Dry eye disease (keratoconjunctivitis sicca)
Dry eye disease (keratoconjunctivitis sicca) is a multifactorial inflammatory disorder of the ocular surface caused by deficient or unstable tear film, presenting with bilateral burning, grittiness, redness, paradoxical tearing, and fluctuating vision. Diagnosis is clinical, supported by a Schirmer test under 5 mm in 5 minutes or ocular surface staining, with a search for Sjogren syndrome, medications, and eyelid disease; treatment escalates from trigger avoidance and artificial tears to lid hygiene, topical cyclosporine, and punctal plugs.
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What this article covers
- Overview
Dry eye (keratoconjunctivitis sicca) is a multifactorial inflammatory disorder caused by abnormal lubrication of the eye, in which a deficient or unstable tear film injures the cornea and conjunctiva.
- Epidemiology
Increases with age: lacrimal gland function and corneal sensitivity decline in older adults, producing dry eye and susceptibility to abrasion.
- Risk factors
Sjogren syndrome, primary or secondary to rheumatoid arthritis, systemic lupus erythematosus, or mixed connective tissue disease.
- Pathophysiology
Aqueous deficiency: immune destruction or infiltration of the lacrimal gland (Sjogren syndrome, sarcoidosis, IgG4-related disease), aging, or loss of the lacrimal branch of the facial nerve reduces tear volume.
- Clinical features
Hallmark: bilateral chronic ocular irritation with a gritty, sandy, or foreign body sensation and burning.
- Differential diagnosis
Microbial keratitis: an ocular emergency with decreased vision, severe pain, photophobia, and circumferential redness, often in contact lens wearers; dry eye itself predisposes to it (see bacterial keratitis).
- Diagnosis
Dry eye is a clinical diagnosis confirmed by objective tear testing: compatible bilateral symptoms plus a Schirmer test showing less than 5 mm of wetting in 5 minutes, or ocular surface staining with…
- Management
First, remove triggers in every patient: stop or substitute an offending medication when possible, reduce screen time, raise ambient humidity, increase fluid intake, avoid wind and air conditioning drafts, and wear protective eyewear.
- Complications
Corneal ulceration and microbial keratitis: loss of the protective tear film allows epithelial breakdown and bacterial invasion, threatening vision.
- Prognosis
Dry eye in Sjogren syndrome is progressive and needs ongoing lubrication and anti-inflammatory treatment.
- Prevention
Use preservative-free tears whenever drops are needed more than 4 times daily to avoid preservative toxicity to the ocular surface.
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Sjogren syndrome is a systemic autoimmune exocrinopathy in which lymphocytic infiltration of the lacrimal and salivary glands causes keratoconjunctivitis sicca and xerostomia, occurring alone (primary) or alongside another rheumatologic disease such as rheumatoid arthritis or lupus (secondary). Diagnosis combines the anti-Ro (SSA) and anti-La (SSB) antibody panel, objective dryness testing, and labial salivary gland biopsy under the 2016 ACR/EULAR classification criteria. Management centers on sicca-directed therapy, pilocarpine or cevimeline for xerostomia and topical cyclosporine for keratoconjunctivitis, with hydroxychloroquine or immunosuppression for extraglandular disease.
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