Unmasking Dermatomyositis: A Case Of Aqueous-Deficient Dry Eye As An Early Indicator

Dermatomyositis (DM) is a rare autoimmune condition that primarily affects the skin and muscles, but ocular manifestations, including chronic dry eye disease (DED), can be an early and often overlooked symptom. This case report aims to highlight the role of DED as the initial manifestation of DM and emphasize the importance of recognizing systemic autoimmune diseases in the diagnostic process for refractory dry eye

The case was managed in an ophthalmology clinic equipped with advanced diagnostic tools for ocular surface analysis, including tear film analysis, corneal pachymetry, Schirmer test and OCT.The clinic collaborates with internists and specialists in autoimmune diseases, allowing for a multidisciplinary approach to address both ocular and systemic aspects simultaneously. It also provides laboratory workup for autoimmune markers, such as creatine kinase (CK) and antinuclear antibodies (ANA).

A 48-year-old woman with a history of Hashimoto’s disease presented with progressively worsening dry eye symptoms, including a gritty sensation, occasional redness, and blurred vision, which did not respond to over-the-counter artificial tears or topical corticosteroids. A comprehensive ophthalmological examination revealed significant tear film instability (TBUT <5 seconds), reduced tear production (Schirmer’s test <5 mm), and corneal punctate epithelial erosions, indicating severe aqueous-deficient dry eye. Additional testing, including ocular surface analysis and meibography, confirmed the diagnosis of aqueous-deficient dry eye. Systemic workup showed elevated creatine kinase (CK) levels and positive antinuclear antibodies (ANA), leading to the diagnosis of dermatomyositis (DM). Corneal pachymetry revealed subtle stromal thinning. A combined treatment plan was initiated, including topical cyclosporine, autologous serum eye drops, and immunosuppressive therapy with methotrexate and corticosteroids. Over the next six months, the patient showed significant improvement in both ocular and systemic symptoms.

Chronic DED, particularly when refractory to standard treatments, can be an early sign of systemic autoimmune diseases, such as dermatomyositis.
Ophthalmologists should maintain a high index of suspicion for underlying autoimmune disorders in patients with unexplained or treatment-resistant dry eye symptoms.
A multidisciplinary approach involving both ophthalmologists and internists is essential for early diagnosis and effective management of both ocular and systemic manifestations of autoimmune diseases like DM.
Timely diagnosis and treatment can significantly improve patient outcomes, highlighting the importance of comprehensive patient evaluation beyond the ocular surface.