Macular corneal dystrophy. Lack of keratan sulfate in serum and cornea

Medium-Term Clinical Outcomes of Deep Anterior Lamellar Keratoplasty versus Penetrating Keratoplasty for Macular Corneal Dystrophy

Purpose

To compare the postoperative outcomes of deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PKP) for macular corneal dystrophy (MCD).

Design

Single-center, retrospective, interventional case series.

Methods

A chart review was performed of 100 patients (157 eyes) who underwent primary DALK (DALK group) and PKP (PKP group) for histopathologically confirmed MCD for whom at least 12 months of follow-up were available. Between-group comparisons were performed of visual acuity (VA), graft survival, and postoperative complications.

Results

There were 22 eyes in the DALK group and 135 in the PKP group. Postoperative best-corrected visual acuity (BCVA) of 20/40 or better was achieved in 90.9% of the DALK group and 76.3% of the PKP group (P=0.12). At last visit, graft survival was 95.5% (21 eyes) and 91.1% (123 eyes) in DALK and PKP groups, respectively (P=0.69, Log rank test). Corneal graft rejection episodes occurred in 1 (4.5%) DALK graft and 19 (14.1%) PKP grafts. Five of the 19 graft rejections in the PKP group were irreversible. Microbial keratitis and cataract occurred in 6 (4.5%) and 15 (11.1%) PKP eyes. One (4.5%) eye in the DALK group had cataract and none of the DALK cases developed microbial keratitis. Clinically significant recurrence was observed in 4 (2.9%) PKP eyes and 1 (4.5%) DALK eye (P=0.69), respectively.

Conclusion

DALK is a viable option for MCD without Descemet membrane involvement. DALK had comparable medium-term visual and survival outcomes to PKP. DALK has the advantage of lower open sky intraoperative complications and lower graft rejection episodes.

Corneal stromal bioequivalents secreted on patterned silk substrates

Emulating corneal stromal tissue is believed to be the most challenging step in bioengineering an artificial human cornea because of the difficulty in reproducing its highly ordered microstructure, the key to the robust biomechanical properties and optical transparency of this tissue. We conducted a comparative study to assess the feasibility of human corneal stromal stem cells (hCSSCs) and human corneal fibroblasts (hCFs) in the generation of human corneal stromal tissue on groove-patterned silk substrates. In serum-free keratocyte differentiation medium, hCSSCs successfully differentiated into keratocytes secreting multilayered lamellae with orthogonally-oriented collagen fibrils, in a pattern mimicking human corneal stromal tissue. The constructs were 90-100 μm thick, containing abundant cornea-specific extracellular matrix (ECM) components, including keratan sulfate, lumican, and keratocan. In contrast, hCFs tended to differentiate into myofibroblasts that deposited less organized collagen in a pattern resembling that of corneal scar tissue. RGD surface coupling coupling was an essential factor in enhancing cell attachment, orientation, proliferation, differentiation and ECM deposition on the silk substratum. These results demonstrated that an approach of combining hCSSCs with an RGD surface-coupled patterned silk film offers a powerful tool to develop highly ordered collagen fibril-based constructs for corneal regeneration and corneal stromal tissue repair.

[Groenouw type II macular corneal dystrophy: case report]

Corneal dystrophies are relatively rare diseases of the young adult. We report a case of a Groenouw type II macular corneal dystrophy. A 34-year-old woman with no prior history was referred by her ophthalmologist for bilateral corneal dystrophy developing for several years. Physical examination revealed decreased visual acuity related to bilateral rounded corneal deposits. The patient underwent penetrating keratoplasty. The diagnosis of Groenouw type II macular corneal dystrophy was confirmed by pathological examination of the recipient cornea. The clinical, pathologic and therapeutic features are discussed.

Structural collagen alterations in macular corneal dystrophy occur mainly in the posterior stroma

PURPOSE

Collagen fibrils in the corneal stroma in macular corneal dystrophy, on average, are more closely spaced than in the normal cornea. This study was conducted to investigate if this occurs uniformly across the stroma or is more prevalent at certain stromal depths.

METHODS

Microbeam synchrotron X-ray fiber diffraction patterns were obtained in 25 microm steps across the whole thickness of a thin strip of a macular corneal dystrophy cornea obtained at keratoplasty. Data were analyzed for mean collagen interfibrillar spacing at all positions. Serum was analyzed immunochemically to determine immunophenotype, and transmission electron microscopy was carried out to visualize stromal ultrastructure.

RESULTS

Keratan sulphate was not detectable in blood serum, classifying the disease as macular corneal dystrophy type I. Collagen interfibrillar spacing dropped linearly with stromal depth from the anterior to posterior cornea, measuring 5-10% less in the posterior 100 microm of the MCD stroma compared to the anterior 100 microm (p < 0.001). Isolated pockets of collagen fibrils with unusually large diameters were identified in the deep stroma.

CONCLUSIONS

Collagen fibril spacing is reduced and large-diameter collagen fibrils are seen in macular corneal dystrophy type I, with the deep stroma affected more. We speculate that the ultrastructural abnormalities are more prevalent in the posterior stroma because the structural influence of sulphated keratan sulphate glycosaminoglycans/proteoglycans is high in this region of the cornea.

Role of keratan sulphate (sulphated poly -N-acetyllactosamine repeats) in keratoconic cornea, histochemical, and ultrastructural analysis

AIMS

Keratan sulphate (KS) is the predominant glycosaminoglycan (GAG) present in the corneal stroma where it is thought to regulate collagen fibril diameter. In this study we investigated the distribution of KS in normal and keratoconic corneas.

METHODS

Four normal, one mild, and four severe keratoconic corneas were used for the study. Distribution of keratan sulphate proteoglycans (KS-PG) was investigated using a primary monoclonal antibody (5-D-4) that recognizes disulphated disaccharides in the poly-N-acetyllactosamine repeats of KS. The immuno-reactivity of 5-D-4 was analyzed by immunohistochemistry and immuno-electron microscopy.

RESULTS

Immuno-histochemistry showed diffuse 5-D-4 staining in keratoconic cornea compared to the punctuate staining in normal corneas. In the single cornea with mild keratoconus, immunogold microscopy revealed a very high density of KS-PG staining, especially in the posterior stroma, compared to severe keratoconic and normal cornea. The amount of KS-PG in the stroma in severe keratoconus was slightly less compared to the normal cornea. In the mild keratoconic cornea, a higher quantity of KS-PG was present around the keratocytes. In severe keratoconic corneas, a higher quantity of KS-PG was present within the keratocytes compared to normal cornea.

CONCLUSIONS

The finding of an altered expression of KS in our keratoconic corneas, in particular the strong expression of KS in keratocytes, is in keeping with reports of an altered expression of proteoglycan metabolism in keratoconus. KS-PG plays an important role in stromal collagen fibril assembly and a dysregulation of KS-PG synthesis or catabolism could explain changes in collagen fibril spacing and diameter, which we have reported elsewhere.

Corneal dystrophies

The term corneal dystrophy embraces a heterogenous group of bilateral genetically determined non-inflammatory corneal diseases that are restricted to the cornea. The designation is imprecise but remains in vogue because of its clinical value. Clinically, the corneal dystrophies can be divided into three groups based on the sole or predominant anatomical location of the abnormalities. Some affect primarily the corneal epithelium and its basement membrane or Bowman layer and the superficial corneal stroma (anterior corneal dystrophies), the corneal stroma (stromal corneal dystrophies), or Descemet membrane and the corneal endothelium (posterior corneal dystrophies). Most corneal dystrophies have no systemic manifestations and present with variable shaped corneal opacities in a clear or cloudy cornea and they affect visual acuity to different degrees. Corneal dystrophies may have a simple autosomal dominant, autosomal recessive or X-linked recessive Mendelian mode of inheritance. Different corneal dystrophies are caused by mutations in the CHST6, KRT3, KRT12, PIP5K3, SLC4A11, TACSTD2, TGFBI, and UBIAD1 genes. Knowledge about the responsible genetic mutations responsible for these disorders has led to a better understanding of their basic defect and to molecular tests for their precise diagnosis. Genes for other corneal dystrophies have been mapped to specific chromosomal loci, but have not yet been identified. As clinical manifestations widely vary with the different entities, corneal dystrophies should be suspected when corneal transparency is lost or corneal opacities occur spontaneously, particularly in both corneas, and especially in the presence of a positive family history or in the offspring of consanguineous parents. Main differential diagnoses include various causes of monoclonal gammopathy, lecithin-cholesterol-acyltransferase deficiency, Fabry disease, cystinosis, tyrosine transaminase deficiency, systemic lysosomal storage diseases (mucopolysaccharidoses, lipidoses, mucolipidoses), and several skin diseases (X-linked ichthyosis, keratosis follicularis spinolosa decalvans). The management of the corneal dystrophies varies with the specific disease. Some are treated medically or with methods that excise or ablate the abnormal corneal tissue, such as deep lamellar endothelial keratoplasty (DLEK) and phototherapeutic keratectomy (PTK). Other less debilitating or asymptomatic dystrophies do not warrant treatment. The prognosis varies from minimal effect on the vision to corneal blindness, with marked phenotypic variability.

Penetrating keratoplasty for macular corneal dystrophy

PURPOSE

To determine the prognosis of penetrating keratoplasty (PK) for macular corneal dystrophy (MCD).

DESIGN

Single-center, retrospective, interventional, noncomparative case series.

PARTICIPANTS

One hundred forty-one patients (229 eyes) with MCD.

INTERVENTION

Retrospective review of the medical record of every patient who underwent primary PK for histopathologically confirmed MCD at the King Khaled Eye Specialist Hospital between January 1, 1983 and December 31, 2002 and for whom at least 12 months of follow-up is available.

MAIN OUTCOME MEASURES

Visual acuity (VA), graft survival, and postoperative complications.

RESULTS

After a mean follow-up period of 5.9+/-3.8 years (range, 1-17), the mean best-corrected VA was 20/50. At the most recent visit, 206 (90.0%) grafts were clear, and 23 (10.0%) had failed. Probabilities of graft survival were 98.1% at 1 year, 89.8% at 5 years, 82.1% at 10 years, and 74.1% at 15 years. There was a statistically significant increased likelihood of graft failure if the patient was older than 40 years at the time of surgery (P<0.00003). The differences in graft failure between patients older than 40 and those younger were not attributable to statistically significant differences in duration of follow-up, donor age, or donor endothelial cell counts. Corneal endothelial rejection episodes occurred in 47 (20.0%) grafts, but resulted in irreversible graft failure in only 8 (3.5%) eyes. Eighteen (27.3%) of 66 eyes with a recipient size of > or =7.5 mm developed a graft rejection episode, compared with 27 (16.6%) of 163 eyes with a recipient size of <7.5 mm (P = 0.04). Microbial keratitis occurred in 14 (6.1%) grafts and was more likely to occur in patients over 40 (14.0% vs. 3.0%, P = 0.01). Clinically significant recurrence was observed in 12 (5.2%) grafts, after a mean interval of 84+/-48.2 months, and was directly related to patient age (P = 0.04) and inversely related to donor graft size (P = 0.04).

CONCLUSIONS

Good visual results and excellent graft survival can be achieved after PK for MCD. The risk of graft failure is higher in patients older than 40 years.

Neonatal corneal stromal development in the normal and lumican-deficient mouse

PURPOSE

The purpose of this study was to characterize temporally stromal growth and transparency in lumican-deficient and normal neonatal mice.

METHODS

Lumican-deficient mice and CD1 wild-type mice were evaluated by in vivo confocal microscopy through-focusing (CMTF) to quantify stromal and epithelial thickness and corneal light-scattering and by laser scanning CM to determine density of keratocytes from 1 day to 12 weeks after birth.

RESULTS

CD1 corneas showed a rapid loss of light-scattering, decreasing by 50% from day 1 to day 12, that paralleled a 60% decrease in density of keratocytes. By contrast, the stroma demonstrated a marked swelling from day 8 to day 12, followed by thinning at day 14. Compared to corneas from CD1 mice, lumican-deficient corneas showed significantly increased (P < 0.05) light-scattering beginning at week 3 that remained elevated above wild-type levels for the duration of the study. Stromal development was also markedly altered, with thinning detected at week 3, followed by no detectable stromal growth for the duration of the study. Density of keratocytes was significantly increased, but the total cell number was similar compared with that in the wild-type cornea, suggesting no effect on keratocyte differentiation.

CONCLUSIONS

Development of normal neonatal corneal transparency appears related to changes in density of keratocytes. The stroma, however, undergoes a marked swelling and thinning at the time of eyelid opening (days 8-14). In the lumican-deficient mouse, stromal swelling is abolished, indicating that this critical phase in stromal development is lumican dependent and essential for normal stromal growth and maintenance of stromal transparency.

Functions of lumican and fibromodulin: lessons from knockout mice

Lumican and fibromodulin are collagen-binding leucine-rich proteoglycans widely distributed in interstitial connective tissues. The phenotypes of lumican-null (Lum(-/-)), Fibromodulin-null (Fmod(-/-)) and compound double-null (Lum(-/-)Fmod(-/-)) mice identify a broad range of tissues where these two proteoglycans have overlapping and unique roles in modulating the extracellular matrix and cellular behavior. The lumican-deficient mice have reduced corneal transparency and skin fragility. The Lum(-/-)Fmod(-/-) mice are smaller than their wildtype littermates, display gait abnormality, joint laxity and age-dependent osteoarthritis. Misaligned knee patella, severe knee dysmorphogenesis and extreme tendon weakness are the likely cause for joint-laxity. Fibromodulin deficiency alone leads to significant reduction in tendon stiffness in the Lum(+/+)Fmod(-/-) mice, with further loss in stiffness in a lumican gene dose-dependent way. At the level of ultrastructure, the Lum(-/-) cornea, skin and tendon show irregular collagen fibril contours and increased fibril diameter. The Fmod(-/-) tendon contains irregular contoured collagen fibrils, with increased frequency of small diameter fibrils. The tendons of Lum(-/-)Fmod(-/-) have an abnormally high frequency of small and large diameter fibrils indicating a de-regulation of collagen fibril formation and maturation. In tissues like the tendon, where both proteoglycans are present, fibromodulin may be required early in collagen fibrillogenesis to stabilize small-diameter fibril-intermediates and lumican may be needed at a later stage, primarily to limit lateral growth of fibrils

Immunohistochemical classification of primary and recurrent macular corneal dystrophy in Germany: subclassification of immunophenotype I A using a novel keratan sulfate antibody

Macular corneal dystrophy (MCD) is an autosomal recessive disease characterized by abnormal deposition of glycosaminoglycans in corneal stroma, keratocytes, Descemet's membrane and corneal endothelium. According to the presence and distribution of sulfated keratan sulfate (KS)-epitopes in serum and cornea (using mAb 5-D-4), MCD can be classified into three immunophenotypes: type I, I A and II. The purpose of this study is to evaluate the immunophenotype of primary and recurrent MCD and to analyze the reactions of a novel KS-antibody in MCD corneas, which recognizes an epitope localized in the binding region of KS-chains to the core protein (mAb 3D12/H7). Indirect immunohistochemistry for KS (mAbs 3D12/H7 and 5-D-4) was performed on 44 corneas of 37 patients with MCD including two recurrences. Immunogold labeling was used to localize KS ultrastructurally within keratocytes. The serum concentration of KS (cKS) was determined in a serum antigen-inhibition assay. Immunohistochemically, no reaction was observed using mAb 5-D-4 in 18 corneas of 16 patients (43% of 37 patients; immunophenotype I). Positive reactions within single keratocytes but not in the stroma, were seen in 22 corneas of 17 patients (46% of 37 patients; immunophenotype I A) and positive reactions in keratocytes and extracellular stroma were found in four corneas of four patients (11% of 37 patients: immunophenotype II). For analysis of cKS a total of seven samples was available. Whereas in the samples of the five patients with immunophenotypes I and I A cKS was below the limit of detection, in the two sera from patients with immunophenotype II, cKS was normal (cKS = 1243 and 1380 nmol l(-1)). The two recurrences demonstrated immunophenotype II. Using mAb 3D12/H7, MCD immunophenotype I A can be further subclassified in type I A 1 (lacking reaction with mAb 3D12/H7 in keratocytes; 77%) and type I A 2 (positive reaction with mAb 3D12/H7 within keratocytes; 23%). MCD immunophenotype I A can not only be found in Saudi Arabia, but is as common as immunophenotype I in German patients. The only recurrences of MCD necessitating regrafting occurred in two patients with immunophenotype II possibly suggesting a higher risk for recurrence in this immunophenotype. The mAb 3D12/H7 allows a further subclassification of immunophenotype I A into type I A1 and 2. This points to a broader spectrum of MCD immunophenotypes and indirectly to a broader corneal proteoglycan pathology in MCD.

Altered fine structures of corneal and skeletal keratan sulfate and chondroitin/dermatan sulfate in macular corneal dystrophy

The content and fine structure of keratan and chondroitin/dermatan sulfate in normal human corneas and corneas affected by macular corneal dystrophies (MCD) types I and II were examined by fluorophore-assisted carbohydrate electrophoresis. Normal tissues (n = 11) contained 15 microg of keratan sulfate and 8 microg of chondroitin/dermatan sulfate per mg dry weight. Keratan sulfates consisted of approximately 4% unsulfated, 42% monosulfated, and 54% disulfated disaccharides with number of average chain lengths of approximately 14 disaccharides. Chondroitin/dermatan sulfates were significantly longer, approximately 40 disaccharides per chain, and consisted of approximately 64% unsulfated, 28% 4-sulfated, and 8% 6-sulfated disaccharides. The fine structural parameters were altered in all diseased tissues. Keratan sulfate chain size was reduced to 3-4 disaccharides; chain sulfation was absent in MCD type I corneas and cartilages, and sulfation of both GlcNAc and Gal was significantly reduced in MCD type II. Chondroitin/dermatan sulfate chain sizes were also decreased in all diseased corneas to approximately 15 disaccharides, and the contents of 4- and 6-sulfated disaccharides were proportionally increased. Tissue concentrations (nanomole of chains per mg dry weight) of all glycosaminoglycan types were affected in the disease types. Keratan sulfate chain concentrations were reduced by approximately 24 and approximately 75% in type I corneas and cartilages, respectively, and by approximately 50% in type II corneas. Conversely, chondroitin/dermatan sulfate chain concentrations were increased by 60-70% in types I and II corneas. Such changes imply a modified tissue content of individual proteoglycans and/or an altered efficiency of chain substitution on the core proteins. Together with the finding that hyaluronan, not normally present in healthy adult corneas, was also detected in both disease subtypes, the data support the conclusion that a wide range of keratocyte-specific proteoglycan and glycosaminoglycan remodeling processes are activated during degeneration of the stromal matrix in the macular corneal dystrophies.

Corneal opacity after repeated photorefractive keratectomy

Corneal opacity developed in an eye that had photorefractive keratectomy (PRK) with a 193 nm excimer laser 5 times over 3 years. Six months after the last PRK, a partial penetrating keratoplasty was performed. The cornea was stained and immunohistochemically evaluated for collagen types. Light microscopy showed thickening of epithelial layers, proliferation of subepithelial fibroblasts, and the absence of Bowman's membrane. Transmission electron microscopy showed irregular collagen lamellae and electron-dense deposits adjacent to keratocytes. The staining was positive for Alcian blue, and immunohistochemistry was positive for type IV and VI collagen. This case suggests that corneal opacity after repeated PRK is the result of deposits of type IV and VI collagen and acidic mucoprotein in the extracellular matrix.

Human corneal GlcNac 6-O-sulfotransferase and mouse intestinal GlcNac 6-O-sulfotransferase both produce keratan sulfate

Human corneal N-acetylglucosamine 6-O-sulfotransferase (hCGn6ST) has been identified by the positional candidate approach as the gene responsible for macular corneal dystrophy (MCD). Because of its high homology to carbohydrate sulfotransferases and the presence of mutations of this gene in MCD patients who lack sulfated keratan sulfate in the cornea and serum, hCGn6ST protein is thought to be a sulfotransferase that catalyzes sulfation of GlcNAc in keratan sulfate. In this report, we analyzed the enzymatic activity of hCGn6ST by expressing it in cultured cells. A lysate prepared from HeLa cells transfected with an intact form of hCGn6ST cDNA or culture medium from cells transfected with a secreted form of hCGn6ST cDNA showed an activity of transferring sulfate to C-6 of GlcNAc of synthetic oligosaccharide substrates in vitro. When hCGn6ST was expressed together with human keratan sulfate Gal-6-sulfotransferase (hKSG6ST), HeLa cells produced highly sulfated carbohydrate detected by an anti-keratan sulfate antibody 5D4. These results indicate that hCGn6ST transfers sulfate to C-6 of GlcNAc in keratan sulfate. Amino acid substitutions in hCGn6ST identical to changes resulting from missense mutations found in MCD patients abolished enzymatic activity. Moreover, mouse intestinal GlcNAc 6-O-sulfotransferase had the same activity as hCGn6ST. This observation suggests that mouse intestinal GlcNAc 6-O-sulfotransferase is the orthologue of hCGn6ST and functions as a sulfotransferase to produce keratan sulfate in the cornea.

Macular corneal dystrophy type I and type II are caused by distinct mutations in a new sulphotransferase gene

Macular corneal dystrophy (MCD; MIM 217800) is an autosomal recessive hereditary disease in which progressive punctate opacities in the cornea result in bilateral loss of vision, eventually necessitating corneal transplantation. MCD is classified into two subtypes, type I and type II, defined by the respective absence and presence of sulphated keratan sulphate in the patient serum, although both types have clinically indistinguishable phenotypes. The gene responsible for MCD type I has been mapped to chromosome 16q22, and that responsible for MCD type II may involve the same locus. Here we identify a new carbohydrate sulphotransferase gene (CHST6), encoding an enzyme designated corneal N-acetylglucosamine-6-sulphotransferase (C-GlcNAc6ST), within the critical region of MCD type I. In MCD type I, we identified several mutations that may lead to inactivation of C-GlcNAc6ST within the coding region of CHST6. In MCD type II, we found large deletions and/or replacements caused by homologous recombination in the upstream region of CHST6. In situ hybridization analysis did not detect CHST6 transcripts in corneal epithelium in an MCD type II patient, suggesting that the mutations found in type II lead to loss of cornea-specific expression of CHST6.

Lumican regulates collagen fibril assembly: skin fragility and corneal opacity in the absence of lumican

Lumican, a prototypic leucine-rich proteoglycan with keratan sulfate side chains, is a major component of the cornea, dermal, and muscle connective tissues. Mice homozygous for a null mutation in lumican display skin laxity and fragility resembling certain types of Ehlers-Danlos syndrome. In addition, the mutant mice develop bilateral corneal opacification. The underlying connective tissue defect in the homozygous mutants is deregulated growth of collagen fibrils with a significant proportion of abnormally thick collagen fibrils in the skin and cornea as indicated by transmission electron microscopy. A highly organized and regularly spaced collagen fibril matrix typical of the normal cornea is also missing in these mutant mice. This study establishes a crucial role for lumican in the regulation of collagen assembly into fibrils in various connective tissues. Most importantly, these results provide a definitive link between a necessity for lumican in the development of a highly organized collagenous matrix and corneal transparency.

Coexistence of macular corneal dystrophy types I and II in a single sibship

BACKGROUND

Macular corneal dystrophy (MCD) is an inherited autosomal recessive disorder that has been subdivided into two primary immunophenotypes, MCD types I and II. The MCD type I gene has been localised previously to chromosome 16q22 and suggestive evidence provided that MCD type II gene is also linked to this region. Here an unusual family is reported where both MCD types I and II are found in a single sibship.

METHODS

Immunoreactivity to an anti-keratan sulphate monoclonal antibody (5-D-4) was evaluated in patients' serum and in corneal tissue obtained at keratoplasty. Chromosomal haplotypes were constructed using microsatellite repeat markers spanning the region of the MCD type I locus.

RESULTS

Immunological studies demonstrated that two of the affected siblings have MCD type II while one has MCD type I. Haplotype analysis suggests that all three affected sibs inherited one identical parental haplotype. However, the two MCD types differ in their alternative chromosome with both MCD type II children sharing an identical haplotype, different from their MCD type I sibling.

CONCLUSION

The findings in this study support the hypothesis that the genes for MCD types I and II co-localise to the same region of chromosome 16 and are likely to be due to allelic manifestations of the same abnormal gene.

Macular corneal dystrophy in Saudi Arabia: a study of 56 cases and recognition of a new immunophenotype

PURPOSE

To determine the immunophenotype or immunophenotypes of macular corneal dystrophy in Saudi Arabia.

METHODS

We studied 56 cases of macular corneal dystrophy. Tissue from 60 corneal transplant buttons was stained by the avidin-biotin complex method using an anti-keratan sulfate monoclonal antibody. The serum antigenic keratan sulfate was measured in 23 of the 56 patients, four unaffected relatives, and 13 individuals with chronic actinic keratopathy. Serum and corneal tissue were studied in 17 of the 50 affected individuals with corneal transplant material.

RESULTS

Thirty-five corneas (58.3%) of 29 of 50 patients did not react with anti-keratan sulfate monoclonal antibody. The stroma and abnormal intracellular and extracellular corneal accumulations reacted with anti-keratan sulfate monoclonal antibody in seven corneas (11.7%). The stroma in the other 18 corneas (30.0%) from 15 patients did not react with the anti-keratan sulfate monoclonal antibody, but corneal fibroblasts did. Twenty-one of the 23 patients with macular corneal dystrophy had no detectable serum antigenic keratan sulfate (< 9 ng/ml); two had values of 12 and 51 ng/ml, respectively, and their corneal stroma and abnormal accumulations reacted with anti-keratan sulfate monoclonal antibody.

CONCLUSIONS

We detected macular corneal dystrophy type IA, a new immunophenotype characterized by the lack of detectable antigenic keratan sulfate in the serum (< 9 ng/ml), and a corneal stroma that did not react with the keratan sulfate monoclonal antibody but in which corneal fibroblasts did react with keratan sulfate monoclonal antibody (in 15 of 50 patients).

Macular corneal dystrophy type II: multiple studies on a cornea with low levels of sulphated keratan sulphate

We investigated an individual macular corneal dystrophy (MCD) type II cornea from a 42-year-old woman with markedly reduced antigenic keratan sulphate levels. A characteristic 4.6 A X-ray reflection was evident, and the mid-stroma contained 30% less sulphur than normal. Close packing of collagen was restricted to the superficial stroma. Abnormally large proteoglycan filaments were noted throughout the extracellular matrix and Descemet's membrane's posterior non-banded zone, but not its anterior banded zone. Small, collagen-associated stromal proteoglycans were susceptible to digestion with chondroitinase ABC, but not keratanase I or N-glycanase. On occasion, collagen fibrils ranged in size from 20 nm to 58 nm, with preferential diameters of 34 nm and 42 nm. Corneal guttae were evident, as were numerous endothelial inclusions, most probably due to intracellular fibrillogranular vacuoles similar to those found in the stroma. The endothelium expressed reduced anti-keratan sulphate labelling.

Macular corneal dystrophy in Iceland. A clinical, genealogic, and immunohistochemical study of 28 patients

BACKGROUND

The frequency of different types of macular corneal dystrophy (MCD) was determined in Iceland where MCD accounts for one third of every penetrating keratoplasty.

METHODS

The authors determined the serum levels of antigenic keratan sulfate (aKS) in 27 patients with MCD and 53 unaffected family members by an enzyme-linked immunosorbent assay that uses an anti-KS monoclonal antibody (5-D-4). The authors also stained sections from 37 corneal buttons (including 2 regrafts) from 23 patients with MCD by the avidin-biotin complex method using the same anti-KS monoclonal antibody.

RESULTS

Based on the serum analyses, 22 patients had MCD type I and 5 had MCD type II. The corneas from patients without detectable KS in the serum lacked immunohistochemical reactivity to the anti-KS antibody. Every MCD cornea examined from individuals with normal serum KS levels showed KS reactivity. All 53 unaffected siblings and parents carrying the recessive gene had normal serum KS levels.

CONCLUSIONS

Macular corneal dystrophy types I (78.6%) and II (21.4%) both occur in Iceland. Members of affected sibships had only one of these types, not both. Nine patients with MCD type I and four persons with MCD type II belonged to a large pedigree in which individuals have been traced as far back as the beginning of the 16th century. The linking of patients with MCD types I and II in an inbred pedigree suggests that both types may be manifestations of the same abnormal gene rather than independent entities. The serum KS levels were not helpful in detecting heterozygous MCD carriers.

Proteoglycans contain a 4.6 A repeat in muscular dystrophy corneas: x-ray diffraction evidence

Synchrotron x-ray diffraction patterns from macular corneal dystrophy (MCD) corneas contain an unusual reflection that arises because of an undefined ultrastructure with a periodic repeat in the region of 4.6 A. In this study, we compared with wide-angle x-ray diffraction patterns obtained from four normal human corneas and four MCD corneas. Moreover, portions of two of the MCD corneas were pretreated with a specific glycosidase to shed light on the origin of the 4.6 A reflection. None of the normal corneas produced an x-ray reflection in the region of 4.6 A, whereas all four of the MCD corneas did (MCD type I at 4.65 A and 4.63 A, MCD type II at 4.63 A and 4.67 A). This reflection was diminished after incubation of the MCD tissues with either chondroitinase ABC or N-glycanase. The findings indicate that glycosaminoglycans or proteoglycans contribute to the unusual MCD x-ray reflection and hence most likely contain a periodic 4.6 A ultrastructure. Furthermore, the results imply that periodic 4.6 A MCD ultrastructures reside in either intact, unsulfated lumican molecules and regions of the CS/DS-containing molecules or in a region of a hybrid macromolecular aggregate formed by the interaction of the two molecules.

Synchrotron X-ray diffraction in atypical macular dystrophy

This report documents the first case of X-ray diffraction techniques aiding the diagnosis of a corneal dystrophy with a clinically ambiguous presentation. Post-operatively, a high-angle synchrotron X-ray diffraction pattern was obtained from an in vitro portion of a pathological cornea. This pattern displayed two X-ray reflections which we recently demonstrated to be unique to the high-angle X-ray diffraction patterns of both type I and type II macular dystrophy corneas; on the basis of this evidence we were able to offer a post-operative diagnosis of macular corneal dystrophy. An electron microscopical evaluation of the cornea revealed stromal lacunae at all levels and an extensive layer of vacuoles, predominantly between Bowman's layer and the anterior stroma. These vacuoles were often associated with large proteoglycan filaments, as identified by Cuprolinic blue staining. Abnormally large collagen fibrils were documented, for the first time, in a macular dystrophy cornea; they existed in localised regions, frequently adjacent to the vacuoles and abnormal proteoglycans, and could well have implications for corneal transparency. We propose that the dystrophy is an atypical variant of macular corneal dystrophy which is encompassed by the heterogeneous nature of the condition.

Alteration of the stromal architecture and depletion of keratan sulphate proteoglycans in oedematous human corneas: histological, immunochemical and X-ray diffraction evidence

The structure and content of the extracellular stromal matrix of several oedematous human corneas was investigated using electron microscopy, X-ray diffraction and biochemical techniques. Electron microscopy revealed the presence of wavy lamellae and various sized collagen-free 'lakes' within the stroma of the oedematous corneas, with their posterior sections containing by far the largest 'lakes'. The existence of 'lakes' was supported by the equatorial X-ray diffraction evidence. Staining the oedematous corneas with Cuprolinic blue prior to electron microscopical and meridional X-ray diffraction studies demonstrated a loss of stromal proteoglycans normally associated with collagen. Immunochemical evidence demonstrated reduced levels of antigenic keratan sulphate in the oedematous corneas while biochemical techniques revealed constant chondroitin sulphate levels in the same corneas.

Macular dystrophy of the cornea. A systemic disorder of keratan sulfate metabolism

The serum of most patients with type 1 macular corneal dystrophy (MCD), the most prevalent subtype, lacks detectable antigenic keratan sulfate (KS), and it has been postulated that such individuals may lack antigenic KS in their cartilage as well. To test this hypothesis, we studied the cornea, serum, and nasal cartilage from an MCD patient using light and electron microscopy, immunohistochemistry, and a quantitative enzyme-linked immunosorbent assay (ELISA) which uses a monoclonal antibody against a sulfated epitope on the KS chain to measure KS content. Histologically, corneal deposits seen were characteristic of MCD. No abnormal deposits were noted in the cartilage. The lack of immunoreactivity in corneal sections with antibodies against sulfated epitope on KS and the absence of this epitope in serum showed that the patient had type 1 MCD. The cartilage specimen showed no immunoreactivity in the chondrocytes or extracellular matrix. Quantitative analysis by ELISA demonstrated that the antigenic KS content of the cornea and cartilage was at least 800 times lower than that in normal controls. This provided direct evidence that the abnormality in the sulfation of keratan in type 1 MCD involves the cornea and cartilage.

Macular corneal dystrophy: reduction in both corneal thickness and collagen interfibrillar spacing

The interfibrillar spacing of collagen fibrils was measured at twenty different positions across a macular dystrophy cornea using synchrotron X-ray diffraction. Unlike previous work of this type the cornea had not been frozen for storage. The spacings were all significantly lower than the spacings which existed at similar positions across a normal adult human cornea. This close-packing of collagen fibrils seems to be responsible for the reduced thickness of the central cornea in macular dystrophy. Neither the patient's serum or corneal tissue contained appreciable amounts of sulfated keratan sulfate, this classifies the disease as Type I macular corneal dystrophy.

Macular corneal dystrophy: the macromolecular structure of the stroma observed using electron microscopy and synchrotron X-ray diffraction

The distribution of sulphated proteoglycans within the stromas of three patients (A,B,C) suffering from macular corneal dystrophy was studied using the specific dye Cuprolinic Blue in a 'critical electrolyte concentration' method. The corneas were examined using transmission electron microscopy and A and C were further studied by low-angle synchroton X-ray diffraction. Sera from all three patients were analyzed for the presence of keratan sulphate using a monoclonal antibody in an enzyme-linked immunosorbent assay. The serum from Patient A contained keratan sulphate, but the chains were thought to be shorter or less sulphate in their sera. Electron microscopy showed many electron-transparent lacunae randomly distributed throughout the specimens. The average collagen fibril diameter was normal but there were differences in packing between the specimens. Specimen A was closely-packed with most collagen fibrils in contact with their neighbours. Specimens B and C showed fewer regions of close packing; in most of the tissue the interfibrillar spacing appeared normal. Staining with Cuprolinic Blue revealed an unusual distribution of proteoglycans in some parts of the interfibrillar matrix, particularly in A, with 'small' proteoglycans running exclusively parallel to the collagen fibrils. Furthermore in A, and to a lesser extent in B and C, some lacunae were filled with clusters of abnormal sulphated proteoglycan filaments (of various sizes) which were chondroitinase ABC susceptible. Clearly defined regions, both within the lacunae and elsewhere, failed to stain with Cuprolinic Blue; this suggests an absence of sulphated proteoglycans within these areas. Equatorial X-ray diffraction of the wet tissues (A and C) gave values for the mean interfibrillar centre-to-centre separation of 43 +/- 2 nm in Specimen A and 52 +/- 3 nm in Specimen C. The differences observed in the serum keratan sulphate levels, the packing of the collagen fibrils and the distribution of chondroitin/dermatan sulphate proteoglycans confirm the heterogeneity that exists within the macular corneal dystrophies.

Immunohistochemical evidence of heterogeneity in macular corneal dystrophy

We used the avidin-biotin complex immunoperoxidase technique to test the reactivity of the abnormal corneal accumulations with five different monoclonal antibodies that recognize specific determinants on keratan sulfate. Eighty-eight corneas from 67 patients with macular corneal dystrophy were immunolabeled with the antibodies. In 31 corneas the abnormal accumulations did not react with any of the antikeratan sulfate antibodies, but 18 corneas reacted with all of the antibodies. The remaining corneas reacted with various combinations of the antibodies. The data suggest that the accumulations in macular corneal dystrophy are not always identical and that keratan sulfate is present in some cases but not in others. Thus, based on differences in the storage material, macular corneal dystrophy appears to manifest heterogeneity with at least two distinct varieties: keratan sulfate negative (type 1) and keratan sulfate positive (type 2).