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Vatinee Y. Bunya, MD, Mina Massaro- Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The authors are receiving research supplies from TearLab for a separate study. Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA *Division of Rheumatology, Penn Presbyterian Medical Center, Philadelphia, PA

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Page 1: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin,

MD, Michael E. Sulewski, MD, and Maureen G.

Maguire, PhD

The authors are receiving research supplies from TearLab for a separate study.

Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA

*Division of Rheumatology, Penn Presbyterian Medical Center,Philadelphia, PA

Page 2: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

PurposePurposeTo study tear film osmolarity in Sjogren’s

syndrome patients

To assess if tear film osmolarity in Sjogren’s syndrome patients is correlated with symptoms (OSDI) or unanesthetized Schirmer testing

To compare patient discomfort associated with tear osmolarity testing to unanesthetized Schirmer testing

Page 3: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

MethodsMethodsProspective study to evaluate the tear film

osmolarity of Sjogren’s syndrome patientsDemographic information and medication usage

was recordedTear film osmolarity: TearLab osmolarity system

System calibrated daily as specified by manufacturer

Unanesthetized Schirmer testing Patient-reported pain scores (0-5 with 5 = severe

pain) after tear osmolarity and Schirmer testingOSDI self-administered Spearman (non-parametric) correlation

coefficients used due to small sample size

Page 4: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Age

Mean (Std), yrs 55.7 (15.5)

Range 18-88

Sex

Male 1 (5%)

Female 19 (95%)

Race/Ethnicity

White 13 (65%)

African-American 6 (30%)

Hispanic 1 (5%)

Sjogren’s Syndrome

Primary 16 (80%)

Secondary 4 (20%)

Results

Page 5: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Systemic Medications

Hydroxychloroquine (Plaquenil) 12 (63%)

Pilocarpine (Salagen) 12 (63%)

Fish oil (not Lovaza) 11 (58%)

Omega-3-acid ethyl esters (Lovaza) 3 (16%)

Flaxseed 6 (32%)

Prednisone (oral) 6 (32%)

Methotrexate 4 (21%)

Azathioprine (Imuran) 2 (11%)

Rituximab (Rituxan) 1 (6%)

Eye Medications

Cyclosporine (Restasis) 5 (26%)

Erythromycin Ointment 2 (11%)

*1 patient did not provide a medication list

Medication UseMedication Use

Page 6: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

ResultsResultsAverage OSDI score: 46.6Average tear osmolarity: 311 mOsmol/LAverage unanesthetized Schirmer score: 13

mm/5 min

Median pain scores Tear osmolarity testing: 1 Unanesthetized Schirmer testing: 4

p < 0.001 (Wilcoxon signed rank test)

Page 7: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

OSDI does not correlate well with unanesthetized Schirmer score (averaged between eyes).

Page 8: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

OSDI correlates well with tear osmolarity (averaged between eyes).

Page 9: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Average unanesthetized Schirmer score does not correlate with average tear osmolarity.

r= - 0.14p= 0.56

Page 10: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Previous studies have suggested that tear film osmolarity may be the single best test in the diagnosis of dry eye.1, 2 To our knowledge, tear osmolarity has not been studied specifically in Sjogren’s syndrome patients.

In our study, the average tear osmolarity was 311 mOsmol/L. This is lower than the referent of 316 mOsmol/L.1 This is most likely due to the fact that 95% of our patients were on treatment at the time of the study. We would expect the tear osmolarity to be higher in untreated patients.

Page 11: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

Tear osmolarity correlated with patient symptoms while unanesthetized Schirmer testing did not. Tear osmolarity did not correlate with unanesthetized Schirmer scores. In addition, pain scores associated with osmolarity testing were lower than for unanesthetized Schirmer testing. Tear osmolarity testing may be superior to Schirmer testing to follow dry eye disease in patients with Sjogren’s syndrome. Future larger studies would be needed to confirm this hypothesis.

Page 12: Vatinee Y. Bunya, MD, Mina Massaro-Giordano, MD, Frederick B. Vivino, MD*, Stephen E. Orlin, MD, Michael E. Sulewski, MD, and Maureen G. Maguire, PhD The

1. Tomlinson A, Khanal S, Ramaesh K, Diaper C , et al. Tear film osmolarity: Determination of a Referent for Dry Eye Diagnosis. Invest Ophthalmol Vis Sci 2006; 47:4309-15.

2. Khanal S, Tomlinson A, McFadyen A, Diaper C, et al. Dry Eye Diagnosis. Invest Ophthalmol Vis Sci 2008; 49:1407-14.


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