November 18, 2016
4 min read

The Patient With Dry Eyes and Dry Mouth

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A 59-year-old woman with a 7-year history of Sjögren’s syndrome, treated symptomatically, has had three episodes of cutaneous vasculitis, successfully treated with oral steroids. She now presents with complaints of a slowly progressive enlargement of her right parotid gland. Her physical exam reveals dry mucous membranes and an enlarged, firm, non-tender right parotid gland.

Laboratory data reveal: low C4 levels, mixed monoclonal cryoglobulinemia, positive ANA, rheumatoid factor and anti-Ro/SSA antibodies. Her CBC is normal.

Key Supporting Information

Sjögren’s syndrome, characterized by keratoconjunctivitis sicca (dry eyes) and xerostomia (dry mouth), is a slowly progressive autoimmune condition that affects the exocrine glands. It also can be associated with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) or mixed collagen vascular disease. The condition is more common in women older than 40 years, with a female-to-male ratio of 9:1, and can improve with time with symptomatic care. This condition can have multisystem manifestations involving the thyroid, kidneys, liver, lungs and vascular system.

This disorder affects 0.3% to 0.6% of the U.S. population, with an incidence of 3.9/100,000. Approximately 5% of patients with RA and 15% of patients with SLE have manifestations of Sjögren’s syndrome.

Symptoms result from immune complex mediated inflammation as well as lymphocyte infiltration of epithelial tissue. The disorder is associated with distinct HLA-DQ and HLA-DR alleles, as well as B-cell activation with polyclonal gammopathy.

The clinical manifestations depend on the organ system involved, with dry eyes resulting in corneal ulcers, blurred vision, gritty sensations and corneal irritation. Dry mouth can result in altered sensation, oral candidiasis, dental caries and impaired digestion. One-third of patients may have parotid gland enlargement, while vaginal dryness, dry skin and persistent cough also have been described. Lymphadenopathy occurs frequently, and 5% of patients may develop B-cell lymphoma, with mucosa-associated lymphoid tissue (MALT) being the most common.

Dry eye disease (DED) is a common, yet frequently underdiagnosed, clinical condition that has challenging etiology and management for health care professionals. DED has only recently been acknowledged as a public health concern. Advances in our understanding of the disease have been made during the past few years in areas of epidemiology, pathogenesis, clinical manifestation, and therapy. It is critical that clinicians keep up to date with the current literature and the most recent guidelines for diagnosis and treatment.

Dry eye prevalence is estimated to range between 5% to 30% of the population older than 50 years, and it is one of the most common reasons for ocular surface disease (OSD). Dry eye is a multifactorial condition involving ocular irritation and inflammation in cascades giving origin to symptoms and to the pathogenesis of the disease. Changes in tear composition, including increased tear osmolarity and increased or altered expression of cytokines, chemokines, metalloproteinases, and T cells in the conjunctiva, are responsible for the symptoms of irritation, ocular surface epithelial disease, and altered corneal epithelial barrier function in individuals with dry eye.

Although the American Academy of Ophthalmology (AAO) Preferred Practice Pattern for dry eye is widely used, a recent study has found conformance to certain elements of the guidelines varies significantly. According to a study conducted at Duke University, 77.3% of the initial physical examination key elements, 67.9% of patient education key elements, 66.4% of the initial history key elements, and 40% of care management key elements were documented. Subspecialty ophthalmologists’ physical exam scores were higher than comprehensive ophthalmologists’ scores.

Although the guidelines are detailed, there is still room for improvement and further clarification. For example, while the guidelines are helpful in initiating treatment, the stepwise approach may not be best for every patient.

New diagnostic modalities continue to surface. Clinicians should track not only individual symptoms but also a more quantifiable “dry eye symptom load.” Therefore, questionnaires that generate a numerical symptom score may aid the process. The Ocular Surface Disease Index (OSDI) and the Standard Patient Evaluation of Eye Dryness (SPEED) are questionnaires known to be effective in diagnosing dry eye.


The Symptom Assessment in Dry Eye (SANDE) questionnaire may be faster and equally efficacious in scoring dry eye symptoms compared with the OSDI, according to a recent study. Data collected from the SANDE questionnaire showed a significant correlation and negligible score differences with those from the OSDI, suggesting the SANDE visual analog scale-based questionnaire has the potential to provide clinicians with a short, quick, and reliable measure for DED symptoms.

A rapid, disposable, in-office test to aid in the diagnosis of DED became available in 2014. The test detects elevated levels of matrix metalloproteinase, a clinically relevant inflammatory marker, in the tears of patients with DED.

Another recent study compared tear meniscus measurements obtained by optical coherence tomography (OCT) and tear osmolarity with dry eye severity according to the Dry Eye Workshop (DEWS) classification system. Both tear osmolarity and tear meniscus OCT measurements comply with the DEWS grading system, and these can be used in the diagnosis and follow-up of dry eye patients in addition to conventional tests.

Conventional therapies and lifestyle modifications are important considerations in the management of DED and OSD. The AAO Preferred Practice Pattern stresses patient education and environmental modifications as important factors in treating these diseases. Simple eyelid therapy, including warm compresses and improved eyelid hygiene, can be implemented easily.

Artificial tears, autologous serum tears, ocular surface lubricants, topical cyclosporine, corticosteroids, and mucolytics are agents that are recommended by the AAO Preferred Practice Pattern for the treatment of DED.

Learning Objectives:

Upon successful completion of this educational activity, participants should be better able to assess ankylosing spondylitis.


Author(s)/Faculty: Ronald A. Codario, MD, FACP, FNLA, RPVI, CCMEP

Source: Healio Rheumatology Education Lab

Type: Monograph

Articles/Items: 7

Release Date: 1/15/2016

Expiration Date: 1/15/2017

Credit Type: CME

Number of Credits: 1

Cost: Free

Provider: Vindico Medical Education

CME Information

Provider Statement: This continuing medical education activity is provided by Vindico Medical Information.

Support Statement: No commercial support for this activity.

Target Audience: This activity is designed for this activity is rheumatologists and other health care professionals involved in the treatment of patients with rheumatological disorders.