Interprofessional Collaboration Pays Off

I was surprised to learn my new 62-year-old patient had been complaining about severe dry mouth to her primary care physician for the past 15 years with no relief. Year after year, she was advised to use mouth moisturizing tablets or a spray, and sent home. But when I heard her complaints of long-standing dry eyes and a dry mouth, I immediately thought of Sjögren syndrome (SS). These two symptoms don’t always indicate SS—especially considering the patient had no other underlying autoimmune conditions, such as systemic erythematous lupus or rheumatoid arthritis, as seen in secondary SS—but it should always be considered and ruled out.

THE PATIENT ENCOUNTER

While in my examination chair, I noticed the patient had a dry cough. She excused herself to grab a cough drop from her purse, which she explained was a daily occurrence. We discussed possible systemic and environmental factors that could exacerbate her dry eye signs and symptoms, and I started her on lifitegrast ophthalmic solution 5% (Xiidra, Bausch + Lomb) twice daily and fish oil. I also gave her a sample of artificial tears. We talked about punctal plugs, and I advised her to reach out to her primary care physician to request testing for SS.

Following up, I sent a simple letter to the patient’s primary care physician, discussing my exam findings and my concern for SS. That same week, her doctor ordered bloodwork, which confirmed that our patient was positive for both the SS-A and SS-B antibodies. According to the American College of Rheumatology and the European League Against Rheumatism classification criteria, our patient had a score greater than 4, confirming her diagnosis of primary SS (Tables 1 and 2).

Our patient’s primary care physician referred her to a rheumatologist, and after years of complaints, she was finally on a path to proper care and effective treatment.

SJÖGREN SYNOPSIS

Because dry eye disease, or keratoconjunctivitis sicca, is a defining factor of SS, it is necessary for optometrists to identify and comanage the condition. In fact, ocular symptoms often precede systemic symptoms of the disease, which means our diagnosis of dry eye can very well be the first step in identifying SS.¹

It’s important to note that SS is not uncommon (see Sjögren Syndrome).^1,2 SS is associated with HLA B-8, HLA DR-w2 in women, and HLA DR-w3 in men. Around 10% to 15% of patients with SS will have involvement of the liver, kidneys, and lungs, which can lead to vasculitis, arthralgia, or arthritis.³ For this reason, it is helpful for providers to examine the skin, tongue, and eyes of patients.⁴ Because the disease targets the exocrine glands of mucous membranes, the hallmark signs of dry eyes and a dry mouth are common. However, various other symptoms can occur with this condition, causing patients to complain of joint and muscle pain, rashes, dry cough, fatigue, vaginal dryness, and tingling and numbness of the extremities.¹ Additionally, patients with SS have increased risk of non-Hodgkin lymphoma.⁵ Whether they also have increased risk of other malignancies is currently unclear.

MORAL OF THE STORY

Although I was excited and relieved for my patient and her potential for an improved quality of life from this diagnosis, it was upsetting to know that she had been dealing with this for more than a decade. We may not see patients with SS often, but as primary eye care providers, we must be able to recognize not only its ocular signs and symptoms, but also its systemic signs and symptoms.

Working closely with her primary care physician, I was able to help this patient with diagnosis, referral, and treatment of SS—she remained in my care for dry eye management—highlighting the significance of effective collaboration among all members of the care team.