Dry Eye and Sjogren’s Syndrome: Decoding the Symbiotic Struggle

Neha Kumari Chaudhary, B. Optom Student

Acharya Institute of Allied Health Sciences, Bangalore, India

 

Dry eye disease (DED) is a common disorder that is frequently connected to other systemic diseases, most notably Sjögren’s Syndrome (SS). This autoimmune condition predominantly affects the body’s moisture-producing glands, resulting in serious eye issues. This blog explores the complex link between DED and SS, focussing on major findings from recent studies.

Dry Eye Disease and Sjögren’s Syndrome:

Sjögren’s Syndrome is a systemic autoimmune illness that mostly affects the exocrine glands, resulting in dry eyes and mouth. DED is a crucial component of SS, characterised by a reduction in tear production or increased tear film evaporation, which results in ocular surface irritation and injury.⁽¹⁾

Cytokine Levels in Tear Fluid

Research was conducted to examine tear cytokine concentrations in SS dry eye, non-SS dry eye, and normal people. The study indicated that cytokine levels, including interleukin (IL-17), Tumour necrosis factor (TNF-α), and IL-6, were considerably greater in SS patients than in non-SS dry eye patients or healthy controls. This points to a more severe inflammatory process in SS-related dry eye. Specifically, IL-17 levels are linked with tear film breakage time (TBUT) and Schirmer test scores in the SS group, indicating their possible relevance in the severity of ocular surface injury. ⁽²⁾

Diagnostic Challenges

DED diagnostics are challenging due to their diverse characteristics. A study investigated whether DED signs and symptoms may differentiate SS from other systemic disorders connected with DED. The study included 182 patients with SS, graft-versus-host disease (GVHD), Graves’ orbitopathy (GO), diabetic mellitus (DM), and glaucoma who were treated with benzalkonium chloride (BAK). The study indicated that the Ocular Surface Disease Index (OSDI), TBUT, and corneal fluorescein staining (CFS) were important criteria in distinguishing SS from other disorders. However, no one test could consistently diagnose DED across all populations.⁽³⁾

Management and Treatment Guidelines

Managing dry eye in SS patients necessitates a holistic strategy. A consensus panel, using the 2007 Report of the International Workshop on Dry Eye (DEWS) as a foundation, suggested many options. These include:

1. Evaluation: Evaluate both pain and visual abnormalities. Determine the effects of aqueous production deficit and evaporative tear loss. Staging and treatment decisions should be guided by objective indicators such tear film stability, tear osmolarity, and ocular surface injury.⁽¹⁾
2. Treatment Options:
   • Tear Supplementation: Using artificial tears to provide lubrication.
   • Inflammation Control: Topical anti-inflammatory therapies to reduce ocular surface inflammation.
   • Tear Conservation: Techniques like punctal plugs to prevent tear drainage.
   • Tear Stimulation: Oral secretagogues may be used, however their efficacy in treating eye dryness is debatable. The literature provides better evidence for their role in relieving mouth dryness.⁽⁴⁾

Conclusion

Sjögren’s syndrome and dry eye have a complicated association that is highlighted by different inflammatory pathways and diagnostic difficulties. Increased cytokine levels in SS patients indicate a highly inflammatory environment that requires specific interventions. Even though there are thorough management recommendations that emphasise the need of supplementing tears, controlling inflammation, and conserving tears, further study is necessary to enhance patient outcomes and further develop these techniques. The objective is to improve the quality of life for those with Sjögren’s syndrome and lessen the burden of dry eye symptoms.

 

References:

1. Foulks GN, Forstot SL, Donshik PC, Forstot JZ, Goldstein MH, Lemp MA, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Vol. 13, Ocular Surface. Elsevier Inc.; 2015. p. 118–32.
2. Lee SY, Han SJ, Nam SM, Yoon SC, Ahn JM, Kim TI, et al. Analysis of tear cytokines and clinical correlations in Sjögren syndrome dry eye patients and non-Sjögren syndrome dry eye patients. Am J Ophthalmol. 2013;156(2).
3. Garcia DM, de Oliveira FR, Módulo CM, Faustino J, Barbosa AP, Alves M, et al. Is Sjögren’s syndrome dry eye similar to dry eye caused by other etiologies? Discriminating different diseases by dry eye tests. PLoS One. 2018 Dec 1;13(12).
4. Akpek EK, Lindsley KB, Adyanthaya RS, Swamy R, Baer AN, McDonnell PJ. Treatment of Sjögren’s Syndrome-associated dry eye: An evidence-based review. Ophthalmology. 2011 Jul;118(7):1242–52.