Unveiling dry eye with autoimmune features (DEAF): insights from a prospective longitudinal study

Dry eye is a prevalent condition that commonly occurs with autoimmune diseases such as Sjögren's disease (SjD). However, some individuals with dry eye were observed to display unique features suggesting an underlying autoimmune process while failing to meet the criteria for a definitive diagnosis of any connective tissue diseases (CTDs). This study aims to describe and propose a novel concept "dry eye with autoimmune features (DEAF)" to define these patients, whose status might suggest a pre-stage of SjD or another unidentified autoimmune condition.

We conducted a prospective longitudinal study in the ophthalmology clinic by continuously collecting patients with dry eye. The patients' medical history was reviewed, and the ocular examinations and extensive serology tests were conducted. In the discovery cohort, patients were randomized and clustered automatically into three groups through heatmap, PCA, and PLS-DA analysis. We defined the groups as healthy controls with dry eye symptoms (dry eye) group, dry eye patients with autoimmune features (DEAF) group, and Sjögren's disease (SjD) group according to their different characteristics. Based on the summarized characteristics, a validation cohort was subsequently extended. We analyzed clinical and serological parameters and followed up DEAF patients for 3 years to monitor the development of any new onset of CTD.

In the discovery cohort of 33 dry eye patients, the heatmap, PCA, and PLS-DA clustering revealed distinct features among the three groups. In the validation cohort of 59 patients, 12 were classified into the dry eye group, 28 were in the DEAF group, and 19 were in the SjD group. DEAF patients showed higher DEQ-5 and SPEED scores but lower IgG levels compared to SjD. Total OSS score was observed with no difference among the three groups, while nasal OSS level was higher than temporal conjunctive in the DEAF and SjD groups. DEAF patients showed a trend toward lower total lymphocyte and CD4⁺ T cell counts compared to dry eye patients. The level of anti-α-fodrin antibody in DEAF was higher than that in the other two groups. After a 3-year follow-up, 39.3% of DEAF patients have developed CTDs, with SjD being predominant.

This study unveiled DEAF patients with significant distinctions in clinical features and serological markers. DEAF may constitute a distinct phase or entity within the autoimmune spectrum, underscoring the intricate nature of autoimmune pathogenesis. Besides, this revelation may bridge the gap between idiopathic dry eye and CTDs. However, these findings are limited to one Chinese cohort, which necessitate multiethnic validation. Keypoints • Patients with dry eye with autoimmune features (DEAF) have significant distinctions in clinical features and serological markers, compared to simple dry eye and Sjögren's disease patients. • DEAF patients may have a higher likelihood of developing connective tissue diseases (CTDs) in the future. • The proposition of DEAF could benefit dry eye patients who have underlying autoimmune disorders in terms of early diagnosis and treatment.