Transcript Tear Film Osmolarity in Sjogren’s Syndrome

Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD,
Frederick B. Vivino, MD*, Stephen E. Orlin, MD,
Michael E. Sulewski, MD, and Maureen G. Maguire, PhD
Scheie Eye Institute, University of Pennsylvania,
Philadelphia, PA
*Division of Rheumatology, Penn Presbyterian Medical Center,
Philadelphia, PA
The authors are receiving research supplies from TearLab for a separate study.
Purpose
 To study tear film osmolarity in Sjogren’s syndrome
patients
 To assess if tear film osmolarity in Sjogren’s syndrome
patients is correlated with symptoms (OSDI) or
unanesthetized Schirmer testing
 To compare patient discomfort associated with tear
osmolarity testing to unanesthetized Schirmer testing
Methods
 Prospective study to evaluate the tear film osmolarity of
Sjogren’s syndrome patients
 Demographic information and medication usage was
recorded
 Tear film osmolarity: TearLab osmolarity system
 System calibrated daily as specified by manufacturer
 Unanesthetized Schirmer testing
 Patient-reported pain scores (0-5 with 5 = severe pain) after
tear osmolarity and Schirmer testing
 OSDI self-administered
 Spearman (non-parametric) correlation coefficients used
due to small sample size
Results
Age
Mean (Std), yrs
55.7 (15.5)
Range
18-88
Sex
Male
1 (5%)
Female
19 (95%)
Race/Ethnicity
White
13 (65%)
African-American
6 (30%)
Hispanic
1 (5%)
Sjogren’s Syndrome
Primary
16 (80%)
Secondary
4 (20%)
Medication Use
Systemic Medications
Hydroxychloroquine (Plaquenil)
12 (63%)
Pilocarpine (Salagen)
12 (63%)
Fish oil (not Lovaza)
11 (58%)
Omega-3-acid ethyl esters (Lovaza)
3 (16%)
Flaxseed
6 (32%)
Prednisone (oral)
6 (32%)
Methotrexate
4 (21%)
Azathioprine (Imuran)
2 (11%)
Rituximab (Rituxan)
1 (6%)
Eye Medications
Cyclosporine (Restasis)
5 (26%)
Erythromycin Ointment
2 (11%)
*1 patient did not provide a medication list
Results
 Average OSDI score: 46.6
 Average tear osmolarity: 311 mOsmol/L
 Average unanesthetized Schirmer score: 13 mm/5 min
 Median pain scores
Tear osmolarity testing:
1
Unanesthetized Schirmer testing:
4
p < 0.001 (Wilcoxon signed rank test)
OSDI by Schirmer score
100
r = 0.27
p = 0.26
OSDI Score
80
60
40
20
0
0
10
20
30
Schirmer (mm/5 min)
40
OSDI does not correlate well with unanesthetized Schirmer score
(averaged between eyes).
OSDI by Tear Osmolarity
100
r = -0.55
p = 0.01
OSDI Score
80
60
40
20
0
275
300
325
350
Average Tear Osmolarity (mOsmol/L)
375
OSDI correlates well with tear osmolarity (averaged between eyes).
r= - 0.14
p= 0.56
Average unanesthetized Schirmer score does not correlate with average
tear osmolarity.
Previous studies have suggested that tear film
osmolarity may be the single best test in the
diagnosis of dry eye.1, 2 To our knowledge, tear
osmolarity has not been studied specifically in
Sjogren’s syndrome patients.
In our study, the average tear osmolarity was
311 mOsmol/L. This is lower than the referent of 316
mOsmol/L.1 This is most likely due to the fact that
95% of our patients were on treatment at the time of
the study. We would expect the tear osmolarity to be
higher in untreated patients.
Tear osmolarity correlated with patient symptoms
while unanesthetized Schirmer testing did not. Tear
osmolarity did not correlate with unanesthetized
Schirmer scores. In addition, pain scores associated
with osmolarity testing were lower than for
unanesthetized Schirmer testing.
Tear osmolarity
testing may be superior to Schirmer testing to follow dry
eye disease in patients with Sjogren’s syndrome. Future
larger studies would be needed to confirm this
hypothesis.
1. Tomlinson A, Khanal S, Ramaesh K, Diaper C , et
al. Tear film osmolarity: Determination of a
Referent for Dry Eye Diagnosis. Invest
Ophthalmol Vis Sci 2006; 47:4309-15.
2. Khanal S, Tomlinson A, McFadyen A, Diaper C, et
al. Dry Eye Diagnosis. Invest Ophthalmol Vis Sci
2008; 49:1407-14.