THE MERCK MANUAL, Sec. 8, Ch. 96, Corneal Disorders

[Guest guest]

I personally have not only PBC, but Raynauds and Sjogren's. I use eye drops...GenTeal is one of several good ones. For the dry mouth I use the Biotene products....all help tremendously. You can have plugs inserted in a tear duct in each eye or do as I did..just stopped wearing my contacts and got new glass's. Talk to your doctor...for more info. You do not want the dry eyes to go untreated!!! Joanne C. (PBC) Owner and Moderator http://www.merck.com/pubs/mmanual/section8/chapter96/96e.htm

This Publication Is Searchable

Keratoconjunctivitis Sicca(Keratitis Sicca)

A chronic, bilateral desiccation of the conjunctiva and cornea due to inadequate tear volume (aqueous tear-deficient keratoconjunctivitis sicca) or to excessive loss of tears due to accelerated evaporation because of poor tear quality (evaporative keratoconjunctivitis sicca).

Symptoms and Signs

Patients complain of itching, burning, photophobia, gritty sensation, pulling sensation, pressure behind the eye, or a foreign body sensation. Some patients note a flood of tears after severe irritation. Symptoms are aggravated by prolonged visual efforts, such as reading, working on the computer, driving, or watching television. Particular local environments can also aggravate symptoms, such as dusty or smoky areas and dry environments, eg, in airplanes, in malls, on days with low humidity, and in areas where air conditioners (especially in the car), fans, or heaters are being used. Certain systemic drugs can aggravate symptoms, including isotretinoin, tranquilizers, diuretics, antihypertensives, oral contraceptives, and all anticholinergics (including antihistamines and many GI medications). Symptoms improve during cool, rainy, or foggy days or in other high-humidity environments, such as in the shower. Although keratoconjunctivitis sicca rarely decreases vision, patients sometimes complain that their eyes are so irritated that it is difficult to use them.

Diagnosis

With both forms of keratoconjunctivitis sicca, the conjunctiva is hyperemic and there is often scattered, fine, punctate loss of the corneal (superficial punctate keratitis) and/or conjunctival epithelium. The involved areas are mainly between the eyelids (the intrapalpebral or exposure zone), and these areas will stain with fluorescein. Patients often blink at an accelerated rate; however, in rare instances it is the reduced rate of blinking that is responsible for the drying.

With aqueous tear-deficient keratoconjunctivitis sicca, the conjunctiva can appear dry and lusterless with redundant folds. This form of keratoconjunctivitis sicca is most commonly an isolated idiopathic condition and is more prevalent in postmenopausal women. Less commonly, it may be secondary to other conditions that cause scarring of the lacrimal ducts, eg, cicatricial pemphigoid; to s- syndrome or trachoma; or as a result of a damaged or malfunctioning lacrimal gland, eg, graft-versus-host disease, after local radiation therapy, or familial dysautonomia.

A Schirmer test is performed by using standardized strips of filter paper placed, without topical anesthesia, at the junction between the middle and lateral third of the lower lid. Five millimeters or less of wetting of the paper after 5 min on two successive occasions confirms the diagnosis of aqueous tear-deficient dry eye. Rarely, severe, advanced, chronic drying may lead to keratinization of the ocular surface or loss of the corneal epithelium resulting in scarring, vascularization, infections, ulceration, and possibly perforation. In these severe cases, significant visual loss usually occurs.

With evaporative keratoconjunctivitis sicca, abundant tears may be present as well as foam at the eyelid margin. Frequently, there is associated blepharitis and acne rosacea (see Ch. 116). Very rarely, with this form of dry eyes, there will be sufficient desiccation to result in loss of the corneal epithelium or decreased vision. Results of the Schirmer test are usually normal. Instillation of a small volume of highly concentrated fluorescein can make the tear film visible, revealing an accelerated rate of loss of an intact tear film (tear breakup test).

Patients with Sjögren's syndrome (see Ch. 50) have aqueous tear-deficient keratoconjunctivitis sicca and a dry mouth. This syndrome may occur as an isolated phenomenon (primary Sjögren's syndrome) or in association with systemic connective tissue diseases such as RA or SLE (secondary Sjögren's syndrome). Serology and labial salivary gland biopsy are used to make the diagnosis. Patients with both primary and secondary Sjögren's syndrome develop non-Hodgkin's lymphoma at 40 times the normal rate and require careful follow-up by their physicians.

Treatment

Frequent use of artificial tears can be effective for both forms of keratoconjunctivitis sicca. More viscous artificial tears coat the ocular surface longer and are particularly useful in evaporative keratoconjunctivitis sicca. Artificial tear ointments applied before sleep are particularly useful when patients have nocturnal lagophthalmos and/or have irritation on waking in the morning. Most cases are treated adequately throughout the patient's life with such supplementation. Avoiding dry, drafty environments and using humidifiers can often help. In recalcitrant cases, occlusion of the nasolacrimal punctum may be indicated. In severe cases, a partial tarsorrhaphy can reduce loss of tears through evaporation.

Patients with evaporative keratoconjunctivitis sicca often benefit from treatment of the concomitant blepharitis, which includes warm compresses, eyelid margin scrubs, or oral tetracyclines (see Ch. 94).