The Sjögren’s Syndrome Foundation (SSF) 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. In 2010 the SSF initiated the development of clinical guideline recommendations for medical practitioners in three categories: rheumatology, oral medicine/dentistry, and eye care providers. Having presented the first of the three sets of SSF CPG for the management of Sjögren’s is a momentous milestone for the SSF and our members!
From an SSF member survey, it was revealed that dry eye symptoms were the most bothersome and activity-limiting aspect of Sjögren’s. The Guidelines established that in a given patient, the clinician must determine whether the dry eye is due to inadequate production of tears, excess evaporation, or a combination of both mechanisms. The success of a treatment option depends upon proper recognition and approach to therapy.
For the development of the SSF Ocular Guidelines, the 2007 Report of the International 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 recommendations for evaluation and management of dry eye disease associated with Sjögren’s. The publications were graded according to the American Academy of Ophthalmology Preferred Practice Pattern guidelines for level of evidence. Strength of recommendation was according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines and recommendations developed using a Delphi process, which relies on a panel of experts answering questionnaires in two or more rounds.
SSF 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 per- formed 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 eye from evaporative dry eye, and this is usually accomplished by the Schirmer test. More advanced diagnosis of dry eye can be achieved by measuring tear film osmolarity, which can also be used to monitor response to therapy. Evaluation of lid blink function and health of the eyelid margin, particularly the meibomian glands, is necessary to quantify evaporative dry eye. Evaluation of the severity of dry eye disease is possible with application of topical dyes, including fluorescein, rose bengal, and lissamine green, to quantify damage to the ocular surface.
Management of dry eye depends upon the nature of the dry 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, particularly 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 inflammation, 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 rheumatologist for systemic treatment.
The Sjögren’s Syndrome 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 Ocular Surface. Please visit www.sjogrens.org to find the most updated information about the SSF Clinical Practice Guidelines and be sure to talk to your physician about them.