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