Keratitis Sicca Clinical Presentation

Depending on the severity of keratitis sicca, the following are the most common patient complaints:

• Foreign body sensation and ocular dryness and grittiness, typically worse toward the end of the day
• Hyperemia
• Mucoid discharge
• Ocular irritation (exacerbated by smoky or dry environments, indoor heating systems, prolonged reading, or computer use)
• Excessive tearing (secondary to reflex secretion)
• Fluctuating and/or blurry vision

Documenting the history of exacerbating or alleviating factors and a systemic past medical history is important, including a history of connective tissue disease, thyroid disease, and rheumatoid arthritis.

A review of systems focused on rheumatologic disease; history of neoplasias; and gastrointestinal and ear, nose, and throat (ENT) symptoms should be documented. In addition, ask about a history of dry mouth and request a list of systemic and topical medications the patient is using.

Before placing any drops in the eye of a patient suspected with keratitis sicca, perform an external and slit lamp examination.

A slit-lamp examination may document some of the following important findings:

• Decreased tear meniscus
• Increased debris in the tear film
• Conjunctival pleating
• Superficial punctate keratopathy (with positive fluorescein, lissamine green and/or rose bengal staining)
• Conjunctival hyperemia
• Mucous plaques and discharge
• Xerostomia (dry mouth) (in association with Sjögren syndrome)
• Corneal filaments
• Corneal epithelial defects or ulceration in more severe cases

Determine tear breakup time after placing a drop of fluorescein in the cul-de-sac.

Use rose Bengal staining to look for conjunctival and corneal staining, particularly at the nasal and temporal limbus and/or inferior paracentral cornea.

Perform the 5-minute Schirmer test with and without anesthesia using a Whatman #41 filter paper that is 5 mm in width × 35 mm in length. (Wetting < 5 mm with anesthesia and < 10 mm without anesthesia are considered abnormal.)

Measure reflex secretion with a Schirmer II test if the initial Schirmer test is abnormal. The Schirmer II test is performed by irritating the nasal mucosa with a cotton-tipped applicator before measuring tear production with a Whatman #41 filter paper. (Wetting < 15 mm after 5 min is considered abnormal.)

Sjögren syndrome is characterized by the combination of aqueous tear deficiency and dry mouth (xerostomia). Women comprise 90-95% of patients with this syndrome that has been classified into 3 different subsets, as follows:

• Patients with systemic immune dysfunction but no defined connective tissue disease (primary Sjögren syndrome)
• Patients who lack evidence of systemic immune dysfunction or a defined connective tissue disease
• Patients who have a defined connective tissue disease, most commonly rheumatoid arthritis (secondary Sjögren syndrome). Dry eye is common in patients with rheumatoid arthritis, including those without Sjögren syndrome.^[3] Dry eye should always be taken into consideration regardless of the rheumatoid arthritis activity, because the severity of dry eye is independent of the rheumatoid arthritis activity.

All cases of Sjögren syndrome are characterized by a progressive lymphocytic (predominantly B and CD4 lymphocytes) infiltration of the lacrimal and salivary glands that leads to disorganization of the normal gland architecture and consequent loss of function. At this time, the most comprehensive criteria for a diagnosis of Sjögren syndrome include the following:

• Abnormally low Schirmer test
• Objective evidence of low salivary flow
• Biopsy-proven lymphocytic infiltration of the labial salivary glands
• Dysfunction of the immune system as manifested by the presence of serum autoantibodies (eg, antinuclear antibodies, rheumatoid factor, anti-Ro [SS-A] and anti-La [SS-B] antibodies)

The following are autoimmune disorders associated with Sjögren syndrome:

• Rheumatoid arthritis
• Scleroderma
• Polymyositis
• Polyarteritis nodosa
• Hashimoto thyroiditis
• Chronic hepatobiliary cirrhosis
• Lymphocytic interstitial pneumonitis
• Thrombocytopenic purpura
• Hypergammaglobulinemia
• Waldenström macroglobulinemia
• Progressive systemic sclerosis
• Dermatomyositis
• Interstitial nephritis