Barbara Caffery

Whole stimulated salivary flow: Correlation with the pathology of inflammation and damage in minor salivary gland biopsy specimens from patients with primary Sjögren's syndrome but not patients with sicca

OBJECTIVE To determine which measure of the salivary flow rate, stimulated or unstimulated, is most strongly associated with pathologic changes in minor salivary gland (MSG) biopsy specimens, and to explore the correlation of salivary flow with oral surface damage, disease duration, and symptom severity in patients with primary Sjögrens syndrome (SS). METHODS In all patients (n = 32), a biopsy of the MSG was performed, and stimulated salivary flow was assessed. Beginning in 2002, unstimulated salivary flow was also assessed. Scores for the severity of symptoms, according to the decayed/missing/filled teeth (DMF) index, were recorded. Associations between measures of salivary flow and covariates characterizing pathology were examined. RESULTS A definite association between stimulated salivary flow and the MSG focus score, the grade of MSG fibrosis, the duration of dry mouth symptoms, and the DMF score was observed. In contrast, unstimulated salivary flow was not associated with fibrosis, atrophy, the DMF score, or the duration of dry mouth symptoms. In patients with primary SS, the DMF score was associated with pathologic changes in the MSG. Among patients with sicca, 57.9% had an abnormal unstimulated salivary flow rate (versus 82.4% of patients with primary SS), and 15.2% had an abnormal stimulated salivary flow rate (versus 61.8% of patients with primary SS). Among patients with sicca, neither stimulated salivary flow nor unstimulated salivary flow was associated with the degree of fibrosis or atrophy or with the DMF score. CONCLUSION Compared with unstimulated salivary flow, stimulated salivary flow appeared to be a better measure of inflammation (according to the focus score) and fibrosis. In patients with sicca, the unstimulated salivary flow rate appeared to be abnormal more commonly compared with the stimulated salivary flow rate. In the future, stimulated salivary flow may serve as a noninvasive surrogate biomarker of inflammation and fibrosis as well as a measure of response to treatment in patients with primary SS.

Rose Bengal Staining of the Temporal Conjunctiva Differentiates Sjögren's Syndrome from Keratoconjunctivitis Sicca

PURPOSE To compare the clinical presentation of 231 patients with primary Sjögrens syndrome (pSS) with 89 patients with aqueous-deficient dry eye (keratoconjunctivitis sicca; KCS), to determine those procedures that best differentiate these groups in the eye care clinic. METHODS The records of all patients seen at the University Health Network Sjögrens Syndrome Clinic from October 1992 to July 2006 were reviewed and documented. The diagnosis of pSS was based on the AECC (American European Consensus Criteria) of 2002. KCS control subjects were non-SS patients with symptoms of dry eye and Schirmer scores of <or=10 mm in 5 minutes in at least one eye. There were 90 variables used in the analysis of the total database. Recursive partitioning was used to generate tree diagrams that demonstrated which characteristics best distinguished pSS from KCS. RESULTS Recursive partitioning of the full database demonstrated that the serum immunoglobulin Ro and the status of the salivary gland biopsy were most important in distinguishing pSS and KCS. The presence of rose bengal staining of the temporal conjunctiva was the most important noninvasive ocular variable that separated the groups. Total rose bengal staining also improved sensitivity. When only noninvasive techniques were used, staining of the temporal conjunctiva and severity of dry mouth symptoms were the major factors in distinguishing pSS from KCS. CONCLUSIONS Rose bengal staining of the ocular surface is an important observation in the detection of SS and the differentiation of pSS and KCS.

Factor analysis of the clinical characteristics of primary Sjogren syndrome.

Purpose. The purpose of this study was to use factor analysis to analyze 90 clinical characteristics of a cohort of 231 patients with primary Sjogren syndrome (pSS). Methods. The records of all patients seen at the University Health Network Sjogren Syndrome Clinic from October 1992 to July 2006 were reviewed and documented. Those diagnosed as pSS by the American European Consensus Criteria of 2002 were included. The 90 clinical variables, including health history, blood analysis, symptoms of dry eye and dry mouth, salivary flow and biopsy, tear flow and staining, were analyzed by factor analysis. Results. Two hundred thirty-one patients with pSS charts were reviewed, and 90 variables were recorded. Factor analysis resulted in three factors: factor 1: ocular surface staining, factor 2: antimicrosomal antibodies and antithyroid antibodies, and factor 3: serum anti-Ro and anti-La. Conclusions. Ocular surface staining accounted for the greatest variance in this population of patients with pSS.

Correlation of tear osmolarity and dry eye symptoms in convention attendees.

Purpose To assess the correlation between tear osmolarity readings and symptoms of dry eye in a nonclinical convenience sample and to determine how well symptoms and osmolarity correlate with the self-assessment of dry eye. Methods Two hundred forty-nine attendees in the exhibit hall at an optometric educational meeting agreed to participate in a dry eye study. Contact lens wearers were excluded. Volunteers supplied demographic information and completed a 5-item Dry Eye Questionnaire (DEQ-5) and answered the question “Do you think you have dry eye” with a yes or no response. Osmolarity testing was done using the TearLab instrument on the right eye, then on the left eye. Pearson correlation analyses were performed to determine the relationship between variables. Results There was no correlation between DEQ-5 scores and average tear osmolarity (correlation coefficient, 0.02) and highest osmolarity (correlation coefficient, 0.03). The mean DEQ-5 score was significantly higher among subjects who self-reported dry eye (mean, 11.3; p < 0.0001) compared with those who did not (mean, 5.4; p < 0.0001). No differences were observed between the yes and no self-reported dry eye groups and average osmolarity (p = 0.23) and highest osmolarity (p = 0.14). Conclusions In this nonclinical population, there was no significant correlation between tear osmolarity and ocular symptoms as reported or between tear osmolarity and the self-assessment of dry eye.

Effect of Lid Debridement-Scaling in Sjögren Syndrome Dry Eye.

Purpose To evaluate the effect of lid debridement-scaling (LDS) on dry eye signs and symptoms in subjects with Sjögren syndrome (SS). Methods This prospective randomized controlled study enrolled 14 female subjects with SS. Seven subjects were randomized into the treatment group where they were selected to receive LDS; the remainder did not receive LDS and served as control subjects. Lid debridement-scaling was conducted using a stainless steel golf club spud (Hilco Wilson Ophthalmics, Plainville, MA) on both the upper and lower eyelids of both eyes. Outcome variables were assessed before LDS and again 1 month later. The outcome variables were the Ocular Surface Disease Index (OSDI), Symptom Assessment iN Dry Eye (SANDE) visual analog scores, ocular staining (SICCA OSS [Sjögren’s International Collaborative Clinical Alliance Ocular Staining Score]), fluorescein tear breakup time (FLBUT), meibomian gland score (MGS), meibomian gland yielding liquid secretions (MGYLS) score, and line of Marx’s (LOM) position. Results Thirteen subjects completed the study. Data from only the right eye were analyzed. For the control group (n = 6; mean [±SD] age, 62.3 [±11.6] years), the pre-LDS, post-LDS, and significance level (pre-LDS mean [±SD] vs. post-LDS mean [±SD]; p value) were as follows: OSDI (58.3 [±22.1] vs. 48.3 [±29.0]; p = 0.051), SANDE (77.4 [±22.1] vs. 89.6 [±32.6]; p = 0.20), SICCA OSS (7.0 [±4.5] vs. 8.2 [±3.5]; p = 0.25), MGS (1.3 [±1.5] vs. 1.0 [±0.9]; p = 0.75), MGYLS (0.3 [±0.5] vs. 0.0 [±0.0]; p = 0.50), FLBUT (2.99 [±1.54] vs. 2.85 [±1.79]; p = 0.63), and LOM (2.0 [±0.0] vs. 2.0 [±0.0]; p = n/a). For the treatment group (n = 7; mean [±SD] age, 58.0 [±8.1] years), the pre-LDS, post-LDS, and significance level were as follows: OSDI (63.2 [±13.3] vs. 46.9 [±19.4]; p = 0.04), SANDE (72.6 [±17.1] vs. 77.0 [±28.0]; p = 0.54), SICCA OSS (6.6 [±2.9] vs. 5.0 [±3.9]; p = 0.02), MGS (1.0 [±1.2] vs. 3.1 [±1.7]; p = 0.01), MGYLS (0.0 [±0.0] vs. 0.6 [±1.0]; p = 0.50), FLBUT (3.13 [±0.81] vs. 3.45 [±1.03]; p = 0.53), and LOM (0.9 [±0.9] vs. 1.0 [±1.0]; p = 1.00). Conclusions This pilot study showed that LDS improved symptoms, ocular staining, and meibomian gland function for the group that received LDS. This indicates that LDS can aid in the management of SS dry eye.

Customary practices in the monitoring of dry eye disease in Sjogren's syndrome

Purpose Diagnostic testing for dry eye disease (DED) in Sjogrens syndrome (SS) is well described. Little is published about monitoring this systemic autoimmune DED. We analyzed the SS related DED tests used in North American optometric practices and compared academic settings to private practice settings. Methods A retrospective chart review of 123 SS charts from 6 optometric practices in North America was conducted. Testing done during the first examination following a SS diagnosis was recorded on Research Electronic Data Capture (REDCap) database. The complete data file was reviewed and testing type and methodology were compared. Results Symptoms of DED (98.4% of charts),meibomian gland dysfunction (76.4% of charts), corneal staining with fluorescein (75.6% of charts) and anterior blepharitis (73.2% of charts) were the most frequently recorded variables. Clinicians used different methodologies to measure and grade these variables. Private practitioners were more likely to use symptom questionnaires and grading scales and to describe anterior blepharitis. Academic settings were more likely to record TBUT and tear meniscus height. Conclusions The monitoring of DED in SS is not uniform in optometric offices across North America. Creating accepted standards of testing will improve the ability of clinicians and researchers to communicate and understand the course of DED in SS.

Sjogren’s syndrome in optometric practices in North America

PURPOSE To describe the presentation of dry eye in Sjogrens syndrome (SS) in optometric practices, to report on the methodology used in dry eye monitoring and to explore the level of corneal staining versus age and time of disease. METHODS Records of SS patients were reviewed in 6 optometric sites. A standardized abstraction tool was developed to collect data from the records including: health history, medications and symptoms and signs of dry eye. The methods of testing symptoms and signs of dry eye were recorded. Variables were recorded at each site and collated at the University of Waterloo. The first visit after January 1, 2000 was selected for description in this paper. RESULTS 123 charts were included. The average time since diagnosis was 7.2 years ±5.1 years. Symptoms of dryness were present in 110/123 = 89.4% of charts. Corneal fluorescein staining was present in 96/123 = 78% of charts. MGD was present in 52% of charts. There were significant differences in the protocols and grading systems used in these 6 sites. Corneal staining levels did not change with greater age or length of disease. CONCLUSION These 123 SS patients presented with a large variation in their symptoms and signs. Symptoms of dryness and corneal fluorescein staining were the most commonly recorded presentations. There was a great deal of inconsistency in dry eye protocols among offices. Future prospective research with standardized testing will contribute to our understanding of the best dry eye protocols for SS patients.