Ocular Symptoms in Sjögren's Syndrome
Patients with Sjögren's syndrome experience dry eye symptoms that range from mild irritation to severe visual dysfunction, with keratoconjunctivitis sicca occurring in virtually all cases. 1, 2
Primary Dry Eye Symptoms
The hallmark ocular complaints include:
- Foreign body sensation (gritty, sandy feeling in the eyes) 3, 1
- Burning or stinging sensation 3, 1
- Eye irritation and itchiness 1
- Ocular pain 1
- Light sensitivity (photophobia) that can impair visual function 3, 1
- Frequent need for eye drops to relieve dryness and irritation 1
These symptoms vary considerably between patients depending on the severity of tear deficiency, the residual tear film's ability to lubricate the ocular surface, and individual pain tolerance. 2
Visual Dysfunction Symptoms
Beyond discomfort, Sjögren's causes significant vision-related problems:
- Fluctuating or blurred vision 3, 1
- Reduced visual acuity 3
- Low contrast sensitivity 3
- Visual dysfunction that negatively impacts quality of life 4
A critical gap exists in current disease activity instruments—the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) includes only one item addressing overall dryness without specifically evaluating dry eye symptoms or vision-related quality of life. 4
Observable Clinical Signs
Patients may notice:
- Eye redness (conjunctival hyperemia) 3
- Mucus discharge or mucous strands 3
- Decreased tear production (reduced tear meniscus visible at lower eyelid margin) 3
Severe Complications (Vision-Threatening)
While less common, Sjögren's can cause serious extraglandular ocular manifestations that ophthalmologists and rheumatologists often underappreciate:
- Corneal melt or perforation 4
- Uveitis 1, 4
- Scleritis 1, 4
- Sterile keratitis 1
- Retinal vasculitis 4
- Optic neuritis 4
- Blepharospasm (secondary to severe ocular inflammation) 3
These vision-threatening complications are notably absent from current SS disease activity measurement instruments like the ESSDAI, representing a significant oversight in disease monitoring. 4
Progressive Nature
Sjögren's-related dry eye is a progressive condition, not a static complaint. 4 The disease typically presents with varying severity levels, and examination findings can fluctuate—in one study, 21% of eyes showed changing keratoconjunctivitis sicca status between consecutive visits in patients with primary Sjögren's syndrome. 5 This variability means that testing should be repeated in symptomatic patients with initially negative results. 5
Clinical Context
Approximately 10% of patients with clinically significant aqueous-deficient dry eye have underlying Sjögren's syndrome, yet widespread underappreciation leads to significant underdiagnosis and diagnostic delays. 3, 1, 4 The symptoms alone are non-diagnostic—they require correlation with objective testing (Schirmer test, ocular surface staining, tear break-up time) and serological evaluation for definitive diagnosis. 5