A randomized multicenter evaluation of the efficacy of 0.15% hyaluronic acid versus 0.05% cyclosporine A in dry eye syndrome.

Hyaluronic acid (HA) and cyclosporine A (CsA) eyedrops are commonly prescribed in dry eye syndrome (DES). The effectiveness of each preparation in DES is well-known, yet the superiority of one over another has been studied little. We assessed the efficacy and tolerability of 0.15% HA compared to combinations of 0.05% CsA plus 0.5% carboxymethylcellulose (CMC), and 0.15% HA plus 0.05% CsA in patients with moderate to severe DES. Total 438 patients with moderate to severe DES were recruited and randomized for one of the three treatments for 12 weeks. Effectiveness was assessed at baseline, 4- and 12-weeks. The primary endpoint was change in corneal staining score. The secondary endpoints were tear break-up time (TBUT), strip meniscometry (SM) score, ocular surface disease index (OSDI) score, and tolerability questionnaire. The change in corneal staining score for 0.15% HA from the baseline was non-inferior to that of 0.05% CsA. Corneal staining score, TBUT, SM score, and OSDI score improved in all groups without statistically significant intergroup differences. Better tolerability and lower prevalence of adverse drug reactions were seen in 0.15% HA. Our findings suggest that 0.15% HA may be equivalently effective and safer than 0.05% CsA in treating moderate to severe DES.

Clinical Outcomes of Cataract Surgery in Patients with Sjögren's Syndrome.

This study compared the biometric accuracy and refractive outcomes, and ocular surface changes after cataract surgery in patients with Sjögren's syndrome (SS, S group), non-SS dry eye patients (D group), and healthy controls (C group). The medical records of patients who underwent cataract surgery and met certain inclusion criteria were reviewed. In total, 167 eyes of 87 patients were enrolled. Refractive parameters were analyzed via optical biometry and combined ultrasound biometry and automated refractokeratometry. The mean absolute errors (MAEs), the uncorrected distance visual acuities (UDVAs), changes in the ocular staining score (OSS), and anterior chamber cell grades were compared for 12 months postoperatively. The S group evidenced more severe and persistent OSS exacerbation after cataract surgery; the OSS returned to baseline by 3 months postoperatively. The mean keratometric values showed a significant linear correlation. There was no significant intergroup difference in either the MAEs (p > 0.530) or anterior chamber inflammation (p > 0.436). The postoperative UDVA of the S group was poorer than that of the C group from 3 months postoperatively (p < 0.047) but not different from that of the D group (p > 0.311). With preoperative ocular surface optimization and optimal postoperative treatment of superficial keratitis, the refractive outcomes of SS patients were comparable to those of other groups and the postoperative UDVA was not inferior to that of non-SS dry eye patients.

Cataract Surgery Practices in the Republic of Korea: A Survey of the Korean Society of Cataract and Refractive Surgery 2018.

PURPOSE: To describe current cataract surgery practice patterns and changing trends among Korean ophthalmologists. METHODS: A survey of members of the Korean Society of Cataract and Refractive Surgery was performed in July 2018. One hundred and two (12.7%) of 801 questionnaires were returned for analysis. The data were analyzed using descriptive statistics and compared with previous surveys. RESULTS: Most of the respondents (75%) had been in practice for 6 or more years and performed an average of 31 cataract surgeries per month. The preferred method for cataract surgery was phacoemulsification (95%); 5% used a femtosecond laser. The use of topical anesthesia markedly increased from 69% (2012) to 80% (2018). The use of optical biometry exceeded that of ultrasound A-scan biometry. A multifocal intraocular lens was used by 76% of the respondents compared with 44% of the respondents in 2012. Topical nonsteroidal anti-inflammatory drugs were used by 70% of the respondents postoperatively. Most (59%) of these anti-inflammatory drugs were prescribed for 4 weeks. CONCLUSIONS: This survey provided a comprehensive update of the present cataract surgery practices in the Republic of Korea. The results emphasized the increasing use of premium intraocular lenses, optical biometry, and topical anesthesia.

Clinical Features of Herpes Simplex Keratitis in a Korean Tertiary Referral Center: Efficacy of Oral Antiviral and Ascorbic Acid on Recurrence.

PURPOSE: To describe the clinical manifestations of herpes simplex keratitis (HSK) in a tertiary referral center in South Korea and to determine whether ascorbic acid treatment prevents recurrence of herpetic epithelial keratitis. METHODS: This retrospective cohort study included all consecutive patients with herpetic keratitis referred to our center from January 2010 to January 2015. Clinical features, ocular complications, and recurrences were recorded. RESULTS: In total, 149 eyes of the 133 patients (72 male and 61 female) were followed for an average of 24.6 ± 13.2 months. Sixteen (12.0%) patients had bilateral HSK. The most frequent HSK subtype was epithelial keratitis (49.7%), which was followed by stromal keratitis (23.5%). Epithelial keratitis was the most likely subtype to recur. Complications occurred in 122 (81.9%) eyes. The most common complication was corneal opacity. Recurrences were observed in 48 (32.2%) eyes. The recurrence rates were lower in the prophylactic oral antiviral agent group (16 / 48 eyes, 33.3% vs. 49 / 101 eyes, 48.5%) and the ascorbic acid treatment group (13 / 48 eyes, 27.1% vs. 81 / 101 eyes, 70.3%) compared with the groups without medications. Univariate logistic regression analysis revealed that both factors significantly reduced the risk of recurrence (acyclovir: odds ratio, 0.25; 95% confidence intervals, 0.12 to 0.51; ascorbic acid: odds ratio, 0.51; 95% confidence intervals, 0.20 to 0.91). CONCLUSIONS: This retrospective study described the clinical findings of HSK in a tertiary referral center in South Korea. Prophylactic oral antiviral agent treatment and oral ascorbic acid administration may lower the risk of recurrence.

Clinical Results and Utility of Herpesviruses Multiplex Polymerase Chain Reaction: Assessment of Aqueous Humor Samples From Patients With Corneal Endotheliitis and High Intraocular Pressure.

PURPOSE: The main purpose of this study was to evaluate herpesvirus infection in patients with corneal endotheliitis and high intraocular pressure (IOP) using multiplex polymerase chain reaction (PCR) in aqueous humor samples. MATERIALS AND METHODS: This was a retrospective, observational study of immunocompetent patients living in South Korea. Eligible subjects had typical corneal endotheliitis with an IOP≥21 mm Hg or required antiglaucoma medication. Multiplex PCR was performed using aqueous humor samples obtained at first visit to detect the DNA of 6 herpesviruses. RESULTS: Forty-two eyes from 42 patients with >6 months' follow-up were analyzed. Of these, 16 were herpesvirus-positive: 3 herpes simplex virus 1, 3 varicella-zoster virus, 9 cytomegalovirus, and 1 Epstein-Barr virus. Eyes with coin-shaped or fine keratic precipitates (kps), high IOP, and a low baseline endothelial cell count were more likely to show a positive result on multiplex PCR. Univariate analysis showed that male sex (P=0.014), a previous history of uveitic glaucoma (P=0.048), and the presence of fine kps (P=0.031) were significantly associated with a positive PCR result. On multivariate analysis, male sex (P=0.010) and a previous history of uveitic glaucoma (P=0.031) showed a significant positive association. CONCLUSIONS: Cytomegalovirus was the most commonly detected herpesvirus in patients with corneal endotheliitis and high IOP. A positive PCR result was seen more frequently in male individuals and patients with fine kps or a history of uveitic glaucoma.

Descemet Membrane Endothelial Keratoplasty for Epithelial Downgrowth After Clear Corneal Cataract Surgery.

OBJECTIVES: To describe the first case of Descemet membrane endothelial keratoplasty (DMEK) combined with argon laser photocoagulation and intracameral 5-fluorouracil (5-FU) injection in a patient with epithelial downgrowth after cataract surgery. METHODS: Case report and review of the literature. RESULTS: A 77-year-old female underwent uneventful cataract surgery using a clear corneal incision in her left eye. Six months after surgery, an epithelial cell sheet began to cover the posterior cornea and then spread to the anterior chamber structures, leading to anterior synechia and corectopia at 2 years. Argon laser photocoagulation was used to remove epithelial downgrowth on the iris surface. However, retrocorneal epithelial downgrowth gradually progressed, resulting in bullous keratopathy. DMEK with intracameral 5-FU injection was performed to remove epithelial tissue and replace the diseased endothelium with healthy endothelium. One year after surgery, her vision improved to 20/50 and the endothelial cell count was 1,643 cells/mm in her left eye. There were no further complications or recurrence of epithelial downgrowth. CONCLUSIONS: DMEK with preoperative argon laser and intraoperative 5-FU is a useful option for the treatment of diffuse epithelial downgrowths.

Iris-fixated phakic intraocular lens implantation in an adult with retinopathy of prematurity: 1-year follow-up.

PURPOSE: To report a case of iris-fixated phakic intraocular lens (pIOL) implantation in a patient with an extremely steep cornea, shallow anterior chamber, and small corneal diameter caused by retinopathy of prematurity (ROP) and scleral encircling. METHODS: Case report. RESULTS: Iris-fixated pIOLs were implanted in a 19-year-old patient with refraction of -18.5 -0.75 × 180 in the right eye and -15.5 -1.25 × 180 in the left eye. The keratometric values were 53.50 and 51.25 diopters (D) in the right eye and 54.75 and 51.75 D in the left eye. The white-to-white diameter and anterior chamber depth were 10.6 and 3.37 mm, respectively, in the right eye and 10.5 and 3.33 mm, respectively, in the left eye. CONCLUSION: A small pIOL was used to guarantee a safety distance and resulted in a one-line gain in uncorrected distant visual acuity and stable endothelial cell density 1 year after surgery. An iris-fixated pIOL Vis therefore an effective option for myopic patients with ROP.

Serratia marcescens endophthalmitis after pterygium surgery: a case report.

BACKGROUND: To report a case of Serratia marcescens endophthalmitis after pterygium surgery using the bare sclera technique with mitomycin C (MMC). CASE PRESENTATION: A 69-year-old male patient underwent pterygium excision surgery using the bare sclera technique and 0.02% MMC. The patient presented with decreased visual acuity and pain from the day after the operation. Trans pars plana vitrectomy was performed and intravitreal antibiotics were administered. Cultures from the aqueous humor and intraocular lens were all positive for S. marcescens, which was sensitive to an empiric antibiotic regimen. The best corrected distant visual acuity, 1 month after treatment, was a finger count/50 cm, but the retinal layer structure and the vasculature were relatively well preserved. CONCLUSIONS: This is the first reported case of S. marcescens endophthalmitis after pterygium surgery. Endophthalmitis caused by S. marcescens has a devastating visual prognosis and may show a high clinical risk-benefit ratio for the application of MMC in pterygium surgery.

Effects of exogenous recombinant human bone morphogenic protein-7 on the corneal epithelial mesenchymal transition and fibrosis.

AIM: To evaluate the effect of exogenous recombinant human bone morphogenic protein-7 (rhBMP-7) on transforming growth factor-ß (TGF-ß)-induced epithelial mesenchymal cell transition (EMT) and assessed its antifibrotic effect via topical application. METHODS: The cytotoxic effect of rhBMP-7 was evaluated and the EMT of human corneal epithelial cells (HECEs) was induced by TGF-ß. HECEs were then cultured in the presence of rhBMP-7 and/or hyaluronic acid (HA). EMT markers, fibronectin, E-cadherin, α-smooth muscle actin (α-SMA), and matrix metaloproteinase-9 (MMP-9), were evaluated. The level of corneal fibrosis and the reepithelization rate were evaluated using a rabbit keratectomy model. Expression of α-SMA in keratocytes were quantified following treatment with different concentrations of rhBMP-7. RESULTS: Treatment with rhBMP-7 attenuated TGF-ß-induced EMT in HECEs. It significantly attenuated fibronectin secretion (31.6%; P<0.05), the α-SMA protein level (72.2%; P<0.01), and MMP-9 expression (23.6%, P<0.05) in HECEs compared with cells grown in the presence of TGF-ß alone. E-cadherin expression was significantly enhanced (289.7%; P<0.01) in the presence of rhBMP-7. Topical application of rhBMP-7 combined with 0.1% HA significantly reduced the amount of α-SMA+ cells by 43.18% (P<0.05) at a concentration of 2.5 µg/mL and by 47.73% (P<0.05) at 25 µg/mL, compared with the control group, without disturbing corneal reepithelization. CONCLUSION: rhBMP-7 attenuates TGF-ß-induced EMT in vitro, and topical application of rhBMP-7 reduces keratocyte myodifferentiation during the early wound healing stages in vivo without hindering reepithelization. Topical rhBMP-7 application as biological eye drops seems to be feasible in diseases involving TGF-ß-related corneal fibrosis with corneal reepithelization disorders.

Effect of Three-Dimensional Printed Personalized Moisture Chamber Spectacles on the Periocular Humidity.

Purpose. To assess the effect of three-dimensional (3D) printed personalized moisture chamber spectacles (PMCS) on the periocular humidity. Methods. Facial computed tomography (CT) scanning was conducted on 10 normal subjects. PMCS was designed based on volume rendered CT images and produced using a 3D printer. Periocular humidity of PMCS and commercially available uniformed moisture chamber spectacles (UMCS) were measured for 30 minutes via microhydrometer. Results. The mean ambient humidity was 15.76 ± 1.18%. The mean periocular humidity was 52.14 ± 3.00% in PMCS and 37.67 ± 8.97% in UMCS. The difference was significant (P < 0.001). Additionally, PMCS always demonstrated lower humidity than dew points. Conclusion. PMCS made by 3D printer provides appropriate fitness for the semiclosed humid chamber. PMCS showed higher performance than UMCS. The wearing of PMCS would be an effective method to provide high enough periocular humidity in low humidity environment.

Clinical Effects and Safety of 3% Diquafosol Ophthalmic Solution for Patients With Dry Eye After Cataract Surgery: A Randomized Controlled Trial.

PURPOSE: To compare the efficacies and safety profiles of 3% diquafosol and 0.1% sodium hyaluronate in patients with dry eye after cataract surgery. DESIGN: Randomized controlled trial. METHODS: setting: Soonchunhyang University Hospital, Seoul, South Korea. STUDY POPULATION: In all, 130 eyes of 86 dry eye patients who had undergone cataract surgery between January 2014 and January 2015 were enrolled and randomly divided into a diquafosol group and a sodium hyaluronate group. INTERVENTION: The diquafosol group used diquafosol 6 times a day and the hyaluronate group used sodium hyaluronate 6 times a day after cataract surgery. MAIN OUTCOME MEASURES: Evaluations of efficacy were conducted based on an Ocular Surface Disease Index questionnaire, tear breakup time (TBUT), Schirmer I test, corneal fluorescein and conjunctival lissamine green staining scores, serial measurement of ocular higher-order aberrations (HOAs), corneal HOAs, and uncorrected distance visual acuity test. Safety evaluations were based on anterior chamber inflammation and discontinuation of the eye drops. RESULTS: Objective signs and subjective symptoms were aggravated at 1 week postoperatively and began to recover significantly 4 weeks after surgery. The diquafosol group showed significantly superior TBUT (P < .001), corneal fluorescein (P = .045), and conjunctival staining (P = .001) compared to the sodium hyaluronate group throughout the study period. TBUT (P < .001) and the change in HOAs (P = .018) recovered significantly more quickly in the diquafosol group. The safety evaluations showed no intergroup differences. CONCLUSIONS: Eye drops of 3% diquafosol may be an effective and safe treatment for the management of cataract surgery-induced dry eye aggravation in patients with preexisting dry eye.

Reconstruction of the limbal vasculature after limbal-conjunctival autograft transplantation in pterygium surgery: an angiography study.

PURPOSE: We evaluated the angiographic features of the affected limbus in patients with pterygia and assessed limbal reconstruction outcomes after limbal-conjunctival autograft (LCA) transplantation in terms of vascular remodeling. METHODS: We studied prospectively 31 eyes of 31 patients who underwent pterygium excision and LCA transplantation; 28 eyes of 28 normal participants served as controls. Anterior segment indocyanine green angiography (ICGA) was performed for each participant preoperatively and at 1 week, and 1 and 3 months postoperatively. The perioperative angiographic features of the pterygium were compared to those in normal eyes. The structural changes of the marginal corneal vascular arcades (MCAs) and LCA were quantitatively assessed postoperatively in terms of vascular density and lacunarity. RESULTS: Deteriorated MCAs that extended beyond the pterygium head were observed in the pterygium group. The pterygium had a dual blood supply from the conjunctival and episcleral circulations. In terms of limbal reconstruction, the engorged reperfusion vessels arose from the adjacent episcleral vessels along the limbus at 1 week postoperatively. The reconstructed MCAs had begun to appear at 1 month postoperatively and became apparent 3 months postoperatively in 26 (83.9%) of 31 eyes of the pterygium group, resulting in a successful clinical outcome. Higher vascular density and lower lacunarity were measured in the limbus and the graft at 3 months than at 1 month (P < 0.001 for all), which indicated fine reorganization of the reconstructed vessels. CONCLUSIONS: The pterygium had a dual blood supply, and the remodeling of the affected limbus and LCA continued up to 3 months postoperatively.

Retinal detachment surgery in eyes with iris-fixated phakic intraocular lenses: Short-term clinical results.

PURPOSE: To evaluate the safety of retinal detachment (RD) surgery in eyes with iris-fixated phakic intraocular lenses (pIOLs) and the efficacy of the pIOLs in correcting myopia after RD surgery. SETTING: Single university-based tertiary referral center. DESIGN: Retrospective case series. METHODS: Eyes that had RD surgery (RD group) and healthy fellow eyes (control group) of the same patients were evaluated over 1 year. Surgical success, corrected distance visual acuity (CDVA), anterior chamber depth (ACD), endothelial cell density (ECD), and intraocular pressure (IOP) were assessed preoperatively and postoperatively to evaluate the safety of the surgery. The uncorrected distance visual acuity (UDVA) and spherical equivalent were assessed to evaluate the efficacy of the pIOL after RD surgery. RESULTS: Twenty-two eyes of 11 patients were assessed. Reattachment was achieved in 10 eyes (90.9%) with the first intervention. After 1 year, the mean UDVA was 0.16 ± 0.15 logMAR (SD) in the RD group and 0.09 ± 0.12 logMAR in the control group (P=.332). The mean CDVA was 0.03 ± 0.07 logMAR in the RD group. The differences in the mean postoperative ACD and ECD between the 2 groups were not significant (P=.088 and P=.270, respectively). The mean IOP in the RD group was significantly higher than in the control group up to 1 month postoperatively; thereafter, the difference was not significant. CONCLUSIONS: Preservation of a pIOL during RD surgery did not diminish the safety of the surgery. The efficacy of the pIOL in correcting myopia was not markedly compromised.

Streptococcus mitis/oralis endophthalmitis management without phakic intraocular lens removal in patient with iris-fixated phakic intraocular lens implantation.

BACKGROUND: To report a case of Streptococcus mitis/oralis endophthalmitis management which had developed after complicated iris-fixated phakic intraocular (pIOL) lens implantation. CASE PRESENTATION: A 23-year-old-woman received pIOL implantation followed secondary intraocular intervention to lower intraocular pressure. The patient presented with severe pain and decreased visual acuity and was managed with intravitreal and intracameral antibiotic injection with topical applications of fortified antibiotics. Culture of aqueous humor was positive for S. mitis/oralis, which was sensitive to the empiric antibiotic regimen. Clinical features started to improve 5 days after treatment and the pIOL was left in place. The uncorrected distant visual acuity and endothelial cell count were 20/32 and 3143 cells/mm2 four weeks after treatment, respectively. CONCLUSION: S. mitis/oralis endophthalmitis after pIOL implantation could be managed with appropriate antibiotic administration without pIOL removal if accompanied by rapid clinical improvement after the initial intensive management in the absence of vitreous involvement.

Traumatic partial aniridia and cataract after iris-fixated foldable phakic intraocular lens implantation.

We present the first case of partial aniridia, traumatic cataract, and peripapillary subretinal hemorrhage after blunt trauma to an eye containing a foldable iris-fixated phakic intraocular lens (pIOL). Although the patient experienced visual loss because of considerable corneal astigmatism and a traumatic cataract, vision was recovered by a 2-stage primary corneal repair and cataract surgery with a toric intraocular lens. This case exhibits clinical manifestations that differ from previously reported trauma of a non-foldable iris-fixated pIOL. A relatively small corneal incision and a large optic diameter of Artiflex pIOLs may prevent posttraumatic total expulsion of intraocular tissues and present different clinical features from the case of non-foldable pIOLs (Artisan). Although the extent of the damage is different, the possibility of aniridia and traumatic cataract exists in eyes with both foldable and non-foldable iris-fixated pIOLs.

Transient anterior subcapsular vacuolar change of the crystalline lens in patients after posterior chamber phakic intraocular lens implantation.

BACKGROUND: We present two cases of transient vacuolar changes in the anterior subcapsular space of the crystalline lens in patients after posterior chamber phakic intraocular lens implantation. CASE PRESENTATION: Implantable collamer lenses (ICL) were implanted in healthy myopic patients. Vacuolar changes developed just after the irrigating procedure through the narrow space between the ICL and the crystalline lens. Slit-lamp examinations and spectral domain optical coherence tomography showed bleb-like lesions in the anterior subcapsular space of one eye in each case, though the lesions gradually improved without visual deterioration. Consequently, the lesions turned into a few anterior subcapsular small faint opacities. CONCLUSION: Direct irrigation of the narrow space confined by the ICL and the crystalline lens is at risk for the development of vacuolar changes in the crystalline lens. The observed spontaneous reversal indicates that surgeons should not rush to surgical intervention but rather opt for close follow over several weeks.

Iris-fixated phakic intraocular lens implantation after retinal detachment surgery: long-term clinical results.

PURPOSE: To assess the efficacy and safety of iris-fixated phakic intraocular lens (pIOL) implantation to correct myopia in eyes with previous retinal detachment (RD) surgery. SETTING: Department of Ophthalmology, Soonchunhyang University College of Medicine, Seoul, South Korea. DESIGN: Retrospective case series. METHODS: Patients having pIOL implantation in both eyes were enrolled. Eyes that had scleral buckling or encircling (RD group) and healthy fellow eyes (non-RD group) were evaluated over a 6-year follow-up. The corrected distance visual acuity (CDVA), endothelial cell density (ECD), intraoperative complications, and long-term complications were safety outcomes. Uncorrected distance visual acuity (UDVA), predictability, and stability of refraction were efficacy outcomes. RESULTS: The study comprised 34 eyes (17 patients). The mean postoperative CDVA and ECD were not significantly different between groups, and no patient lost CDVA. The rate of transient intraocular pressure spike was significantly higher in the RD group (P=.043). After 3 years and 6 years, the mean postoperative UDVA was 0.06 logMAR ± 0.09 (SD) and 0.08 ± 0.10 logMAR, respectively, in the RD group and 0.04 ± 0.08 logMAR and 0.04 ± 0.09 logMAR, respectively, in the non-RD group (P=.518 and P=.478, respectively). The rate of eyes within ±0.50 diopter of the desired refraction and the postoperative refraction was not significantly different between groups. No eye had vitreoretinal changes requiring secondary surgical intervention. CONCLUSION: Iris-fixated pIOL implantation corrected the myopic refractive error in patients who had scleral buckling or encircling surgery for RD with a high degree of efficacy, safety, and long-term stability. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Optical coherence tomographic findings of crystal deposits in the lens and cornea in Bietti crystalline corneoretinopathy associated with mutation in the CYP4V2 gene.

BACKGROUND: We report the optical coherence tomography (OCT) findings of crystalline deposits in the cornea and lens of a patient with Bietti crystalline dystrophy (BCD), thus providing evidence for a better understanding of the pathophysiology of BCD. PATIENT: A 49-year-old man showing typical chorioretinal degeneration with a CYP4V2 mutation was diagnosed with BCD. OBSERVATIONS: The anterior segment OCT images clearly showed flat hyperreflective plaques just beneath the corneal epithelium and in the lens epithelium. The crystals were not located on the outer surface of the lens capsule as previously described but on the inner surface of the anterior capsule. CONCLUSIONS: This finding suggests that the crystals in the lens of patients with BCD may be produced in the same way as corneal or retinal crystalline deposits and therefore result from a systemic abnormality of lipid metabolism rather than by previously considered possibilities, such as release from the retina adhering to the lens capsule.

Prognostic factors for the clinical severity of keratoconjunctivitis sicca in patients with Sjogren's syndrome.

AIMS: To determine whether prognostic immunological profiles predict the severity of keratoconjunctivitis sicca (KCS) in patients with Sjögren's syndrome (SS). METHODS: 121 patients diagnosed with SS and followed for at least 1 year were enrolled in this study. Patients were allocated to either a mild KCS group (Mi-KCS; n=65) or to a moderate to severe KCS group (MS-KCS; n=56) based on the Oxford scheme and response to treatment. These groups were each sub-divided into two groups based on the clinical severity of KCS and the presence of associated rheumatic disease (primary SS vs secondary SS). Anti-Ro/anti-La antibody, rheumatoid factor and tear interleukin (IL)-17 levels and Schirmer test results were compared between each group. RESULTS: Anti-Ro/SSA antibody and anti-La/SSB antibody concentrations were significantly higher in the MS-KCS group than in the Mi-KCS group for total and primary SS. The presence of anti-La/SSB antibody was significantly higher in the MS-KCS than the Mi-KCS group for total and primary SS. The mean tear IL-17 concentration in the MS-KCS group was significantly higher than in the Mi-KCS group for both total SS and primary SS patients. CONCLUSION: Serum anti-La/SSB antibody, serum anti-Ro/SSA antibody and tear IL-17 are likely to be strongly involved in the clinical severity of KCS in patients with primary SS.