GENERAL:
The dry eye syndrome (SS) is becoming more prevalent due to current living conditions.
Indeed, the dry air conditioned and heated and screen work which reduces the eyelid blink promote drying. The SS is more common in the elderly due to polypharmacy and glandular atrophy senile.
Its prevalence is over 20% beyond 60 years and in fact one of the main reasons for ophthalmologic consultation.
It defi nes the SS as all clinical manifestations resulting from a qualitative or quantitative decrease secretions various mucous membranes or skin. It mainly affects the eyes (xerophthalmia) and mouth (xerostomia), but also the vagina, respiratory tract, gastrointestinal tract and skin.
SS objectives must be distinguished (confirmed by tests) subjective SS (set of symptoms experienced by patients).
The management of the SS has a threefold purpose:
– Prevention and detection of secondary lesions in SS regardless of the cause;
– Determine the SS indicative of a general disease;
– Relief and reassurance.
SS pose multiple challenges:
– Potential for paradoxical watering;
– Poor correlation between symptoms and amount of secretions;
– Sometimes hard drugs responsible to identify or stop;
– Choice of etiological explorations;
– Limited treatments.
DIAGNOSTIC:
The clinical examination is to collect the evidence to authenticate the SS, assess its impact and look for a cause.
Dry eye syndrome signs:
Simple questions corresponding to the diagnostic criteria for Sjogren’s syndrome (SS) produce “reliable” answers. Does the patient have:
– Daily feeling of dry eye for more than three months?
– Frequent printing of sand or gravel in the eyes?
– Need to use artificial tears more than three times a day?
– Daily feeling of dry ouche b for more than three months?
– The need to frequently drink to swallow dry food.
These validated elements (but not specific) are mainly intended for obtaining standardized patients in study groups.
However, they stress that the persistence of subjective signs is important to help define a SS.
Xerophthalmia can also be seen as an embarrassment to the opening of the eyes in the morning, burning, itching, photophobia, or decreased visual acuity or a paradoxical watering. Likewise, xerostomia may also be perceived as a glossodynia, oral burning, thick saliva sensation or discomfort to speak or swallow.
These symptoms can be caused by any other disease: conjunctivitis, blepharitis, cataract, tonsillitis, glossitis, stomatitis, etc.
We must then seek other SS locations: cutaneous (skin dry, flaky, itchy), genital (dyspareunia, pruritus, etc.), respiratory (cough, hoarseness, nasal crusts, epistaxis) or digestive (retrosternal burns).
In addition to these symptoms, a simple examination provides an objective argument for SS: evaluation of unstimulated salivary flow.
This is to spit his saliva to the patient in a container for a quarter of an hour, without chewing or drug stimulation. If the flow is less than 1.5 mL, it is an objective xerostomia.
Resounding:
This assessment is particularly important because the SS can cause disasters including ocular and oral, especially in patients little cozy, negligent or desocialized who do not consult SS.
Ocular complications:
This is especially the ophthalmologist who search but the suspect can motivate the emergency consultation. In this context of SS, the recent onset of decreased visual acuity, ocular pain or redness must fear a dry keratitis. These keratitis may be ulcerated or secondary infection, and leave corneal scarring with persistent loss of visual acuity.
Oral repercussion:
The hyposialie can make speech, chewing and swallowing difficult or painful.
The buccal and lingual mucosa are willingly dull, glazed, the depapillated language.
You can see cracks commissure lip or tongue and mouth or lip sores. SS favors recurrent bacterial or fungal infections: caries, periodontitis, gingivitis, glossitis, stomatitis, sialadenitis, etc. This complication can lead to tooth loss and the need for equipment. This is often poorly tolerated because psychologically and even the SS.
Psychological impact:
Persistent discomfort of the SS, its various complications and fear of an underlying disease often have a detrimental effect on these patients already willingly anxiodepressive field.
Referral to a cause:
The causes are many SS, but because of their frequent involvement must be sought before any drug taken.
The medical and surgical history must be listed in the search for a cure or disease can induce a SS and autoimmune diseases may be complicated by secondary SS (rheumatoid arthritis, primary biliary cirrhosis, autoimmune chronic hepatitis , dysthyroidism autoimmune diseases, systemic lupus erythematosus, systemic sclerosis, dermatopolymyositis).
Somatic examination mainly looking swollen salivary glands or tear, arthritis or arthralgia, myalgia, lymphadenopathy, splenomegaly, hepatomegaly, jaundice, pruritus, purpura, Raynaud syndrome, peripheral neuropathy or signs of thyroid dysfunction.
ADDITIONAL TESTS:
These examinations are adapted to the context: decision-drying medicines, physiological age, autoimmune disease known underlying, impact of SS.
Eye Exam:
Systematic, it looks SS complications (see above) and a local cause of SS: meibomianitis chronic disorder of the eyelid static etc.
It mainly shows the SS objective elements:
– Schirmer test: a graduated filter paper strip is inserted into the cul-de-sac lower conjunctival. Xerophthalmia is objectified if less than 5 mm are moistened in 5 minutes. However, this test is not reliable beyond 60 years;
– Rose Bengal test or lissamine green: it highlights keratoconjunctivitis sicca by staining dead cells of the conjunctiva and cornea;
– Breaking time of the tear film (break up time [GOAL]): it assesses the stability of the tear film made visible by fluorescein. It is pathological less than 10 seconds.
Oral exam:
In the absence of recent consultation, the patient should be referred to a dentist or oral surgeon who research and treat complications of SS (see above) several times a year.
Laboratory tests:
If a cause of SS is evoked by the clinical examination, it is specifically sought.
In the absence of etiological if medication discontinuation possibly cause does not remove the SS, the minimum biological assessment includes: NFS, VS, serum electrolytes, urea, creatinine, glucose, calcium, protein electrophoresis (EPP), antinuclear antibodies (ANA), and anti-SSA-SSB, latex test and Waaler- Rose reaction and a hepatitis C serology
Following these reviews, if any guidance is found, a biopsy of the salivary glands (BGSA) should be considered. It consists of three biopsy salivary glands located on the inside of the lower lip, under local anesthesia by a dentist, internist or rheumatologist.
It evaluates a focal lymphoplasmacytic infi ltrate, which determines the next Chisholm score between 0 and 4; Stages 3 and 4 are very evocative of SMS. Some laboratories rather make a score of lymphoplasmacytic homes: this “focus score” greater than or equal to 1 corresponds to a Chisholm 3 or 4. The Congo red staining identifies amyloidosis.tuberculoid granulomas without casein suggest sarcoidosis.
ETIOLOGY:
The causes are multiple SS and only the main developed here.
The senile SS, although common (over 20%) should remain a diagnosis of exclusion. In fact, the glandular atrophy lacrimal and salivary age-related bit is usually symptomatic.
In the elderly, it is mainly the drying superimposed symptomatic medications that make the drought: they are involved in two thirds of cases.
Drug taking:
Drug taken render count of nearly half of the SS. The most common drugs involved are various psychotropic drugs (antidepressants, antipsychotics), antiparkinsonians, opioids, anticholinergics antihistamines and retinoids type of acne. Some toxic taken must also be sought: tobacco, cannabis, cocaine, ecstasy. Their arrest is desirable but often difficult.
Sjögren’s syndrome:
The syndrome of Sjogren always includes a SS. It is a connective which affects about 0.3% of the general population, 90% of women.
The diagnosis is usually made between 40 and 60 years.SMS is important because of its systemic complications (70% at diagnosis) and lymphoma (relative risk assessed 44).It can be described as an autoimmune exocrinopathy related focal lymphoplasmacytic infiltrates, but is currently defined by international standards. Swelling of the salivary glands is frequent. The extraglandular events can be numerous and sometimes inaugural: arthritis or polyarthralgie, myalgia, peripheral or central neurological disorders, purpura, Raynaud’s syndrome, interstitial pulmonary syndrome, renal tubular damage, etc. A anxiodepressive syndrome is common. Thyroid dysfunction exists in 15% of SGS. Biologically, we often find: ANA (70%), especially anti-SSA (60%) and anti-SSB (40%), rheumatoid factor (60%), a mostly polyclonal hypergammaglobulinemia may raise the VS, cryoglobulinemia, etc. In the absence of anti-SSA-SSB or antibody, BGSA classified Chisholm 3 or 4 is required for diagnosis.
The SMS may be primary or secondary to autoimmune disease: rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, primary biliary cirrhosis, chronic autoimmune hepatitis, autoimmune thyroid dysfunction, etc. The risk of developing lymphoma seems less frequent in case of secondary SS. This risk is known as increased by the existence of organomégalies (parotidomégalie, spleen, lymph nodes), a vascular purpura or appearance of laboratory abnormalities (hypogammaglobulinemia, monoclonal gammopathy, C4 low, cryoglobulinemia or elevated β2microglobulinémie) .
Diagnosis of SMS, are carried out: a complete physical examination, complete blood count, a chemistry panel, creatinine, an EPP, complement assay (C3, C4) and β2microglobuline and a chest X-ray and a dosage TSH. Apart from the last two, these examinations are part of monitoring at least annually of SMS.
Hydroxychloroquine is readily associated with the symptomatic treatment of SS. This molecule acts on arthromyalgia and improve the SS or limit its development. Corticosteroids and immunosuppressants are used in case of systemic manifestations.
Diabetes mellitus:
Diabetes mellitus are major providers of SS. A third of diabetics have xerophthalmia.
The diagnosis is easy since it is usually advanced or decompensated diabetes.
Hepatitis C:
Hepatitis C is complicated by SS in 12% of cases reaching more mouth than the eyes.
Thyroid dysfunction:
Among the patients with thyroid dysfunction, 3% have a SS. Post-thyroiditis hypothyroidism are more affected than Graves’ disease.
Sarcoidosis:
The SS of sarcoidosis is often moderate. The salivary and lacrimal glands are usually swollen that dried up.
The diagnosis is suggested by some classic events: parotidomégalie, uveitis, erythema nodosum, mediastinal lymphadenopathy, interstitial lung disease, etc. MSGB reveals tuberculoid granulomas without casein in almost half of cases. The diagnosis is confirmed by the absence of other causes of granulomatosis.
Amyloidosis:
SS affects 1-5% of patients with amyloidosis, more mouth the eyes.
The diagnosis is sometimes difficult due to the polymorphism of the disease (renal failure, heart failure, neuropathy, orthostatic hypotension, etc.). A context of monoclonal gammopathy, chronic inflammatory disease or familial amyloidosis can help diagnosis. This is obtained by MSGB in over 80% of cases.
Lymphomas:
Lymphomas often affect the salivary glands asymptomatically (28%), but are also likely to result in SS.
Faced with glandular swelling, the diagnosis is quickly discussed in a context of prolonged deterioration of general condition, night sweats, lymphadenopathy or splenomegaly.
Multiple sclerosis and Parkinson’s disease:
Multiple sclerosis and Parkinson’s disease can cause neurogenic SS aggravated by drugs necessary for their care.
At the stage occurs SS, the diagnosis is easy. The examination is usually sufficient to evoke graft against the host, parotidectomy, a sub-maxillectomy, a head and neck radiotherapy or treatment with radioactive iodine.
Rare causes:
Cystic fibrosis, hemochromatosis or thalassemia:
It is exceptional for a cystic fibrosis, hemochromatosis or thalassemia are revealed by an SS
Sialadénose:
The sialadénose is a cause of isolated SS. It preferentially affects diabetic patients, alcoholics, malnourished or bulimic.
Bilateral and painless parotidomégalie is common.
The diagnosis is made by biopsy of the salivary gland showing acini enlarged but not compressing inflammatory glandular channels.
Aplasia of the salivary glands:
Aplasia of the salivary glands is rare and often detected in the first days of life. The anhidrotic ectodermal dysplasia Christ-Siemens is a recessive genetic disorder linked to the X including a dysmorphia and agenesis or dysplasia of the exocrine glands.
Idiopathic sicca syndrome:
Idiopathic SS often because in about 20% of patients, no cause is found.
TREATMENT:
Treatment includes specific support for the causal affection of the SS and stops drying medicines as well as tobacco and alcohol. Contact lenses are not recommended. The air must be humidified. An eye tracking and multi-year oral is recommended.
Local treatments:
Xerophthalmia:
You should use single-dose topical preservative-free, because they can be irritating or toxic to the conjunctiva. Tear supplementation is still required by physiological serum eye drops and / or gels, sodium hyaluronate or soluble implants propyl. They have a prolonged effect, but are often poorly tolerated. The punctal occlusion by elastomer studs limits the leakage of residual tears and supplementation. In severe forms, glasses wet room and tears pumps are discussed.
The healing eye drops (vitamin A), antiseptic and anti-inflammatory drugs should be prescribed only temporarily and by an ophthalmologist.
cyclosporine eye drops are used in the SMS.
Xerostomia:
The recall of good oral hygiene rules is fundamental. Sugary foods should be avoided. Chewing gums and sugar free candy stimulates salivary secretion remaining. Saliva substitutes (gels, sprays) are often of limited value, but allow better tolerance dentures. Fungal secondary infections are preventable daily bicarbonate mouthwash and treated early by the local amphotéricine®. The dentist performs descaling
regular and evaluates the usefulness of the gutters by fluoride application.
Other locations of dry eye syndrome:
Vaginal dryness is treated by local lubricant application. The xeroderma is treated
by regular application of moisturizer.
Nasal dryness is treated by instillation of physiological saline and, in case of crusting rhinitis by applying Homéoplasmine®.
General treatments:
Adequate hydration should be ensured, at best by repeated small quantities in order to have a direct positive effect on xerostomia.
Water is preferred. Sugary or alcoholic drinks should be avoided.
Pilocarpine orally increases the salivary and lacrimal flow. It improves oral and ocular comfort in respectively 60 and 40% of cases. Its adverse effects include sweating, flushing, urinary frequency, nausea, headache and visual disturbances. The dose is 5 mg / x4 / d majorable up to 30 mg / day if the tolerance permits.
The manufactured tablets currently on the market have an authorization to place on the market restricted to certain indications: SMS and post-radiation therapy after failure of local SS treatments.
The bromhexidine and ANETHOLTRITHIONE are often used but have not proven their effectiveness.
