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Dry Eye and Autoimmune Diseases

People who suffer from an autoimmune disorder are very likely to develop dry eye syndrome (DES) as well. In fact, this is so common that doctors will look out for it even when patients don’t have any symptoms yet. DES appears in 5% to 17% of the normal population, but it appears in 19% to 31% of the population with autoimmune disorders.

Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory condition that affects the joints, which often swell up. It can be highly disabling and can also cause permanent and irreversible damage to the joints. Around 1% of the population suffers from it, and it is twice as common in women as what it is in men. It is not known what causes this condition, although the environment and genes are most likely linked to it. In some cases, this disease starts to affect the salivary glands and the eyes as well, which leads to what is known as secondary Sjogren’s syndrome, or Sjogren’s syndrome caused by rheumatoid arthritis.

Patients with this condition find that they experience significant dryness in the eyes, mouth and vagina and these symptoms often get worse with age, and with taking certain types of medication. The more severe the arthritis, the worse the dryness seems to get. Around 25% of people with rheumatoid arthritis will develop some sort of eye problem, including:

  • Scleritis
  • Keraconjunctivitis sicca
  • Keratitis
  • Episcleritis
  • Ulceration of the peripheral cornea

More rarely, they may experience:

  • Retinal vasculitis
  • Choroiditis
  • Retinal detachment
  • Episcleral nodules
  • Macula edema

The most common eye condition is keratoconjunctivitis sicca, or dry eye syndrome, happening in between 15% and 25% of people with rheumatoid arthritis. It usually gets worse towards the end of the day, when the tear film starts to evaporate. Doctors can assess this condition by looking at the lacrimal glands through the phenol red threat test or the more invasive Schirmer test.

Scientists believe that people who experience DES as a result of rheumatoid arthritis do so because the ocular surface becomes inflamed, which leads to improper tear secretion. As a result, using anti-inflammatory drugs tend to be very effective. Corticosteroids have also been proven to be very effective, although they have to be used for a long period of time. Punctal plugs are also effective.

Sjogren’s Syndrome

Sjogren’s syndrome is an autoimmune condition that leaves people with a variety of tear deficiency problems. It is very common and chronic and affects the exocrine glands. There are two main types of Sjogren’s syndrome:

  1. Primary Sjogren’s syndrome, whereby this is the only autoimmune disorder people have.
  2. Secondary Sjogren’s syndrome, whereby the condition develops as a response to another autoimmune disorder.

The condition is chronic and can lead to irritation and damage of the eye, in turn causing dry eye syndrome. The most common symptoms of Sjogren’s syndrome affecting the eyes include:

  • Grittiness
  • Feeling like there is a foreign body in the eye
  • Photosensitivity (being sensitive to light)
  • Irritation
  • Thick secretions inside the corner of the eye

Sjogren’s syndrome is generally a manageable condition, while chronic. However, it can lead to complications, including eyelid infections, bacterial keratitis and corneal ulceration and scarring. This is most often caused by people rubbing their eyes.

Doctors can assess whether Sjogren’s syndrome is present through the Schirmer’s test, which measures production of tears. They can also complete the TBUT (tear break-up time) test, to see how stable the tear film is. Finally, they can use staining to see if there are erosions on the cornea.

Scientists now have a greater understanding of the role chronic inflammation plays in the development of DES (keratoconjunctivitis sicca). If there is a dysfunction in the lacrimal gland, the tear film becomes destabilized and this can lead to inflammation. People with an autoimmune disorder respond differently to inflammation and this often leads to a cascade reaction that affects the corneal. Whichever autoimmune disorder someone suffers from, it is vital that this is treated primarily, and that secondary treatment is provided for the dry eye syndrome.

Currently, studies are taking place into the effectiveness of the following types of medication to treat secondary DES in people with an autoimmune disorder:

  • Sodium hyaluronate, which could replace artificial tears. Preliminary tests have shown some improvement.
  • Diquafosol tetrasodium, which is a topical agent that helps to increase the production of tears.
  • Pilocarpine, which stimulates the exocrine glands. This has been shown to be particularly beneficial in people with primary or secondary Sjogren’s syndrome.
  • Cevimeline, which has shown some preliminary results of increasing the secretion of tears.

A number of other treatment options have been used in the past to treat secondary DES, with varying levels of success. These treatments include:

  • Anti-inflammatory drugs: NSAIDs, cyclosporine A and topical corticosteroids.
  • Surgery: Botulinum-toxin induced ptosis, tarsorrhaphy and punctal inclusions.
  • Anti-tumor necrosis factor agents, although further testing must be completed in this.

Rosacea

Rosacea is a skin disorder whereby people develop red rashes and bumps, generally on the central part of the face. Some 14 million people in this country have this condition, which generally starts between the age of 20 and 30. It visibly progresses over the next ten years, with full presentation between the ages of 40 and 50. The condition remains poorly understood, although we know it is a type of inflammation. It involves the body’s immune system, vascular disturbances, UV radiation, bacteria and other foreign bodies, infections, the environment and more. There are four different types of rosacea, which describe how the condition presents:

  1. Papulopustular-persisent, which means redness appears in the center of the face with transient pustules and papules.
  2. Erythematotelangiectaticfacial redness.
  3. Rhinophyma, which is a thickening of the facial skin.
  4. Rosacea on the eye.

The last type of rosacea is the one that most commonly leads to DES as well. Signs and symptoms of this type include:

  • Burning
  • Feeling like there is a foreign body in the eye
  • Tearing
  • Irritation
  • Blurred vision
  • Photophobia
  • Red eyes

Most patients with this type of rosacea will eventually develop blepharitis, which is an infection that affects the Meibomian glands, which secrete the oily part of the tear film. If chronic, it can lead to scars of the lid margin.

Secondary DES in rosacea is usually treated with:

  • Oxytetracycline
  • Antibiotics
  • Topical steroids
  • Topical tacrolimus
  • Restasis (cyclosporine)
  • Lid scrubs and warm compresses, although patients are warned that this can make inflammation worse, particularly if they do not take steroid medication.

Systemic Lupus Erythematosus

Lupus is a chronic autoimmune disorder that affects multiple parts of the body. It is not known what causes it. The condition leaves autoantibodies in any part of the body. One third of people with lupus also develop problems with their eyes. There are 11 different features associated with lupus according to the American College of Rheumatology, and someone can be diagnosed with lupus if they meet at least four of those features.

Lupus often goes into remission, but then comes back. Often, each flare-up is worse than the previous one. Unfortunately, it is possible for people with lupus to go fully blind, particularly if the immune complex disposition starts to affect the blood vessels of the cornea, ciliary body, sclera, choroid, retina or conjunctiva.

The mechanisms of DES with lupus are very similar to those found with Sjogren’s syndrome, meaning the tear production is inadequate. Around 20% of patients with lupus have secondary Sjogren’s syndrome as well. Symptoms can range from some mild redness and irritation to full blindness and severe pain.

Treatment of DES with lupus is limited and includes:

  • Artificial tears
  • Anti-inflammatory drugs

Other Autoimmune Disorders

Almost any autoimmune disorder has the potential to affect the eyes and thereby cause keratoconjunctivitis sicca. The table below highlights some of the other disorders and how these affect the eyes.

Autoimmune disorder Effect on Dry Eye Syndrome
Behcet disease This is a very rare condition, but it is the developing world’s leading cause of blindness. It also affects the mouth and genitals.
Multiple sclerosis Almost everybody with multiple sclerosis notices effects on the eye. In fact, this link is so strong that it is often when people present with eye problems that the condition is diagnosed. DES in multiple sclerosis patients is usually caused by inflammation of the optic nerve, which can also cause full, permanent or temporary blindness.
Psoriasis This is a chronic skin condition that can also affect the conjunctiva, leading to redness and pain.
Reiter’s syndrome This is a type of reactive arthritis that can cause inflammation to the eye’s frontal parts.
Thyroid diseases Various thyroid diseases affect the eyes, mainly because they increase the chance of developing glaucoma. Hyperthyroidism, including Graves’ disease, most commonly affects the eye, causing pressure.
Type 1 diabetes In this country, one of the leading causes of blindness is type 1 diabetes. This is because the blood vessels found at the back of the eye become damaged due to poor sugar control.
Crohn’s disease or ulcerative colitis Around 5% of people with this condition develop DES, although it is not known why.
Uveitis An autoimmune condition that effects the colored part of the iris, leading to redness, floaters and blurred vision. Uveitis, like Sjogren’s syndrome, can be primary or secondary.

Resources and References:

Sjogren’s Syndrome – Information on Sjogren’s syndrome. (MedicineNet)

Ocular Manifestations of Autoimmune Disease – Autoimmune disease effects on the eyes. (American Family Physician)