Examination «

Examination

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.

What do you think might explain the absence of significant burning and foreign body sensation, which are common complaints in patients with the Sjögren’s syndrome-associated severe dry eye?

○	a. MGD I did not consider this a likely explanation. MGD is frequently found in patients with Sjögren’s syndrome, contributing to dry eye symptoms and ocular surface changes through excessive evaporation and tear film instability.¹ MGD would likely increase rather than ameliorate symptoms. Please select again. Shimazaki J, Goto E, Ono M, et al. Meibomian gland dysfunction in patients with Sjögren syndrome. Ophthalmology. 1998;105(8):1485-8.
○	b. Punctate epithelial keratopathy Punctate epithelial keratopathy is a common form of ocular surface damage often seen in cases of tear hyperosmolarity and ocular surface inflammation. That said, I do not think epitheliopathy explains the absence of pain symptoms. Please select again.
○	c. Corneal hypoesthesia Yes. Corneal hypoesthesia—reduced corneal sensation—has been observed in patients with chronic dry eye.¹ Those with Sjögren’s syndrome may exhibit corneal hypoesthesia to even a greater extent due to more severe corneal nerve damage.² Indeed, Sjögren’s syndrome patients with extensive corneal staining usually have fewer dry eye symptoms than those with less corneal stain, and this discrepancy between objective signs and subjective symptoms has been attributed to the loss of corneal sensation.^2,3 In this patient’s case, the neurotrophic state of the cornea probably explains why dry eye manifested itself largely through vision disturbances rather than through significant symptoms of discomfort. Bourcier T, Acosta MC, Borderie V, et al. Decreased corneal sensitivity in patients with dry eye. Invest Ophthalmol Vis Sci. 2005;46(7):2341-5. Han SB, Hyon JY, Wee WR, et al. Reduced corneal sensitivity in patients with primary Sjögren's syndrome. Acta Ophthalmol. 2010;88(7):277-8. Adatia FA, Michaeli-Cohen A, Naor J, Caffery B, et al. Correlation between corneal sensitivity, subjective dry eye symptoms and corneal staining in Sjögren's syndrome. Can J Ophthalmol. 2004;39(7):767-71.
○	d. Conjunctivochalasis This is an unlikely the explanation. The presence of conjunctivochalasis can contribute to pathogenesis of dry eye and exacerbate dry eye symptoms.¹ Please select again. Di Pascuale MA, Espana EM, Kawakita T, et al. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. Br J Ophthalmol. 2004;88(3):388-92.

Douglas K. Devries, OD, is a co-founder and managing partner of Eye Care Associates of Nevada and serves as both clinical director and optometric residency program director for the state-wide practice. He is an adjunct clinical professor of optometry at Pacific University and serves on the advisory board or speakers' bureau of Abbott Medical Optics, Alcon, Allergan, Akorn, Bio Tissue, BVI Medical, Bausch + Lomb, TearLab, NiCox, OcuSoft, and Ophthalmic Resources.

Shire Test Prep

Examination

What do you think might explain the absence of significant burning and foreign body sensation, which are common complaints in patients with the Sjögren’s syndrome-associated severe dry eye?

Eye Care Professionals Only