids should be examined to see if the lash line is infected or flaking, a condition called anterior blepharitis. The meibomian glands should be observed and pressure put on them to observe how easily they secrete and whether the secretions are clear, as they should be, or milky.
At the end of all of this, your practitioners should be able to tell you whether or not you have dry eye disease, whether it is mild moderate or severe, and the most likely cause of the disease. At this point a treatment plan should be put in place.
Dry Eye Treatment Options
Treatment plans will vary depending on the degree and complexity of dry eye disease. This is where your relationship with your practitioner is so important. Most dry eye is chronic and needs regular attention. The treatments fall into 3 major categories: internal, topical and environmental.
- The body is an integrated unit and therefore keeping your body healthy will maximize the health of your tears. Therefore do not smoke, eat your fruits and vegetables, increase the omega 3 fatty acids in your diet, maintain a normal weight, exercice, get enough sleep and drink plenty of water. Avoid dehydrating substance like alcohol and coffee.
- Using lubricants on the ocular surface regularly is the mainstay of dry eye treatment. There are numerous topical agents, both preserved and non-preserved that are helpful for dry eye patients. The rule of thumb is that if you use eye drops more than 4 times per day, it is better to use a non-preserved drop. Sometimes gels are useful especially at night. Be proactive with your drops. Use your drops regularly even if your eyes feel fine. By the time they hurt the damage may be harder to treat. If the drops are not doing enough there are other treatments that may help. Your practitioner can put plugs in the small opening of the lids called the puncta the prevent the tears from leaving the surface quickly. Also these openings can be cauterized for more permanent results. Anti-inflammatory drops such as Restasis and topical steroids are sometimes prescribed for very severe dryness. The steroids cannot be used for long periods of time because of the complications they may cause. Finally, serum drops can be prepared by drawing your blood and taking the clear plasma part and mixing it with tear lubricants. Care of your lids is also important as inflammation of the lash line or the oil glands, called blepharitis, can cause tear evaporation. Massaging the lids and using lid scrubs and hot soaks will help to clean the lids and allow the glands to function. Applying warm compresses on the eyes a couple of times each day can make the meibomian glands secrete better and may relieve irritation and ease discomfort. The use of humidity shield glasses and Panoptyx glasses can greatly improve the symptoms. These can be made up with a prescription.
- Add humidifiers wherever you can. Humidify the house and the office. In the car use only the floor vents for air conditioning and heating. Avoid drafts. Protect yourself from the wind with wrap sunglasses or humidity shield glasses. When working on a computer, raise your chai or lower the table so that your gaze is downward as this leaves less of your ocular surface exposed and reduces eye fatigue. BLINK ! The very act of blinking can help to replenish the tear film and make the meibomian glands secrete. Sometimes the simplest things are the best.
Remember that some systemic medications can cause increased dryness All of your conditions must be treated appropriately but do discuss this with your doctor. There may be alternative medications for your contition that are less drying.
Many researchers are working hard to learn more about Sjögren’s syndrome and dry eye disease. As the disease is better understood, new treatments and perhaps one day prevention will be available. For now know that your dry eyes are serious but rarely sight threatening. Do take care of your eyes with regular lubrication and a healthy lifestyle and see your eye care practitioner regularly.
Sjögren’s (pronounced SHOW-grins) syndrome is a serious autoimmune disease that preferentially attacks and damages the salivary, tear and mucous-secreting glands, resulting in dry eyes, dry mouth, or swollen salivary glands. Hallmark symptoms of Sjögren’s is a chronic, systemic disease that can result in infllammation of the lungs, kidneys, GI system, blood vessels, liver, brain or thyroid gland. For more information go to www.sjogrenscanada.org
To learn more about Sjögren’s syndrome, please contact:
Sjögren’s Society of Canada
31 Mechanic Street, Suite 304
Paris, Ontario, N3L 1K1
Infra-red Imaging of Meibomian Glands and Evaluation of Lipid Layer in Sjogren’s Syndrome Patients. Sjogren’s Syndrome has been defined as an autoimmune disease characterized by inflammation and destruction of sweat, salivary and tear glands.
Dry eye and Sjogren’s Syndrome occurs primarly in women, particularly during or post-menopause. Although the mechanism as to why this correlation exists is not fully understood, an underlying similarity between Sjogren’s Syndrome and menopausal women is a deficiency in androgens / hormones. The androgen-deficiency may lead to destruction of oil secreting glands (meibomian glands) in the eyelids or gland loss, leading to an increase in the evaporation of the tear film and subsequently dry eye experienced by many Sjogren’s Syndrome patients.
Meibomian glands and Dry Eyes
Meibomian glands are sebaceous oil glands located in the upper and lower eyelids. There are about 30-40 glands in the upper lid and 20-30 glands in the lower lid. Tears on the surface of the eye have two functional layers, the outermost layer composed of oils. The meibomian glands function to secrete the oils of the tears onto the surface of the eye which aids in preventing quick evaporation of the tear film and subsequent discomfort felt by the eye.
Meibomian gland dysfunction (MGD) has been classified by the International Workshop on Meibomian Gland Dysfunction as a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct gland obstruction and / or qualitative / quantitative changes in the glandular secretion. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease. Meibomian gland dysfunction (MGD) has been shown to increase with age, contact lens wear, and as mentionned above, androgen deficiency. Thus, the recent findings would suggest that not only are the severe dry eye manifestations experienced in Sjogren’s syndrome due to lack of tear production, but may also be due to poor tear quality due to lack of oil layer present over the pre-ocular tear film.
Few studies have investigated meibomian gland loss in patients with Sjogren’s syndrome and to our knowledge; none have compared gland loss evaluations to the measured lipid (oil) layer thickness in thes patients. Thus, the purpose of this study was to evaluate and compare the meibomian gland drop out and the lipid layer thickness in patient with and without Sjogren’s syndrome.
Lipid Layer Thickness Evaluation
The tear film lipid layer thickness was measured for each participant using the Keeler Tearscope Plus (Broomall, USA). During evaluation, the lipid layer of for each participant would reflect a certain pattern back to the examiner. From the reflected pattern, the examiner was able to determine the thickness of the lipid layer.
Non-Invasive Tear Break-Up Time
The non-invasive tear break-up time was measured using the Atlas Corneal Topographer (Oberkochen, Germany). Tear break-up time measures how quickly the tear film evaporates off of the surface of the eye. Each participant was asked to look at the center of the concentric ring pattern displayed on the instrument screen. The ring pattern was reflected off of the participant’s tear film and viewed by the experimenter on a screen. The participant was instructed to blink 3 consecutive times and then asked to hold their eyes open for as long as they could or until the researcher asked the participant to blink. The time elapsed between the last blink and first sign of distortion occurring of the ring pattern or subsequent blink was recorded as the non-invasive tear break-up time. This was repeated a number of 3 times for each eye.
Meibomian gland loss was analyzed using an infrared camera system. Multiple images were taken of the upper and lower eyelids of both eyes for each participant. Gland loss-out was first evaluated subjectively using a grading scale of 0-3 based on the grading system created by Arita et al. with grade 0 = no gland loss; grade 1 = areas of gland loss were less than 33% of total gland area; grade 2 = area of gland loss was between 33% and 67% of total area; grade 3 = area of gland loss was greater than 67%. Scores were for the upper and lower eyelids were summed to obtain a score for each eye.
Meibography images were also analysed using a computer software programme (ImagJ, National Institute of Health). Total area of the eyelid where glands should be present was calculated and the area that still had glands present was calculated. The gland area value was then subtracted from the total area and converted to a percent of area that had gland loss.
The investigator was not aware as to whether the participant had Sjogren’s syndrome or not during the subjective and digital analysis of gland loss.
There were 10 participants without Sjogren’s syndrome enrolled in the study (3 male and 7 females) with an average age of 58.5 years. 11 participants with Sjogren’s Syndrome were enrolled (1 male and 10 females) with an average age of 56.0 years. Not one participant in the control group reported the use of artificial tear drop and all 11 participants in the Sjogren’s group reported use of artificial tear drops.
All of the participants in the Sjogren’s group had been diagnosed with Sjogren’s syndrome for at least 4 years, the earliest diagnosis in the group being 1999 and the latest being 2008. All participants also reported that dry eye symptoms preceded diagnosis with Sjogren’s syndrome.
Tear evaporation was approximately 4x quicker in the participants with Sjogren’s syndrome compared to the participants without Sjogren’s. The Lipid layer thickness was also significantly reduced in the participants with Sjogren’s compared to those without Sjogren’s syndrome.
Subjective gland loss were different for the upper right eyelid and lower left eyelid with the scores in the Sjogren’s syndrome group being higher indicating more loss of the glands. There was little difference in subjective gland loss for the lower lid of the right eye and the upper lid of the left eye. Digital grading scores showed significant difference in gland loss values between the control and Sjogren’s syndrome groups for the upper lid of the right and left eye and the lower lid of the left eye, again with the Sjogren’s group exhibiting higher degree of gland loss than the control group. There was no significant difference between the digital gland loss scores between groups in the lower right lid.
In this study, the participants in the Sjogren’s syndrome group presented with a significantly thinner lipid layer, with the majority of the lipid layers being relatively thinner than the group of participants without Sjogren’s syndrome. The Sjogren’s group also had a shorter non invasive tear break-up time which could be attributed to the thinner lipid layer thickness leading to quicker evaporation of the tear film.
The shorter tear break-up time and thin lipid layer thickness found in the Sjogren’s group could be further explained by the higher degree of gland loss found in the Sjogren’s syndrome group. As mentionned previously, the meibomian glands secrete the lipid layer of the tears, thus if there are fewer glands present, not as much lipid would be secreted, leading to a thinner lipid layer and short tear break-up time.
In conclusion, this study supports previous work suggesting that meibomian gland dysfunction plays an essential role in the severe dry eye experienced by patients with Sjogren’s syndrome. It also exemplifies the use of meibography for a quick and easy assessment of the degree of gland dropout in patients with Sjogren’s syndrome which could aid in a better understanding and management of the disease.
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