Dryness beyond the surface: Sjogren’s and the eye

Background: Sjogren’s syndrome is a chronic systemic autoimmune disease characterized by lymphocytic infiltration and progressive destruction of exocrine glands, particularly the lacrimal and salivary glands. It may occur as a primary condition or secondary to other autoimmune diseases, most commonly rheumatoid arthritis. The hallmark pathology involves autoimmune mediated damage leading to aqueous tear deficiency and resultant keratoconjunctivitis sicca. Ocular dryness in Sjogren’s syndrome is typically severe and associated with significant ocular surface inflammation compared to non autoimmune dry eye disease. Early recognition is essential as ocular manifestation may precede systemic features and facilitate timely diagnosis and management.

Case Presentation: A 62 years old lady presented with a one year history of bilateral blurred vision that worsen throughout the day accompanied by painless persistent gritty and sandy sensation, photophobia, and sticky eye discharge. During a recent dental visit, she reported persistent oral dryness with a gradual decline in salivary flow over time, and clinical assessment confirmed xerostomia. Ocular examination revealed right eye visual acuity of 6/36, improving to 6/24 with pinhole. She had meibomian capping with mildly injected conjunctiva and minimal whitish mucous discharge. Cornea had superficial corneal vascularization at the inferior limbus, with generalized punctate epithelial erosions and inferoparacentral corneal thinning with a small epithelial defect. The anterior chamber was deep and quiet with no hypopyon, the pupil was round and reactive, and intraocular pressure was normal. Upon further investigation, multiple autoimmune work up showed positive for rheumatoid factor and Sjogren syndrome. Symptoms and clinical signs improved after completion of intravenous methylprednisolone and oral hydroxychloroquine.

Conclusion: Recognising dry eye early in Sjogren's syndrome is important as ocular symptoms often precede systemic manifestations and provide a key window for intervention. If left untreated, chronic dryness may result in corneal damage, recurrent infections, and significant visual impairment disrupting activity of daily living. Early diagnosis allows for timely initiation of therapies including lubricating drops, anti-inflammatory and immunomodulatory medications. It also prompts evaluation for systemic disease enabling more comprehensive patient care.