Sjogren’s Syndrome: Not a Candidate, not Anymore!
With the completion of Sjögren’s Awareness Month, I recently spoke at a focus group meeting at the American Academy conference on treating these patient’s dry eyes and in many cases offering them the possibility to safely and effectively become candidates for vision corrective surgery to see without glasses and contact lenses
Sjögren’s (“SHOW-grins”) is a systemic autoimmune disease that affects the entire body. Along with symptoms of extensive dryness of the eyes, other associated symptoms could include fatigue, chronic pain, major organ involvement, neuropathies and lymphomas.
It is estimated that around 4 million Americans are living with this disease and nine out of ten patients are women with an average age of onset in the late 40’s. However, Sjögren’s can occur in all age groups, even in children.
Most of these patients present to eye doctors with symptoms of dryness and also in many cases being turned away by Lasik centers as “Not a Candidate” for Vision without glasses
With new generation treatment and diagnostic modalities for Dry eyes including for cases like Sjogren’s, this indeed can become a possibility.
I like to approach such patients as previously described in my article on Dry eyes to first determine the exact nature of dry eyes and delineate the cause among 4 basic variants right from aqueous deficient to combination pathologies
Once the diagnosis is determined, then attack the dry eyes with that effective treatment regimen directed to not only that cause but also to improve the overall tear film layer and ocular surface
Our tear film is actually about 7microns thick and is made up of three layers:
The Innermost, Mucin Layer (produced by the Conjunctival Goblet cells on the surface of the eye) and this layer makes the tear film “Stick” to the eyeball.
The Middle, Aqueous Layer (produced by the Lacrimal glands which are located on the upper and outer side of your eye socket). This is the real Tear Film if you may and contains all of the chemicals and nutrients that are needed for the ocular health and safety.
The Outermost, Lipid layer (produced by the Meibomian glands which are arranged along the eyelid margins vertically in rows like “Tooth Paste Tubes” with their “Mouths” opening at the lid margin close to the eye lashes). This layer actually provides surface tension to the tear film and hence maintains its vertical distribution on the eye despite gravity and also decreases evaporation of your tear film.
Despite a detailed analytical system for dry eye diagnosis and management (Gulani Matrix), essentially Dry eyes can be broken down into two basic kinds (and ofcourse various permutations and combinations):
I. Quantitative (Decreased Quantity)
1. Decreased production
2. Increased Loss
II. Qualitative (Decreased quality / altered chemical content of either one or all three layers despite good quantity)
I like to breakdown the treatment protocol into 3 levels:
1. Local
a. Medical (Specific Artificial tears/ medicated eye drops)
b. Procedures (Lacrimal Plugs/ Meibomian Gland probing/LipiFlow)
2. Systemic (oral medications/diet/environment modification)
3. Accessories (Moisture chamber goggles/sleep masks)
In cases like Sjogren’s, one can work in tandem with the patient’s rheumatologist and internist to also achieve systemic stability
Once the above is achieved then the ART of Vision corrective surgery can be applied not only as surface Laser techniques like SMILE or Laser ASA over LASIK but also in many cases the ocular surface could be avoided completely by correcting the patient’s spectacle prescription surgically from inside the eye.
My approach in designing their vision looks at their age and ocular status so for young patients (not cataract age yet), one can offer Refractive Lens exchange surgery (Exchanging patient’s natural lens for an artificial lens implant)
Or
with ICL technology (a miniature contact lens is placed in the eye)
If patient is in the cataract age group then use cataract surgery as an avenue to correct vision without glasses using new generation lens implants like Multifocal/Progressive/Accommodative lenses
Even such patients with Keratoconus and High Astigmatism can undergo INTACS (microsegments in the cornea) surgery
If we think about it, there can be nothing more uncomfortable for Sjogren’s patients than having to wear contact lenses especially if they have high refractive errors (glasses prescriptions) where glasses are not as helpful.
In many such cases, we can now offer them modalities for vision corrective surgeries to lead a life of visual freedom.