Cyclosporine drops are appropriate for this patient. She has primary Sjögren syndrome with dry eyes (keratoconjunctivitis sicca), which has not responded to topical lubrication or punctal plugs. Sjögren syndrome is an immune-mediated disease of unknown cause manifesting primarily as inflammation of exocrine glands, including the major and minor salivary glands, lacrimal glands, and, less commonly, other exocrine glands such as the pancreas. The most prominent clinical feature is dryness (sicca), particularly of the eyes and mouth. Dry eyes can lead to corneal damage and visual impairment. Sicca symptoms are primarily treated with hydration and lubrication, although other local measures and medications may be helpful. Topical cyclosporine has been demonstrated in trials to improve the symptoms of dry eyes in patients with primary Sjögren syndrome. An alternative therapy is punctal occlusion (placement of plugs in the tear drainage duct openings of the lower eyelids to increase eye moisture). There is controversy as to the timing and type of plug to use when performing this procedure.

Certolizumab pegol is a tumor necrosis factor (TNF)-α inhibitor used to treat diseases such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. This agent is not appropriate for this patient because trials of other TNF-α inhibitors (etanercept and infliximab) did not demonstrate benefit for sicca symptoms.

Hydroxychloroquine is used to treat diseases such as systemic lupus erythematosus and rheumatoid arthritis. This agent has not been demonstrated to improve sicca symptoms, although it could be useful for treating arthritic and other systemic symptoms associated with Sjögren syndrome.

Olopatadine drops reduce histamine release from mast cells and are used to treat allergic conjunctivitis; they would therefore not be helpful for Sjögren-related sicca symptoms.

Prednisone is a potent anti-inflammatory agent that is very effective in many rheumatologic diseases. It has not been demonstrated to improve sicca symptoms, although it could be useful for treating systemic manifestations of Sjögren syndrome.