eMedicine Specialties > Ophthalmology > Cornea

Keratoconjunctivitis, Sicca: Treatment & Medication

Author: Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Contributor Information and Disclosures

Updated: Apr 21, 2006

Treatment

Medical Care

Supplemental lubrication is the mainstay of treatment for mild and moderate keratitis sicca. Treatment of very severe keratitis sicca or keratitis sicca associated with a connective tissue disorder, including Sjögren syndrome, should be coordinated with an internist/rheumatologist.

Recently, the use of topical cyclosporine A (tCSA) 0.05% ophthalmic emulsion (Restasis) to treat keratoconjunctivitis sicca in a real-world setting has proven to be an effective treatment.

  • Prescribe artificial tears, preferably preservative-free artificial tears, and a lubricating ointment. Mild cases can be treated with drops 4 times a day. More severe cases require more aggressive treatment, such as drops 10-12 times a day. Thick artificial tear drops or gels also can be used in more severe cases, although they tend to blur the vision. Tear ointments can be used during the day, but they generally are reserved to bedtime use because of the poor vision after placement.
  • Treat any associated abnormalities, such as meibomian gland dysfunction, as these conditions can greatly exacerbate dry eye symptoms.
  • Patch with lubrication at night.
  • If mucous strands or filaments are present, remove with forceps, and add 10% acetylcysteine 4 times a day.
  • Place an artificial tear insert (eg, Lacrisert) into the inferior cul-de-sac every morning.
  • Insert temporary punctal occlusion with collagen (dissolvable) or silicone (permanent) plugs, and, if they are effective, perform electric cauterization of puncti.

Surgical Care

The surgical treatment of keratitis sicca is reserved for very severe cases where ulceration or impending perforation of the sterile corneal ulcer occurs. Surgical care includes the following:

  • Sealing of the perforation or descemetocele with corneal cyanoacrylate tissue adhesive
  • Corneal or corneoscleral patch for an impending or frank perforation
  • Lateral tarsorrhaphy - Temporary tarsorrhaphy (50%) is indicated in patients with keratitis sicca secondary to exposure keratitis after facial nerve paralysis and after trigeminal nerve lesions that give rise to keratitis sicca secondary to loss of corneal sensation.
  • Conjunctival flap

Consultations

  • If a patient has a connective tissue component or symptoms suggestive of Sjögren syndrome, consultation with a rheumatologist or an internist is appropriate.
  • Regular dental examinations are important because dry mouth significantly increases the risk of dental problems.
  • Women should receive regular checkups from their gynecologists.

Medication

Lubricating supplements are the most common medications used to treat this condition. If they are to be used more frequently than every 3 hours, preservative-free formulations are the treatment of choice. If a patient has Sjögren syndrome, the use of systemic immunosuppressants should be considered.

Lubricating drops

Used to reduce morbidity and to prevent complications.


Carboxymethylcellulose and similar lubricants (TheraTears, Bion Tears)

Lubricates and relieves dry eyes and eye irritation associated with deficient tear production.

Adult

1 gtt q1-4h prn

Pediatric

Administer as in adults

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Do not use with contact lenses; discontinue use if eye pain, irritation, continued redness, or vision changes occur

Ocular inserts

Reduce symptoms resulting from moderate-to-severe dry eye syndromes.


Hydroxypropyl cellulose (Lacrisert)

Acts to stabilize and thicken precorneal tear film and to prolong tear film breakup time, which occurs with dry eye states.

Adult

Insert 5 mg qd into inferior cul-de-sac beneath the base of the tarsus; some patients may require bid frequency

Pediatric

Administer as in adults

Pregnancy

A - Safe in pregnancy

Precautions

Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort, or irritation may occur

Lubricating ointments

Used to prevent complications from dry eyes.


White petrolatum, mineral oil, and similar lubricants (Duolube, HypoTears)

Serves as lubricant and emollient.

Adult

Pull down lid of affected eye, and apply small amount (0.25 in) of ointment to inside of the lid from every hour to just at bedtime depending on severity

Pediatric

Administer as in adults

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Do not use with contact lenses; discontinue use if eye pain, irritation, continued redness, or vision changes occur

Mucolytic agents

Lower mucous viscosity by digesting mucoproteins. Use when mucous discharge or plaques are present.


10% N-acetylcysteine drops (Mucomyst)

This mucolytic agent can be used successfully in patients with corneal filaments secondary to extreme keratitis sicca.

Adult

1 gtt tid/qid

Pediatric

1 gtt tid/qid

Do not use simultaneously with contact lenses

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Do not use in patients with a possible infectious ulcer or concomitantly with topical antibiotics

Immunomodulators

Cyclosporine ophthalmic drops are thought to act as a partial immunomodulator. The exact mechanism of action is not known.


Cyclosporine ophthalmic (Restasis)

Used to relieve dry eyes caused by suppressed tear production secondary to ocular inflammation.

Adult

Instill 1 gtt in each eye q12h

Pediatric

<16 years: Not established
>16 years: Administer as in adults

Documented hypersensitivity; ocular infection

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Herpes keratitis; do not administer while wearing contact lenses; may cause ocular burning, conjunctival hyperemia, ocular discharge, excessive tearing, eye pain, foreign body sensation, pruritus, stinging, or blurred vision

More on Keratoconjunctivitis, Sicca

Overview: Keratoconjunctivitis, Sicca
Differential Diagnoses & Workup: Keratoconjunctivitis, Sicca
Treatment & Medication: Keratoconjunctivitis, Sicca
Follow-up: Keratoconjunctivitis, Sicca
References
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References

  1. Barber LD, Pflugfelder SC, Tauber J. Phase III safety evaluation of cyclosporine 0.1% ophthalmic emulsion administered twice daily to dry eye disease patients for up to 3 years. Ophthalmology. Oct 2005;112(10):1790-4. [Medline].

  2. Fox RI, Chan R, Michelson JB. Beneficial effect of artificial tears made with autologous serum in patients with keratoconjunctivitis sicca. Arthritis Rheum. Apr 1984;27(4):459-61. [Medline].

  3. Fujita M, Igarashi T, Kurai T. Correlation between dry eye and rheumatoid arthritis activity. Am J Ophthalmol. Nov 2005;140(5):808-13. [Medline].

  4. Lamberts DW, Foster CS, Perry HD. Schirmer test after topical anesthesia and the tear meniscus height in normal eyes. Arch Ophthalmol. Jun 1979;97(6):1082-5. [Medline].

  5. Lee HK, Ryu IH, Seo KY. Topical 0.1% prednisolone lowers nerve growth factor expression in keratoconjunctivitis sicca patients. Ophthalmology. Feb 2006;113(2):198-205. [Medline].

  6. Mathers WD. Ocular evaporation in meibomian gland dysfunction and dry eye. Ophthalmology. Mar 1993;100(3):347-51. [Medline].

  7. Murillo-Lopez F, Pflugfelder SC, eds. Cornea and External Disease: Clinical Diagnosis and Management, Vol II. 1997;663-686.

  8. Nelson JD. Diagnosis of keratoconjunctivitis sicca. Int Ophthalmol Clin. Winter 1994;34(1):37-56. [Medline].

  9. Pflugfelder SC, et al. Correlation of goblet cell density and mucosal epithelial mucin (MEM) expression in patients with ocular irritation. Invest Ophthalmol Vis Sci. 1995;36:S399.

  10. Pflugfelder SC, Roussel TJ, Culbertson WW. Primary Sjogren''s syndrome after infectious mononucleosis. JAMA. Feb 27 1987;257(8):1049-50. [Medline].

  11. Stonecipher K, Perry HD, Gross RH. The impact of topical cyclosporine A emulsion 0.05% on the outcomes of patients with keratoconjunctivitis sicca. Curr Med Res Opin. Jul 2005;21(7):1057-63. [Medline].

  12. Tsubota K, Toda I, Yagi Y. Three different types of dry eye syndrome. Cornea. May 1994;13(3):202-9. [Medline].

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Further Reading

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Keywords

dry eye syndrome, sicca syndrome, keratitis sicca, KCS, xerophthalmia

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Contributor Information and Disclosures

Author

Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Stephen D Plager, MD, FACS, Chief, Department of Ophthalmology, Dominican Hospital; Assistant Clinical Professor, Department of Ophthalmology, Stanford University Hospital
Stephen D Plager, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and California Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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