EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW CORNEA 28 by Laura M. Periman, MD test for Sjögren's syndrome, called Sjö (Nicox, Fort Worth, Texas), with novel biomarkers that detect Sjögren's syndrome earlier and with higher sensitivity and specificity, is invaluable for diagnosing patients earlier and more accurately. Sjögren's syndrome is a po- tentially serious systemic disease, and early detection is important. A retrospective review of 183 pri- mary Sjögren's syndrome patients found one-third had extraglandular ophthalmic complications from Sjögren's. Nearly half of these pa- tients had some type of potentially vision-threatening complication such as corneal ulceration, corneal melt/perforation, cicatrizing conjunctivitis, uveitis, optic neuritis or retinal vasculitis. Sjögren's syndrome The Swedish ophthalmologist Henrik Sjögren (1899–1986) de- scribed a patient with low lacrimal and salivary gland secretions and introduced the term keratocon- junctivitis sicca. Dry eye is likely the heralding symptom of Sjögren's syndrome; new studies find the prevalence of Sjögren's syndrome in the dry eye patient population is approximately 11.6%. About 40% of the patients that I see on any given clinic day have some form of dry eye. I am suspicious of potential systemic disease in approximately 10% of those dry eye patients. In every eye exam, I look for ocular surface signs of dry eye disease such as low tear volume, poor wetting and spreading of the tear film, extensive staining with fluorescein and/or lissamine green, as well as a rapid tear film breakup time. Red flags for potential systemic disease are extensive dry eye or dis- ease out of proportion to risk factors for dry eye, such as 2+ to 3+ corneal and/or conjunctival staining in a young patient not on drying system- ic over-the-counter medications. Once the dry eye patient is identified and the index of suspi- cion is raised, it is incumbent upon eyecare providers to consider further screening and testing. To determine if the dry eye patient should be tested for Sjögren's syndrome, I ask S jögren's syndrome is one of the most common rheumatologic disorders and is a highly underdiag- nosed condition. It is also the second most common systemic cause of dry eye. One reason for the underdiag- nosis of this condition is that the laboratory testing is highly unre- liable. More precisely, rheumatoid factor (RF) and antinuclear antibody (ANA) are not disease-specific, and the more Sjögren-specific antibody A (SS-A) and Sjögren-specific antibody B (SS-B) yield 30% false negative rates. On many occasions, I have had a high level of clinical suspi- cion for Sjögren's syndrome in a dry eye patient whose laboratory test results came back negative for ANA, RF, SS-A, and SS-B. The develop- ment of a simple, in-office panel Testing for Sjögren's syndrome expands dry eye protocol August 2014 for expanded family history, surgical history, and symptoms (see sidebar). Identifying Sjögren's patients early may serve as a catalyst for establishing a referral network with general internists as well as specialists such as rheumatologists and dentists. We have pre-printed letters ready to send to providers for patients who receive a positive test result, with the lab report included. The letter further states that we wish to work as a team to confirm the diagnosis as well as establish the various treatment modalities neces- sary to prevent the patient's condi- tion and disease manifestations from progressing. Lymphoma is a serious complication that occurs in 4% to 5% of Sjögren's patients. With early diagnosis and treat- ment, the potential to make a signif- icant impact on a patient's overall and long-term health is tremendous. Diagnostic test Sjö is fast and easy to administer. First, the patient signs a form that allows the lab to directly bill his or her insurance. Our technician quickly learned how to take the blood sample from the patient with Review of symptoms Gastrointestinal: Dry mouth, dental problems, difficulty moistening food, difficulty swallowing, GERD, history of pancreatitis Respiratory: Chronic cough, recurrent bronchitis, pneumonia, and shortness of breath Ear, nose, and throat: Dry nose, epistaxis, and history of chronic sinusitis or sinus surgery Dermatology: Dry skin, vasculitis, Raynaud's phenomenon, vaginal dryness Neurologic: Numbness or tingling of the extremities, depression, concentration or memory problems Laura M. Periman, MD continued on page 30 A double row of droplets is collected to ensure adequate sample for laboratory analysis. Backside of the collection card. Saturation through to the backside of the card ensures an adequate sample. Source (all): Laura M. Periman, MD