Topical lubricants, steroids may help dry eye due to Sjögren's syndrome

NEW YORK (Reuters Health) - Eyedrops containing lubricants, corticosteroids, cyclosporine, or autologous serum improve dry eye due to Sjögren's syndrome (SS), according to a literature review. Evidence also shows some benefit from punctual occlusion and from oral drugs that stimulate saliva and tear production.

On the other hand, topical nonsteroidal anti-inflammatory medications (NSAIDs) can damage the cornea, leading the reviewers at Johns Hopkins Institutions in Baltimore, MD, to oppose NSAIDs for SS sicca syndrome. Data were too weak to support use of dietary supplements or systemic immunomodulatory agents.

However, studies were small and of short duration, and none of the therapies changed the disease course, the authors report in Ophthalmology published online April 4.

For their outcomes analysis, first author Dr. Esen Karamursel Akpek and colleagues searched PubMed and the Cochrane Collaboration database for prospective, comparative trials of dry eye therapies published between 1975 and 2010. The 62 studies they identified each included at least 10 patients with SS.

Topical agents

Four trials looked at topical lubricants (sodium hyaluronate; hydroxypropyl cellulose inserts plus saline or oxypropyl methylcellulose; or aluminum sucrose sulfate). Results showed improvements in symptoms and in objective signs, such as tear film breakup time and conjunctival staining.

One trial of short-term pulse topical methylprednisolone showed symptom relief and objective improvements. In four trials of cyclosporine, evidence supported less discomfort, better test results, and in one trial, a decrease in activated lymphocytes in conjunctival biopsies.

However, in a trial of NSAIDs, diclofenac worsened corneal staining.

In three of four trials, autologous serum or umbilical cord serum eased ocular discomfort, and one trial showed better results on objective tests.

The two studies of punctual plugs both showed symptomatic and objective improvement. Since about a third of these plugs become dislodged, the authors suggest that permanent surgical closure may be an option to consider.

Systemic treatments

Secretagogues seem to be helpful: Three trials of pilocarpine all showed moister eyes. In four trials of cevimeline -- an acetylcholine derivative - three indicated subjective improvement. However, these drugs trouble many patients with their side effects.

On the other hand, systemic immunosuppressive/immunomodulatory therapy couldn't be recommended. These trials involved hydroxychloroquine, rituximab, antitumor necrosis factor agents, D-penicillamine, mycophenolic acid, interferon alpha-2, and oral corticosteroids. Although they relieved systemic SS symptoms, they did not bring tears to the eye.

"Unfortunately, the current literature includes almost exclusively short-term studies with small sample sizes," and more research is required, Dr. Akpek's team concludes.

Still, Dr. George Papaliodis, who was not involved in the review, called their findings "completely reasonable." Dr. Papaliodis is director of the Immunology-Uveitis Service at Massachusetts Eye and Ear Infirmary in Boston and professor of ophthalmology at Harvard Medical School.

He tends to start these patients on topical lubricants and serum, plus punctal occlusion if the patient has tears. As he explained, plugs keep tears on the eye longer by blocking drainage into the nasolacrimal duct. "But many patients with Sjögren's have zero tear production."

Instead, he has "a low threshold" for starting topical cyclosporine, with its "very elegant way of treating the underlying disease process" -- the immune-mediated attack against the lacrimal gland. And unlike topical corticosteroids, which raise the risk for cataracts and glaucoma, cyclosporine has no long-term adverse effects.

Dr. Papaliodis at times recommends flaxseed oil because of anecdotal reports that it stabilizes the lipid layer of the tear film. Just as Dr. Akpek's team found, it has not been proven effective in randomized controlled trials, Dr. Papaliodis said, but "there's also no evidence of harm."

By Karla Gale

Source: https://bit.ly/hVQZtt

Ophthalmology 2011.

Last Updated: 2011-04-12 18:08:07 -0400 (Reuters Health)

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