Sjögren's syndrome in systemic sclerosis. A clinical study of 26 patients

A Wide Spectrum of Ocular Manifestations Signify Patients with Systemic Sclerosis

Objectives: Systemic sclerosis (SSc) is a rare, chronic connective tissue disease involving multiple organ systems, including the eye. We evaluated the detailed clinical ocular manifestations of outpatients with SSc.Methods: Demographics, disease duration and subtype, nailfold capillaroscopy (NFC) patterns and laboratory parameters encompassing the autoantibody profile of 51 SSc patients were evaluated, and a general ocular examination was performed for each participant.Results: Twenty-nine patients (56.86%) had eyelid skin alterations, 26 (50.98%) had retinal abnormalities, 26 (50.98%) had cataracts, 8 (15.69%) had conjunctival changes, 7 (13.73%) had iris abnormalities, 33 (64.71%) suffered from dry eye disease (DED), and 11 (21.57%) suffered from glaucoma. Significant positive correlations were found between NFC data and both tear breakup time and Ocular Surface Disease Index test values.Conclusions: Eyelid skin abnormalities, DED and retinal abnormalities are among the most common SSc-related ocular involvements. Diverse ophthalmic findings are attributed to the heterogeneity of SSc.

Ocular involvement in systemic sclerosis: A systematic literature review, it's not all scleroderma that meets the eye

OBJECTIVES

Systemic sclerosis (SSc) is a rare and complex autoimmune disorder characterized by microvascular damage and progressive fibrosis which affects the skin and multiple other organs. Much of the published data concerning SSc and the eye consists of single case reports or small case studies. This systematic review aims to provide an overview of the current level of evidence for SSc-related ocular changes.

MATERIALS AND METHODS

A systematic literature review was conducted using 3 electronic databases, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A combination of following keywords was used: "Systemic Sclerosis" and ophthalmology-related search terms, including the keywords "Eye", "Ocular" and "Ophthalmic". All articles were screened by 2 independent reviewers at title, abstract and full text level. We solely included case-control studies that investigated specific ocular findings in SSc patients compared to healthy controls.

RESULTS

Nine of 270 articles were retained. Dry eye symptoms are associated with SSc, whereas objective signs (Schirmer I testing) show conflicting results. There is insufficient evidence of SSc-related changes to the central corneal thickness. In terms of posterior segment involvement, choroidal vasculature appears to be affected to greater extent than the retinal microcirculation. However, the limited number of patients included in the studies renders it hazardous to draw overall conclusions.

CONCLUSIONS

There is a paucity of well-designed case-control studies investigating possible ocular involvement in SSc. Our systematic review demonstrates limited proven associations between SSc and ocular abnormalities, mainly in terms of dry eye symptoms and choroidal thickness. Future standardized prospective studies are needed to clarify the impact of the disease on the eye.

Determining the Risk Factors and Clinical Features Associated With Severe Gastrointestinal Dysmotility in Systemic Sclerosis

OBJECTIVE

A subset of patients with systemic sclerosis (SSc) develop severe gastrointestinal (GI) dysmotility. We sought to determine predictors of severe SSc GI dysmotility and to identify distinct features associated with this phenotype.

METHODS

Patients with SSc who required supplemental nutrition (enteral or parenteral tube feeding) were compared to SSc patients with mild GI symptoms in a cross-sectional analysis. The association between severe GI dysmotility and clinical and serologic features was examined using logistic regression. Baseline data were examined to determine predictors of developing severe GI dysfunction using Cox regression.

RESULTS

SSc patients with severe GI dysmotility (n = 66) were more likely than those patients with mild GI symptoms (n = 1,736) to be male (odds ratio [OR] 2.47 [95% confidence interval (95% CI) 1.34-4.56]; P = 0.004), and to have myopathy (OR 5.53 [95% CI 2.82-10.82]; P < 0.001), and sicca symptoms (OR 2.40 [95% CI 1.30-4.42]; P = 0.005), even after adjustment for potential confounders. Baseline features that were associated with the future development of severe GI dysfunction included male sex (hazard ratio [HR] 2.99 [95% CI 1.53-5.84]; P = 0.001) and myopathy (HR 5.08 [95% CI 2.21-11.67]; P < 0.001).

CONCLUSION

Distinct clinical features are present in SSc patients who are at risk of developing severe GI dysmotility. This finding is not only important clinically but also suggests that a unique pathologic process is at work in these patients.

Association between objective signs and subjective symptoms of dry eye disease in patients with systemic sclerosis

The aim of this study was to evaluate the association between clinical signs and symptoms of dry eye disease (DED) in patients with systemic sclerosis (SSc). This cross-sectional observational study included 19 SSc patients and 19 normal subjects with no ocular symptoms or ocular surface disorders. Clinical parameters included tear film break-up time (tBUT), Schirmer I, lissamine green (LG) dye, and tear film osmolarity tests, tear production, and tear secretion flow. For assessment of the dry eye symptoms, the Ocular Surface Disease Index (OSDI) questionnaire was administered to all patients. The following mean values were found in SSc patients: OSDI 33.6 ± 19.86; osmolarity of the tear fluid 310.8 mOsmol/l ± 14.47; tBUT time 5.158 ± 2.328 s; Schirmer I test 5.395 mm/5 min; LG grading score 2.026 ± 0.8893; collected tear fluid volume 6.397 ± 2.761 µl. The calculated average tear velocity was 4.654 ± 1.963 µl/min. A significant correlation was found between the OSDI as a subjective parameter and disease duration. Early recognition of dry eye symptoms, a possible extra-intestinal manifestation of SSc, should be included in the check up of the disease to reduce ocular complications. The objective tear functional tests were strongly influenced by individual factors like age and disease duration.

Relationship between disease characteristics and orofacial manifestations in systemic sclerosis: Canadian Systemic Sclerosis Oral Health Study III

OBJECTIVE

Systemic sclerosis (SSc; scleroderma) is associated with decreased saliva production and interincisal distance, more missing teeth, and periodontal disease. We undertook this study to determine the clinical correlates of SSc with these oral abnormalities.

METHODS

Subjects were recruited from the Canadian Scleroderma Research Group cohort. Detailed dental and clinical examinations were performed according to standardized protocols. Associations between dental abnormalities and selected clinical and serologic manifestations of SSc were examined.

RESULTS

One hundred sixty-three SSc subjects were included: 90% women, mean ± SD age 56 ± 11 years, mean ± SD disease duration 14 ± 8 years, 72% with limited cutaneous disease, and 28% with diffuse cutaneous disease. Decreased saliva production was associated with Sjögren's syndrome-related autoantibodies (β = -43.32; 95% confidence interval [95% CI] -80.89, -5.75), but not with disease severity (β = -2.51; 95% CI -8.75, 3.73). Decreased interincisal distance was related to disease severity (β = -1.02; 95% CI -1.63, -0.42) and the modified Rodnan skin thickness score (β = -0.38; 95% CI -0.53, -0.23). The number of missing teeth was associated with decreased saliva production (relative risk [RR] 0.97; 95% CI 0.94, 0.99), worse hand function (RR 1.52; 95% CI 1.13, 2.02), and the presence of gastroesophageal reflux disease (GERD; RR 1.68 [95% CI 1.14, 2.46]). No clinical or serologic variables were correlated with periodontal disease.

CONCLUSION

In SSc, diminished interincisal distance is related to overall disease severity. Decreased saliva production is related to concomitant Sjögren's syndrome antibodies. Tooth loss is associated with poor upper extremity function, GERD, and decreased saliva. The etiology of excess periodontal disease is likely multifactorial and remains unclear.

Evaluation of dry eye signs and symptoms in patients with systemic sclerosis

BACKGROUND

One of the most frequent ocular features of systemic sclerosis (SSc) is dry eye disease (DED), which has been identified to occur in 37-79% of patients. Although several studies have found weak or no correlations between symptoms and signs of dry eye, symptoms are often the motivation for seeking eye care, and are therefore a critical outcome measure when assessing treatment effect. The aim of this study is to evaluate the impact of symptoms of dry eye on vision-related quality of life in patients with systemic sclerosis, and to investigate the relation between clinical tests and symptoms of dry eye in these patients.

METHODS

In this cross-sectional study, 45 consecutive patients with SSc were enrolled. For evaluation of the symptoms the "Ocular Surface Disease Index (OSDI)" questionnaire was applied to all patients. After that, all individuals were submitted to a full ophthalmic examination, including the following tests: tear break-up time, Schirmer I, rose bengal staining. Patients were then grouped into dry eye and non-dry eye groups with regard to the diagnosis of dry eye. Mann-Whitney test was used to compare continuous variables, whereas the Fisher exact test was used to compare categorical data between groups. Spearman's correlation test was used to analyze the correlations between clinical tests and OSDI scores. P values <0.05 were considered significant.

RESULTS

Dry eye disease was diagnosed in 22 patients (48.9%). Other ocular surface abnormalities found were: blepharitis (40% of the patients), pterygium (15.6%), pinguecula (82.2%), and superficial punctate keratitis (26.7%). Among the 45 patients, 29 patients (64.4%) had symptoms of ocular surface disease. The mean OSDI score was 26.8 ± 25.8 (SD). There were no statistically significant differences in OSDI scores between DED and non-DED patients. No substantive correlations were found between OSDI scores and TBUT, Schirmer I, or rose bengal staining score, and none of the observed correlations reached statistical significance.

CONCLUSION

Symptoms of dry eye have a moderate impact on vision-related quality of life in patients with systemic sclerosis and do not correlate well with clinical findings.

Oral health of Chinese people with systemic sclerosis

The aim was to study oral health status, salivary function, and oral features of Chinese people with Systemic Sclerosis (SSc). Chinese people with SSc attending a university specialist clinic were invited for a questionnaire survey and a clinical examination. Ethics approval was sought (UW 08-305). Gender- and age-matched individuals without SSc who attended a university dental hospital were recruited for comparison. Forty-two SSc patients with a mean age of 54.0 ± 12.2 were examined. This study found no Chinese people with systemic sclerosis were periodontally healthy and many (76%) had periodontal pockets despite most of them (93%) practiced daily tooth-brushing. They all had caries experience (DMFT = 10.5) and many (65%) had untreated decay. Mucosal telangiectasia was a common oral feature (80%). They had lower resting salivary flow rates (0.18 ± 0.17 ml/min vs. 0.31 ± 0.21 ml/min; p = 0.003) and pH values (6.90 ± 0.40 vs. 7.28 ± 0.31; p < 0.001) and reduced maximal mouth opening (40.1 ± 6.5 mm vs. 43.6 ± 7.0 mm) than people without SSc.

Often forgotten manifestations of systemic sclerosis

Many clinical manifestations of systemic sclerosis (scleroderma) often go unrecognized; yet they can cause significant morbidity and are challenging to manage. This article discusses osteolysis, avascular necrosis of the wrist, oral manifestations, erectile dysfunction, pharyngeal weakness, fecal incontinence, nonscleroderma renal disease, liver disease, thyroid disease, and neurological disease in the scleroderma patient.

The ocular surface and tear film and their dysfunction in dry eye disease

The ocular surface, tear film, lacrimal glands, and eyelids act as a functional unit to preserve the quality of the refractive surface of the eye and to resist injury and protect the eye against changing bodily and environmental conditions. Events that disturb the homeostasis of this functional unit can result in a vicious cycle of ocular surface disease. The tear film is the most dynamic structure of the functional unit, and its production and turnover is essential to maintaining the health of the ocular surface. Classically, the tear film is reported to be composed of three layers: the mucin, aqueous, and lipid layers. The boundaries and real thickness of such layers is still under discussion. A dysfunction of any of these layers can result in dry eye disease.

Analysis of the oral manifestations of systemic sclerosis

The oral signs and symptoms in 32 patients with systemic sclerosis were evaluated. Oral mucosal telangiectasia was present in 18 cases (56.3%) and was not restricted to the limited form of systemic sclerosis. The interincisal distance was significantly decreased in the patients with systemic sclerosis compared with the 17 controls (p < 0.001). The distance between the vermillion borders was also significantly decreased when the 14 patients with salivary hypofunction were compared with the 18 cases without decreased salivary secretion (p < 0.05). Twenty-two (69%) of the patients exhibited keratoconjunctivitis sicca, salivary hypofunction, or both. Lip biopsy was performed in 16 cases. Two cases with inflammatory signs characteristic of Sjögren's syndrome were found, and six patients showed the histologic signs of labial gland fibrosis. Five of these cases belonged to the group of limited cutaneous systemic sclerosis that indicates the generalized nature of the fibrotic processes even in systemic sclerosis with less extensive skin involvement. Of the 10 cases investigated by electron microscopy, all but one showed a thickening of the capillary basal lamina, lamellar arrangement within the basement membrane, or capillary endothelial vacuolization. Three of these cases belonged to the patients with disease onset within 2 years, showing that capillary vascular lesion is present in the early cases and that vascular injury affects even those tissues that do not seem to be evidently involved by clinical examination.

HIV-salivary gland disease. Salivary scintiscanning with technetium pertechnetate

The salivary disease in two patients with human immunodeficiency virus infection was investigated by technetium pertechnetate scintiscanning. Although there was good histologic evidence of benign lymphoepithelial disease, scintiscanning failed to delineate any salivary lesions. Technetium pertechnetate scintiscanning seems to be of little value in the detailed investigation of salivary disease in human immunodeficiency virus infection, though gallium scanning can help. Fine needle aspiration or biopsy remain the main diagnostic tools.

Clinical and histological analysis of labial lip biopsy in Sjögren syndrome

Labial lip biopsy findings from 52 patients with Sjögren syndrome (SjS) and cutaneous manifestations were clinically analyzed. Findings of the labial lip biopsy with more than one focus (a cluster of at least 50 lymphocytes) were positive in 52% (28/52). Sixteen patients who presented with oral dryness had negative labial lip biopsy findings with less than one focus score and five patients without oral dryness had positive results. Cells infiltrating into the salivary gland were categorized as plasma cell rich (Group 1), lymphocyte rich (Group 3), intermediate (Group 2), or no gland in biopsied specimens (Group 4). Sicca complaint and the grade of lip biopsy score were significantly higher in Group 3 than in Group 1; no differences were observed in laboratory findings between Groups 1 and 3. The patterns of age distribution and salivary flow rate were also not statistically significant in these two groups. The patients with plasma cell rich infiltrate presented oral dryness, although their clinical and grade of lip biopsy scores were relatively low; most of these patients have secondary SjS. Some of the patients in Group 4 showed an advanced stage of the disease through their lip biopsy score was grade 1 with atrophic or no gland. These data suggest that labial lip biopsy is a useful screening method for the diagnosis of Sjögren syndrome and that clinical manifestations may differ in parallel with the type of infiltrating cell.