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Dry eye treatment can help ophthalmologists reintegrate with medical colleagues
A new test helps to earlier identify patients with Sjögren’s syndrome, which allows quicker referrals for systemic or localized care.
Happy New Year to all of my colleagues in eye care. My new year’s gift, courtesy of the editors of Ocular Surgery News and Healio.com/Ophthalmology, is a monthly column dedicated to issues that involve dry eye and ocular surface disease care. Because I have been blogging on the same topic for a few months, they certainly have some idea of what they are getting into. Thanks to all for the opportunity to interact with other eye care professionals around a topic about which I am quite passionate.
I think a worthy topic to launch this column involves interacting with our colleagues, but not necessarily colleagues who share our specialty. If you are like me, you have probably noticed a steady decline in the frequency with which you discuss mutual patients with colleagues on the medical side of the aisle. In many ways, for reasons good and bad, much of ophthalmology has grown increasingly isolated from the broader world of medicine. As a specialty surgeon working predominantly in an outpatient setting, the common places where we once mingled with our medical colleagues have become almost like exotic vacation destinations. Think about it: When is the last time you had lunch in the doctors’ lounge at your primary hospital? I used to eat there twice a week, every week, when I was a much younger doc, but it is becoming increasingly hard for me to put a face with the name of a primary care doc on my patient’s EMR page.
With the many changes occurring in medicine, now might be a good time to re-engage with a broader collection of physicians in our community. What comes up in everyday clinic life for us can, in some cases, be vitally important to the overall health of our patients. While it is more than a bit of a cliché, the eye is not only the window to the soul, but also quite often a window into some aspect of a patient’s health not directly related to the eye itself. In this way, ophthalmologists can help other physicians to see what we see as they assess broader systemic health. The treatment of dry eye is a quintessential example.
Darrell E. White
Sjögren’s syndrome
An excellent opportunity to do this is with Sjögren’s syndrome, a serious systemic autoimmune disease that we can look for in our dry eye patient population. Historically, Sjögren’s syndrome has been classified into two types. Primary Sjögren’s syndrome consists of aqueous-deficient dry eye syndrome in combination with symptoms of dry mouth, caused by reduced salivary secretions and confirmed with a positive focus score on a minor salivary gland biopsy and biomarkers in the blood. Secondary Sjögren’s syndrome occurs in patients who have another autoimmune disease, such as lupus or rheumatoid arthritis. It exhibits the features of primary Sjögren’s syndrome in combination with an overt autoimmune connective tissue disease, most commonly rheumatoid arthritis.
There are an estimated 4 million Sjögren’s syndrome patients in the United States, making it one of the most common autoimmune diseases. However, only 1 million have been definitively diagnosed. The typical route to a diagnosis does not presently involve an ophthalmologist in the majority of cases, and mean time to diagnosis is 4.7 years. This delay has very real consequences. The most dramatic of these is that patients with Sjögren’s syndrome have a much higher incidence of lymphoma than other age-matched patients; identifying them can put their primary care doctor on alert for this risk. In our dry eye universe, the consequences are not life-threatening, but they can certainly be life-altering. Once the salivary and lacrimal glands have sustained significant damage from the autoimmune attack, they will no longer respond to treatment, either systemic or topical, leaving the patient with symptoms that can become unbearable.
Here is where we come in. Dry eye is present in up to 93% of Sjögren’s syndrome patients. Early Sjögren’s syndrome patients can present like all of our other dry eye patients, often with relatively mild symptoms, with both evaporative (dysfunctional tear syndrome) and aqueous deficient components. At this point, traditional screening methods will probably fail to identify these patients as having Sjögren’s syndrome, contributing to the delay in diagnosis. Recently, a new point of service test for the identification of Sjögren’s syndrome patients has come to the market. This panel test, aptly named Sjö (Nicox), incorporates a proprietary panel of biomarkers designed to make the diagnosis earlier than the current standard.
The American College of Rheumatology currently advises blood testing for Sjögren’s syndrome that includes Sjögren-specific antibodies A and B, as well as rheumatoid factor and antinuclear antibody. Sjö not only identifies these biomarkers but also three new antibodies: salivary gland protein-1, carbonic anhydrases-6 and parotid secretory protein. Together these three newer biomarkers have been shown in research studies to achieve both sensitivity and specificity greater than 90%, leading to a diagnosis rate of 50% for early and new cases.
A simple test
The test itself is simple and easy for both patients and staff members. Dry eye patients suspected of having Sjögren’s syndrome have a blood sample taken using an Accu-Chek lancet. With the help of a technician, they then touch designated circles on the collection card. The card and accompanying paperwork are sent via a pre-addressed FedEx Clinical Pak to Immco Diagnostics, the developer of the technology. The results, along with specific instructions regarding follow-up and referrals, are then sent back to the office.
Having the ability to quickly and easily test my dry eye patients for Sjögren’s syndrome has significantly affected my ability to act as the front line of defense against this systemic disease. Identifying Sjögren’s patients earlier in their disease progression gives me the ability to alter my treatment paradigm accordingly, as well as refer them through the proper channels — to a rheumatologist for systemic care, or perhaps another specialist for localized care — allowing them to get an important head start on facing the disease. Remember that once the salivary and lacrimal glands are destroyed by Sjögren’s, all of our standard treatments are dramatically less effective. By looking for and finding early autoimmune patients in our dry eye population, ophthalmologists can take tangible steps to improve their patients’ overall health before it is too late to make a significant difference.
Here is a chance for us to be proactive, to reach across the aisle, so to speak, on behalf of our dry eye patients while at the same time reintegrating ourselves more tightly into the wider medical community. To be sure, the majority of our work will continue to be best described as peripheral to most general medical care, and that is OK. This is one instance in which we can step away for a moment from our “oculo-centric view” and return to our roots as physicians by participating in the identification and treatment of a rather common autoimmune disease, Sjögren’s syndrome.