The patient’s uncorrected visual acuity was 20/25 OD and 20/30 -2 OS. External evaluation showed bilateral meibomian gland dysfunction (MGD) and a punctal plug OD (missing plug OS). Anterior segment evaluation showed conjunctival injection, conjunctivochalasis, and diffuse punctate epithelial keratopathy across the entire corneal surface of both eyes.
Tear osmolarity measured 333 mosm/L OD and 287 mosm/L OS. Testing for matrix metalloproteinase-9 found elevated levels. Tear film breakup time was 2-3 seconds, and Schirmer test results were 2mm OD, 3mm OS.
These results support a diagnosis of poorly controlled Sjögren’s syndrome-associated dry eye. Notably, the patient was not experiencing significant pain despite the advanced state of her disease.