Analysis of novel Sjogren’s syndrome autoantibodies in patients with dry eyes
© The Author(s). 2017
Received: 19 July 2016
Accepted: 11 February 2017
Published: 7 March 2017
Dry eye is a common problem in Ophthalmology and may occur for many reasons including Sjogren’s syndrome (SS). Recent studies have identified autoantibodies, anti-salivary gland protein 1 (SP1), anti-carbonic anhydrase 6 (CA6) and anti-parotid secretory protein (PSP), which occur early in the course of SS.
The current studies were designed to evaluate how many patients with idiopathic dry eye and no evidence of systemic diseases from a dry eye practice have these autoantibodies.
Patients from a dry eye clinic and normal controls were assessed by Schirmer’s test for tear flow. Sera were assessed for autoantibodies using ELISA assays. Statistics was performed with Prism 7 software and student’s unpaired t test.
In this study 60% of the dry eye patients expressed one of these autoantibodies. Only 30% expressed one of the autoantibodies associated with long-standing SS, which are included in the diagnostic criteria for SS, anti-Ro and anti-La. Patients with disease for less than 2 years and mild dry eyes did not express anti-Ro or anti-La, while 25% expressed anti-SP1. Similar observations, with smaller numbers, were made when patients had not only dry eye but also dry mouth.
Antibodies to SP1, CA6 and PSP occur in some patients with idiopathic dry eyes. Further studies will be needed to determine how many of these patients go on to develop systemic manifestations of SS. Testing for these autoantibodies may allow early recognition of patients with SS. This will lead to improved management of the patients and the development of new strategies to maintain normal lacrimal and salivary gland function in patients with SS.
KeywordsSjogren’s syndrome Dry eyes Corneal abrasion Autoantibodies
Dry eyes and their complications are commonly seen in Ophthalmology practices [1, 2]. Recent studies have demonstrated that Sjogren’s syndrome (SS) is common among patients with dry eyes and is likely underestimated in this patient population [3, 4]. Current diagnostic criteria for SS include serological tests, anti-nuclear antibodies (ANA), rheumatoid factor (RF), anti-La and anti-Ro . Studies investigating dry eye patients with SS diagnosed by clinical criteria note that anti-Ro and anti-La may frequently be negative . Lip biopsies are then required to make a diagnosis of SS.
Studies initially utilizing animal models for SS and various subgroups of SS patients have demonstrated novel autoantibodies, anti-salivary gland protein 1 (SP1), anti-carbonic anhydrase 6 (CA6) and anti-parotid secretory protein (PSP) . In animal models, anti-SP1, anti-CA6 and anti-PSP are expressed earlier in the course of the disease than anti-Ro and anti-La. Various studies have suggested that this may be true in patients with SS [7, 8].
The current studies were established to investigate the presence of anti-SP1, anti-CA6 and anti-PSP in a population of patients with dry eyes. Patients were classified according to the degree of dysfunction noted by Schirmer’s test. No patients had significant medical co-morbidities. Normal controls were obtained from the general community.
This was a retrospective study performed on a population of patients being followed in a Dry Eye Practice (Investigator SE). All patients were included in the study who lacked a primary cause for their dry eyes, such as medication with anti-cholinergic effects, radiation therapy, sarcoidosis, hepatitis C, HIV, lymphoma or graft-versus-host disease. Normal controls were obtained from the general population. The Institutional Review Board, SUNY at Buffalo School of Medicine, approved these studies.
Schirmer’s tests were performed as previously described . Tear osmolarity was determined by The TearLab Osmolarity System following the manufacturer’s instruction. The serology studies for anti-Ro (IgG), anti-La (IgG), anti-SP1 (IgG, IgA & IgM), anti-CA6 (IgG, IgA & IgM), and anti-PSP (IgG, IgA & IgM), were performed at by utilizing enzyme linked immunosorbent assay (ELISA) at Immco Diagnostics, Buffalo, NY .
Statistical analysis was performed using Prism 7 software. Comparison of various groups was performed using unpaired student’s t test.
SCH < 3 mm
3 mm < SCH < 6 mm
Number in Group
40 – 95 (mean 67.8) yrs.
44 – 80 (mean 63.8) yrs.
31-93 (mean 57.4 years)
Duration of Dry Eyes
1 – 30 (mean 13) yrs.
0.5 – 10 (mean 4.1) years
Presence of Dry Mouth
The current studies demonstrate that many patients with “idiopathic” dry eyes, with or without dry mouth, have autoantibodies that are seen in patients with early SS. Some of these patients have autoantibodies included in the current diagnostic criteria for SS, anti-Ro and anti-La, while more patients express more recently discovered autoantibodies associated with an early stage of SS, anti-SP1, anti-CA6 and anti-PSP, without anti-Ro or anti-La.
Previous studies from an academic Sjogren’s center demonstrated that many patients referred with a diagnosis of dry eyes in fact had SS that met full criteria established by the American College of Rheumatology . Many of these patients had evidence of systemic manifestations of SS as well. In the current study, patients were studied from a private dry eye practice who lacked evidence of systemic manifestations of SS. These patients were in fact often self-referred or referred by an Internist for an initial evaluation. They likely had earlier disease than the patients referred to a tertiary academic center. Nonetheless, there was still a significant delay in the evaluation by the Ophthalmologist relative to the onset of dry eyes as indicated by the clinical history but also by the fact that the predominant autoantibodies were of the IgG or IgA isotype rather than the IgM isotype.
Animal models have demonstrated that the earliest manifestations of SS are loss of salivary gland function secondary to involvement of the innate immune system [7, 12, 14]. Lacrimal gland involvement likely occurs initially in the same manner, although this has not yet been studied completely. At this stage, antibodies anti-SP1, anti-CA6 and anti-PSP are noted. In the next stage lymphocytic infiltration of the glands occurs followed by progression from a local disease to a systemic disease, with lung and kidney involvement. Antibodies anti-Ro and anti-La are identified in the animals at the point when the disease goes from being local to being systemic . It should be noted, however, that one study demonstrated anti-Ro and anti-La antibodies in the sera of patients who developed SS years before clinical expression of their disease [15, 16]. So, in some cases, anti-Ro and anti-La may occur in early disease as well. The challenge from a therapeutic point of view is to identify the SS patients at the very earliest stages, before there has been permanent damage to the lacrimal and salivary glands [17–19]. In animal models, treatment at this stage can lead to halting of the disease process [20–22]. The current studies suggest that Ophthalmologists see patients who are in very early stages of SS. Perhaps with greater vigilance in the medical community, Ophthalmologists can see these patients at even earlier stages.
At the same time, many of the patients in this study had dry eyes for longer than 10 years without the development of systemic symptoms. They had autoantibodies consistent with immune mediated lacrimal gland injury. Perhaps many patients develop a form of SS that involves only the lacrimal and/or salivary glands without ever progressing to more systemic manifestations. These patients would not meet the accepted criteria for SS, but in fact may deserve the same type of immunomodulatory therapy. This therapy could theoretically be given locally under these circumstances rather than systemically. Further study will be necessary to address these issues.
In conclusion, many patients with “idiopathic dry eyes” identified in a private dry eyes practice have evidence of immune mediated lacrimal gland injury with serum autoantibodies consistent with early SS. The criteria for SS may have to change to accommodate these patients. Future studies will be necessary to determine the most appropriate therapies for these patients.
The current studies demonstrate that many patients with idiopathic dry eyes with or with out dry mouth have markers for early Sjogren’s syndrome, anti-SP1, anti-CA6 and anti-PSP. Further study will be necessary to assess antibody positive patients for various features of SS over a long period of time and to develop therapies appropriate for patients showing evidence of early SS.
Carbonic anhydrase 6
Enzyme linked immunosorbent assay
Parotid secretory protein
Salivary gland protein 1
The work for this proposal was supported from institutional funds SUNY at Buffalo School of Medicine and Immco Diagnostics.
Availability of data and materials
The data have not been placed in any online data storage. They can be provided on request to the authors.
SE took care of the patients, provided the necessary samples for the study, helped design the study, reviewed the data and helped write the paper. SV and VC helped collect the data, analyze the data and review the paper. LS, LS and KM helped design the experiments, run the assays, review the data and write the paper. NLC helped design the experiments, recruit the normal controls, review the data and write the paper. JLA helped organize and design the study, review the data and write the paper. All authors read and approved the final manuscript.
The novel autoantibodies that are discussed in this manuscript were discovered by Long Shen, PhD and Julian L. Ambrus Jr., MD. SUNY at Buffalo School of Medicine. They hold a patent on these autoantibodies that is licensed to Immco Diagnostics and Sub-licensed to Valeant for commercial sale. Lakshmanan Suresh, DDS, MS, Long Shen, PhD and Kishore Malyavantham, PhD are employees of Immco Diagnostics.
Consent for publication
Ethics approval and consent to participate
The studies were approved by the Institutional Review Board SUNY at Buffalo. All patients signed consents to participate. Publications does not involve divulging and personal information so no consent to publish was obtained.
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