Sjogren's Syndrome

Dry eyes in a middle-aged woman don't always mean she sleeps too little or stares too long at a computer screen.

Sjogren's syndrome usually attacks women over 40. Dry eyes are a symptom.

Tears, called lacrimae in Greek, come from the almond-sized almond-shaped lacrimal gland, tucked in back of the bone near the tail of the eyebrow. This gland is a group of lobules and ducts that open along the upper and outer sides of the upper eyelid. Together with a number of microscopic glands, the lacrimal moistens and lubricates the surfaces of the eye and the eyelids, under the direction of the lacrimal nerve.

The lacrimal glands form part of the secretory immune system. Like all immune cells, those of the secretory system originate in the bone marrow. Once made they travel to the lacrimal and salivary glands, to the lymphoid tissues in the breast, the lungs' bronchi, the intestines, and genitourinary tract. These are the body's high-risk tissues, unprotected by skin, that come in contact with the world outside. The secretory immunoglobulins bind and react with micro-organisms, preventing the micro-organisms from attaching to and invading mucosal tissue.

• Dry eyes
• Difficulty swallowing
• Difficulty speaking
• Feeling of "sand under eyelids"

Dry eyes can be a failure in this first line of defense. Sjogren's syndrome, a chronic, slowly progressive autoimmune disease in which lymphocytes infiltrate the exocrine glands, causing dry eyes, dry mouth, and overactivity in the B-lymphocyte immune cells. The syndrome predominantly affects middle-aged women. Problems associated with diminished lacrimal and salivary gland function may be minor annoyances such as difficulty in swallowing food and speaking, and dry eyes with a sandy or gritty sensation under the eyelids. Fluid replacement alleviates these symptoms,

The trouble doesn't end there. Sjogren's syndrome may appear together with other autoimmune rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma. Problems beyond dry tear glands may include fatigue, low-grade fever, myalgias, and arthralgias. Pulmonary problems, though rare, should be watched for, particularly diffuse interstitial lung disease that may not be severe enough to show up in a casual clinic exam. Possible kidney complications include interstitial nephritis.

After years of apparently benign Sjogren' syndrome, a small but significant number of patients may develop malignant lymphoma. Parenchymal organs such as lungs and gastrointestinal tract can be affected.

For more on the lacrimal gland, see Guyton A.C. (1991) Textbook of Medical Physiology, W.B. Saunders Co., Philadelphia, PA; Isselbacher et al. (1994) Harrison's Principles of Internal Medicine; and Sherwood L. (1989) Human Physiology, West Publishing, St. Paul, MN.