An optometrist’s guide to Sjögren’s syndrome

By Robert E. Prouty, O.D.

Dry eye syndrome is commonly seen in optometric practices. Nearly 10% of the U.S. population has signs or symptoms of dry eye. A wide range of treatment options are available. However, dry eye has varied causes and severities. As a result, it can be difficult to classify after an initial diagnosis, making the condition difficult to treat. Most practicing optometrists would probably acknowledge that dissatisfied dry eye patients are common.

For that reason, practitioners should be prepared to look beyond the ophthalmic conditions and environmental factors commonly associated with dry eye, to systemic conditions, including autoimmune disorders, that may manifest as dry eye. An example is Sjögren’s syndrome

In an optometric practice, Sjögren’s syndrome may be considered a potential cause of dry eyes, particularly in cases that are persistent or resistant to treatment. There is no single test that will confirm a diagnosis. However, optometrists may utilize a Schirmer test to measures tear production, as well as rose bengal or lissamine green topical eye dyes to examine the surface of the eye for dry spots and corneal desiccation defects, as a means of identifying potential Sjögren’s patients. When such patients are identified, practitioners should be ready to not only prescribe appropriate treatment for the ocular manifestations of the condition, but to also provide appropriate counseling and referral to other health care practitioners as warranted.

Sjögren’s syndrome is one of the nation’s most prevalent autoimmune disorders; with upward of 4,000,000 Americans suffering from the condition. Nine out of 10 Sjögren’s patients are women. Although early diagnosis and treatment are critical in preventing complications, Sjögren’s syndrome goes undiagnosed on average for nearly seven years following initial onset.

With dry eyes being a hallmark symptom, optometrists clearly have a potentially important role in both the diagnosis and care of the condition. Identifying, diagnosing and managing Sjögren’s Syndrome is a multidisciplinary endeavor.

Optometry is uniquely positioned to see Sjögren’s patients during routine eye exams. Referrals for rheumatological, gastrointestinal, neurological, dermatological and dental consultations often assist these patients with their myriad of symptoms. Working in concert with other specialists to fine-tune and personalize the management of patients with Sjögren’s syndrome offers the best outcomes for these patients. Frequently, the primary care optometrist can be the doctor that offers answers to a patient’s symptoms that have gone undiagnosed for years.

Many would argue that there is inadequate awareness of Sjogren’s Syndrome among both health care practitioners and the general public. Given the range of materials available for health care professionals, optometrists can easily hone their diagnostic skills to better diagnose this notoriously under-diagnosed condition. And with the range of patient resources available, just about any practitioner can easily begin providing patient counseling when Sjögren’s syndrome is diagnosed.

About Sjögren’s syndrome

Sjögren’s Syndrome is a chronic slowly progressive autoimmune disease that results in inflammation of the exocrine glands of the body. It is most commonly characterized by dryness of the mouth and eyes. Since the disease was first identified in 1933 by Henrik Sjögren, M.D., it has been proven to affect virtually every racial and ethnic group. Sjögren’s symptoms frequently overlap with or “mimic” those of other diseases including lupus, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, and multiple sclerosis.

This autoimmune illness involves inflammation in exocrine glands of the body that are responsible for producing tears and saliva, as well as the other moisture secreting tissues of the body. Inflammation of the lacrimal glands leads to decreased production of tears leading to dry eyes. Inflammation of the glands that produce the saliva in the mouth salivary glands leads to dry mouth and dry lips. Other glands that can become inflamed, though less commonly, in Sjögren’s syndrome include those of the lining of the breathing passages (leading to lung infections) and the vagina (sometimes causing pain during intercourse or recurrent vaginal infections).

Although the hallmark symptoms are dry eyes and dry mouth, Sjögren’s may also cause other dysfunctions including fatigue, joint pain or inflammation (arthritis), Raynaud’s phenomenon, lung inflammation, lymph node enlargement, and kidney, pancreas, nerve, and muscle disease. Ultraviolet (UV) radiation from the sun and other light sources can affect Sjögren’s patients, leading to skin rashes, disease flares, eye sensitivity and pain.

About half of the time Sjögren’s occurs alone; the other half it occurs in the presence of another autoimmune connective tissue disease such as rheumatoid arthritis, lupus, or scleroderma. When Sjögren’s occurs alone, it is referred to as “Primary Sjögren’s.” When it occurs with another connective tissue disease, it is referred to as “Secondary Sjögren’s.”

The exact cause of Sjögren’s Syndrome is not known. However, there is growing evidence that it occurs due to genetic factors. The illness is sometimes found in other family members. It is also found more commonly in families that have members with other autoimmune illnesses, such as systemic lupus erythematosus, autoimmune thyroid disease, type I diabetes, etc. All instances of Sjögren’s are systemic, affecting the entire body. Symptoms may remain steady, worsen, or, uncommonly, go into remission. While some people experience mild discomfort, others suffer debilitating symptoms that greatly impair their functioning. Early diagnosis and proper treatment are important — they may prevent serious complications and greatly improve a patient’s quality of life.

Health care provider resources

Information on Sjögren’s Syndrome is available from a number of sources including the Sjögren’s Syndrome Foundation (SSF) which offers a range of information and tools to assist health care practitioners in diagnosing Sjögren’s and managing its complications for patients. The following are available free-of-charge from the SSF.

The Sjögren’s Quarterly – This medical and scientific newsletter is distributed free-of-charge to thousands of health care providers in rheumatology, ophthalmology, optometry, dentistry, and research. It features the latest news in Sjögren’s research and treatment and best practices, written and edited by experts in Sjögren’s.

Educational brochures – The foundation offers a selection of brochures and fact sheets free of charge to health care providers for their offices. Sjögren’s patients commonly have a number of questions about the disorder, the foundation notes. The easy-to- comprehend educational brochures and fact sheets have been developed to help those individuals understand the condition. The foundation releases new brochures and fact sheets monthly.

Professional education opportunities – The SSF offers educational opportunities for health care providers and their staff to attend the foundation’s Patient Seminars and National Patient Conferences free of charge. Information on upcoming seminars is available through the foundation offices.

The Sjögren’s Book (Oxford University Press) has been developed by the SSF as the “Bible for Sjogren’s,” designed to help both patients and health professionals understand the many aspects of the disease. Edited by renowned rheumatologist Daniel J. Wallace, M.D., the book offers 35 chapters, all authored by internationally recognized experts in their fields, with in-depth information on genetics, the nervous system (central, peripheral and autonomic), vasculitis, gynecology and pregnancy, the gastrointestinal (GI) tract, lymphoma, musculoskeletal pain, vitamin D, and other topics.

In addition, the foundation offers for purchase a number of books, audio CDs, and its Moisture Seekers clinical publication.

Practitioners can order or download resources on the foundation’s website (www.sjogrens.org).