title: Systemic immunomodulatory therapy in severe dry eye secondary to inflammation.
abstract: OBJECTIVE
  To report four patients with unusually severe acute keratitis sicca secondary to lacrimal tissue and ocular surface inflammation who eventually required systemic immunosuppressive therapy.
  
  
  METHODS
  Observational case series of four patients with extremely severe acute dry eye syndrome who were profoundly disabled by pain and photophobia (to the extent of staying in dark rooms) despite aggressive conventional therapy. Clinical data including visual acuities, other treatments administered for dry eye, systemic medical conditions, Schirmer and rose bengal staining results, degree of conjunctival injection, and medications were recorded. All four patients were treated with systemic immunomodulatory therapy.
  
  
  RESULTS
  All four patients were female with a mean age at presentation of 40 years (range 22-58 years), and all had systemic autoimmune diseases: systemic lupus erythematosus (SLE) and Sjogren's syndrome (n = 2), Sjogren's syndrome (n = 1), rheumatoid arthritis (RA) and psoriasis (n = 1). Schirmer test values at onset ranged from 0 to 2 mm. All patients had failed aggressive lubrication, topical cyclosporine, lid care, and punctual plugs. In two patients, serum tears and hyphrecation punctal occlusion were tried without success. Various systemic immunosuppressive agents were used to control inflammation of the lacrimal glands: methotrexate and cyclosporine A (patient 1), cyclosporine A (patient 2), prednisone (patient 3), and methotrexate and infliximab (patient 4). Treatment with systemic immunomodulatory agents resulted in resolution of the acute inflammatory assault on the lacrimal glands and control of signs and symptoms of keratoconjunctivitis sicca in all four patients, and visual acuities improved in all of them. Post-treatment Schirmer values ranged from 7 to 10 mm.
  
  
  CONCLUSIONS
  Systemic immunosuppressive agents may be required in the treatment of recalcitrant primary and secondary Sjogren's syndrome caused by systemic autoimmune conditions. We show that systemic immunomodulatory therapy leads to significantly improved tear production and resolution of the keratoconjunctivitis in these rare but severe cases.
authors.affiliation: Massachusetts Eye Research & Surgery Institute, Cambridge, MA 02142, USA.
authors.forename: Miguel
authors.initials: M
authors.lastname: Cordero-Coma
authors.forename: Fahd
authors.initials: F
authors.lastname: Anzaar
authors.forename: Lucia
authors.initials: L
authors.lastname: Sobrin
authors.forename: C Stephen
authors.initials: CS
authors.lastname: Foster
mesh_terms: D000328:Adult; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000150:complications*; D016572:Cyclosporine / Q000627:therapeutic use; D004333:Drug Administration Routes; D004359:Drug Therapy, Combination; D015352:Dry Eye Syndromes / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D007249:Inflammation / Q000150:complications; D000069285:Infliximab; D008727:Methotrexate / Q000008:administration & dosage / Q000627:therapeutic use; D008875:Middle Aged; D011241:Prednisone / Q000008:administration & dosage / Q000627:therapeutic use; D011565:Psoriasis / Q000150:complications*; D012720:Severity of Illness Index; D012859:Sjogren's Syndrome / Q000150:complications*; D014409:Tumor Necrosis Factor-alpha
chemical_list: D000911:Antibodies, Monoclonal; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha; D016572:Cyclosporine; D000069285:Infliximab; D011241:Prednisone; D008727:Methotrexate