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Treatment of dry eye in Sjögren's syndrome

Alan N Baer, MD, FACP
Esen K Akpek, MD
Section Editor
Robert Fox, MD, PhD
Deputy Editor
Paul L Romain, MD


Sjögren’s syndrome (SS) is a chronic multisystem inflammatory disorder characterized by diminished lacrimal and salivary gland function. This results in the “sicca complex,” a combination of dry eye (xerophthalmia) and dry mouth (xerostomia). A variety of other disease manifestations may also be present, including systemic signs and extraglandular features. The term “keratoconjunctivitis sicca” was coined by Henrik Sjögren in 1933 to describe the ocular surface disease resulting from severe aqueous tear deficiency in a series of 19 patients [1]. This term has been largely supplanted in the medical literature by “dry eye.”

SS occurs in a primary form not associated with other diseases and in a secondary form associated with other autoimmune rheumatic conditions, including rheumatoid arthritis and systemic lupus erythematosus.

The treatment of dry eye in patients with SS will be reviewed here. Other issues in SS are discussed separately, including the clinical manifestations and diagnosis of SS, the treatment of dry mouth and other non-ocular sicca symptoms in patients with SS, and the treatment of extraglandular manifestations of SS. (See "Clinical manifestations of Sjögren's syndrome: Exocrine gland disease" and "Clinical manifestations of Sjögren's syndrome: Extraglandular disease" and "Diagnosis and classification of Sjögren's syndrome" and "Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren's syndrome" and "Treatment of systemic and extraglandular manifestations of Sjögren’s syndrome".)

Dry eye unrelated to SS and an overview of dry eye, including the clinical manifestations, diagnosis, and management of dry eye unrelated to SS, are also presented separately. (See "Dry eyes" and "Diagnosis and classification of Sjögren's syndrome", section on 'Dry eye and mouth in older adults' and "Diagnosis and classification of Sjögren's syndrome".)


Patients with Sjögren’s syndrome (SS) benefit from multidisciplinary care. An eyecare professional should diagnose and manage the dry eye of SS patients for a number of reasons. Several tests for diagnosing and monitoring dry eye, including ocular surface staining and the tear break-up time, require a slit lamp and therefore an ophthalmological examination (see "Diagnosis and classification of Sjögren's syndrome", section on 'Tests for dry eye'). Measuring the tear film osmolarity can be performed by non-ophthalmologists as point-of-care testing and has been reported useful to assess presence of dry eye [2]. Nevertheless, conflicting reports also exist [3]. Symptoms of ocular irritation may arise from multiple causes, not only aqueous tear deficiency, and these can be differentiated by an eye care professional. Over 80 percent of patients with SS have a meibomian gland dysfunction as well, and this requires recognition and specific treatment [4,5]. Finally, patients with SS and severe dry eye disease are at risk of vision-threatening ocular complications, sometimes with minimal antecedent symptoms and regular monitoring by an eye care professional is therefore warranted [6].


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Literature review current through: Sep 2016. | This topic last updated: Oct 5, 2015.
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  1. Sjögren H. Zur Kenntnis der Keratoconjunctivitis sicca. Keratitis filiformis bei Hypofunktion der Tränendrüsen. Acta Ophthalmol (Copenh) 1933; 1:151.
  2. Utine CA, Bıçakçıgil M, Yavuz S, Çiftçi F. Tear osmolarity measurements in dry eye related to primary Sjögren's syndrome. Curr Eye Res 2011; 36:683.
  3. Szalai E, Berta A, Szekanecz Z, et al. Evaluation of tear osmolarity in non-Sjögren and Sjögren syndrome dry eye patients with the TearLab system. Cornea 2012; 31:867.
  4. Shimazaki J, Goto E, Ono M, et al. Meibomian gland dysfunction in patients with Sjögren syndrome. Ophthalmology 1998; 105:1485.
  5. Akpek EK, Klimava A, Thorne JE, et al. Evaluation of patients with dry eye for presence of underlying Sjögren syndrome. Cornea 2009; 28:493.
  6. Akpek EK, Mathews P, Hahn S, et al. Ocular and systemic morbidity in a longitudinal cohort of Sjögren's syndrome. Ophthalmology 2015; 122:56.
  7. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006; 25:900.
  8. 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.
  9. Ramos-Casals M, Brito-Zerón P, Sisó-Almirall A, et al. Topical and systemic medications for the treatment of primary Sjögren's syndrome. Nat Rev Rheumatol 2012; 8:399.
  10. Akpek EK, Lindsley KB, Adyanthaya RS, et al. Treatment of Sjögren's syndrome-associated dry eye an evidence-based review. Ophthalmology 2011; 118:1242.
  11. Foulks GN, Forstot SL, Donshik PC, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Ocul Surf 2015; 13:118.
  12. Yu HD, Chou AH, Yang MW, Chang CJ. An analysis of perioperative eye injuries after nonocular surgery. Acta Anaesthesiol Taiwan 2010; 48:122.
  13. Wolkoff P, Nøjgaard JK, Franck C, Skov P. The modern office environment desiccates the eyes? Indoor Air 2006; 16:258.
  14. Hagan S, Lory B. Prevalence of dry eye among computer users. Optom Vis Sci 1998; 75:712.
  15. Blehm C, Vishnu S, Khattak A, et al. Computer vision syndrome: a review. Surv Ophthalmol 2005; 50:253.
  16. Rosenfield M. Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic Physiol Opt 2011; 31:502.
  17. Dimit R, Gire A, Pflugfelder SC, Bergmanson JP. Patient ocular conditions and clinical outcomes using a PROSE scleral device. Cont Lens Anterior Eye 2013; 36:159.
  18. Aragona P, Di Stefano G, Ferreri F, et al. Sodium hyaluronate eye drops of different osmolarity for the treatment of dry eye in Sjögren's syndrome patients. Br J Ophthalmol 2002; 86:879.
  19. Aragona P, Papa V, Micali A, et al. Long term treatment with sodium hyaluronate-containing artificial tears reduces ocular surface damage in patients with dry eye. Br J Ophthalmol 2002; 86:181.
  20. Brignole F, Pisella PJ, Dupas B, et al. Efficacy and safety of 0.18% sodium hyaluronate in patients with moderate dry eye syndrome and superficial keratitis. Graefes Arch Clin Exp Ophthalmol 2005; 243:531.
  21. Condon PI, McEwen CG, Wright M, et al. Double blind, randomised, placebo controlled, crossover, multicentre study to determine the efficacy of a 0.1% (w/v) sodium hyaluronate solution (Fermavisc) in the treatment of dry eye syndrome. Br J Ophthalmol 1999; 83:1121.
  22. McDonald CC, Kaye SB, Figueiredo FC, et al. A randomised, crossover, multicentre study to compare the performance of 0.1% (w/v) sodium hyaluronate with 1.4% (w/v) polyvinyl alcohol in the alleviation of symptoms associated with dry eye syndrome. Eye (Lond) 2002; 16:601.
  23. Toda I, Shinozaki N, Tsubota K. Hydroxypropyl methylcellulose for the treatment of severe dry eye associated with Sjögren's syndrome. Cornea 1996; 15:120.
  24. Nilforoushan MR, Latkany RA, Speaker MG. Effect of artificial tears on visual acuity. Am J Ophthalmol 2005; 140:830.
  25. Lenton LM, Albietz JM. Effect of carmellose-based artificial tears on the ocular surface in eyes after laser in situ keratomileusis. J Refract Surg 1999; 15:S227.
  26. Pucker A, Marrone M, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev 2012; :CD009729.
  27. Baudouin C, Labbé A, Liang H, et al. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res 2010; 29:312.
  28. Pisella PJ, Pouliquen P, Baudouin C. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Br J Ophthalmol 2002; 86:418.
  29. Jaenen N, Baudouin C, Pouliquen P, et al. Ocular symptoms and signs with preserved and preservative-free glaucoma medications. Eur J Ophthalmol 2007; 17:341.
  30. Uusitalo H, Chen E, Pfeiffer N, et al. Switching from a preserved to a preservative-free prostaglandin preparation in topical glaucoma medication. Acta Ophthalmol 2010; 88:329.
  31. Foulks GN. Treatment of dry eye disease by the non-ophthalmologist. Rheum Dis Clin North Am 2008; 34:987.
  32. Fox RI, Howell FV, Bone RC, Michelson P. Primary Sjogren syndrome: clinical and immunopathologic features. Semin Arthritis Rheum 1984; 14:77.
  33. Dastjerdi MH, Hamrah P, Dana R. High-frequency topical cyclosporine 0.05% in the treatment of severe dry eye refractory to twice-daily regimen. Cornea 2009; 28:1091.
  34. Gupta A, Sadeghi PB, Akpek EK. Occult thyroid eye disease in patients presenting with dry eye symptoms. Am J Ophthalmol 2009; 147:919.
  35. Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group. Arch Intern Med 1999; 159:174.
  36. Petrone D, Condemi JJ, Fife R, et al. A double-blind, randomized, placebo-controlled study of cevimeline in Sjögren's syndrome patients with xerostomia and keratoconjunctivitis sicca. Arthritis Rheum 2002; 46:748.
  37. Papas AS, Sherrer YS, Charney M, et al. Successful Treatment of Dry Mouth and Dry Eye Symptoms in Sjögren's Syndrome Patients With Oral Pilocarpine: A Randomized, Placebo-Controlled, Dose-Adjustment Study. J Clin Rheumatol 2004; 10:169.
  38. Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology 2000; 107:631.
  39. Yen MT, Pflugfelder SC, Feuer WJ. The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. Am J Ophthalmol 2001; 131:314.
  40. Roberts CW, Carniglia PE, Brazzo BG. Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Cornea 2007; 26:805.
  41. Ramos-Casals M, Tzioufas AG, Stone JH, et al. Treatment of primary Sjögren syndrome: a systematic review. JAMA 2010; 304:452.
  42. Tatlipinar S, Akpek EK. Topical ciclosporin in the treatment of ocular surface disorders. Br J Ophthalmol 2005; 89:1363.
  43. Kunert KS, Tisdale AS, Stern ME, et al. Analysis of topical cyclosporine treatment of patients with dry eye syndrome: effect on conjunctival lymphocytes. Arch Ophthalmol 2000; 118:1489.
  44. Barber LD, Pflugfelder SC, Tauber J, Foulks GN. Phase III safety evaluation of cyclosporine 0.1% ophthalmic emulsion administered twice daily to dry eye disease patients for up to 3 years. Ophthalmology 2005; 112:1790.
  45. Kim EC, Choi JS, Joo CK. A comparison of vitamin a and cyclosporine a 0.05% eye drops for treatment of dry eye syndrome. Am J Ophthalmol 2009; 147:206.
  46. Marsh P, Pflugfelder SC. Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjögren syndrome. Ophthalmology 1999; 106:811.
  47. Pflugfelder SC, Solomon A, Stern ME. The diagnosis and management of dry eye: a twenty-five-year review. Cornea 2000; 19:644.
  48. Pflugfelder SC, Maskin SL, Anderson B, et al. A randomized, double-masked, placebo-controlled, multicenter comparison of loteprednol etabonate ophthalmic suspension, 0.5%, and placebo for treatment of keratoconjunctivitis sicca in patients with delayed tear clearance. Am J Ophthalmol 2004; 138:444.
  49. Berdoulay A, English RV, Nadelstein B. Effect of topical 0.02% tacrolimus aqueous suspension on tear production in dogs with keratoconjunctivitis sicca. Vet Ophthalmol 2005; 8:225.
  50. Nell B, Walde I, Billich A, et al. The effect of topical pimecrolimus on keratoconjunctivitis sicca and chronic superficial keratitis in dogs: results from an exploratory study. Vet Ophthalmol 2005; 8:39.
  51. Avunduk AM, Avunduk MC, Varnell ED, Kaufman HE. The comparison of efficacies of topical corticosteroids and nonsteroidal anti-inflammatory drops on dry eye patients: a clinical and immunocytochemical study. Am J Ophthalmol 2003; 136:593.
  52. Hong S, Kim T, Chung SH, et al. Recurrence after topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjögren's syndrome. J Ocul Pharmacol Ther 2007; 23:78.
  53. Hamano T. Lacrimal duct occlusion for the treatment of dry eye. Semin Ophthalmol 2005; 20:71.
  54. Mansour K, Leonhardt CJ, Kalk WW, et al. Lacrimal punctum occlusion in the treatment of severe keratoconjunctivitis Sicca caused by Sjögren syndrome: a uniocular evaluation. Cornea 2007; 26:147.
  55. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol 2001; 131:30.
  56. Gilbard JP, Rossi SR, Azar DT, Heyda KG. Effect of punctal occlusion by Freeman silicone plug insertion on tear osmolarity in dry eye disorders. CLAO J 1989; 15:216.
  57. Willis RM, Folberg R, Krachmer JH, Holland EJ. The treatment of aqueous-deficient dry eye with removable punctal plugs. A clinical and impression-cytologic study. Ophthalmology 1987; 94:514.
  58. Musadiq M, Mukherji S, Sandramouli S. Pyogenic granuloma following silicone punctal plugs: report of two cases. Orbit 2005; 24:149.
  59. Kim BM, Osmanovic SS, Edward DP. Pyogenic granulomas after silicone punctal plugs: a clinical and histopathologic study. Am J Ophthalmol 2005; 139:678.
  60. Cohen EJ. Punctal occlusion. Arch Ophthalmol 1999; 117:389.
  61. Vrabec MP, Elsing SH, Aitken PA. A prospective, randomized comparison of thermal cautery and argon laser for permanent punctal occlusion. Am J Ophthalmol 1993; 116:469.
  62. Fox RI, Dixon R, Guarrasi V, Krubel S. Treatment of primary Sjögren's syndrome with hydroxychloroquine: a retrospective, open-label study. Lupus 1996; 5 Suppl 1:S31.
  63. Yavuz S, Asfuroğlu E, Bicakcigil M, Toker E. Hydroxychloroquine improves dry eye symptoms of patients with primary Sjogren's syndrome. Rheumatol Int 2011; 31:1045.
  64. Rihl M, Ulbricht K, Schmidt RE, Witte T. Treatment of sicca symptoms with hydroxychloroquine in patients with Sjogren's syndrome. Rheumatology (Oxford) 2009; 48:796.
  65. Kruize AA, Hené RJ, Kallenberg CG, et al. Hydroxychloroquine treatment for primary Sjögren's syndrome: a two year double blind crossover trial. Ann Rheum Dis 1993; 52:360.
  66. Gottenberg JE, Ravaud P, Puéchal X, et al. Effects of hydroxychloroquine on symptomatic improvement in primary Sjögren syndrome: the JOQUER randomized clinical trial. JAMA 2014; 312:249.
  67. Meijer JM, Meiners PM, Vissink A, et al. Effectiveness of rituximab treatment in primary Sjögren's syndrome: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2010; 62:960.
  68. Dass S, Bowman SJ, Vital EM, et al. Reduction of fatigue in Sjögren syndrome with rituximab: results of a randomised, double-blind, placebo-controlled pilot study. Ann Rheum Dis 2008; 67:1541.
  69. Carubbi F, Cipriani P, Marrelli A, et al. Efficacy and safety of rituximab treatment in early primary Sjögren's syndrome: a prospective, multi-center, follow-up study. Arthritis Res Ther 2013; 15:R172.
  70. Fox PC, Datiles M, Atkinson JC, et al. Prednisone and piroxicam for treatment of primary Sjögren's syndrome. Clin Exp Rheumatol 1993; 11:149.
  71. Skopouli FN, Jagiello P, Tsifetaki N, Moutsopoulos HM. Methotrexate in primary Sjögren's syndrome. Clin Exp Rheumatol 1996; 14:555.
  72. van Woerkom JM, Kruize AA, Geenen R, et al. Safety and efficacy of leflunomide in primary Sjögren's syndrome: a phase II pilot study. Ann Rheum Dis 2007; 66:1026.
  73. Price EJ, Rigby SP, Clancy U, Venables PJ. A double blind placebo controlled trial of azathioprine in the treatment of primary Sjögren's syndrome. J Rheumatol 1998; 25:896.
  74. Mariette X, Ravaud P, Steinfeld S, et al. Inefficacy of infliximab in primary Sjögren's syndrome: results of the randomized, controlled Trial of Remicade in Primary Sjögren's Syndrome (TRIPSS). Arthritis Rheum 2004; 50:1270.
  75. Zandbelt MM, de Wilde P, van Damme P, et al. Etanercept in the treatment of patients with primary Sjögren's syndrome: a pilot study. J Rheumatol 2004; 31:96.
  76. Sankar V, Brennan MT, Kok MR, et al. Etanercept in Sjögren's syndrome: a twelve-week randomized, double-blind, placebo-controlled pilot clinical trial. Arthritis Rheum 2004; 50:2240.
  77. Meiners PM, Vissink A, Kroese FG, et al. Abatacept treatment reduces disease activity in early primary Sjögren's syndrome (open-label proof of concept ASAP study). Ann Rheum Dis 2014; 73:1393.
  78. Mariette X, Seror R, Quartuccio L, et al. Efficacy and safety of belimumab in primary Sjögren's syndrome: results of the BELISS open-label phase II study. Ann Rheum Dis 2015; 74:526.
  79. Romero-Rangel T, Stavrou P, Cotter J, et al. Gas-permeable scleral contact lens therapy in ocular surface disease. Am J Ophthalmol 2000; 130:25.
  80. van der Worp E, Bornman D, Ferreira DL, et al. Modern scleral contact lenses: A review. Cont Lens Anterior Eye 2014; 37:240.
  81. Schornack MM, Pyle J, Patel SV. Scleral lenses in the management of ocular surface disease. Ophthalmology 2014; 121:1398.
  82. Tsubota K, Goto E, Fujita H, et al. Treatment of dry eye by autologous serum application in Sjögren's syndrome. Br J Ophthalmol 1999; 83:390.
  83. Kojima T, Ishida R, Dogru M, et al. The effect of autologous serum eyedrops in the treatment of severe dry eye disease: a prospective randomized case-control study. Am J Ophthalmol 2005; 139:242.
  84. Fox RI, Chan R, Michelson JB, et al. Beneficial effect of artificial tears made with autologous serum in patients with keratoconjunctivitis sicca. Arthritis Rheum 1984; 27:459.
  85. Pan Q, Angelina A, Zambrano A, et al. Autologous serum eye drops for dry eye. Cochrane Database Syst Rev 2013; :CD009327.
  86. Yoon KC, Heo H, Im SK, et al. Comparison of autologous serum and umbilical cord serum eye drops for dry eye syndrome. Am J Ophthalmol 2007; 144:86.
  87. Guidera AC, Luchs JI, Udell IJ. Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Ophthalmology 2001; 108:936.
  88. Aragona P, Bucolo C, Spinella R, et al. Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjögren's syndrome patients. Invest Ophthalmol Vis Sci 2005; 46:4474.
  89. Oxholm P, Manthorpe R, Prause JU, Horrobin D. Patients with primary Sjögren's syndrome treated for two months with evening primrose oil. Scand J Rheumatol 1986; 15:103.
  90. Miljanović B, Trivedi KA, Dana MR, et al. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr 2005; 82:887.
  91. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea 2003; 22:97.
  92. Sullivan DA, Edwards JA. Androgen stimulation of lacrimal gland function in mouse models of Sjögren's syndrome. J Steroid Biochem Mol Biol 1997; 60:237.
  93. Pillemer SR, Brennan MT, Sankar V, et al. Pilot clinical trial of dehydroepiandrosterone (DHEA) versus placebo for Sjögren's syndrome. Arthritis Rheum 2004; 51:601.
  94. Thanou-Stavraki A, James JA. Primary Sjogren's syndrome: current and prospective therapies. Semin Arthritis Rheum 2008; 37:273.
  95. Tauber J, Davitt WF, Bokosky JE, et al. Double-masked, placebo-controlled safety and efficacy trial of diquafosol tetrasodium (INS365) ophthalmic solution for the treatment of dry eye. Cornea 2004; 23:784.
  96. Gamache DA, Wei ZY, Weimer LK, et al. Corneal protection by the ocular mucin secretagogue 15(S)-HETE in a rabbit model of desiccation-induced corneal defect. J Ocul Pharmacol Ther 2002; 18:349.
  97. Jumblatt JE, Cunningham LT, Li Y, Jumblatt MM. Characterization of human ocular mucin secretion mediated by 15(S)-HETE. Cornea 2002; 21:818.
  98. Gipson IK, Hori Y, Argüeso P. Character of ocular surface mucins and their alteration in dry eye disease. Ocul Surf 2004; 2:131.
  99. Urashima H, Okamoto T, Takeji Y, et al. Rebamipide increases the amount of mucin-like substances on the conjunctiva and cornea in the N-acetylcysteine-treated in vivo model. Cornea 2004; 23:613.
  100. Peral A, Domínguez-Godínez CO, Carracedo G, Pintor J. Therapeutic targets in dry eye syndrome. Drug News Perspect 2008; 21:166.
  101. Nakamura M, Endo K, Nakata K, Hamano T. Gefarnate stimulates secretion of mucin-like glycoproteins by corneal epithelium in vitro and protects corneal epithelium from desiccation in vivo. Exp Eye Res 1997; 65:569.
  102. Campos M, Takahashi R, Tanaka H, et al. Inflammation-related scarring after photorefractive keratectomy. Cornea 1998; 17:607.
  103. Di Pascuale MA, Liu TS, Trattler W, Tseng SC. Lipid tear deficiency in persistent dry eye after laser in situ keratomileusis and treatment results of new eye-warming device. J Cataract Refract Surg 2005; 31:1741.
  104. Albietz JM, Lenton LM, McLennan SG. Dry eye after LASIK: comparison of outcomes for Asian and Caucasian eyes. Clin Exp Optom 2005; 88:89.
  105. Graham WP 3rd, Messner KH, Miller SH. Keratoconjunctivitis sicca symptoms appearing after blepharoplasty. The "dry eye" syndrome. Plast Reconstr Surg 1976; 57:57.
  106. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: guidelines for surgery? Plast Reconstr Surg 1981; 68:249.
  107. Rees TD, LaTrenta GS. The role of the Schirmer's test and orbital morphology in predicting dry-eye syndrome after blepharoplasty. Plast Reconstr Surg 1988; 82:619.
  108. Saadat D, Dresner SC. Safety of blepharoplasty in patients with preoperative dry eyes. Arch Facial Plast Surg 2004; 6:101.