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]

• Dry Eyes

  Keratoconjunctivitis sicca (dry eye) is dryness of the conjunctiva and cornea. Dry eyes may be due to inadequate tear production (aqueous tear deficient dry eyes). [web.archive.org]

  Dry eye disease may be subdivided into 2 main types as follows: Dry eye disease unassociated with SS (non-SS KCS) Dry eye disease can also be subdivided into pure aqueous deficiency dry eye and evaporative dry eye. [3] Eighty-six percent of patients with [emedicine.medscape.com]

• Lacrimation

  Aplasia of the lacrimal and salivary glands may present with symptoms of congenital lacrimal obstruction, and failure to make an early diagnosis will result in inappropriate lacrimal surgery and dry eye. [ncbi.nlm.nih.gov]

  Eye tear system anatomy, (Description) a. tear gland / lacrimal gland, b. superior lacrimal punctum, c. superior lacrimal canal, d. tear sac / lacrimal sac, e. inferior lacrimal punctum, f. inferior lacrimal canal, g. nasolacrimal canal. [emedicine.medscape.com]

• Blurred Vision

  However, people sometimes feel that their blurred vision or eye irritation is so severe, frequent, and prolonged that it is difficult to function normally. [merck.com]

  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]

  Q: Should I be worried about blurred vision as a result of keratoconjunctivitis sicca? A: Temporarily blurred vision can be a symptom of keratoconjunctivitis sicca. Although an inconvenience, it can usually be managed through treatment. [ada.com]

• 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]

  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]

  They may complain of a dry sensation or of a foreign body sensation of the eyes. The conjunctiva is hyperemic, and thick strands of mucus may cover the eye. [sideeffects.embl.de]

  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]

  Typical symptoms include intermittent itching; burning; a gritty, pulling, or foreign body sensation; and photosensitivity. [merckmanuals.com]

• Excessive Tearing

  tearing (secondary to reflex secretion) Documenting the history of exacerbating or alleviating factors and a systemic past medical history is important, including history of connective tissue disease, thyroid disease, and rheumatoid arthritis. [web.archive.org]

  This is why excess tearing can occur from dry eyes. Risk Factors Tear production normally decreases as we age. [umkelloggeye.org]

  Some other symptoms of keratoconjunctivitis sicca include: The sensation of a burning, itching, or foreign body in the eye Sensitivity to light Redness or irritation of conjunctiva Excess tearing (poor quality tears) Discomfort with contact lenses Most [winchesterhospital.org]

• 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]

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].

• 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]

• 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]

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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.
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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.