Ask the Experts on . . .
Sjögren's Syndrome and the Lasik Procedure
 Question
A 30-year-old man presented with dry
eyes; the condition has become worse since a Lasik procedure. He has no
noted xerostomia. Antinuclear antibody (ANA) titer was 1:160 nucleolar;
SGOT/AST, 47; lactate dehydrogenase, 148; SGPT/ALT, 71 (normal, 0-45);
SS-A and SS-B were negative; and the remainder of the ANA panel is
negative as well. Findings were also negative for hepatitis A, B, and C,
and antimitochondrial antibody. Would it be appropriate to pursue
confirmation of Sjögren's syndrome with lachrymal biopsy? What are other
possibilities?
Gregory A. Robertson, MD
Responsefrom Robert
Fox, MD, 09/25/00
Two questions are asked.
With regard to the possible exacerbation of sicca symptoms by
refractive excimer laser surgery, there is relatively little published
literature. One study suggests that patients with Sjögren's syndrome who
do not tolerate contact lenses can undergo excimer laser surgery.[1] However, our local ophthalmologists who
specialize in Sjögren's syndrome have found that patients do have
increased problems with dryness after Lasik surgery. This may derive from
the process that involves first cutting a "flap" of the cornea with a
microtome in order to remove this area from the axis of the excimer laser.
Since the cornea sends its afferent nerves downward, it would be expected
that the microtome would cut across these afferent nerves. Such a
denervation would decrease the normal signals originating from the corneal
surface that serve to stimulate tearing reflexes.[2]
Thus, more careful follow-up on the use of Lasik surgery needs to be
available before this procedure can be endorsed in an unqualified manner.
There is a huge marketing program for this cosmetic surgery in southern
California. It is important to remember that this procedure replaces other
cosmetic procedures that were each touted in their time as perfectly safe.
The second question involves the diagnosis of the particular patient.
It is unclear whether this patient has an associated autoimmune disease.
The ANA titer of 1:160 may be a false-positive finding. Studies on the
sensitivity and specificity of ANA have indicated that it is a sensitive
tests but has a high false-positive rate.[3,4] The reason for the elevated liver function
tests is also unclear. Medications (including herbal remedies) may
contribute to elevation, and patients may not include these agents on
their medication lists unless specifically questioned.
References
- Toda I, Yagi Y, Hata S, Itoh S, Tsubota K. Excimer laser
photorefractive keratectomy for patients with contact lens intolerance
caused by dry eye. Br J Ophthalmol. 1996;80:604-609.
- Stern Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC. The
pathology of dry eye: the interaction between the ocular surface and
lacrimal glands. Cornea. 1998;17:584-589.
- Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear
antibodies in "healthy" individuals. Arthritis Rheum. 1997.40:1601-1611.
- Lightfoot R. Cost effective use of laboratory tests in rheumatology.
Bull Rheum Dis. 1997;46:1-3.
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