Kerato-conjunctivitis sicca and rheumatoid arthritis.

Although the ophthalmic lesions which constitute kerato-conjunctivitis sicca have long been known, the nature of the condition has remained obscure. Duke-Elder (1930) reviewed those rare cases in which lesions of the lacrimal secretary nerves or of the gland parenchyma (including congenital aplasia, surgical extirpation, infiltrations by sarcoid, leu-kaemic or malignant tissue) resulted in deficient lacrimal secretion and the subsequent development of corneal and conjunctival lesions of the sicca type. These rare cases, however, accounted for only a small proportion of all the patients suffering from kerato-conjunctivitis sicca, and in the majority no local ophthalmic cause for deficient lacrimation and sicca lesions could be found. Sjogren (1933) described in detail his observations on eighteen patients with idiopathic kerato-conjunctivitis sicca and drew attention to its frequent association with such clinical features as poly-arthritis, xerostoma, and salivary gland enlargement, occurring especially in middle-aged women. To this triad the name Sjogren's syndrome was given, but the variations and increasing complexity of the condition soon became apparent. Holm (1949) reviewing 440 cases of rheumatoid disease stated that "The conception of kerato-conjunctivitis sicca as a disease sui genesis (Sjogren) is fundamentally incorrect": but he considered that rheumatoid arthritis was of importance as an aetiological factor. The term Sjbgren's syndrome continued to be applied to any condition in which the classical triad of kerato-conjunctivitis sicca, polyarthritis, and salivary gland enlargement was present, as well as those in which arthritis was absent (approximately 40 per cent. of all cases of kerato-conjunctivitis sicca). Writers, however, remained cautious of associating the condition with rheumatoid arthritis. Coverdale (1948) considered that "Sj6gren's syndrome" indicated a general constitutional or systemic disturbance of unknown origin, while Henderson (1950) stated: "I do not feel that poly-21 arthritis is an integral part of the symptom complex. It is my feeling that the arthritis is an incidental finding." Ellman, Weber, and Goodier (1951) remarked that: "rheumatoid arthritis is fairly common among women, and that very few patients with rheumatoid arthritis ever manifest any symptoms resembling Sjogren's disease". They recorded the case history and autopsy findings in a patient who did suffer from rheumatoid arthritis, but in whom the symptoms of xerostoma, salivary gland enlargement, and ocular inflammation preceded the development of the arthritis by several years. However, Reader, Whyte, and Elmes (1951) confirmed the opinion of Holm (1949) that many patients who suffered from rheumatoid arthritis also had a deficiency of lacrimal secretion, as estimated by Schirmer's …