A 73-year-old woman comes to the office due to dry eyes. For the last year, she has had mild burning discomfort associated with a sensation of dust or sand in the eyes. Recently, the patient has had difficulty reading small-print books due to decreased visual acuity. She uses over-the-counter eye drops to relieve the discomfort. Her medical history is notable for hypothyroidism and osteoarthritis of the knees, which are treated with levothyroxine and acetaminophen, respectively. She drinks a glass of wine nightly and does not smoke. Vital signs are normal. On examination, the pupils are symmetrically round and reactive to light. The conjunctivae are normal bilaterally, and funduscopic examination is normal. Oropharyngeal examination shows dry mucosa with mild dental caries. Neurologic examination is unremarkable. Serum chemistry panel, complete blood count, and TSH are normal. Serum antinuclear antibody assay is negative. Which of the following is the most likely cause of this patient's symptoms?

Question

A 73-year-old woman comes to the office due to dry eyes.  For the last year, she has had mild burning discomfort associated with a sensation of dust or sand in the eyes.  Recently, the patient has had difficulty reading small-print books due to decreased visual acuity.  She uses over-the-counter eye drops to relieve the discomfort.  Her medical history is notable for hypothyroidism and osteoarthritis of the knees, which are treated with levothyroxine and acetaminophen, respectively.  She drinks a glass of wine nightly and does not smoke.  Vital signs are normal.  On examination, the pupils are symmetrically round and reactive to light.  The conjunctivae are normal bilaterally, and funduscopic examination is normal.  Oropharyngeal examination shows dry mucosa with mild dental caries.  Neurologic examination is unremarkable.  Serum chemistry panel, complete blood count, and TSH are normal.  Serum antinuclear antibody assay is negative.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient, an older woman with dry eyes and mouth, has typical features of age-related sicca syndrome (ARSS), also called age-related dry eye syndrome. Exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis, and ductal dilation of the glands. Decreased blink rates, oxidative damage, excessive evaporation of tears (eg, due to meibomian dysfunction), and use of anticholinergic medications in older individuals can also contribute to eye dryness. ARSS is more common in women, with increased risk in patients with diabetes or thyroid disorders. Besides ocular discomfort, patients can develop corneal epithelial erosions, leading to impaired vision. Management is primarily with artificial tears or other ocular lubricants applied frequently, especially in dry or windy conditions. Cyclosporine drops can also be used to increase tear secretion. Other causes of dry eyes and mouth include radiation exposure, graft-versus-host disease, and certain infections (eg, hepatitis C). (Choices B, C, and E) Sjögren syndrome is an autoimmune disorder characterized by a lymphocytic inflammatory infiltrate in the exocrine glands and can present with dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). It may occur independently or as a manifestation of another autoimmune disorder (eg, systemic sclerosis). However, onset is typically in middle age, and initial presentation after age 65 is unusual. Also, a majority of patients have a positive antinuclear antibody assay, and some (especially those with systemic sclerosis) have associated systemic manifestations. (Choice D) The nasolacrimal duct can become obstructed by involutional stenosis, dacryolith formation, orbital fracture, or blockade by granulomatous disease (eg, sarcoidosis) or neoplasm. Symptoms include excessive tearing with drainage to the face (epiphora). Educational objective: Age-related sicca syndrome is due to a decrease in exocrine output from the lacrimal and salivary glands. Decreased blink rates, oxidative damage, and use of anticholinergic medications can also contribute. Sjögren syndrome is an autoimmune disorder of the exocrine glands that can also present with dry eyes and dry mouth but occurs in younger patients and is associated with a positive antinuclear antibody assay. References: Aging: a predisposition to dry eyes. (http://www.ncbi.nlm.nih.gov/pubmed/25197560)

A 73-Year-Old Woman Comes to the Office Due to Dry