EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW CORNEA 30 a simple finger stick using a lancet. To make the process more time effi- cient, we preheat a microwaveable, reusable gel pack, check that the temperature is warm yet safe, and ask the patient to allow the non- dominant hand to warm with the gel pack. The initial finger stick with the lancet is delivered to the pad of the ring finger of the nondominant hand. In our area, this can be delegated to the technician under physician supervision. The gloved technician or patient milks the finger until a large drop appears and falls into the dotted circle, which fills and saturates the circle com- pletely. After filling the 5 dotted circles, we collect 3–5 additional droplets below the row of dotted circles to ensure that the laboratory has an adequate sample to run the assays. We then let the sample air dry for 30 minutes prior to sealing it in a plastic envelope with a desiccat- ing package. The sample, patient information card, physician orders, and diagnostics codes are placed in a paper envelope supplied in the kit. I collect all the labeled samples from the day and place them in one biohazard mailing bag (the lancet, order form, collection card, and pa- tient information form is contained within each kit). The test results are typically received within 1 week. Case study A 49-year-old female who lived a healthy and active lifestyle present- ed with red eyes, burning, irritation, and "recurrent eye infections." She noted that air travel was virtually intolerable given the effects on her eyes. Review of systems was positive for chronic sinusitis, dry mouth, extensive dental problems, and arthritis. Family history revealed her maternal grandfather had a "rare autoimmune problem" and two maternal aunts suffered from severe systemic lupus erythematosus. Ocu- lar surface examination revealed lev- el 3 dry eye disease with a very low tear volume, poor corneal wetting and tear spread, tear breakup time of 2 seconds, 3+ corneal staining with fluorescein, 2+ lid margin, and 2+ conjunctival staining with lissamine green. I started her on the typical dry eye medications Restasis (cyclospo- rine, Allergan, Irvine, Calif.) BID, Lotemax 0.5% (loteprednol, Bausch + Lomb, Bridgewater, N.J.) BID, omega 3 supplements, and preservative-free artificial tears. We started talking about the pos- sibility of adding doxycycline (for the secondary MGD), moisture chambers and autologous serum if necessary per the International Task Force guidelines. The patient eagerly accepted the Sjö test and the results came back unequivocally positive. She is now scheduled to see a nearby rheumatologist for diagnostic confirmation and systemic treat- ment. She is happy to know that there is a potentially unifying cause of her multi-system complaints that can be treated successfully. Knowing her underlying diagnosis urges me to partner with a rheumatologist to control the systemic process as well as employ more intensive and aggressive treatments for her dry eye manifestation of Sjögren's in order to halt progression and prevent further tissue destruction. The addition of this new clinical tool to accurately test for Sjögren's syn- drome is invaluable in identifying suspected cases among the dry eye patient group. EW References 1. Liew MS, Zhang M, Kim E, Akpek EK. Prevalence and predictors of Sjögren's syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012;96 (12):1498–1503. 2. Shen L, Suresh L, Lindemann M, Xuan J, Kowal P, Malyavantham K, Ambrus J. Novel autoantibodies in Sjögren's syndrome. Clinical Immunology. 2012;145:251–255. 3. Meijer JM, Meiners PM, Vissink A, et al. Effectiveness of rituximab treatment in primary Sjögren's syndrome: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2010;62(4):960–8. 4. Sjögren's Syndrome Foundation. 2001. Available at www.sjögrens.org. Accessed March 3, 2014. 5. Reksten TR, Jonsson MV. Sjögren's syndrome: an update on epidemiology and current insights on pathophysiology. Oral Maxillofac Surg Clin North Am. 2014; 26(1):1–12. 6. Behrens A, Doyle JJ, Stern L, Chuck RS, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006;25(8):900–907. 7. Mathews PM, Hahn S, Baer AN, Akpek EK. Analysis of ocular and systemic morbidities in patients with primary Sjögren's syndrome. Poster presented at: TFOS 2013. September 18, 2013; Taormina, Sicily. Editors' note: Dr. Periman is an ophthalmologist at Redmond Eye Clinic in Seattle. She has financial interests with Allergan. Contact information Periman: lperiman@comcast.net 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: stephensinst@aol.com www.stephensinst.com Femtosecond Laser Cataract Surgery Instruments S5-1535 LRI Enhancement Forceps Cross-action provides accurate spreading of incisions pre- or post-operatively, or during slit-lamp examinations. S4-1700 Femtosecond Spatula Double ended sizing and spear shaped, thin blunted tips offer versatility for opening primary and secondary femtosecond laser incisions. S4-1710 Femtosecond Chopper Special design chops femtosecond laser fragmented nuclei with its unique shaped tip. August 2014 Testing for Sjögren's syndrome continued from page 28