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Abstract
BACKGROUND Dry eye syndrome is a disorder of the tear film and is associated with symptoms of ocular discomfort. Punctal occlusion is a mechanical treatment in which the tear drainage system is blocked in order to aid in the preservation of natural tears on the ocular surface. OBJECTIVES The objective of this review was to assess the safety and efficacy of punctal plugs for the management of dry eye. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 6), MEDLINE (January 1950 to June 2010), EMBASE (January 1980 to June 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to June 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (http://clinicaltrials.gov). We also searched the Science Citation Index-Expanded database and reference lists of included studies. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 21 June 2010. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials of collagen or silicone punctal plugs in symptomatic participants diagnosed with aqueous tear deficiency or dry eye syndrome. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study investigators for additional information. MAIN RESULTS Seven randomized controlled trials including 305 participants (601 eyes) met the inclusion criteria and are summarized in this review. We did not perform meta-analysis due to appreciable variability in interventions and follow-up intervals. Although punctal plugs provided symptomatic improvement and clinical outcomes also improved from baseline measures, few studies demonstrated a benefit of punctal plugs over the comparison intervention. Reported adverse effects included epiphora (overflow of tears), foreign body sensation, eye irritation, and spontaneous plug loss. AUTHORS' CONCLUSIONS This systematic review shows a relative scarcity of controlled clinical trials assessing the efficacy of punctal occlusion therapy in dry eye. Although the evidence is very limited, the data suggest that silicone plugs can provide symptomatic relief in severe dry eye. Moreover, temporary collagen plugs appear similarly effective to silicone plugs on a short-term basis.
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Affiliation(s)
- Ann-Margret Ervin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Maryland, Baltimore, USA
| | - Robert Wojciechowski
- Inherited Disease Research Branch, National Human Genome Research Institute (NIH), Maryland, Baltimore, USA
| | - Oliver Schein
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Maryland, Baltimore, USA
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Emina MO. Aging and topical pilocarpine concentrations effects on pupil size and tear flow rate. JOURNAL OF OPTOMETRY 2010; 3:102-106. [PMCID: PMC3974300 DOI: 10.1016/s1888-4296(10)70014-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Accepted: 12/29/2009] [Indexed: 07/30/2023]
Abstract
Purpose This is to evaluate the effects of age and different concentrations of pilocarpine on tear flow rate and pupil size. Methods The tear flow rates and pupil sizes of eighty-one volunteers were measured with Schimer's strips and a meter rule gauge, respectively. These procedures were also employed in testing the effects of 2 % and 4 % concentrations of pilocarpine on tear secretion and pupil constriction. Results There were significant differences between the initial mean tear flow rate and the mean tear flow rates after the installation of 2 % pilocarpine (critical t = 1.96 and calculated t = 6.46) and 4 % pilocarpine (calculated t = 8.83). There were no significant differences in the initial tear flow rates between the sexes. There were significant differences between the mean tear flow rates obtained with 2 % and 4 % concentrations of pilocarpine (calculated t = 3.41). The mean initial tear flow rate for the eighty-one volunteers was 13.84 mm ± 1.19 (SD).There were significant differences between the mean initial pupil size 2.96 mm ± 1.04 (SD) and the mean pupil sizes 2.38 mm ± 1.11(SD) after the instillation of 2 % pilocarpine (Critical t = 1.96 and calculated t = 2.46). Conclusion The basal tear flow rate decreased with advancing age and topical pilocarpine increased tears secretion in all the age groups. The age groups (31 years and above) were more tolerant to the stinging effect of pilocarpine and induced reduced pupil sizes, but there were no significant differences between the mean pupil sizes obtained with the pilocarpine concentrations.
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Affiliation(s)
- Michael O. Emina
- Correspondence. Department of Optometry, University of Benin. P.M.B. 1154, Benin City, Nigeria.
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Abstract
Introduction. Dry eye disease or dysfunctional tear syndrome is among the
most frequently established diagnoses in ophthalmology. It can be defined as
a disorder of the tear film resulting in changes in the ocular surface.
Mechanisms in development of dry eye disease. There are many factors causing
dry eye and they can be related to deficiency in any of the components of the
tear film. It has been suggested that dry eye is an inflammatory disorder
that affects the ocular surface and lacrimal gland. Inflammation is the most
important mechanism of corneal and conjunctival cell damage, which is
responsible for the symptoms and signs of ocular surface pathology. Hormonal
imbalance (particularly androgens), neural dysfunction, increased levels of
pro-inflammatory cytokines and loss of immune homeostasis of the lacrimal
gland and ocular surface could be possible mechanisms in the pathogenesis of
dry eye disease. Discussion. The aim of this paper was to review the advances
in the pathogenesis and management of the dry eye disease. The appropriate
dry eye treatment presupposes knowledge of all existing pharmacologic and
non-pharmacologic therapeutic modalities. The mainstay of therapy is still
artificial tears, with anti-inflammatory therapy and punctual occlusion
therapy as second and third line therapies.
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Kanehira T, Yamaguchi T, Takehara J, Kashiwazaki H, Abe T, Morita M, Asano K, Fujii Y, Sakamoto W. A pilot study of a simple screening technique for estimation of salivary flow. ACTA ACUST UNITED AC 2009; 108:389-93. [DOI: 10.1016/j.tripleo.2009.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/06/2009] [Accepted: 04/09/2009] [Indexed: 10/20/2022]
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Doughty MJ, Glavin S. Efficacy of different dry eye treatments with artificial tears or ocular lubricants: a systematic review. Ophthalmic Physiol Opt 2009; 29:573-83. [PMID: 19686307 DOI: 10.1111/j.1475-1313.2009.00683.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To objectively review the outcome of clinical studies where rose bengal stain (RB) has been used as an outcome measure to assess the efficacy of artificial tears (AT) in patients with dry eye. METHODS From peer-reviewed articles published between 1947 and 2008, information was sought on dry eye status, as reported using a grading scheme, after use of RB as a diagnostic test, before and after use of a specific regimen of artificial tears or ocular lubricants for approximately 30 days. Mean baseline scores and post-treatment scores were calculated, along with the net change and the percentage change in the RB scores. RESULTS From a total of 33 suitable data sets, published between 1985 and 2006, the group mean pre-treatment RB score was 4.25 +/- 1.55 (+/-S.D.), which decreased to 2.84 +/- 1.24 after 30 days of treatment. This represented a net change of -1.43 (95% CI of -1.04 to -1.45). For use of traditional AT (saline, hypromellose, etc), the net change was -0.95, it was -1.33 for use of carbomer (polyacrylic acid) gels and -2.10 for hyaluronic acid (HA) products. These changes represented net improvements of 25.9 +/- 18.4%, 38.0 +/- 20.7% and 41.8 +/- 16.3% respectively. The greater change with HA was not associated with a lower final outcome score, but with higher pre-treatment scores. CONCLUSIONS Based on RB grading schemes used by numerous different clinicians over many years, treatment of dry eye with artificial tears or ocular lubricants can be expected to improve the condition of the exposed ocular surface. Assuming no improvement without treatment, a 30 days treatment period can be projected to produce an overall improvement of around 25%, but with no unambiguous statistical differences between product types.
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Affiliation(s)
- Michael J Doughty
- Department of Vision Sciences, Glasgow-Caledonian University, Glasgow G4 OBA, Scotland, UK.
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57
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Abstract
BACKGROUND Xerostomia is the feeling of dryness in the mouth, usually owing to hypofunctioning of the salivary glands. Causes of xerostomia include medications, the effects of radiation therapy on the salivary glands during the treatment of head and neck cancer or thyroid cancer, and autoimmune diseases such as Sjögren's syndrome. The primary treatment to reduce xerostomia is oral pilocarpine. OBJECTIVE This review discusses the randomized trials available on the efficacy and tolerability of oral pilocarpine for the treatment of xerostomia. METHODS The randomized trials of pilocarpine for xerostomia available in the medical literature are reviewed. RESULTS/CONCLUSION Pilocarpine has some efficacy in the treatment of xerostomia from radiation therapy, graft-versus-host disease and Sjögren's syndrome. It has limited activity for the prevention of xerostomia during radiation therapy. It may have increased efficacy in combination with newer forms of radiation therapy.
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Affiliation(s)
- Lawrence Berk
- Moffitt Cancer Center at Tampa General Hospital, Moffitt Cancer Center, Radiation Oncology, 2 Columbia Dr, Tampa, FL 33606, USA.
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58
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Abstract
Sjögren's syndrome is a systemic autoimmune disease that is characterized by the presence of keratoconjunctivitis sicca, xerostomy and a large spectrum of signs and symptoms that translate into a very heterogeneous disease. The mild form that affects mucosal tissues is the most frequent, but there are more severe and active patterns, manifested by the presence of extraglandular affection with a worse prognosis. The clinical spectrum includes anything from mucosal alterations, Raynaud's phenomenon, parotid enlargement or arthritis, but can be aggravated by the presence of neurological, lung or renal affection. Initial therapy includes topical treatment with artificial tears, nocturnal cream and drugs that stimulate secretion for important glandular affection, while severe systemic affection merits immunosuppressant therapy. There has been recent evidence that biologic therapy is useful for the treatment of severe and resistant cases.
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59
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Abstract
Sjogren's syndrome (SS) is a chronic autoimmune disorder affecting mainly middle-aged women. It is characterized by lymphocytic infiltration and destruction of the exocrine glands (mainly the salivary and lacrimal glands), resulting in dry mouth and eyes. Symptoms of SS are chronic and sometimes devastating, compromising the quality of life at a major extent. Despite its autoimmune nature, evidence for the use of immunosuppressive agents, which are the mainstay of therapy of diseases of autoimmune origin, is limited. Keratoconjunctivitis sicca (KCS), the main ocular manifestation of SS, is managed with tear substitutes, as well as local and systemic stimulators of tear secretion and supportive surgical procedures. Management of oral manifestations includes intense oral hygiene, prevention and treatment of oral infections, use of saliva substitutes, and local and systematic stimulation of salivary secretion. Cholinergic agents, such as pilocarpine and cevimeline are the cornerstone of current therapy in SS. Corticosteroids, cyclophoshamide, and nucleoside analogues are reserved for severe extraglandular manifestations of SS. The role of anti-B-cell therapy is a promising option for glandular and extraglandular manifestations of the disease, as well as for the management of SS-associated lymphoma.
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60
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Seitsalo H, Niemelä RK, Marinescu-Gava M, Vuotila T, Tjäderhane L, Salo T. Effectiveness of low-dose doxycycline (LDD) on clinical symptoms of Sjögren's syndrome: a randomized, double-blind, placebo controlled cross-over study. J Negat Results Biomed 2007; 6:11. [PMID: 18163919 PMCID: PMC2235889 DOI: 10.1186/1477-5751-6-11] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Accepted: 12/31/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are proteolytic enzymes that may contribute to tissue destruction in Sjögren's syndrome (SS). Low-dose doxycycline (LDD) inhibits MMPs. We evaluated the efficacy of LDD for the subjective symptoms in primary SS patients. This was a randomized, double blind, placebo controlled cross-over study. 22 patients were randomly assigned to receive either 20 mg LDD or matching placebo twice a day for 10 weeks. The first medication period was followed by 10-week washout period, after which the patient received either LDD or placebo, depending on the first drug received, followed by the second washout period. Stimulated saliva flow rates and pH were measured before and after one and ten weeks of each medication and after washout periods. VAS scale was used to assess the effect of LDD and placebo on following six subjective symptoms: xerostomia; xerophtalmia; difficulty of swallowing; myalgia; arthralgia; and fatigue. The effect was evaluated for each medication and washout period separately. RESULTS Overall, the effects of medications on subjective symptoms were minor. Wilcoxon test demonstrated increased fatigue with LDD during medication (p < 0.05). The differences may, however, reflect normal fluctuation of symptoms in SS patients. CONCLUSION LDD may not be useful in reducing the primary SS symptoms.
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Affiliation(s)
- Hubertus Seitsalo
- Institute of Dentistry, University of Helsinki, and Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital (HUCH), PO BOX 14, 00014 University of Helsinki, Finland.
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Thanou-Stavraki A, James JA. Primary Sjogren's syndrome: current and prospective therapies. Semin Arthritis Rheum 2007; 37:273-92. [PMID: 17714766 DOI: 10.1016/j.semarthrit.2007.06.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Revised: 06/05/2007] [Accepted: 06/17/2007] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To summarize data on existing and experimental therapies for primary Sjogren's syndrome (pSS), referring both to sicca syndrome and to other systemic disease manifestations. METHODS Relevant English and non-English articles acquired through Medline were reviewed. RESULTS pSS usually has a benign clinical course, centered on sicca features and general musculoskeletal manifestations, and is managed symptomatically. However, a subset of patients develops more severe extraglandular disease that warrants close monitoring and aggressive treatment. For dry eyes and mouth, nonpharmacologic measures to preserve secretions, and tear and saliva substitutes, offer some symptomatic relief. Muscarinic agonists and topical cyclosporine yield well-documented improvement in ocular sicca features. Although traditional antirheumatic drugs are used empirically for polyarthritis and other Sjogren's symptoms, their efficacy in pSS overall and as disease-modifying agents is limited. For the potential severe, nonexocrine manifestations complicating pSS, standard high-dose immunosuppression is used. Among the biologic agents already examined in pSS, those targeting tumor necrosis factor (TNF)-alpha failed to demonstrate significant benefit. Nonetheless, rituximab and other B-cell-depleting therapies appear promising. CONCLUSIONS Treatment of pSS patients with severe extraglandular disease should differ from that of patients with predominantly sicca features and/or general muscoloskeletal manifestations. pSS treatment is mainly symptomatic, primarily directed against sicca complaints. The traditional anti-rheumatic agents show limited efficacy in the systemic process and use of systemic TNF-alpha inhibitors has been very disappointing. B cell depleting treatments and other newer biologic therapies appear more promising.
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Affiliation(s)
- Aikaterini Thanou-Stavraki
- Arthritis and Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73104, USA
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Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:163-78. [PMID: 17508120 DOI: 10.1016/s1542-0124(12)70085-x] [Citation(s) in RCA: 396] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The members of the Management and Therapy Subcommittee assessed current dry eye therapies. Each member wrote a succinct evidence-based review on an assigned aspect of the topic, and the final report was written after review by and with consensus of all subcommittee members and the entire Dry Eye WorkShop membership. In addition to its own review of the literature, the Subcommittee reviewed the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force (ITF) Delphi Panel on Dry Eye. The Subcommittee favored the approach taken by the ITF, whose recommended treatments were based on level of disease severity. the recommendations of the Subcommittee are based on a modification of the ITF severity grading scheme, and suggested treatments were chosen from a menu of therapies for which evidence of therapeutic effect had been presented.
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63
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Abstract
For the treatment of sicca symptoms as a manifestation of Sjögren's syndrome there are various tear substitutes as well as artificial saliva. The appropriate substances are discussed in this article. In addition to reducing symptoms, some of the effective compounds offer the advantage of infection prophylaxis in the form of better lubrication of the mucous membranes in the airways as well as reduced susceptibility to candidiasis. The presence of bromhexin in the catalogue of the statutory medical insurance agencies is recommended. Certain of the available drugs are still only available in foreign pharmacies.
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Affiliation(s)
- A Gause
- Internistisch-Rheumatologische Schwerpunktpraxis, Elmshorn.
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64
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65
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Wu CH, Hsieh SC, Lee KL, Li KJ, Lu MC, Yu CL. Pilocarpine hydrochloride for the treatment of xerostomia in patients with Sjögren's syndrome in Taiwan--a double-blind, placebo-controlled trial. J Formos Med Assoc 2006; 105:796-803. [PMID: 17000452 PMCID: PMC7134824 DOI: 10.1016/s0929-6646(09)60266-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background/purpose Sjögren's syndrome (SS) is characterized by diminished exocrine secretions with the resultant symptoms of dry mouth and dry eye. As genetic predisposition and ethnicity may alter the effectiveness of drug treatment, evaluation of the efficacy and safety of the secretagogue pilocarpine hy-drochloride in the treatment of xerostomia in patients with SS in different populations is needed. Methods Forty-four patients with SS were enrolled in this double-blind, placebo-controlled trial. Patients were randomized to receive 5 mg pilocarpine (Salagen) or placebo tablet four times daily for 12 weeks. Global evaluation and subjective responses of patients were assessed by questionnaires with visual analog scales and categorical checkboxes. Saliva production was also measured by modified Saxon's test. Results Pilocarpine treatment significantly improved global assessment of dry mouth, symptoms associated with dry mouth (mouth comfort, ability to sleep and ability to speak), and saliva production compared to placebo. The drug was well tolerated and the most common adverse effect was sweating (5/23, 21.7%) resulting from the muscarinic agonist action of the drug. No serious drug-related adverse effect was found in this study. Conclusion The results of this study suggest that therapy with 5 mg pilocarpine four times daily is effective, safe and well tolerated for the relief of oral symptoms in patients with SS in Taiwan.
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Affiliation(s)
- Cheng-Han Wu
- Division of Immunology, Rheumatology and Allergy, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan
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66
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Mavragani CP, Moutsopoulos NM, Moutsopoulos HM. The management of Sjögren's syndrome. ACTA ACUST UNITED AC 2006; 2:252-61. [PMID: 16932698 DOI: 10.1038/ncprheum0165] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 12/14/2005] [Indexed: 12/19/2022]
Abstract
Sjögren's syndrome is a chronic autoimmune disorder, characterized by lymphocytic infiltration and malfunction of the exocrine glands, resulting in dry mouth and eyes. The syndrome can present either alone (primary Sjögren's syndrome) or in the context of an underlying connective tissue disease (secondary Sjögren's syndrome). Systemic features, resulting from cutaneous, respiratory, renal, hepatic, neurologic, and vascular involvement, often occur. Two types of primary Sjögren's syndrome are currently recognized: a benign disease that affects quality of life, and a systemic syndrome associated with increased morbidity and mortality owing to a high risk of malignant transformation, and that requires close follow-up. Ocular involvement, manifested as keratoconjunctivitis sicca, is managed with local and systemic stimulators of tear secretion and supportive surgical procedures. Treatment of oral manifestations includes intense oral hygiene, prevention and treatment of oral infections, use of saliva substitutes, and local and systematic stimulation of salivary secretion. Cholinergic agents, such as pilocarpine and cevimeline, are helpful in patients with residual salivary function, and ciclosporin ocular drops seem to be of some benefit. Systemic immunosuppressives are reserved for treatment of severe extraglandular manifestations of Sjögren's syndrome. Anti-B-cell therapy is a new potential therapy for the glandular and extraglandular manifestations, such as glomerulonephritis or vasculitis, in addition to the management of lymphoma associated with Sjögren's syndrome. Induction of oral tolerance and gene-transfer modalities were recently attempted in animal models, with promising results.
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67
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Tomiak C, Dörner T. [Sjögren's syndrome. Current aspects from a rheumatological point of view]. Z Rheumatol 2006; 65:505-17; quiz 518-9. [PMID: 17004051 DOI: 10.1007/s00393-006-0101-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sjögren's syndrome is an autoimmune disease of the exocrine glands characterized by the leading symptoms of keratoconjunctivitis and stomatitis sicca based on a complex pathogenesis. The prevalence is about 0.5-1%; primary Sjögren's syndrome is differentiated from secondary Sjögren's syndrome associated with other autoimmune disorders. The diagnosis is established by the presence of subjective complaints and objective evidence of sicca symptoms, anti-Ro(SSA)/La(SSB) antibodies, and/or focal lymphocytic infiltration of the glandular tissue. In addition to the typical sicca symptomatology, which is managed symptomatically by substitution and stimulation therapy, some patients exhibit extraglandular manifestations. Complaints involving the musculoskeletal system and inner ear dominate and are treated by the rheumatologist. The indication for base therapy is tailored to individual needs, but the efficacy of this approach has not been established in studies. About 5-10% of the patients with primary Sjögren's syndrome develop a B-cell non-Hodgkin's lymphoma. The disease requires interdisciplinary management including, among others, ophthalmologists, dentists, and otorhinolaryngologists, depending on the clinical picture.
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Affiliation(s)
- C Tomiak
- Reha-Zentrum Bad Aibling, Deutsche Rentenversicherung Bund, Rheumazentrum - AHB, Kolbermoorer Strasse 56, 83043 Bad Aibling, Deutschland.
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Brito-Zerón P, Ramos-Casals M, Nardi N, Font J. Resultados del tratamiento con pilocarpina oral en 100 pacientes con síndrome de Sjögren primario. Med Clin (Barc) 2006; 126:637. [PMID: 16759558 DOI: 10.1157/13087738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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69
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Aragona P, Di Pietro R, Spinella R, Mobrici M. Conjunctival epithelium improvement after systemic pilocarpine in patients with Sjogren's syndrome. Br J Ophthalmol 2006; 90:166-70. [PMID: 16424527 PMCID: PMC1860166 DOI: 10.1136/bjo.2005.078865] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To evaluate the effect of oral pilocarpine treatment on conjunctival epithelium of patients with Sjögren's syndrome (SS). METHODS 15 primary SS patients were included in this prospective, single masked, comparative study. Patients underwent oral pilocarpine treatment for 2 months and were studied before (T0) and after 1 month (T1), 2 months (T2), and 15 days after treatment suspension (T3). Systemic and ocular symptoms, tear film break up time (BUT), corneal fluorescein vital staining, Schirmer I test, tear basal secretion test, and conjunctival imprinting were performed. Student's t test and Mann-Whitney U test were used for statistics. RESULTS The conjunctival imprinting showed an increase of goblet cells number at T1 (1.6 (1.2) v 0.6 (0.7) at T0, p = 0.025) improving at T2 (5.1 (1.7); p<0.001 v T0 and T1). At T3 the number of goblet cells significantly decreased (1.9 (1.1); p<0.001 v T2). An improvement of dry mouth started at T1 and returned towards baseline values at T3. For ocular symptoms, burning and foreign body sensation were improved at T1 while ocular dryness improved at T2. BUT showed a statistically significant improvement at T2. CONCLUSIONS Oral pilocarpine induced an increase in goblet cells number and an amelioration of conjunctival epithelium not dependent on tear secretion.
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Affiliation(s)
- P Aragona
- Department of Surgical Specialties, Section of Ophthalmology, Ocular Surface Diseases Unit, University of Messina, Italy.
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70
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Samarkos M, Moutsopoulos HM. Recent advances in the management of ocular complications of Sjögren's syndrome. Curr Allergy Asthma Rep 2005; 5:327-32. [PMID: 15967078 DOI: 10.1007/s11882-005-0077-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sjögren's syndrome (SS) is an autoimmune disorder, the principal ocular manifestation of which is decreased tear production leading to chronic irritation and damage to the corneal and conjunctival epithelium. The most important advance in the treatment of ocular manifestations of SS is the introduction of topical anti-inflammatory agents such as cyclosporine A, which increases tear production and decreases symptoms without any significant side effect. Stimulators of tear secretion, both topical, such as diquafosol, and systemic, such as pilocarpine and cevimeline, are also effective, although they have been associated with frequent side effects. Topical use of autologous serum is another new and effective form of treatment, but problems in the preparations prevent their widespread use. Additionally, nonpharmacologic treatments, such as insertion of punctal plugs, are beneficial in the dry eye of SS, whereas several other modalities, such as anti-CD4 monoclonal antibody eye drops and gene transfer, are still in experimental phases.
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Affiliation(s)
- Michael Samarkos
- Department of Pathophysiology, University of Athens School of Medicine, 25 Mikras Asias street, 115 27, Athens, Greece.
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71
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Abstract
The hormonal status and in particular sex steroids play a role in the ocular surface homeostasis and function, during the whole life and in both sexes, accomplished by estrogenic and androgenic receptors located on corneal and conjunctival epithelia and Meibomian gland. The ocular surface is an integrated unit and any dysfunction results in a scarce or unstable preocular tear film which produces dry eye, a chronic inflammatory condition with increasing incidence as people get older but always more frequent among females. In post-menopausal women endocrine changes join the aging effects in the pathogenesis of dry eye, but still it remains controversial whether estrogen or androgen deficiency or their imbalance impair ocular surface function. Another questionable issue concerns the efficacy of hormonal replacement therapy in the amelioration of dry eye symptoms and recovery of tear function, since the scientific literature stands in between a therapeutic or a promoting effect of eye dryness. Therapy of dry eye is usually based upon topical administration of tear substitutes; estrogen or androgen-based eye drops represents a promising innovative treatment based upon important scientific rationale.
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Affiliation(s)
- Piera Versura
- Department of Surgical Science and Transplants, Ophthalmology Section I, Alma Mater Studiorum Universitá di Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, I-40138 Bologna, Italy.
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72
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Abstract
Sjögren's syndrome (SS) is a chronic autoimmune disease affecting the exocrine glands, primarily the salivary and lacrimal glands. It has been suggested that exogenous agents may trigger SS in genetically predisposed individuals. However, at present, the etiology of SS is far from being understood, and no direct evidence for any of these triggers has been presented. The salivary and lacrimal glands from patients with SS harbor unique and highly selected T- and B-cell populations. Disturbance in glandular cell apoptosis may be one possible explanation for the sicca symptoms in SS. However, discrepancies between glandular destruction and salivary flow give rise to processes causing glandular dysfunction preceding or triggering glandular cell destruction. Recent reports suggested autoantibodies inhibiting neuronal innervation of acinar cells and defective water transport to be implicated in salivary secretion deficiency observed in SS. Several types of autoantibodies have been suggested to contribute to the pathogenesis of SS. However, how the tolerance to these structures is broken down is unknown at present. Studies on B-cell activating factor indicated that diminished apoptosis and disturbed B-cell maturation could be responsible for the occurrence of autoreactive B-cells and B-cell hyperreactivity. B-cell activation may also provide a basis for lymphoma development observed in up to 5% of the patients with SS.
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Affiliation(s)
- Nicolas Delaleu
- Clinic for Geriatric and Special Care Dentistry, University of Zürich, Zürich, Switzerland.
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73
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Abstract
One in four patients attending ophthalmic clinics report symptoms of dry eye, making it one of the most common complaints seen by ophthalmologists. Aqueous-layer deficiency is the most common form of dry eye and is frequently caused by decreased secretion of tears by the lacrimal glands. Evaporative dry eye is often secondary to meibomian gland disease and results in a defective lipid layer. Tear replacement or preservation using artificial tears and/or punctal occlusion are the mainstay of treatment. Newer forms of therapy were designed to modify the underlying disease process. These include the use of topical cyclosporin A, autologous serum, and sodium hyaluronate drops, which suppress underlying inflammation, provide growth factors, and prevent the onset of squamous metaplasia in ocular surface epithelium. Hormonal therapy might have a role in the future of dry eye therapy.
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Ramos-Casals M, Tzioufas AG, Font J. Síndrome de Sjögren. Nuevas perspectivas terapéuticas. Med Clin (Barc) 2005; 124:111-5. [PMID: 15710099 DOI: 10.1157/13070854] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Manuel Ramos-Casals
- Servicio de Enfermedades Autoinmunes Sistémicas, Hospital Clínic de Barcelona, Barcelona, Spain.
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Ramos-Casals M, Tzioufas AG, Font J. Primary Sjögren's syndrome: new clinical and therapeutic concepts. Ann Rheum Dis 2004; 64:347-54. [PMID: 15498797 PMCID: PMC1755414 DOI: 10.1136/ard.2004.025676] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Sicca features are the central clinical manifestations of Sjögren's syndrome (SS), but recent studies have confirmed that primary SS has a systemic expression, including extraglandular manifestations. Patients with a predominantly extraepithelial expression should be managed differently from patients with predominantly periepithelial or sicca limited disease. In coming years treatment will be based on muscarinic agonists for sicca features and immunosuppressive/biological agents for extraglandular features.
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Affiliation(s)
- M Ramos-Casals
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain.
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