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Keratoconjunctivitis Sicca

Keratoconjunctivitis sicca is one of the terms denoting dry eye disease, which can be seen in a myriad of conditions of different etiologies. Impaired vision, erythema, photophobia, pruritus, and sensations of stinging or as if a foreign body is present are notable signs and symptoms reported in patients with this condition. Without an early diagnosis and appropriate treatment, conjunctival and/or corneal scarring, ulceration, and even perforation might occur. Thus, a full ophthalmological exam coupled with a detailed patient history is a crucial step to recognize keratoconjunctivitis sicca.


Presentation

The clinical presentation of keratoconjunctivitis sicca (more commonly known as "dry eye") stems from an excessive evaporation of tears and/or their deficiency [1] [2]. This condition is a relatively frequent disorder in general practice, particularly in the elderly population, with the most common complaints being a burning, stinging, foreign body sensation, as well as pruritus and photophobia [1] [2] [3] [4]. Keratoconjunctivitis sicca has shown to significantly affect the quality of life due to its overall effect on vision [2] [5]. Driving could be problematic, reading speed is frequently markedly reduced, while looking at the computer screen can be quite disturbing and unpleasant [2] [5]. In fact, anxiety and depression were shown to be much more frequent among patients suffering from dry eyes compared to disease-free individuals [2] [5] [6]. Aside from present complaints, keratoconjunctivitis sicca predisposes individuals to numerous complications. Scarring, ulceration, and even perforation of the cornea, bacterial keratitis (an infection with the potential to cause blindness), post-procedural complications from eye surgeries, blepharitis, meibomitis, and conjunctival pathologies have all been reported [1] [2].

Lymphedema
  • Intrinsic causes Meibomian gland disease may involve a reduced number of functioning glands, as in congenital deficiency or acquired meibomian gland dysfunction, or complete gland replacement, as in distichiasis, lymphedema-distichiasis syndrome, or metaplasia[emedicine.medscape.com]
Asymptomatic
  • CONCLUSIONS: Patients with HAM/TSP manifested more ophthalmologic symptoms than asymptomatic HTLV-1-infected individuals, with significantly higher KCS and immunologic alterations.[ncbi.nlm.nih.gov]
  • STUDY DESIGN: 104 HTLV-1 infected patients (51 asymptomatic and 52 with HAM/TSP) from the HTLV reference center in Salvador, Brazil were followed from June 2008 to May 2010.[ncbi.nlm.nih.gov]
  • METHODS: Schirmer 1 tear testing, corneal fluorescein staining and conjunctival impression cytology for quantitation of goblet cell density were performed in ten patients with Sjögren's syndrome-associated keratoconjunctivitis sicca and ten asymptomatic[ncbi.nlm.nih.gov]
  • Whereas a significant proportion of patients with KCS may be asymptomatic; it is unknown if the degree of dryness of the eyes, irrespective of symptomatology, has an association with the overall quality of life and functional ability.[ard.bmj.com]
  • The prevalence of KCS in patients with HAM/TSP (49.1%) found herein was sharply higher than in asymptomatic individuals, which is consistent with previous reports. 15,17,19 Furthermore, we confirmed a positive association between KCS and HAM/TSP, which[bjid.org.br]
Foreign Body Sensation
  • The patients were interviewed regarding the 5 major KCS symptoms, foreign body sensation, dry eye sensation, photophobia, ocular pain, and blurred vision, with each graded from none (0) to very severe (4).[ncbi.nlm.nih.gov]
  • This condition is a relatively frequent disorder in general practice, particularly in the elderly population, with the most common complaints being a burning, stinging, foreign body sensation, as well as pruritus and photophobia.[symptoma.com]
  • Patients will often describe the irritation as burning or a foreign body sensation or a feeling of "sand" or "grit" or "an eyelash" in the eye when nothing is there. Sometimes the symptoms get worse as the day progresses.[visualdx.com]
  • Clinical features: Symptoms: Foreign body sensation, itching, burning and moderate conjunctival redness Decreased vision, pain and photophobia usually occur in advanced cases Exacerbated by wind, blinking or prolonged reading.[columbiaeye.org]
  • Symptoms of dry eyes include irritation, burning, itching, a pulling sensation, pressure behind the eye, and grittiness or a feeling as if something is in the eye (foreign body sensation).[merck.com]
Red Eye
  • "Some people use drops for red eyes, but that can make the eyes even more dry," Begley says. Red eyes could be caused by numerous factors, from allergies to an eye infection, which is why a proper diagnosis is important.[web.archive.org]
  • Dry eye symptoms Symptoms of dry eyes and dry eye syndrome include: Burning sensation Itchy eyes Aching sensations Heavy eyes Fatigued eyes Sore eyes Dryness sensation Red eyes Photophobia Blurred vision Another common symptom is something called a foreign[allaboutvision.com]
  • eye Globe rupture Keratomycosis Phthisis bulbi Persistent fetal vasculature / Persistent hyperplastic primary vitreous Persistent tunica vasculosa lentis Familial exudative vitreoretinopathy Pathways Optic nerve Optic disc Optic neuritis optic papillitis[en.wikipedia.org]
Burning Eyes
  • eyes Scratchy eyes Stinging eye Watery eyes Light sensitivity Gritty sensations Eye pain Blurred vision In addition to physiological conditions, symptoms can be worsened by exposure to environmental conditions such as wind, air conditioning, and temperature[decisionmakerplus.net]
Prostatic Disease
  • Patients on antiandrogenic therapy for prostate disease also have increased viscosity of meibum, decreased tear breakup time (TBUT), and increased tear film debris, all of which indicate a deficient or abnormal tear film.[emedicine.medscape.com]

Workup

Because keratoconjunctivitis sicca may be a constitutive feature of a very large number of diseases, the physician should obtain a detailed patient history and conduct a thorough physical examination in order to determine the underlying etiology. The course of symptoms, their progression, as well as severity must be assessed, whereas the presence of any systemic disease (for example diabetes mellitus), history of drug use (postmenopausal estrogens, tricyclic antidepressants, diuretics, beta-blockers, antihistamines), and recent corneal surgery are some of the factors that might play a crucial role in the pathogenesis [1] [2] [7]. Sjogren's syndrome, however, is one of the most important causes of keratoconjunctivitis sicca and thus appropriate studies need to be carried out [2] [7]. After a detailed inspection of the eye (assessment of blinking rate and the lids being important components), a slit-lamp examination can solidify clinical suspicion [2]. Evaluation of eyelid margins, tear film, and meibomian glands, staining of the ocular surface (with fluorescein), and the Schirmer test are recommended studies [2]. On the other hand, appropriate laboratory studies are equally useful. Both anti-Ro (SSA) and anti-La (SSB) antibodies need to be measured to rule out Sjogren's syndrome and other autoimmune disorders as the cause [2].

HLA-B8
  • Pathophysiology A genetic predisposition in SS-associated dry eye disease exists, as is evidenced by the high prevalence of human leukocyte antigen B8 (HLA-B8) haplotype in these patients.[emedicine.medscape.com]
HLA-DR4
  • There was no significant association of HLA-DR4, Pi phenotype and KCS with bronchial reactivity. We conclude that there is no overall significant association of HLA-DR4, Pi phenotype and KCS with airflow obstruction and bronchial reactivity in RA.[ncbi.nlm.nih.gov]
  • The association of these two autoimmune disorders is suggested by the low incidence of VKH syndrome in Italy and might be related to HLA DR4.[ncbi.nlm.nih.gov]
Liver Biopsy
  • In patients with KCS a higher staging score was noted in liver biopsy compared to those without KCS (4.50 /- 1.65 vs 3.06 /- 1.88, p 0.005). CONCLUSION: Greek patients with chronic HCV infection have a high prevalence of KCS (36.6%).[ncbi.nlm.nih.gov]

Treatment

  • […] compared to those of pre-treatment.[ncbi.nlm.nih.gov]
  • RESULTS: The correlation (c) of keratoconjunctivitis sicca (KCS) and DRP after laser treatment was c 0.24 and after central laser treatment was c 0.22; the correlation without laser treatment was 0.54.[ncbi.nlm.nih.gov]
  • The patient was overcorrected with the initial treatment and had 2 subsequent hyperopic treatments, resulting in central corneal irregularity.[ncbi.nlm.nih.gov]
  • More than 60% reported decreased use of artificial tears at both 30 days and 60 days post-treatment initiation. CONCLUSIONS: Results suggest that in a real-world setting tCSA is an effective treatment for patients suffering from KCS.[ncbi.nlm.nih.gov]
  • Pre-treatment and post-treatment (6 weeks and 1 year) evaluations included temporal and inferior quadrant impression cytology examinations, Schirmer-1, BUT, corneal fluorescein and rose-bengal staining patterns and questionnaire scores.[ncbi.nlm.nih.gov]

Prognosis

  • Levels of activated CD8 T cells could be used as a prognosis marker of inflammatory disease manifestation to follow-up AS individuals.[ncbi.nlm.nih.gov]
  • We also wished to determine the incidence of the various manifestations of Sjögren's syndrome among patients with keratoconjunctivitis sicca and to study the course and prognosis of both conditions.[jamanetwork.com]
  • In general, the prognosis for visual acuity in patients with dry eye disease is good. Patients with SS or prolonged untreated dry eye represent a subgroup with a worse prognosis, requiring a longer course of treatment.[emedicine.medscape.com]

Etiology

  • Keratoconjunctivitis sicca is one of the terms denoting dry eye disease, which can be seen in a myriad of conditions of different etiologies.[symptoma.com]
  • This similarity suggests an etiological association between the sclerosing peritonitis of this case and that caused by practolol.[ncbi.nlm.nih.gov]
  • PURPOSE: Herpesvirus infection of the lacrimal gland was investigated as an etiologic factor for keratoconjunctivitis sicca in patients who were positive for human immunodeficiency virus (HIV).[ncbi.nlm.nih.gov]
  • […] conjunctiva of patients with keratoconjunctivitis sicca (KCS), assessing the relationship between tear function parameters and the severity of the disease, and searching for any differential pattern that could lead to early and diagnosis help clarify the etiology[ncbi.nlm.nih.gov]
  • MATERIAL AND METHODS: 94 adult patients were treated for follicular conjunctivitis with symptoms of KCS with possible Chlamydia pneumoniae etiology.[ncbi.nlm.nih.gov]

Epidemiology

  • Tom Lietman, a Professor in both the Departments of Ophthalmology and Epidemiology and Biostatistics at UCSF. Dr.[grantome.com]
  • C lassification / type of disease: Epidemiology : it becomes more common with increasing age. Dry eyes affects about 7 in 100 people in their 50s, and about 15 in 100 people in their 70s. Women are affected more often than men.[mymedicalstudentnotes.com]
  • Dry Eye or Keratoconjunctivitis sicca syndrome (KCS or dry eye) is a problem of major epidemiologic importance.[uveitis.org]
  • The book opens with a review of the epidemiology and the multifactorial etiologies of dry eye disease.[web.archive.org]
  • Epidemiological aspects and world distribution of HTLV-1 infection. Front Microbiol, 3 (2012), pp. 388 [25] B. Galvao-Castro, L. Loures, L.G. Rodriques, et al.[bjid.org.br]
Sex distribution
Age distribution

Pathophysiology

  • For KCS and other forms of dry eye, current treatments are limited, with many medications providing only symptomatic relief rather than targeting the pathophysiology of disease.[ncbi.nlm.nih.gov]
  • It is well established that ocular surface inflammation has an important role in the pathophysiology of DED and that anti-inflammatory cyclosporine A (CsA) improves the treatment outcomes of most patients with DED.[unboundmedicine.com]
  • Pathophysiology : complications can include conjunctivitis, keratitis, corneal ulceration or perforation of globe Transmission Treatment / management: Artificial tears: Eye drops and gels, and are usually good at relieving symptoms.[mymedicalstudentnotes.com]
  • Pathophysiology The tear film is constituted by 3 layers, as follows: (1) a lipid layer (0.11 µm thick), produced by the Meibomian glands; (2) an aqueous layer (7.0 µm thick), produced by the main and accessory lacrimal glands of Krause and Wolfring;[web.archive.org]
  • Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol, 100 (2016), pp. 300-306 Copyright 2019. Sociedade Brasileira de Infectologia[bjid.org.br]

Prevention

  • Anticipation of this problem can prevent it, but lack of recognition may result in permanent central scarring from ulceration, which responds slowly to treatment.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To summarize operation key points, prevention and management of complications in vascularized autotransplantation of submandibular gland for treatment of severe keratoconjunctivitis sicca.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Our study demonstrates that topical oestrogen is successful in treating keratoconjunctivitis sicca while it seems that the blood-eye barrier prevents systemic oestrogens from acting on the conjunctivae.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To evaluate the feasibility of microvascular autologous transplantation of partial submandibular gland (SMG) to prevent or reduce epiphora in severe keratoconjunctivitis sicca (KCS).[ncbi.nlm.nih.gov]
  • Prevention It is not possible to prevent keratoconjunctivitis sicca. It is possible to prevent complications of keratoconjunctivitis sicca, such as infections, from developing.[winchesterhospital.org]

References

Article

  1. Javadi M-A, Feizi S. Dry Eye Syndrome. J Ophthalmic Vis Res. 2011;6(3):192-198.
  2. Messmer EM. The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease. Dtsch Arztebl Int. 2015;112(5):71-82.
  3. Solomon A, Dursun D, Liu Z, Xie Y, Macri A, Pflugfelder SC. Pro- and anti-inflammatory forms of interleukin-1 in the tear fluid and conjunctiva of patients with dry-eye disease. Invest Ophthalmol Vis Sci. 2001;42:2283–2292.
  4. Jones DT, Monroy D, Ji Z, Atherton SS, Pflugfelder SC. Sjögren’s syndrome: cytokine and Epstein-Barr viral gene expression within the conjunctival epithelium. Invest Ophthalmol Vis Sci. 1994;35:3493–3504.
  5. Miljanovic B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007;143:409–415.
  6. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157:799–806.
  7. Whitcher JP. The treatment of dry eyes. Br J Ophthalmol. 2004;88(5):603-604.

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Last updated: 2019-07-11 20:24