A new craniofacial disorder involving hypertelorism and malformations of external nose, palate and pituitary gland

The aim of the present study was to describe and pathologically evaluate an apparently unreported craniofacial malformation, based on comparison of the cranial midsagittal components with similar components under normal developmental conditions. A severely malformed fetus with a gestational age of about 17 weeks underwent whole body and special craniofacial radiography. Following autopsy dissection, the midsagittal segment of the cranial base, including the eyes, was radiographed in different projections. Midsagittal tissue blocks were serially sectioned for microscopy. Routine stains and immunohistochemical stains were applied. The face was characterized by hypertelorism, absence of external nose but with open shell-like cavities medio-cranially to the eyes, and by a palate fused in the midline and with extensive bony ridges laterally. There was absence of normal nasal cavities, presence of nasal septum and vomer, normal eyes, and nasal ducts covered with nasal mucosa ending blindly in the cartilage. No olfactory bulbs were found. The palatal ridges consisted of bony tissue. The pituitary gland was severely malformed and consisted solely of adenopituitary gland tissue, located in its full extent in the pharyngeal mucosa. There was no sella turcica. From a pathogenetic point of view, it is suggested that the neural crest cells in the frontonasal region of the crest were reduced in amount or late in migration to the midfacial region compared to the neural crest cells to the maxillary region. Therefore, we believe that the malformations observed in the nasal placodes and in the pituitary placode, combined with abnormal migration or abnormal timing of neural crest cells during the craniofacial development, are important factors behind this disorder.

Precise correlation of histopathological and fluorescein angiographic morphology using retinal vascular casting

The histopathology of three eyes obtained post mortem from 2 patients with age-related macular degeneration was correlated with the pre mortem fluorescein angiographic morphology. A precise point-by-point correlation between histopathology and the corresponding angiographic appearance was ensured by using the cast retinal vascular system as a pattern of reference. The study showed that both the photoreceptors, the pigment epithelium, and substances accumulated between the retinal and the choroidal vascular systems, may have a blocking effect on choroidal background fluorescence as seen on fluorescein angiograms. Furthermore, it is confirmed that fluorescein angiographic hyperfluorescence may be due to a lack of blocking of the choroidal fluorescence because of a window defect in the retinal photoreceptor layer and/or the pigment epithelium.

Malignant melanoma of the conjunctiva: occurrence and survival following surgery and radiotherapy in a Danish population

PURPOSE

To describe patient characteristics, risk of recurrence, and survival in patients with premalignant and malignant melanocytic lesions of the conjunctiva.

METHODS

In a retrospective study, 55 cases with a minimum follow-up of 10 years were reviewed.

RESULTS

The actuarial 5-and 10-year survival rates were 86% (95% Cl: 76-96%) and 73% (95% Cl: 60-87%) respectively. The 5-year risk of local recurrence was 35% (95% Cl: 21-49%), and the 10-year risk was 43% (95% Cl: 28-58%). Primary acquired melanosis with atypia was the first manifestation in 13 cases, malignant melanoma in 42 cases. No significant difference in survival and recurrence was found between the two groups or by gender, location of primary lesion, histological characteristics, or extent of surgical procedure. A minimum incidence of 0.052 cases a year per 100 000 in Denmark was calculated.

CONCLUSION

The results are estimated to represent a nationwide sample of patients. No prognostic factors of significance were identified.

Conjunctival naevi in Denmark 1960-1980. A 21-year follow-up study

The clinicopathological characteristics of 343 naevi of the conjunctiva were studied. A significant increase in the number of naevi excised per annum was observed. This may have been caused by an increased exposure to actinic rays. Approximately even distribution in the three main locations: caruncle, limbal area and eyeball, was found. Intrastromal naevi were excised at a higher median age than compound naevi, and the lowest observed median age at excision was for junction naevi, which is in accordance with the known histopathological nature of naevi. Recurrence occurred in nine patients (2.7%), and one transformed to a malignant melanoma. Eight of the recurring naevi were located in the limbal area. Eight of the nine patients were women, suggesting hormonal factors as a possible cause. Recommendations for the handling of conjunctival naevi are given, based on the present findings and on previous reports.

An ocular bioavailability comparison in rabbits of prednisolone acetate after repeated topical applications formulated as a high-viscosity gel and as an aqueous suspension

To increase contact time between drug and ocular surface and thus improve the ocular bioavailability, we used the high-viscous, water-soluble polymer carbomer Leogel (carbomer 0.5%). We compared the bioavailability of prednisolone acetate 0.5% given in 1) Leogel using fusidic acid 1% with that obtained using 2) aqueous sulfacetamide sodium 10% as vehicle. We applied the drugs to Copenhagen white rabbits as repeated topical applications (gel preparation: twice daily; aqueous preparation: four times daily) for one week. Dosis regimen was chosen according to earlier investigations (Johansen et al. 1995). Prednisolone concentrations in cornea, conjunctiva and aqueous humour were shown to be higher using the Leogel vehicle than using the aqueous suspension. Fusidic acid and sulfacetamide sodium values were compared with values from a single application (Johansen et al. 1995). Fusidic acid reached higher concentration levels in cornea, conjunctiva and aqueous humour after repeated applications than after a single application. Sulfacetamide sodium concentrations did not rise when applied four times daily for one week. Leogel increases the ocular bioavailability of substance(s) in the gel and allows lower drug concentrations and/or application frequencies.

A bioavailability comparison in rabbits after a single topical ocular application of prednisolone acetate formulated as a high-viscosity gel and as an aqueous suspension

To increase contact time between drug and ocular surface and thus improve the bioavailability, we used the high-viscous, water-soluble polymer carbomer Leogel (carbomer 0.5%). The drugs were applied to Copenhagen white rabbits as a single application. We compared the bioavailability of prednisolone acetate 0.5% in Leogel with fusidic acid 1% after 1, 4, 7 and 10 h (n = 3 at each time points) with that obtained when doubling the prednisolone acetate concentration in unchanged Leogel and fusidic acid 1% in 12 rabbits. In addition we compared the bioavailability of prednisolone acetate 0.5% given in 1) Leogel using fusidic acid 1% with that obtained using 2) aqueous sulfacetamide sodium 10% as vehicle after 0.5, 1, 1.5, 2, 3, 6, 8 and 12 h (n = 6 at each time points) in 54 rabbits. When doubling the prednisolone acetate dose an increase in bioavailability was achieved in conjunctiva, cornea and aqueous humour with 1.57, 3.86 and 2.18 times, respectively. Prednisolone concentrations in cornea, conjunctiva and aqueous humour were higher using the Leogel vehicle than using the aqueous suspension. The bioavailability in 0-12 h for prednisolone acetate in Leogel and fusidic acid 1% to conjunctiva was significantly higher (p = 0.003) than for prednisolone acetate in aqueous and sulfacetamide sodium 10%. The bioavailability (0-6 h) for conjunctiva was significantly higher for the Leogel preparation than for the aqueous suspension (p < 0.001). For cornea and aqueous humour, the bioavailability values for the total period (0-12 h) do not differ significantly. However, for the first 6 h the difference is significant (p < 0.001 for cornea and p = 0.003 for aqueous humour).

Ocular findings in cystic fibrosis patients receiving vitamin A supplementation

BACKGROUND

Vitamin A deficiency with eye symptoms has been reported in patients with cystic fibrosis who received the recommended daily intake of vitamin A.

METHODS

We measured serum retinol, dark adaptation, contrast sensitivity, and dry eye status in 35 adult cystic fibrosis patients to ascertain whether they had ocular signs or symptoms.

RESULTS

Median serum retinol concentration was 1.95 mumol/l, range 1.08-4.01 mumol/l, with no values indicating vitamin A deficiency. Retinal light sensitivity was normal. Nineteen patients had reduced contrast sensitivity. Conjunctival imprints all showed plenty of goblet cells, but were characteristic of dry eye in 42% of patients (n = 14). Decreased tear film stability was found in 49% (n = 17), tear production was low in 31% (n = 11), and 23% (n = 8) showed an increased amount of dying epithelial cells. Nine patients (26%) had keratoconjunctivitis sicca according to the Copenhagen criteria.

CONCLUSION

Our patients had no biochemical or clinical signs of vitamin A deficiency. We speculate that the high incidence of dry eye could be a primary manifestation of cystic fibrosis.

Sjögren's syndrome: terminology

In spite of our continuously improved pathobiological understanding, there is still no consensus on terminology and disease criteria in Sjögren's syndrome (SS). This survey points out discrepencies in the current description of the syndrome, and argues for a new classification model. We suggest that the present nomenclatures for the global disease (Sjögren's disease) and disease subsets (primary and secondary SS) be retained until additional pathobiological insights give rise to new and descriptive terms. We do find evidence, however, to support a new terminology and classification of the main immunoinflammatory manifestations of primary SS. Accordingly, three "exocrine" and four "non-exocrine" subgroups of disease manifestations are here defined. The usefulness of the proposed model should be evaluated in clinical studies and in a debate engaging all of the medical specialities involved.

Differential diagnosis of choroidal melanomas and nevi using scanning laser ophthalmoscopical indocyanine green angiography

Fluorescein angiography is one of several standard ancillary diagnostic techniques in the evaluation of suspected malignant choroidal melanoma. Indocyanine green choroidal angiography has improved visibility of the choroidal circulation in comparison with fluorescein angiography. Studies concerning the use of indocyanine green angiography in the differentiation between nevi and melanomas have been few and the results inconclusive. A case of a choroidal melanoma (verified by histopathological examination) and a nevus in the same eye is documented by fluorescein and indocyanine green choroidal angiography performed by scanning laser ophthalmoscopy. This modality may be considered in the evaluation of a suspected malignant choroidal melanoma.

The morphology of conjunctiva after long-term topical anti-glaucoma treatment. A quantitative analysis

On biopsy material, differences in the degree of conjunctival inflammation and fibrosis between topically treated glaucoma patients and age matched controls, were examined histologically. Eighteen patients with primary glaucoma underwent goniotrephinations, because maximal medical therapy had failed. The patients had received at least two types of topical anti-glaucoma drugs for at least 12 months (mean 46 months). The control group consisted of 18 age-matched control patients without glaucoma, who had received no topical therapy. These patients underwent cataract surgery or squint surgery. Biopsies were taken from the infero-temporal bulbar quadrant with a biopsy forceps. The specimens were fixed while stabilized on a rubber support to exclude any major shrinkage. Specimens were analyzed by light microscopy for the content of inflammatory cells (plasma cells, lymphocytes, polymorphs, macrophages and mast cells), goblet cells and fibroblasts. No significant difference in the histologic parameters between the two groups could be demonstrated. The study suggests that topical treatment for periods up to 4 years with anti-glaucoma drugs does not induce morphological signs of inflammation and fibrosis of the conjunctiva.

Gas gangrene panophthalmitis. A case from Greenland

A case of clostridium perfringens gas gangrene panophthalmitis developed after a penetrating eye injury. The affected eye became amaurotic, but the panophthalmitis was controlled by minimal surgical debridement and systemic antibiotic therapy with penicillin, fucidic acid and metronidazole. Elective enucleation was performed 15 days after the trauma for cosmetic reasons. The enucleated eye was examined histopathologically and showed massive retinal necrosis but no signs of bacteriae.

Collection and concentration of tear proteins studied by SDS gel electrophoresis. Presentation of a new method with special reference to dry eye patients

An obvious obstacle in the analysis of tear film samples from patients with dry eyes is the drastically reduced tear volume. To overcome this problem we have developed a method by which the surface of the eye is flushed with saline, diluting the sparse tear fluid, followed by a concentration of the wash fluid. We compared undiluted tears, diluted tears, tear fluid collected by flushing, reconcentrated diluted tears and reconcentrated flush fluid. Gel electrophoresis of the tear samples obtained showed a representative collection of tear proteins, with bands ranging in molecular weight from about 10 kDa to about 90 kDa. The method may therefore provide a useful alternative to the analysis of undiluted tear fluid in such patients. After storage at -80 degrees C for 1 month, electrophoresis often showed some weakening of band intensities. However, no specific loss of bands was found, and by ultracentrifugation a band profile similar to that of fresh, undiluted tears was obtained. For most purposes, therefore, samples may be kept by this means for later analysis.

[Temporal arteritis without histological changes]

A patient with severe giant cell arteritis with involvement of both eyes is presented. The symptoms were partly reversible by treatment with high doses of prednison. Three months previously (having symptoms of polymyalgia rheumatica) she had started treatment with a low dosage of prednison. Biopsies of both temporal arteries showed no signs of giant cell arteritis at that time, and the results of eye examinations were normal. The importance of follow-up on patients with symptoms of polymyalgia rheumatica, even if biopsies of the temporal arteries show no histological changes, is emphasised.

Immunologically induced purulent anterior segment inflammation of the guinea pig eye

A single conjunctival application of ovalbumin to inbred guinea pigs (IMM/S 209) immunized with the same antigen in Freund's complete adjuvant provoked an acute purulent inflammation of the anterior segment of the eyes with a duration of up to 1 week. Intense conjunctival injection and chemosis were followed by a purulent discharge. A corneal haze was observed regularly, and a considerable proportion of the animals developed a pronounced pannus and corneal ulcers. Tear fluid cytology revealed a rapid increase in cell concentration, from the normal level (less than 10(8)/l) to greater than 10(11)/l. Seventy to 95% of the cells were polymorphonuclear leukocytes. Histological examination revealed an acute inflammatory reaction which radiated from the conjunctival fornices to the entire anterior segments of the eyes. The process was characterized by an intense oedema, vasodilation and perivascular aggregations of polymorphonuclear leukocytes, and to a lesser extent eosinophilic granulocytes which characteristically infiltrated and penetrated the epithelial layers. Neovascularization could be observed early after challenge in the stroma of all parts of the outer eye. Ulcerations of the conjunctival and corneal epithelia were observed frequently. After a number of reiterations of the antigenic challenge, a marked infiltration with lymphocytes and basophils/mast cells was observed, and significant scarring of the conjunctival mucosa developed. In several animals, a slight, but significant co-reaction of the contra-lateral, non-challenged eye was observed.

[Choroid melanoma. A retrospective randomized comparative study of ruthenium irradiation vs enucleation]

A randomized retrospective study concerning survival of Ruthenium treatment and enucleation in melanoma patients has been performed. For 112 patients from Hamburg who underwent Ruthenium therapy individual match partners were selected in Copenhagen where during the same period of time enucleation was the standard procedure. Selection took place concerning patient's age and sex at the time of treatment, initial tumor volume and the time of treatment. The present status of the patients was not known during the selection process. During the observation time of 12 years there was a survival rate after irradiation of 77.9% and after enucleation of 78.6%. Cox' regression disclosed a coefficient of 0.049 with a standard aviation of 0.293 and a P-value of 0.867. All parameters were showing no statistical difference between Ruthenium treated and enucleated patients. The survival rate in males was 69.2%, female patients 87.2%. For male patients there was a 2,4-fold higher risk to develop metastasis compared with female patients. Patient's age at the time of treatment correlated significantly with the prognosis. There was an increase in mortality risk by factor 1.4 per decade.

Histopathological changes in exocrine glands of murine transplantation chimeras. I: The development of Sjögren's syndrome-like changes secondary to GVH induced lupus syndrome

Sjögren's syndrome (SS) is a connective tissue disease characterized by general affection of exocrine glands. The three main components of SS are: dry eyes, dry mouth, and other connective tissue disease. When only two of these, dry eyes and dry mouth, are present, the disease is designated primary SS. In the presence of the third component, most commonly SLE or RA, with one or both of the two first components the disease is designated secondary SS. In murine transplantation chimeras, we have demonstrated the development of both primary and secondary SS depending upon the mouse strains used. We transferred large numbers of viable leucocytes from homozygotic donors to heterozygotic recipients. When DBA/2 mice were used as donors, a full-developed SLE-syndrome, with autoantibodies against native DNA, nuclear antigens, and red blood cells was observed. We found immune deposits in skin ("lupus band") and kidneys, immune complex glomerulonephritis (ICGN), proteinuria, ascites, and hepatosplenomegaly. In later stages, we found a generalized dacryoadenitis. In the kidneys we found interstitial nephritis, and occasionally "half-moon" nephritis. In skin, immune deposits were demonstrated in intercellular spaces. These findings are similar to those found in patients with Sjögren's syndrome secondary to SLE. The murine transplantation chimera is therefore an experimental model for spontaneous autoimmune diseases.

Histopathological changes in exocrine glands of murine transplantation chimeras. II: Sjögren's syndrome-like exocrinopathy in mice without lupus nephritis. A model of primary Sjögren's syndrome

Autoimmune reactions are evoked in hybrid mice after induction of a chronic graft-versus-host reaction by transfer of viable leucocytes from one of the parental strains to non-irradiated F1 recipients. We have previously demonstrated an SLE-like syndrome early in the reaction, with an additional Sjögren's syndrome-like glandular affection occurring later. In this study, we used Balb/c mice as donors and Balb/cxCBA/H-T6 F1 hybrids as recipients. We found serum autoantibodies characteristic of SLE after 9 weeks but not after 20 weeks. No clinical signs of disease were seen at any time. After prolonged studies (5 months), we found heavy inflammation in Harderian, salivary, and tear glands. All animals survived the entire length of the experiment without signs of renal failure. The pathological manifestations: lymphocytic infiltration of exocrine glands, and enlargement of lymph nodes, are similar to those seen in patients with Sjögren's syndrome. This murine transplantation chimera may be a useful experimental model for primary Sjögren's syndrome.

Biochemical changes in rabbit sclera following destruction of pigment epithelium

The long-term effect of destruction of the pigment epithelium by sodium iodate on the biochemistry of rabbit sclera was studied in one group with intravenous injection of sodium iodate, and in a second group with injection of sodium iodate into the right eye. Intravenous treatment produced a non-significant increase in the uronic acid concentration. In the second group the untreated fellow eye was microscopically intact, but was shown (as the treated eye) to alter the concentration of uronic acid in different parts of the sclera. All eyes from treated animals exhibited changes in the relative content of the various glycosaminoglycans and in the content of hydroxyproline, hydroxylysine and proline. This work indicates that the pigment epithelium may play a key role in the control mechanism of the scleral connective tissue, and this again has major implications in terms of a possible medical treatment of axial myopia.

The normal human tear glycoprotein profile detected with lectin probes

Tear samples were collected from 46 healthy volunteers evenly distributed according to sex and age (mean age 43.5 years). Samples were denatured in a Tris-HCl sample buffer containing 2-mercaptoethanol and SDS, and applied to a gradient SDS-polyacrylamide gel for electrophoresis. The proteinaceous material was transferred to nitrocellulose by a semi-dry blotting technique, and the glycoprotein content subsequently visualized by incubation with four lectins (WGA, PHA, PSA and SBA) and staining with avidin horseradish-peroxidase. Glycoprotein bands were generally found to be significantly less frequent in persons under the age of 30 years. Apart from this the technique gave a uniform picture of the glycoprotein profile, with only modest differences according to age and/or sex. The technique may therefore be suitable for the detection of differences in the glycoprotein composition indicative of disease.

Beneficial effect of sodium sucrose-sulfate on the ocular surface of patients with severe KCS in primary Sjögren's syndrome

Sucralfate (aluminium sucrose-sulfate), a well known gastric mucosal protectant, has been tested topically on 22 patients (20 females and 2 males) suffering from primary Sjögren's syndrome. Median treatment period was 6 months (range 1-19 months). Statistically significant improvement in the ocular surface condition was found judged from the reduction in Rose-Bengal score (P less than or equal to 0.00005). The beneficial effect appeared within the first 1-4 months of treatment. No adverse side effects were encountered.