Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Treatment of dry eye in Sjögren's syndrome: General principles and initial therapy

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 ocular or systemic 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 general principles and initial treatment of dry eye in patients with SS will be reviewed here. The treatment of dry eye in patients with moderate to severe involvement and other issues in SS, 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, are discussed separately. (See "Treatment of moderate to severe dry eye in Sjögren's syndrome" and "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 "Overview of the management and prognosis 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".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Apr 04, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  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. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006; 25:900.
  5. Shimazaki J, Goto E, Ono M, et al. Meibomian gland dysfunction in patients with Sjögren syndrome. Ophthalmology 1998; 105:1485.
  6. Akpek EK, Klimava A, Thorne JE, et al. Evaluation of patients with dry eye for presence of underlying Sjögren syndrome. Cornea 2009; 28:493.
  7. Akpek EK, Mathews P, Hahn S, et al. Ocular and systemic morbidity in a longitudinal cohort of Sjögren's syndrome. Ophthalmology 2015; 122:56.
  8. Akpek EK, Lindsley KB, Adyanthaya RS, et al. Treatment of Sjögren's syndrome-associated dry eye an evidence-based review. Ophthalmology 2011; 118:1242.
  9. Foulks GN, Forstot SL, Donshik PC, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Ocul Surf 2015; 13:118.
  10. 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.
  11. 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.
  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. Fraunfelder FT, Sciubba JJ, Mathers WD. The role of medications in causing dry eye. J Ophthalmol 2012; 2012:285851.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. Toda I, Shinozaki N, Tsubota K. Hydroxypropyl methylcellulose for the treatment of severe dry eye associated with Sjögren's syndrome. Cornea 1996; 15:120.
  25. Nilforoushan MR, Latkany RA, Speaker MG. Effect of artificial tears on visual acuity. Am J Ophthalmol 2005; 140:830.
  26. 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.
  27. Pucker A, Marrone M, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev 2012; :CD009729.
  28. 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.
  29. 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.
  30. 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.
  31. 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.
  32. Foulks GN. Treatment of dry eye disease by the non-ophthalmologist. Rheum Dis Clin North Am 2008; 34:987.
  33. Fox RI, Howell FV, Bone RC, Michelson P. Primary Sjogren syndrome: clinical and immunopathologic features. Semin Arthritis Rheum 1984; 14:77.
  34. Abelson MB, Ousler G, Smith L, Santanam U. Bring them to tears with your treatment. Rev Ophthalmol 2015.
  35. Campos M, Takahashi R, Tanaka H, et al. Inflammation-related scarring after photorefractive keratectomy. Cornea 1998; 17:607.
  36. 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.
  37. Albietz JM, Lenton LM, McLennan SG. Dry eye after LASIK: comparison of outcomes for Asian and Caucasian eyes. Clin Exp Optom 2005; 88:89.
  38. Graham WP 3rd, Messner KH, Miller SH. Keratoconjunctivitis sicca symptoms appearing after blepharoplasty. The "dry eye" syndrome. Plast Reconstr Surg 1976; 57:57.
  39. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: guidelines for surgery? Plast Reconstr Surg 1981; 68:249.
  40. 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.
  41. Saadat D, Dresner SC. Safety of blepharoplasty in patients with preoperative dry eyes. Arch Facial Plast Surg 2004; 6:101.