Clinical Image: Sjögren’s Syndrome

A 55-year-old woman presented with chief complaints of foreign body sensation and dryness of eyes for 3-4 years, which worsened during nights. Past medical history suggested that she had vitiligo, dry mouth and rheumatoid arthritis for approximately XXX years. Schirmer’s test (Figure 2) showed wetting of less than 6 mm per 5 minutes, suggestive of severe dry eyes. Based on these findings and previous medical records, the diagnosis of Sjögren’s syndrome was made. Since there is no curative treatment for this condition, the patient was offered symptomatic treatment for dry eyes i.e. artificial tears for day time and lubricating eye ointment for night use. In addition, she was advised to wear goggles to retain and create moisture around the eyes. She follows up regularly and has reported some relief from symptoms. With the progression of the disease, her symptoms are likely to get worse and become unresponsive to current therapy, at which point she is expected to benefit from punctal plugs. Punctal plugs are small devices that are inserted into the upper or lower tear drainage canals to block these canals leading to preservation of tears and hence lubricating the eyes. This patient is also being followed by a rheumatologist for management of her extraocular symptoms. The management of Sjögren’s syndrome involves a multidisciplinary approach addressing all aspects of the disease. Management of extraocular symptoms may include prescription of NSAIDS,

immunosuppressive drugs including corticosteroids, disease-modifying antirheumatic drugs (DMARDs) and methotrexate.

Lozenges are given for xerostomia or dry mouth to stimulate salivary flow and moisturizing lotions are given for dry skin. Patients are also advised regular dental check-ups in order to avoid dental complications.

FIGURE 1: Sjögren’s syndrome. Clinical photograph of a 55-year-old woman with Sjögren’s syndrome, vitiligo and rheumatoid arthritis. Sjögren’s syndrome is a chronic autoimmune disorder, characterized by dysfunction and destruction of exocrine glands particularly the salivary and lacrimal glands, leading to dry eyes and mouth [1].

 FIGURE 2: Sjögren’s syndrome. Photograph demonstrating Schirmer’s test, which is used to detect deficient tear production in patients with dry eyes as in Sjögren’s syndrome. The filter paper strip is placed at the junction of eyelid margins and the extent of moisture is examined after 5 minutes; 15 mm paper should be moistened if tear production is normal. Patients with Sjögren’s syndrome have less moistening, as shown here.

1. Manousakis MN, Moutsopoulos HM. Sjögren’s syndrome: autoimmune epithelitis. Baillieres Best Pract Res Clin Rheumatol. 2000;14:73-95.