Dry syndrome

Tear droughts are frequent, it is still necessary to look for it. The complaints expressed by the patients are not very typical sensation of sand, significant discomfort in the light, burns, discomfort when opening the eyes in the morning, itching, loss of visual acuity.

The eyelids continuously sweep the ocular surface by blinking, allowing tears to spread over the surface of the cornea.

These tears, which are constantly secreted by the lacrimal glands and other eyelid glands, are mainly made of water (lacrimal glands) but not only lipids and mucus (eyelid glands) are essential for the good stability of the tear film which therefore extends like a thin protective barrier in front of the cornea, preventing it from drying out, infection and opacification.

Dry syndrome corresponds to one of the following three propositions :

• - decreased quality of tears
• - decrease in the amount of tears
• - decreased tear film stability

The first problem posed by the patient with sicca is that of his diagnosis :

Questions about the ability of patients to cry remain decisive. Rare are patients with sicca syndrome who still have the possibility of crying while peeling onions or during strong emotions. The classic Schirmer test is certainly useful but will only be positive in the advanced forms. We can even see a reactional lacrimation in the early forms.

More decisive are the examination of the break-up time and the taking of fluorescein which will make it possible to sort out the symptoms where the subjective part often remains major. The examination by lissamine green or rose bengal certainly remains one of the key examinations of the ocular surface analysis.

Long considered a mucus analysis and a marker of cellular vitality, the rose bengal test is in fact more of a marker of cellular suffering.

The score of Van Bijsterveld appreciates the intensity of the marking he considers each sector (nasal, temporal and corneal to give it a score of 0 to 3) and gives a score out of 9. However, even with these different tests, the diagnosis of sicca syndrome is often based. on a presumption, sum of several elements.

Indeed, there is no real pathognomonic test for sicca syndrome. In some cases, the conjunctival imprint may be of some interest. This analysis of the superficial conjunctival layers makes it possible to objectify the intensity of epithelial cell suffering and the reduction in the number of mucus cells.

The ophthalmologist is then confronted with a patient with a defective tear secretion and ocular signs of cellular distress. The clinical forms of dry syndromes are extremely varied, it is certain that between a discreet subjective sensation of dryness and the objective signs of cellular suffering, there is a great variety where the determination to find a systemic cause is not always necessary square.

Here again, the questioning should take precedence over the absence of long-term sedatives or anti-anxiety drugs, the notion of associated dry mouth or joint pain or any other point of systemic appeal will lead to a search for a systemic disease.

There are many pathologies, apart from rheumatoid arthritis, which associate a sicca syndrome with a general disease (hepatitis c, primary biliary cirrhosis, sarcoidosis, etc.)

If the vast majority of dry syndromes are linked to senile involution of the lacrimal gland, other added factors are likely to worsen the formerly well-balanced situation to tip it towards an attack badly felt by the patient.

Indeed, the decrease in tear function with age is a well-known fact, but it is often aggravated by the prolonged intake of drugs leading to a decrease in tear secretion such as antidepressants, neuroleptics, beta-blockers.

Eye drops after eye surgery or following treatment for an eye pathology can upset the tear balance and accelerate or cause the onset of sicca syndrome.

The dry syndrome is currently more frequent because of the external conditions which favor the drying out air conditioning, overheated but not humidified atmosphere of the dwellings, pollution and especially abuse of treatment reducing the secretion of tears.

However, some general illnesses are accompanied by disabling sicca syndrome. They give severe forms of sicca syndrome and require appropriate treatments.

It is a condition whose frequency seems to have increased markedly in recent years.

However, more than a real alteration of the tear film linked to a hypothetical systemic cause, we should certainly rather see in it the responsibility of the deterioration of living conditions, increase in pollution, air conditioning, global drying up of the atmosphere by insulation more and more perfect ...

Faced with this increased demand for treatment to replace a defective tear secretion, the practitioner is often confronted with a diagnostic orientation but also with a problem of therapeutic choice.

There is no ideal treatment and practitioners will first and foremost have to stick to the adage. Indeed, the chronic instillation of eye drops can be at the origin of a conjunctival inflammation source of disorders badly felt by the patient.

We will therefore turn above all to eye drops in single doses which have the advantage of dispensing treatment with the active factor but without preservative.

Of course, the therapeutic escalation depends on the severity of the disorders from the instillation of physiological serum to the administration of the gels, there is a whole panel available to the practitioner to adapt according to the clinical signs.

The other small means which consist in improving the humidification of the rooms, in eliminating the products reducing the secretion of tears are not negligible elements. Of course, the treatment of sicca syndrome progressing in the context of a general illness will first and foremost involve the treatment of the general illness.

To conclude...

The increase in the number of dry syndromes is less due to their better detection than to a deterioration in living conditions (pollution, drying out of the atmosphere, etc.).

Light forms sont facilement accessibles à des traitements peu lourds.

Serious forms restent toutefois peu sensibles aux traitements locaux, les substituts de larmes n'étant actuellement que des pis aller destinés à améliorer la symptomatologie mais absolument pas à traiter l'affection initiale.