The challenge of severe dry eyes – Not for the fainthearted

Tear replacement in a patient with severe dry eyes, for instance due to Sjögren’s syndrome, is a challenge that many oculoplastic and lacrimal surgeons encounter, together with their colleagues specialising in the external eye and corneal disease. Severe dry eye is like a desert where nothing flourishes and the surface life dies (see Figure 1); management must be effective but not damaging, as with severe flooding (see Figure 2). The treatment of severe dry eye must have an acceptably low morbidity. It is with that in mind that I read the article by Professor Juan Murube on a subcutaneous pump-reservoir for severe dry eye. First, however, let us put dry eye into perspective. In Sjögren’s syndrome, a chronic autoimmune disease first described by Henrik Sjögren (b 1899, d 1986) in his thesis, written in 1933, entitled ‘Zur Kenntnis der Keratoconjunctivitis sicca’, there is hypofunction of the exocrine glands affecting both the lacrimal and salivary glands and the gastrointestinal tract. Women make up 90% of the cases, with onset between 35 and 55 years of age. The syndrome is characterised by severe fatigue, dry eyes, nose and throat, dental caries and digestive problems. Vision can be impaired by epithelial damage and subsequent conjunctival and corneal scarring. Primary or Type I Sjögren’s syndrome is idiopathic (approximately 50%) whilst secondary or Type II is associated with rheumatoid arthritis, lupus or scleroderma.Recent research has shown that androgen deficiency may have a role in reducing meibomian function and lipid production in Sjögren’s patients, hence increasing the rate of tear evaporation. This raises the possibility of immunologic and endocrine manipulation of tear function in the future. Other causes of severe dry eye include Stevens-Johnson syndrome, ocular cicatricial pemphigoid, lacrimal gland trauma (surgical excision or ductile destruction), chemoor radiotherapy, and thermal injury, severe meibomian gland dysfunction, fibromyalgia and chronic fatigue syndrome. These patients suffer severe adverse psychological effects from chronic discomfort and the need for continuous tear