Anterior Segment Tests Discern Sjögren Syndrome-Related Dry Eye

Positive staining — inferior corneal fluorescein and nasal lissamine green — can indicate immune disorder-caused DED, especially Sjögren syndrome.

A pair of anterior segment tests can help identify if a patient’s dry eye disease (DED) is associated with Sjögren syndrome-related tear-deficiency, according to data published in Cornea. The research found that positive corneal fluorescein staining scores (CFS_I) combined with a positive nasal lissamine green staining score (LG_N) suggests a high risk for Sjögren syndrome.

Investigators reviewed charts of individuals who sought care for DED or ocular allergy at an academic hospital ophthalmology department in Tokyo from August 2020 to January 2021. After exclusions such as active or undertreated ocular surface conditions, 502 patients met study criteria. Diagnostic groups comprised Sjögren syndrome, ocular graft-vs-host disease, other disorders, simple DED, or no dry eye disease. Ophthalmologists conducted anterior segment tests, including imaging with 10x magnification, diffuse and blue light techniques.

The findings of our study suggested that inferior CFS and nasal LG staining may be used as screening tools for SS-related DED diagnosis.

Patients in the Sjögren syndrome cohort exhibited significantly greater inferior corneal fluorescein staining (CFS-I) results (P <.001). Similarly, this group also displayed high scores in nasal conjunctival lissamine green staining (P <.001). Considering the anterior segment tests together, investigators estimated sensitivity to distinguish Sjögren-positive from Sjögren-negative cases at 80.6% (95% CI, 75.3 to 84.9), specificity 91.1% (95% CI, 88.9 to 93.0), and AUC of the receiver operating characteristic curve 0.926 (95% CI, 0.899 to 0.953).

All groups revealed worse CFS-I than in central and superior regions, but the widest difference occurred in participants with Sjögren syndrome. “The findings of our study suggested that inferior CFS and nasal LG staining may be used as screening tools for SS-related DED diagnosis,” the researchers report.

Previous research has shown high LG staining scores in those with primary Sjögren syndrome DED, as well as that conjunctival LG staining and CFS were meaningfully related to other characteristics of Sjögren syndrome. This investigation is first to individually evaluate nasal, central, and temporal conjunctival staining in these cases.

Participants were at least 20 years of age at the tome of anterior segment testing. Limitations of this paper included a retrospective design with unequal age and sex proportions among groups, a single-site population, and no division of primary and secondary Sjögren syndrome. The International Chronic Ocular GVHD Consensus Group: Proposed Diagnostic Criteria zoning system was employed, but additional scales are also in current use.


Shimizu E, Sato S, Asai K, et al. Clinical features of Sjogren syndrome-related dry eye disease in anterior segment photographs. Cornea. July 17, 2023. doi:10.1097/ICO.0000000000003342