For many patients, dry eye disease (DED) is a persistent problem that leads to a level of discomfort highly detrimental to their quality of life. During counseling, these patients often tell me that they have visited three or four doctors in an attempt to get relief from the burning, itching, fluctuating vision, and redness. Although we eye care professionals aggressively treat conditions such as uveitis and corneal abrasion, we often have a more relaxed approach to treating DED. Not only should we be more diligent in relieving the uncomfortable— even painful—symptoms of this syndrome, we should also consider every manifestation of DED as a hallmark of a potential systemic disease. Diagnosing Sjögren syndrome in patients with DED, for example, can help provide a clearer, targeted treatment path.
DIAGNOSIS
As many as 4 million people in the United States suffer from
Sjögren syndrome, but only 1 million have been diagnosed.1-3
This discrepancy is largely due to the fact that biomarkers
associated with traditional Sjögren syndrome testing—Sjögrenspecific
antibody A, Sjögren-specific antibody B, rheumatoid
factor, and antinuclear antibody—are not specific or sensitive
enough to accurately identify the disease at an early
stage. A new serology test for Sjögren syndrome (Sjö; Nicox)
includes the identification of three novel biomarkers—salivary
gland protein-1, carbonic anhydrase-6, and parotid secretory
protein—in addition to the aforementioned traditional
biomarkers. This comprehensive diagnostic panel helps to
detect Sjögren syndrome earlier and with a high specificity and
sensitivity.4 The test also displays markers indicative of other
autoimmune diseases such as rheumatoid arthritis.
THE TEST IN PRACTICE
I use Sjö in my practice to identify a potential systemic
etiology in DED patients whom I suspect of having deeper
problems. I have found that close to 40% of my DED patients
also experience dry mouth and dry skin, yet some do not notice those symptoms until I question them. This is valuable
information, as it relates to the possibility of systemic disease,
particularly Sjögren, which attacks the lacrimal and salivary
glands and, if left untreated and unmonitored, increases
patients' risk of developing lymphoma.5 Knowing if an autoimmune
cause underlies a patient's DED enables me to tailor
my treatment plan accordingly and ultimately improve his or
her outcomes.
Once my colleagues and I decided to start screening for Sjögren syndrome in our practice, we leveraged our established relationships with rheumatologists, who are able to manage affected patients from a systemic standpoint. When an autoimmune disease has been diagnosed, many promising medications can be prescribed, including hydroxychloroquine and other immunosuppressors. Just as with numerous other diseases, beginning treatment early in the disease state increases the chances of controlling symptoms and progression.
CONCLUSION
As eye care practitioners, it is important for us to take
advantage of improvements in the diagnosis and treatment
of diseases such as Sjögren syndrome that were previously
misunderstood and underdiagnosed. By taking this front-line
approach, we gain relevance and, more importantly, become
better physicians.
Paul Singh, MD, is an ophthalmologist at The Eye Centers of Racine & Kanosha in Racine, Wisconsin. He acknowledged no financial interest in the product or company mentioned herein. Dr. Singh may be reached at Ipsingh@amazingeye.com.
- Sjögren's Syndrome Foundation. Sjögren's Syndrome Foundation. 2001. http://www.sjogrens.org. Accessed September 5, 2013.
- Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Sjögren syndrome. Arch Intern Med. 2004;164:1275-1284.
- Liew M, Zhang M, Kim E, et al. Prevalence and predictors of Sjögren's syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012;96:1498-1503.
- Shen L, Suresh L, Lindemann M, et al. Novel autoantibodies in Sjögren's syndrome. Clin Immunol. 2012;145:251- 255.
- Pillemer SR. Lymphoma and other malignancies in primary Sjögren's syndrome. Ann Rheum Dis. 2006;65(6):704- 706.
