POS0102 GO ASK YOUR PATIENTS! PSS-QoL REPORTED PERCEPTION OF DRYNESS CORRELATES WITH LACRIMAL AND SALIVARY FLOW IN PRIMARY SJÖGREN’S SYNDROME

Background:

The patient perspective is an essential outcome parameter in the quest for effective therapy in primary Sjögren’s Syndrome (PSS). The EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) is recommended by EULAR to quantify patient’s symptom burden and has been used in several clinical trials. Surprisingly, the patient’s perception of dryness quantified with ESSPRI does not correlate with objective measures of salivary or lacrimal flow.

Objectives:

Thus, we evaluated a newly developed assessment tool-the Primary Sjögren’s Syndrome Quality of Life Questionnaire (PSS-QoL) - for quantifying symptoms of dryness in comparison with the ESSPRI and objective measurements of salivary and lacrimal flow.

Methods:

Data of patients from the PSS registry of the Medical University of Graz fulfilling the 2016 ACR/EULAR classification criteria for PSS were analysed. The patient perspective was analyzed by PSS-QoL, ESSPRI, Xerostomia Inventory (XI) and Ocular Surface Disease Index (OSDI). Sicca signs were measured with Schirmer’s test, unstimulated salivary flow test (USF) and stimulated salivary flow test (SSF). Patients were categorized into groups based on the presence of subjective and/or objective dryness: 1) objective dryness only, 2) subjective dryness only, and 3) both, subjective and objective dryness. ESSDAI (EULAR Sjögren’s Syndrome Disease Activity Index) and EGA (Evaluator Global Assessment, numeric rating scale from 0 to 10) were obtained. In addition, free light chains (FLC) ĸ and λ, rheumatoid factor (RF) IgM and IgA were determined.

Results:

Data from 123 PSS patients were analyzed; 91.9% (n=113) were female, with a mean disease duration of 6.2 (±5.3) years and mean age of 60.1 (±12.4) years. PSS-QoL-dryness revealed significant negative correlations with Schirmer’s test (r=-0.31, p<0.05) and SSF-test (r=-0.39, p<0.01). In contrast, we found no significant correlation between ESSPRI-dryness and any objective dryness test. Lower perceived dryness was associated with higher immunological activity determined by increased levels of IgG, FLC and RF-IgA. Patients with objective signs and subjective symptoms of dryness had higher clinical and immunological disease activity compared to patients with subjective symptoms only (table 1).

Table 1.

Comparison of perceived dryness-groups with clinical parameters

PSS-QoL MouthpPSS-QoL Eyespsubjobj/subjsubjobj/subjEGA1.0 [0-5]2.0 [0-7]<0.051.0 [0-3]2.0 [0-7]<0.05ESSDAI1.0 [0-144.0 [0-15<0.053.0 [0-74.0 [0-15nsESSPRI-pain3.0 [0-9]3.0 [0-10]ns4.0 [1-8]3.0 [0-10]<0.05RF-IgM19.0 [5-524]31.0 [7-417]ns10.0[5-33]26.0[7-524]<0.01FLC-λ15.1 [7.0-68.3]20.1 [2.6-124.0]<0.0113.4 [7.0-54.5]18.7[2.6-124.0]<0.01IgG11.9 [6.5-37.2]16.1 [7.4-33.8]ns12.8 [6.5-20.6]14.8[7.4-37.2]nsC40.2 [0.01-0.41]0.17 [0.00-0.43]<0.010.2 [0.09-0.41]0.18 [0.00-0.43]nsRF-IgA11.0 [1-500]103 [0-500]<0.014.5 [1-465]63 [0-500]<0.01

C4=Complementfactor 4; EGA=Evaluators Global Assessment; ESSDAI=EULAR Sjögren Syndrome Disease Activity Index; ESSPRI=EULAR Sjögren Syndrome Patient Reported Index; FLC-λ=Free light chain Lambda; IgG=Immunoglobulin G; obj/subj=objective and subjective dryness-group; PSS-QoL=Primary Sjögren Syndrome Quality of Life Questionnaire; RF-IgA=rheumatoid factor Immunoglobulin A; RF-IgM=rheumatoid factor Immunoglobulin M; subj=subjective dryness-group.

Conclusion:

Patients’ perception of dryness assessed by PSS-QoL correlates with objective measurements of salivary gland function while ESSPRI-dryness did not. Based on the PSS-QoL and objective measures of dryness two distinct groups of PSS patients could be distinguished, which may have implications in daily practice and future clinical studies.

Disclosure of Interests:

None declared

SAT0164 MC2-03 (CICLOSPORIN EYEDROPS) IMPROVES TEAR PRODUCTION IN SJÖGREN’S PATIENTS WITH MODERATE-TO-SEVERE KERATITIS: RESULTS FROM A PHASE 2B RANDOMIZED, CONTROLLED TRIAL

Background:

Sjögren Syndrome (SS) is a multifaceted disease with variable symptoms, but the SS associated keratoconjunctivitis is one of the most frequent disease manifestations of the syndrome and the manifestation that has the greatest impact on the quality of life for these patients.

Objectives:

To report the clinical efficacy of MC2-03 eyedrops in Sjögren’s patients with moderate-to-severe keratitis from a 6-month trial looking at the Schirmer score which assess the tear production by the lacrimal gland. A Schirmer score of ≤5mm/5 min is one of the criteria used in the 2016 final classification of ACR/EULAR to diagnose Sjögren`s syndrome.

Methods:

The NORTHERN LIGHTS trial is a randomized, double masked, controlled multicentre European trial that assessed MC2-03 eyedrops (ciclosporin 0.03% and 0.06%) for the treatment of moderate-to-severe dry eye disease in 255 patients having corneal fluorescein staining score 3 or 4 at baseline. The Schirmer score (per 5 min) was assessed during this trial. A total of 66 patients (25.9%) with medical history of Sjögren’s syndrome were randomized in the trial.

Results:

Demographics and baseline disease characteristics were comparable between treatment arms: mean age 60.4 years, 90.9% were females (n=60) and the mean Schirmer score in the worst eye was ~3mm (2.8mm – 3.2mm, except for the vehicle, mean Schirmer score of 5.5mm).

The mean Schirmer score improved rapidly from baseline to month 1 for MC2-03 0.03% eye drops (+2.4mm) reaching statistical significance versus vehicle (-0.5mm, p=0.028) and lubricant therapy (-0.6mm, p=0.020). This improvement was maintained at month 6 where the change was +2.5mm for MC2-03 0.03% eye drops compared to -1.1mm for vehicle (p=0.028). Statistical significance was also achieved at Month 6 comparing the higher strength MC2-03 0.06% eye drops (+2.8mm) to vehicle (-1.1mm, p=0.005) and lubricant alone (-0.5mm, p=0.009).

Three in eleven (27.3%) Sjögren`s patients treated with MC2-03 0.03% eye drops improved from a diagnostically low Schirmer ≤5mm at baseline (10/12, 83.3% ≤5mm) to Schirmer >5mm at month 3 and month 6 (6/11, 54.5% ≤5mm), while on the other hand 1 in 14 (7.1%) patients worsened in the vehicle group. A similar response was seen for MC2-03 eye drops 0.06%.

For Sjögren´s patients with Schirmer ≤5mm at baseline, a greater proportion of patients improved ≥3mm at month 6 when treated with MC2-03 eye drops 0.03% (44.4%, 4/9) and 0.06% (53.8%, 7/13) compared to vehicle (0%, 0/9) and lubricant (7.7%, 1/12). At month 6, a statistically significantly higher proportion of patients achieved clinically meaningful improvements in both corneal staining (≥2 grades improvement) and Schirmer score (≥3mm/5 min) when treated with MC2-03 0.03% eye drops (45.5%, 5/11) compared to both vehicle (0%, 0/14, p=0.009) and lubricant (0%, 0/15, p= 0.007). A higher number of patients treated with MC2-03 0.06% was observed without statistical significance.

Conclusion:

MC2-03 eye drops once daily rapidly increased tear production and further improved corneal staining in Sjögren´s patients with moderate to severe keratitis, which both are objectives included as diagnostic criteria for Sjögren’s disease. MC2-03 eye drops were well tolerated with no unexpected safety findings.

Disclosure of Interests: :

Frederic Gomez Consultant of: MC2 Therapeutics, Morten Præstegaard Employee of: MC2 Therapeutics, Johan Selmer Employee of: MC2 Therapeutics, Jutta Horwath-Winter Consultant of: CromaPharma, Omnivision, MC2 Therapeutics, Speakers bureau: Allergan, Bausch&Lomb, Cromapharma, Ursapharma, Thea, TRB-Chemedica, Santen, Maite Sainz de la Maza: None declared, Steffen Heegaard Consultant of: Sanofi, MC2 Therapeutics, Speakers bureau: Santen, Sanofi, Thea, Leo

The Triple Classification of Dry Eye for Practical Clinical Use

PURPOSE

"Dry Eye is a condition produced by the inadequate interrelation between lacrimal film and ocular surface epithelium, and is caused by quantitative and qualitative deficits in one or both of them. It can be produced by one or combined etiologic causes, affecting one or several of the secretions of the glands serving the ocular surface, and producing secondary manifestations of different grades of severity". Clinicians need a practical classification to face diagnosis, prognosis and treatment. Dry eyes have many etiologies and pathogenesis, different affectation of the various dacryoglands and ocular surface epithelium, and diverse grades of severity. The specialists in xero-dacryology must know these three parameters to evaluate any case of dry eye, and to establish an adequate treatment.

METHODS

To facilitate this, an open session in the 8th congress of the International Society of Dacryology and Dry Eye (Madrid, April, 2005) proposed modifying the Triple Classification of dry eye approved in the XIV congress of the European Society of Ophthalmology (Madrid, June, 2003). There was consensus of all conclusions.

CONCLUSIONS

The following classification has been established: First, a classification of the etio-pathogenesis, distributed in ten groups: age-related, hormonal, pharmacologic, immunopathic, hyponutritional, dysgenic, infectious/inflammatory, traumatic, neurologic and tantalic. Second, a classification of the affected glands and tissues, which under the acronym of ALMEN includes the Aqueo-serousdeficient, Lipodeficient, Mucindeficient and Epitheliopatic dry eyes, and the Non dacryological affected exocrine glands (saliva, nasal secretion, tracheo-pharyngeal secretion, etc). And thirdly, a classification of severity, in three grades: Grade 1 or mild (symptoms without slitlamp signs), grade 2 or moderate (symptoms with reversible signs), and grade 3 or severe (symptoms with permanent signs).

[Cryotherapy in discoid lupus erythematosus (DLE)]

Discoid lupus erythematosus (DLE) is a chronic, scarring, photosensitive autoimmune dermatosis that usually occurs in sun-exposed areas. While the face, chest, and extremities are often affected, involvement of the eyelid is rare. In cases of DLE lesions that are resistant to local or systemic recommended therapies, contact cryotherapy should be considered as an alternative treatment option.

Evaluating an impression cytology grading system (IC score) in patients with dry eye syndrome

PURPOSE

To evaluate the IC score, a newly developed grading system for the morphological alterations of the ocular surface as a diagnostic tool in relation to type and severity of dry eye disease.

METHODS

Impression cytological specimens of 309 patients with simple dry eye (S-DE), 50 patients with Sjögren's syndrome and dry eye (SS-DE), and 39 patients with connective tissue disease and dry eye (CTD-DE) were examined. In all, 10 different morphological parameters were judged with points (IC subscores) and summarized to the IC score. IC score and subscores were correlated to tear function test results and with each other.

RESULTS

SS-DE patients had the highest IC scores and IC subscores. IC scores and IC subscores correlated significantly with the fluorescein staining of the cornea in all three patient groups. They were correlated to the rose bengal score in SS-DE and S-DE patients. The analysis of the IC subscores showed that there are significant correlations between most of the morphological alterations investigated. This underlines the importance of each parameter for the summarized IC score.

CONCLUSION

The IC score provides detailed information about the morphological alterations of the bulbar conjunctiva. It has proven to be useful for the differentiation of dry eye diseases and might help in the investigation of the pathogenesis of these diseases as well as for follow-up and therapy control.

Iodide iontophoresis as a treatment for dry eye syndrome

BACKGROUND/AIMS

Among the causes related to the development or perpetuation and aggravation of dry eye disease, oxidative reactions may have a role in the pathogenesis of this disorder. Antioxidants, such as iodide, have shown a strong effect in preventing the oxidative damage to constituents of the anterior part of the eye. In this clinical trial the effectiveness of iodide iontophoresis and iodide application without current in moderate to severe dry eye patients was compared.

METHODS

16 patients were treated with iodide iontophoresis and 12 patients with iodide application without current for 10 days. Subjective improvement, frequency of artificial tear application, tear function parameters (break up time, Schirmer test without local anaesthesia), vital staining (fluorescein and rose bengal staining) as well as impression cytology of the bulbar conjunctiva were evaluated before treatment, 1 week, 1 month, and 3 months after treatment.

RESULTS

A reduction in subjective symptoms, frequency of artificial tear substitute application, and an improvement in certain tear film and ocular surface factors could be observed in both groups. A stronger positive influence was seen after application of iodide with current (iontophoresis), as observed in a distinct improvement in break up time, fluorescein and rose bengal staining, and in a longer duration of this effect compared with the non-current group. No significant change in Schirmer test results and impression cytology were observed in both groups.

CONCLUSIONS

Iodide iontophoresis has been demonstrated to be a safe and well tolerated method of improving subjective and objective dry eye factors in patients with ocular surface disease.

Cytotoxicity Evaluation of Soft Contact Lens Care Solutions on Human Conjunctival Fibroblasts

PURPOSE

To determine whether different contact lens care solutions for soft lenses cause damage to human conjunctival cells.

METHODS

Primary cultured human conjunctival fibroblasts were incubated with various concentrations of four different commercially available soft contact lens care solutions (OptiFree, Renu, SoloCare, Titmus) at concentrations of 5, 10 and 50 microl/ml medium. Toxicity was examined by determination of (1) the cell viability and mitochondrial activity with the colorimetric MTT test, and (2) the number of living cells with a cell analysis system (CASY 1) as compared with untreated cells.

RESULTS

For all four soft contact lens care solutions at a concentration of 5 mul/ml medium, no significant decrease in mitochondrial activity of the human conjunctival fibroblasts was found by the MTT test. At 10 microl/ml, only OptiFree and Titmus reduced mitochondrial viability significantly. The greatest reduction in mitochondrial activity occurred with all of the four soft contact lens care solutions at a concentration of 50 microl/ml. No significant decrease in the number of living conjunctival fibroblasts was observed by CASY 1 even at higher concentrations of the four solutions investigated.

CONCLUSION

This in vitro study demonstrates that the examined soft contact lens care solutions induce changes in mitochondria of human conjunctival cells only at higher doses as observed by the MTT test. However, this damage to the mitochondria did not lead to cell death as shown by the cell analysis system.

Botulinum toxin A treatment in patients suffering from blepharospasm and dry eye

BACKGROUND

Many patients with essential blepharospasm also show dry eye signs and symptoms. Botulinum toxin A is an effective treatment for reducing spasms in these patients. In this investigation, the effect of botulinum toxin A injections on tear function and on the morphology of the ocular surface in patients suffering from blepharospasm in combination with a dry eye syndrome was investigated.

METHODS

Botulinum toxin A injections were applied to 16 patients with blepharospasm. All patients complained of dry eye symptoms and had reduced tear break up time values. A subjective questionnaire and ocular examinations including tear break up time, Schirmer test without local anaesthesia, and rose bengal staining were evaluated before, 1 week, 1 month, and 3 months after injection. Impression cytology was performed before, 1 month, and 3 months after botulinum toxin A treatment.

RESULTS

Although all patients were relieved of blepharospasm after botulinum toxin injections, only three noticed an improvement in dry eye symptoms. Eight patients noticed no difference and five complained of worsening. Tear break up time was found to be increased 1 week and 1 month after injections. Schirmer test measurements were reduced up to 3 months. Rose bengal staining slightly increased 1 week after injections. Impression cytology showed no definite change in conjunctival cell morphology 1 month and 3 months after botulinum toxin A injections.

CONCLUSION

In the patients presented here suffering from blepharospasm and dry eye, botulinum toxin A injections were effective in relieving blepharospasm but were not successful in treating dry eye syndrome.

[Psoriasis and hypogonadism in chronic blepharokeratoconjunctivitis. A case report]

BACKGROUND

Ocular symptoms occur in approximately 10% of patients with psoriasis vulgaris.

PATIENT

We report the clinical course of a 35-year-old male patient with obstructive meibomian gland dysfunction, keratoconjunctivitis and reduced reflex secretion of both eyes. Psoriasis vulgaris and hypothalamic hypogonadism were also present. Genetic testing (cytogenetic and DNA analysis) was performed because of additional facial dysmorphia, brachydactylia and obesity. No chromosomal anomaly was found and no genetic syndrome has yet been diagnosed. The therapeutic regimen included preservative-free artificial tears, occlusion of the puncta and a systemic dose of doxycycline. Dermatological symptoms were treated topically and the hypogonadism was treated with intramuscular injections of testosterone.

CONCLUSION

Lacrimal and meibomian glands are influenced by androgens. Therefore hormonal dysfunction can also have contributed to the blepharokeratoconjunctivitis in this patient.