Are dry eye and mouth the key?
If a patient presents with xerophthalmia (dry eye) and xerostomia (dry mouth), does that equal a diagnosis of Sjögren’s syndrome? Here’s the thing: Even though we learned in optometry school that those two complaints together often equate to Sjögren’s syndrome, it’s important to remember that “often” is not the same as “always.”
Here I provide the reasons, along with related action steps.
Unfortunately, the autoimmune disease mimics other conditions, such as allergies, chronic fatigue syndrome, fibromyalgia, lupus, menopause, medication side effects, multiple sclerosis and rheumatoid arthritis.
Action step: Optometrists should review the patient’s medical history and ask questions about her current health to gauge whether one of these conditions could be a possibility. If answers indicate this, O.D.s should refer these patients to their primary care physicians for further assessment.
DED symptom surveys can be incredibly useful in this patient base. As a whole, patients with severe DED have the most difficult time distinguishing between small levels of improvement. Surveys can highlight small victories and work to instill patient compliance to the O.D.’s recommended treatment regimen.
These patients also require additional point-of-care testing, such as Schirmer’s or phenol red thread testing, to measure the aqueous volume of the tears. Additionally, utilization of osmolarity testing and instillation of dyes, such as fluorescein and lissamine green, can be essential in identifying areas of ocular surface defect.
A NARROW FOCUS
As is the case with other health care specialists who lock in on their area of the body, optometrists can tend to focus on dry eye disease (DED) as the primary manifestation of Sjögren’s syndrome. Although the most common symptoms of the condition are dry eye and dry mouth, Sjögren’s syndrome patients may experience symptoms of burning or dry throat, changes in smell and taste, crippling fatigue, a cracked or sore tongue, dental decay, digestive issues, a dry nose, dry or peeling lips, joint pain, skin dryness in other areas of the body and trouble chewing, swallowing or talking, according to the Sjögren’s Syndrome Foundation. Additionally, symptoms can vary from patient to patient.
Action step: O.D.s should make a point of asking patients whether they experience any of these other symptoms.
Medications, such as anti-allergy drugs, can have a drying effect on both the eye and mouth. Additionally, polypharmacy (taking five or more medications daily) increases the oral drying effect. Thus, a patient’s dry eye and dry mouth complaint could be due to medication use rather than rooted in this autoimmune disease.
Action step: Optometrists should review the patient’s medications, if any, to see whether medication use may be causing the problem.
If patients remain suspicious for Sjögren’s syndrome, O.D.s should perform in-office blood work, such as the Sjö Test (Bausch + Lomb) (if the state’s scope-of-practice law enables the O.D. to do so) and/or refer the patient to a rheumatologist, who can order blood work and a lip biopsy, the latter of which is viewed as the “gold standard” for a definitive diagnosis. OM