Ocular Management

Sjögren’s in Sjögren’s Patients

Foundation The Sjögren’s Foundation has developed the first-ever U.S. Clinical Practice Guidelines
for Ocular Management in Sjögren’s to ensure quality and consistency of care for the
assessment and management of patients.

Clinical The Clinical Practice Guidelines for Ocular Management in Sjögren’s established that, in a
given patient, the clinician must determine whether the dry eye is due to inadequate pro-
duction of tears, excess evaporation, or a combination of both mechanisms. The success

Practice
of a treatment option depends upon proper recognition and approach to therapy. For the
development of the Sjögren’s Foundation Ocular Guidelines, the Report of the Interna-
tional Workshop on Dry Eye (DEWS) was used as a starting point, then panels of eye care
providers and consultants evaluated peer-reviewed publications and developed recom-

Guidelines mendations for evaluation and management of dry eye disease associated with Sjögren’s.

Ocular Guidelines Summary and Recommendation:

Evaluation of symptoms can be accomplished by use of a number of questionnaires to
grade severity of symptoms. Practical considerations recommend use of three specific
questions (Table 1). A number of clinical tests of tear function can be performed in the
office setting to quantify the volume and stability of tear function, including tear meniscus
height and rapid tear film breakup time (TFBUT). Determination of tear secretion rate is
the most helpful way to differentiate aqueous-deficient dry
Table 1 – Screening Questions for Dry Eye eye from evaporative dry eye, and this is usually accom-
Key screening questions for dry eye disease plished by the Schirmer test. More advanced diagnosis of
dry eye can be achieved by measuring tear film osmolarity,
A patient reporting ‘Yes’ to any of the following warrants which can also be used to monitor response to therapy.
a full ocular examination Evaluation of lid blink function and health of the eyelid
How often do your eyes feel dryness, discomfort, or margin, particularly the meibomian glands, is necessary to
irritation? Would you say it is often or constantly? (Y/N) quantify evaporative dry eye. Evaluation of the severity of
When you have eye dryness, discomfort, or irritation, does dry eye disease is possible with application of topical dyes,
including fluorescein, rose bengal, and lissamine green, to
this impact your activities (e.g. do you stop or reduce your
quantify damage to the ocular surface.
time doing them)? (Y/N)
Management of dry eye depends upon the nature of the dry
Do you think you have dry eye? (Y/N)
eye and the severity of symptoms. The algorithm presented
in Figure 1 details the options available. In early disease,
tear replacement with topically applied artificial tear or lubricant solutions may be
sufficient, but progressive or more severe inflammation of the lacrimal gland and ocular
surface occur both as an inciting event in many cases and as a secondary effect as the dry
eye disease worsens, called keratoconjunctivitis sicca (KCS), requires the use of dietary
supplements (omega 3 essential fatty acids), anti-inflammatory measures (e.g., topical
corticosteroids or cyclosporine), or oral secretagogues.
Plugging of the lacrimal puncta can be done once the inflammatory component of dry
eye is controlled. Control of lid margin (meibomian gland) disease may require topical
antibiotic or systemic doxycycline therapy. The most severe cases of dry eye, particular-
ly those unresponsive to more standard therapy, may require use of topical autologous
serum or partial closure of the interpalpebral fissure to reduce surface exposure. Scleral
contact lenses may be needed to control severe ocular surface damage.
Dry eye may signal the presence of Sjögren’s, particularly when it is associated with in-
flammation, difficulty in management, or dry mouth. A patient with suspected Sjögren’s
should be referred to a dentist for oral disease prevention/management and to a rheu-
matologist for systemic treatment.
SF20106.01
Figure 1: Treatment Algorithm Based Upon Severity Level and Response to Therapy
Diagnosis Treatment | Severity Level 11 Severity Level 2 Severity Level 3 Severity Level 4 Evidence2 Recommendation3
Dry eye disease – l Education and environment/diet modification good STRONG
l Elimination of offending systemic medication good STRONG
Aqueous deficiency
l Artificial tears, gels, ointments good STRONG
without meibomian

gland disease l Omega 3 essential fatty acid supplement moderate MODERATE STRONG
l Anti-inflammatory therapy: cyclosporine good MODERATE STRONG
l Anti-inflammatory therapy: pulse steroids good MODERATE STRONG
l Punctal plugs good MODERATE STRONG
l Secretagogues good MODERATE STRONG
l Moisture chamber spectacles good MODERATE STRONG
l Topical autologous serum good MODERATE STRONG
l Contact lenses good MODERATE STRONG
l Permanent punctal occlusion good MODERATE STRONG
l Systemic anti-inflammatory medication moderate DISCRETIONARY
l Eyelid surgery good MODERATE STRONG

l Education and environment/diet modification good STRONG

Dry
eye disease – l Elimination of offending systemic medication good STRONG
Aqueous deficiency l Artificial tears with lipid component good STRONG
l Eyelid therapy: warm compress, massage good STRONG
with meibomian

gland disease l Omega 3 essential fatty acid supplement moderate MODERATE STRONG
l Anti-inflammatory therapy: cyclosporine good MODERATE STRONG
l Anti-inflammatory therapy: pulse steroids good MODERATE STRONG
l Topical azithromycin good MODERATE STRONG
l Liposomal spray good MODERATE STRONG
l Possible oral doxycycline good MODERATE STRONG
l Expression of meibomian glands good MODERATE STRONG
l Punctal plugs good MODERATE STRONG
l Secretagogues good MODERATE STRONG
l Moisture chamber spectacles good MODERATE STRONG
l Topical autologous serum good MODERATE STRONG
l Contact lenses good MODERATE STRONG
l Permanent punctal occlusion good MODERATE STRONG
l (Lipiflow pulsed thermal compression) insufficient DISCRETIONARY
l (Probing of meibomian gland) insufficient DISCRETIONARY
l Systemic anti-inflammatory medication moderate DISCRETIONARY
l Eyelid surgery good MODERATE STRONG
1 Assumes use of the International Dry Eye Workshop severity scale 2 Evidence is graded as good, moderate and insufficient 3 Recommendations range from strong, moderate strong and discretionary

The Sjögren’s Foundation Clinical Practice Guidelines Committee (CPGC): Gary N. Foulks, MD, FACS, S. Lance Forstot, MD, FACS, Peter C. Donshik, MD, Joseph Z. Forstot, MD, FACP, FACR,
Michael H. Goldstein, MD, MM, Michael A. Lemp, MD, J. Daniel Nelson, MD, FACS, Kelly K. Nichols, OD, MPH, PHD, Stephen C. Pflugfelder, MD, Jason M. Tanzer, DMD, PHD, Penny Asbell, MD, MBA, FACS,
Katherine Hammitt, MA, and Deborah S. Jacobs, MD

This information was taken from the Journal of the American Dental Association (JADA). Please visit www.sjogrens.org to find the most updated
information about the Sjögren’s Foundation Clinical Practice Guidelines and be sure to talk to your physician about them.

www.sjogrens.org