Dry eye disease in chronic graft-versus-host disease: results from a Spanish retrospective cohort study

We describe the incidence, clinical features, and final outcome of dry eye disease (DED) associated with chronic graft-versus-host disease (GVHD) over a 5-year period. We reviewed 109 clinical charts from patients undergoing hematopoietic stem cell transplantation (HSCT) between January 2000 and December 2005, abstracting data from the 57 patients who developed chronic GVHD and survived at least 180 days after allogenic HSCT. DED occurred in 22 (40%) patients at an average of 16.5 months after HSCT. Photophobia, irritation, and foreign body sensation were the most frequent symptoms, while punctate keratitis was the most common sign. DED tended to improve over time, with fewer than 5% of patients requiring more than two topical medications at the end of follow-up. Our study represented a formal evaluation of DED incidence among Spanish chronic GVHD patients. It is of utmost importance to assure patients will undergo a comprehensive ophthalmologic evaluation throughout their follow-up.

[Lack of concordance between dry eye syndrome questionnaires and diagnostic tests]

PURPOSE

To report the prevalence of dry eye syndrome (DES) in a subset of patients > 50 years old in Valladolid, Spain, calculate internal validity of two DES screening questionnaires, and correlate the results with DES diagnostic tests.

METHODS

Patients > 50 years-old were randomly selected from the medical network census in Valladolid; they answered the modified McMonnies questionnaire (Q1) and the Ocular Surface Index questionnaire (Q2) and then underwent an ophthalmic evaluation which included: tear break-up time (TBUT), fluorescein and Rose Bengal staining, and Schirmer with anesthesia were performed. Descriptive analysis, test concordance analysis, and Q1 and Q2 reliability using ROC curves were performed.

RESULTS

A total of 270 subjects (58.2% female; 41.8% male) with an average age of 64.5 years (95% CI: 63.3 - 65.7) were enrolled. The prevalence of DES based on the Schirmer-Tear break-up time tests combination was 24.2%. The mean Q1 score was 1.2, and 1.4 for Q2. Grittiness and discomfort in dry environments (28.9%) were the most common symptoms recorded for Q1. For Q2 "grittiness" (99.2%) and "burning sensation" (98.9%)were the most common symptoms. With the Schirmer-TBUT combination, DES prevalence in Valladolid was 24.2%, 45.8% with TBUT, and 45.6% with Schirmer test. Values for the areas under the ROC curve for Q1, Q2, and most objective tests were < 0.5, except for Q2 and TBUT (0.503). Cronbach alpha was > 0.7 for all Q1 and Q2 items. Statistically significant concordance was reported for Schirmer - TBUT (κ=0.14) and TBUT- fluorescein staining (κ=0.09); (P<0.05).

CONCLUSIONS

Q1 and Q2 were unreliable for DES diagnosis and showed poor internal consistency. Fluorescein and Rose Bengal staining were the most concordant tests for DES diagnosis. Finally, there was no correlation between either screening questionnaire and objective DES diagnostic tests.

[Limbal transplantation: multicenter retrospective case series analysis]

PURPOSE

To report the results of limbal transplantation (LT) in patients with limbal stem cell deficiency (LSCD) in the context of ocular surface diseases.

MATERIALS AND METHODS

A multicenter (5 centers) retrospective case series analysis of patients who underwent LT between 1996 and 2004 was performed. Data were collected by the same researcher using a customized database. Success was defined by the absence of a persistent corneal epithelial defect, on-going inflammation or recurrence of a pterygium.

RESULTS

Data from 72 LT performed in 61 patients (65 eyes) with a mean follow-up of 20.8 months (SD 23.5; range, 3-115) were analyzed. There were 33 males and 28 females with a mean age of 55.8 years (SD: 15.6; range, 20-89). Fifty-eight (80.6%) LT were autografts (40 pterygia, 12 alkali burns, 3 iatrogenic cases, 2 viral infections, 1 neoplasia case) and 14 (19.4%) were allografts from cadaveric donors (7 immune-based disorders, 6 alkali burns, 1 iatrogenic case); all patients receiving allografts also received systemic immunosuppression. Of the total number of LT, 48 (66.7%) were successful. This proportion increased to 81.0% (47/58) when autografts were used. However, only 7.1% (1/14) of all allografts were successful. The success rate was higher (80.0%) when performed for a pterygium and lower when done for immune-based inflammation (14.3%).

CONCLUSION

Autograft tissue for LT is always preferable to allografts to surgically treat LSCD, as clinical success is significantly higher, and systemic immunosuppression is avoided. As expected, immune-based disorders are the most difficult cases to treat. LT has been shown to be an excellent option for recurrent pterygium, although prospective studies need to be performed to further corroborate these results.

Nonspecific provocation of target organs in allergic diseases: EAACI-GA(2)LEN consensus report

It is widely accepted that nonspecific tissue reactivity is a distinct pathophysiological hallmark of allergic diseases, influenced by genetic and environmental factors different from those involved in causing sensitization and allergen response of target organs. This consensus document aims at reviewing procedures currently used for nonspecific provocation of the bronchi, nose and eye and for measuring their responsiveness to nonspecific stimuli.

[Ocular Behçet disease. Retrospective study]

OBJECTIVE

To study clinical features, visual prognosis and response to immunosuppressive drugs in patients with ocular Behçet Disease (BD).

PATIENTS AND METHODS

clinical data of 17 patients (33 eyes) were retrospectively reviewed from May 1996 to May 2003.

RESULTS

The male/female ratio was 12/5. The commonest manifestations were oral ulceration (100%) and skin lesions (88%). Anterior uveitis was present in 59%, posterior uveitis was in 76% and panuveitis was in 88.1%. Visual acuity improved in 11 (33.3%) eyes, remind stable in 18 (54.5%) eyes and four (12.1%) eyes lost two or more lines. Main drug therapy consisted of colchicine and cyclosporine (59%). Seven patients had received three drugs simultaneously.

CONCLUSIONS

BD can lead to an irreversible visual loss; however, the visual prognosis is good (85%) if immunosuppressor treatment is implemented.

Levels of mucin gene expression in normal human conjunctival epithelium in vivo

PURPOSE

Conjunctival impression cytology (CIC) samples were used to determine the mean and normal range of mRNA levels of human MUC1, MUC2, MUC4, MUC5AC, and MUC7 mucin genes.

METHODS

Real time PCR was performed to determine normal mRNA levels in CIC samples of 24 male and 19 female healthy donors. Correlation coefficients between gene expression levels were obtained.

RESULTS

All five mucin genes were expressed in the CIC samples. MUC1 and MUC4 were present at the highest level and MUC2 was at the lowest. There were no gender differences. Significant positive correlations existed between MUC2 and MUC4 and between MUC2 and MUC7 levels.

CONCLUSIONS

Normal levels and ranges of mRNAs for MUC1, MUC2, MUC4, MUC5AC and MUC7 conjunctival mucin genes have been established for the first time. These data may serve as the normal threshold values for future comparisons in different experimental and pathological conditions involving the ocular surface.

[Normal human conjunctival epithelium expresses MUC13, MUC15, MUC16 and MUC17 mucin genes]

PURPOSE

The ocular surface epithelia express at least five mucin genes of the total of 17 human mucin genes that have been identified so far. This study was designed to determine the expression profile of mucin genes in conjunctival impression cytology (CIC) samples from healthy subjects.

METHODS

Two polyethersulfone filters were applied to the superior conjunctiva of both eyes from eight healthy donors. Polymerase chain reaction (PCR) was performed using isolated and retrotranscripted total RNA obtained from the CIC samples to study the expression of all known human mucin genes. Following amplification, PCR products were electrophoresed on 1.5% agarose gel and stained with ethidium bromide to confirm that only a single band was obtained when amplifying all cDNAs with the convenient primers.

RESULTS

Transcripts of the previously reported conjunctival mucin genes MUC1, MUC2, MUC4, MUC5AC, and MUC7 were detected in all samples. In addition, transcripts of MUC13, MUC15, MUC16 and MUC17 mucin genes also were detected. Amplified products by conventional PCR showed the expected amplicon size. Transcripts of MUC3A, MUC3B, MUC5B, MUC6, MUC8, MUC11, and MUC12 mucin genes were not detected.

CONCLUSION

The expression of four additional mucin mRNA (MUC13, MUC15, MUC16, and MUC17) has been proved in human conjunctival epithelium from healthy donors for the first time. The function of these genes remains to be further elucidated.

[In vitro toxicity of non-preserved artificial-tear formulations]

PURPOSE

To analyse the putative toxic effect of three commercially available non-preserved artificial tear formulations on in vitro human conjunctival cells.

MATERIAL AND METHOD

A conjunctival human epithelial cell line was exposed to Cellufresh, Oculotect and Acuolens formulations during 1, 3 and 24 hours. Cytotoxicity was measured by calculating the percentage of cell viability examination and scanning electron microscopy (SEM). Controls underwent exposure to supplement free DMEM-F12 (negative control) and exposure to 0.005% benzalkonium chloride solution (positive control).

RESULTS

Cell viability after 1 or 3 hours incubation with Cellufresh and Oculotect was similar to that obtained for negative controls. With Acuolens incubation however, cell viability showed significant reduction after 3 and 24 hours compared to control. SEM showed that Cellufresh and Oculotect exposed cells presented similar behavior to control cells. All three cell lines presented evidence of cellular surface alteration after incubation for 1 or 3 hours compared to controls, Acuolens showing the highest rate of alterations in exposed cells and an additional increment in cell loss was observed.

CONCLUSION

In the present study, non preserved artificial tears formulations showed a different degree in their in vitro toxicity, Acuolens being more toxic than Cellufresh or Oculotect.

Fuchs' heterochromic iridocyclitis: a review of 26 cases

Fuchs' heterochromic iridocyclitis (FHI), an unusual form of uveitis of unknown etiology, is frequently misdiagnosed.

PURPOSE

To report the analysis of 26 patients (27 eyes) with FHI who were diagnosed and observed over a period of 1-7 years (mean: 3.42 +/- 2.2 years).

METHODS

Ocular and systemic examinations were performed on all patients.

RESULTS

The most common presenting symptom was visual deterioration (42.3%); one patient was affected bilaterally. Characteristic keratic precipitates (100%), cataracts (77.8%), and heterochromia (70.4%) were the major signs. Eleven eyes (40.7%) required cataract surgery. At the initial examination, four eyes (14.8%) had glaucoma, and no new cases of glaucoma developed during the follow-up period. One eye required filtration surgery. Vitrectomy was performed in two eyes (7.4%) because of vitreous opacities. Most patients (73.0%) did not require active treatment; pre- and postoperative anti-inflammatory treatment for cataract extraction was performed successfully to minimize the risk of inflammation. No severe uveitis was seen in any patient after surgery, but visual acuity did not improve greatly after cataract extraction; 54.5% eyes had visual acuity better than 20/40 before surgery, and 45.4% postoperatively.

CONCLUSION

Posterior capsule opacification, glaucoma, and vitreous opacity were the major obstacles to visual rehabilitation after cataract surgery in patients with this type of uveitis.

Pars planitis: epidemiology, treatment, and association with multiple sclerosis

During retrospective and prospective studies, we attempted to determine the clinical characteristics, treatment, and visual outcome of patients with pars planitis and to evaluate the association between pars planitis and multiple sclerosis (MS). The retrospective study included 44 patients with pars planitis, who had been examined between October 1986 and January 1999. We analyzed age, sex, visual acuity (VA), median follow-up time, and medical and surgical treatments. The prospective study, which included 21 consecutive patients with pars planitis, was performed to determine the presence of MS. In the retrospective study, the mean patient age was 22.4 years (SD +/- 11.5) and the median follow-up was 34.9 months (SD +/- 27.2). Complications included macular edema (47.7%), vitreous opacities (38.6%), papillitis (38.6%), vasculitis (36.4%), and cataract (20.5%). Forty patients (90.9%) had a final bilateral VA better than 20/40. In the prospective study, magnetic resonance imaging (MRI) was performed. Demyelinating lesions were found in 10 (47.6%) of the 21 patients and relapsing-remitting clinically definite MS was diagnosed in seven (33.3%). With the exception of age, no significantly statistical differences were observed when the visual prognosis and the clinical and epidemiologic characteristics were compared between the two groups of patients with and without associated MS; a diagnosis of MS was more frequently made in patients over 25 years of age. With appropriate treatment, patients with pars planitis have a good visual prognosis. Because the presence of demyelinating lesions seems to be high among patients with pars planitis, MRI should be considered, especially in patients over 25 years of age.

[Acute macular neuroretinopathy: a case report]

CASE REPORT

A 68 year old woman developed a sudden decrease in her visual acuity in both eyes with several central scotomas. Funduscopy demonstrated a motted alteration of the retinal pigment epithelium in both maculae. The fluorescein angiography showed a choroidal ischemia at the macular level in both eyes.

DISCUSSION

The patient was diagnosed of acute macular neuroretinopathy. This entity is included among the so-called <<white dot syndromes>>. However, it is important to determine which of these diseases each patient suffers in order to determine if treatment is necessary, the visual prognosis and the possibility of recurrences.

Ocular allergies: association with immune dermatitis

PURPOSE

To describe the type of skin involvement that patients with ocular allergies are prone to suffer due to the atopic association of the condition.

METHODS

Review of the published literature and retrospective data from our patient series.

RESULTS

Patients with ocular allergies may have skin affected with one or several combinations of the following dermatologic problems: contact dermatitis, urticaria/angioedema, and atopic dermatitis, with secondary infections as a possible consequence of this later disorder. Other rare skin disorders have been occasionally reported in association with ocular atopy.

CONCLUSION

Patients with ocular allergies may have a spectrum of 'allergic' skin problems, the most severe of which is atopic dermatitis. Ocular surface involvement in atopic dermatitis should be diagnosed as atopic keratoconjunctivitis, a sight-threatening disorder, until proven otherwise.

The treatment of dry eye

The most widely used therapy for dry eye disease is tear replacement by topical artificial tears. Punctal occlusion to prevent the drainage of natural or artificial tears is the most common non-pharmacological treatment. These and other traditional therapies for dry eye disease are only palliative, however, as they replace or conserve the tears without necessarily correcting the underlying disease process. As our understanding of the pathology of dry eye disease improves, new treatment strategies are being developed. Topical anti-inflammatory and immunomodulatory agents, such as cyclosporin A, are under investigation in the treatment of dry eye, as it is anticipated that they will correct the vicious cycle of inflammation and cell damage on the ocular surface and lacrimal glands.

[Usefulness of conjunctival biopsy as diagnostic technique]

PURPOSE

The conjuctival biopsy is described as a useful technique in the diagnosis of some chronic conjunctivitis, with low specific signs and with poor response to the conventional treatment. Furthermore it is quite important in the diagnosis of conjunctival diseases with potential dangerous treatment.

PATIENTS AND METHODS

Three clinical cases are described. Case 1: A 37 years old woman with a chronic lesion of conjuctiva and the suspicion of blepharoconjunctivitis. There was no improvement with treatment. Case 2: A 58 years old woman with a chronic conjunctivitis and follicular reaction. Case 3: A 66 years old man who suffers from a cicatricial conjunctivis in both eyes with corneal lesion in one eye. A conjunctival biopsy was perfomed and studied under light microscopy and immunohistochemistry. There is a description of the technique.

RESULTS

The results of every clinical case are described. In the first case the biopsy established the diagnosis of conjunctival lymphoma. In the second, the biopsy showed the appearance of granulomas and a diagnosis of conjunctival sarcoidosis was performed. In the third case a diagnosis of ocular cicatricial pemphigoid was established.

CONCLUSION

Conjunctival biopsy is a useful and effective technique in the diagnosis of chronic conjunctivitis.

Classification of ocular atopic/allergic disorders and conditions: an unsolved problem

PURPOSE

To review the different classifications of ocular allergic diseases and to define the most suitable one according to the current understanding of the pathophysiology and clinical course of these disorders.

METHODS

Review of the major published ocular allergy classifications.

RESULTS

Based on past and present classifications, the author proposes the following classification: 1. allergic conjunctivitis (acute and chronic); 2. giant papillary conjunctivitis; 3. vernal keratoconjunctivitis; and 4. atopic keratoconjunctivitis. In addition, use of the term "allergic conjunctivitis" as a synonym for all ocular allergic disease is discouraged.

CONCLUSION

The proposed classification for ocular allergic disorders intends to unify the present criteria and to serve as an initial forum of discussion. This should enhance a common understanding among and between ophthalmologists and other allergy specialists. Constructive criticism of this classification system is required for further improvement.

Expression of ICAM-1 and HLA-DR by human conjunctival epithelial cultured cells and modulation by nedocromil sodium

It is unclear whether conjunctival epithelial cells participate in the development of immune-mediated events. Using a previously reported in vitro system of human conjunctival epithelium, we determined whether conjunctival epithelial cells express two relevant markers in the antigenic presentation process. Moreover, the potential capability of nedocromil sodium, an antiallergic and antiinflammatory drug, to modulate such expression was investigated. Primary cultures of human conjunctival epithelium and Chang conjunctival cells, incubated with or without 100 U/ml IL-1beta and/or IFNgamma for 1, 3 or 6 h, were simultaneously exposed to 10(-5) M nedocromil sodium. The expression of the intercellular adhesion molecule-1 (ICAM-1) and the human leukocyte antigen-DR (HLA-DR) was determined immunocytochemically. Constitutive expression of ICAM-1 and HLA-DR was observed in primary cultures and Chang cells and was minimally affected by incubation with IL-1beta and/or IFNgamma. The addition of nedocromil sodium resulted in complete abolition of HLA-DR expression and a notable reduction in ICAM-1 expression in primary cultures and Chang cells. These results suggest that epithelial cells from human conjunctiva constitutively express ICAM-1 and HLA-DR in vitro and that such expression is downregulated by nedocromil sodium. This may indicate that conjunctival epithelial cells may be another target for this drug.

Carbomer- versus cellulose-based artificial-tear formulations: morphologic and toxicologic effects on a corneal cell line

PURPOSE

Frequent instillation of artificial tears is the primary disadvantage of the treatment for dry-eye syndrome. Recently gel formulations have been proposed as an alternative to classic cellulose formulations. The higher viscosity of these gels presumably prolongs tear-retention time in the eye and results in fewer daily applications. However, no toxicologic studies with gel formulations have been performed. Our aim was to study the toxic effects of these formulations on corneal cells.

METHODS

SIRC cells from rabbit cornea were exposed for 30 min, and 1, 3, and 6 h to five commercially available artificial tears, three of them carbomer gel formulations (Lacrivisc, Lacrivisc unit-doses, and Viscotears) and two carboxymethylcellulose (CMC) formulations (Celluvisc and Cellufresh). A cytotoxicity assay and a scanning electron microscopy (SEM) study were used to analyze the putative toxic effects of the formulations. The preservatives of the gel formulations also were tested.

RESULTS

Carbomer gel formulations, both with and without preservatives, caused more in vitro toxic effects in the corneal cells than did CMC formulations and caused severe damage even after 30 min of exposure. SEM revealed dramatic cell-surface alterations. Preservatives added to Lacrivisc and Viscotears also had toxic effects on cells, whose effects were not significantly different from those of the commercial preparations.

CONCLUSION

These results demonstrate that in the in vitro study, CMC artificial tears are less toxic than carbomer gel formulations. Questions about the benefits of using high-viscosity gels in the treatment of dry-eye syndrome still remain.

Analysis of human ocular mucus: effects of neuraminidase and chitinase enzymes

PURPOSE

Our goal was to establish the characteristic migration pattern on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of high molecular weight mucins from human ocular mucus and the effects of treatment with exo- and endoglycosidases.

METHODS

Chromatography by gel filtration with Sepharose CL-4B was performed on samples collected from normal subjects. Human ocular mucins from the high molecular weight fraction were digested with exoglycosidases (neuraminidase, N-acetyl-beta-D-glucosaminidase, beta-D-glucosidase) and endoglycosidases (chitinase, lysozyme); and the resulting products were analyzed by electrophoresis. Carbohydrate identification was performed using lectin probes.

RESULTS

The migration of the ocular mucins on SDS-PAGE stopped after treatment with neuraminidase, which removes the terminal negatively charged sialic acid residues from mucin. Chitinase (beta(1-4)N-acetylglucosaminidase) treatment increased the electrophoretic migration of mucins. Staining with wheat germ agglutinin and Maackia amurensis agglutinin lectins showed that these mucins contain beta(1-4)NAcGlc and SAa(2-3)Gal linkages.

CONCLUSIONS

These studies demonstrate that the mobility of human ocular mucins on SDS-PAGE is determined by their intrinsic total negative charge and is not dependent on SDS treatment. It is interesting to note that human ocular mucus contains chitinous material resistant to lacrimal lysozyme, which is accessible to chitinase, an enzyme now found to degrade human ocular mucins. These chitinous linkages could be in part responsible for the mucus resistance.

Efficacy of topical cyclosporine-loaded nanocapsules on keratoplasty rejection in the rat

PURPOSE

To evaluate the efficacy of a topical formulation of nanocapsules loaded with 1% cyclosporine A (CsA), which has been previously demonstrated to enhance CsA corneal penetration, compared to 1% CsA in migliol oil on a penetrating keratoplasty rejection model in the rat.

METHODS

Lewis rats received orthotopic corneal allografts from inbred Fisher donors. Rats were treated with 10 microliters of the following topical solutions four times daily for 30 days, starting one day before surgery: Group 1 (n = 9), 1% CsA-loaded nanocapsules; group 2 (n = 13), 1% CsA dissolved in migliol oil; group 3 (n = 12), migliol oil; group 4 (n = 13), no treatment. Rejection index, mean survival time and rejection percentage were calculated for each group, and CsA levels in blood were measured.

RESULTS

The rejection percentage was 84.6% for group 2, 91.7% for group 3, and 100% for groups 1 and 4, with no significant differences among groups. Mean graft survival time was 7.3 days for group 1, 15.5 days for group 2, 8.36 days for group 3, and 7.69 days for group 4, with significant differences between group 2 and the other groups. Systemic CsA levels were only detectable in group 2.

CONCLUSIONS

CsA formulated in migliol oil delayed corneal rejection onset, but blood levels were evident in this group. CsA loaded-nanocapsules showed no effect on rejection and the drug was not detectable in blood. These data, along with the current concepts on corneal graft rejection immunology, suggest that the immunomodulatory effect of topical CsA in the prevention of corneal graft rejection may be systemically-mediated.

Characterization of epithelial primary cultures from human conjunctiva

Primary cultures of human epithelial cells from normal conjunctiva were developed and characterized to determine whether they retained epithelial characteristics. Conjunctival explants were obtained from the upper fornix of healthy donors and cultured in supplemented DMEM/F-12 medium for 5 days. The epithelial outgrowth was maintained for an additional 10 days. Primary cultures were then processed for light microscopy, transmission and scanning electron microscopy (TEM, SEM), and immunocytochemistry. They exhibited typical features of conjunctival epithelium on light microscopy (polygonal morphology, intimate cohesion, production of mucins), TEM (abundant desmosomes, keratin bundles, granules, microvilli), SEM (polygonal shape, microvilli, intimate cohesion), and immunocytochemistry (positivity for the receptor of epidermal growth factor, desmosomal proteins, and cytokeratins). In conclusion, primary cultures developed from normal human conjunctiva maintained the epithelial characteristics in vitro. Because the conjunctiva is a major component of the anterior ocular surface, we propose this in vitro system as suitable for physiopathologic and toxicologic studies.

Influence of topical anesthesia on tests diagnostic of blepharitis-associated dry eye syndrome

PURPOSE

Despite the high frequency and clinical relevance of blepharitis-associated dry-eye syndrome, no agreement exists about whether diagnostic tests should be performed with or without topical anesthesia. The aim of this study was to compare the influence of topical anesthesia on the mean values of Schirmer's test, tear lysozyme, tear lactoferrin, and tear osmolarity in patients suffering from blepharitis-associated dry eye syndrome.

METHODS

The authors compared the mean values of Schirmer's test, tear osmolarity, tear lysozyme (turbidimetric assay), and tear lactoferrin (radial immunodiffusion) before and after topical anesthesia in the following groups: 56 normal subjects (group 1), 62 blepharitis patients (group 2), and 15 patients with blepharitis-associated dry eye syndrome (group 3). All clinical and laboratory tests were performed by masked observers.

RESULTS

In group I, mean values of Schirmer's test decreased 24.8% (p < 0.01) when performed after application of topical anesthesia. The other tests were not significantly modified. In groups 2 and 3, significant differences were seen in Schirmer's test (25.33% and 24.19% respectively, p < 0.001) and the lysozyme determination (14.00% and 13.22% respectively, p < 0.01). Differences between the normal subjects (group I) and the patient groups increased when the tests were performed after application of topical anesthesia reaching statistical significance in group 3 for all the tests.

CONCLUSIONS

Performing diagnostic tests after topical anesthesia instillation could be useful in detecting dry eye associated with blepharitis.

Effects of cationic diamidines on polyamine content and uptake on Leishmania infantum in in vitro cultures

The effect of a series of cationic diamidines recently synthesized by Ciba Geigy, bearing diarylic (CGP040215A and CGP039937A) or monoarylic moieties (CGP033829A, CGP035537A and CGP036958A), was analyzed on some metabolic targets and cell proliferation of in vitro cultures of Leishmania infantum promastigotes (insect form). The action of these compounds on intracellular polyamine pools and putrescine transport suggests that diarylic structures were more effective than their monoarylic counterparts in depleting polyamine levels and inhibiting putrescine transport, although these processes correlate poorly with the antiproliferative rate of these compounds. Finally, the displacement of cationic diamidines to kDNA observed in the presence of several concentrations of spermidine suggests a possible combined mode of action of these molecules, first depleting intracellular polyamine pools and, then, displacing spermidine from its site of interaction to kDNA.

Efficacy of nedocromil sodium and cromolyn sodium in an experimental model of ocular allergy

BACKGROUND

Because ocular allergic disorders are important in terms of frequency and severity, there is a constant search for new topical antiallergic drugs. Nedocromil sodium has recently been introduced as a potential substitute for the mast cell stabilizer cromolyn sodium.

OBJECTIVE

We compared the efficacy of topical 2% nedocromil sodium to that of 2% cromolyn sodium in treatment of the early-phase reaction of an experimental model of allergic conjunctivitis.

METHODS

Guinea pigs were challenged topically with egg albumin 14 days after systemic immunization. Fifteen minutes before, immediately prior to, and 15 minutes after topical challenge, the animals received either 2% nedocromil sodium or 2% cromolyn sodium topically in one eye and phosphate buffered saline (PBS) in the other eye. Antigen-induced increase in vascular permeability was measured by the extravasation of intravenously injected Evans blue dye. Animals that were immunized and topically challenged but did not receive Evans blue were used for histologic studies.

RESULTS

Evans blue extravasation from ocular tissues significantly decreased in drug-treated eyes compared with PBS-treated eyes (P < .01). Further, the cellular infiltrate (mast cells, eosinophils, and neutrophils) in the substantia propria of the conjunctiva was markedly reduced in the drug-treated eyes. No significant difference was observed between the nedocromil sodium- or cromolyn sodium-treated eyes.

CONCLUSIONS

Topical 2% nedocromil sodium reduces the early-phase reaction of the allergic response as effectively as 2% sodium cromoglycate in a guinea pig model of ocular anaphylaxis.

Referral patterns of uveitis in a tertiary eye care center

OBJECTIVE

To analyze the referral patterns and diagnosis of uveitis during the past decade in a large tertiary eye center.

DESIGN

The records of 1237 patients with uveitis referred to the Immunology Service of the Massachusetts Eye and Ear Infirmary from 1982 to 1992 were classified and analyzed. Data regarding sex, race, nationality, referral site, ages at presentation and onset of uveitis, ocular involvement, clinical characteristics, ocular condition, and systemic disease associations were obtained.

RESULTS

The mean age at onset of uveitis was 37.2 years; the male-to-female ratio was 1:1.4. Most patients were white (85.8%), born in the United States (83.1%), and referred from within New England (84.7%). Anterior uveitis was most common (51.6%), followed by posterior uveitis (19.4%), panuveitis (16.0%), and intermediate uveitis (13.0%). Chronic (58.3%), nongranulomatous (77.7%), and noninfectious (83.1%) were the most frequent types of uveitis. The most common entities included idiopathic (34.9%), seronegative spondyloarthropathies (10.4%), sarcoidosis (9.6%), juvenile rheumatoid arthritis (5.6%), systemic lupus erythematosus (4.8%), Behçet's disease (2.5%), and the acquired immunodeficiency syndrome (2.4%).

CONCLUSION

The appearance of new uveitic entities, such as the acute retinal necrosis syndrome, multifocal choroiditis and panuveitis, birdshot retinochoroidopathy, and acquired immunodeficiency syndrome-related uveitis, and the reemergence of the classic infectious causes of uveitis, tuberculosis and syphilis, have changed the way we approach the diagnosis and management of posterior and panuveitis at the Massachusetts Eye and Ear Infirmary.

Putrescine active uptake system in the Trypanosomatid Crithidia fasciculata

Using the insect Trypanosomatid Crithidia fasciculata as a model parasite of mammalian pathogenic flagellates, i.e. Leishmania and Trypanosoma spp., we have studied the kinetic and regulatory characteristics of the polyamine uptake system. Putrescine transport was age-dependent with maximum expression values at the proliferative logarithmic phase. Putrescine transport in Crithidia fasciculata was energy-dependent and against a putrescine concentration gradient. The integrity of the membrane sulfhydryl groups was absolutely required for optimum transport rates. The specificity of this mechanism was studied in the presence of a series of different chain length aliphatic diamines, showing the high specificity for putrescine and the poor effect of this series at the highest concentration analyzed as well as the higher polyamines spermidine and spermine. Finally, the well-known inhibitor of polyamine biosynthesis, DFMO, led to an upward regulation of putrescine uptake correlating with the depletion of intracellular polyamine pool. In addition, the presence of high concentrations of putrescine in the culture medium produced a downward regulation of this system.

Polyester nanocapsules as new topical ocular delivery systems for cyclosporin A

PURPOSE

Nanocapsules composed of an oily core (Migliol 840) (MG) surrounded by a poly-epsilon-caprolactone (PECL) coat were evaluated as potential vehicles for the topical ocular administration of cyclosporin A (CyA).

METHODS

A 2(3) experimental factorial design was applied to optimize the coating of the oily nanodroplets by a solvent displacement technique and to encapsulate a high dose of CyA. The variables investigated were: volume of oil (MG), amount of polymer (PECL), and volume of the organic solvent (acetone) used to dissolve the polymer.

RESULTS

Nanocapsules had a mean size in the range of 210-270 nm, a negative zeta potential (between -55 and -60 mV) and a maximum loading capacity of 50% (CyA/PECL ratio). These highly loaded nanocapsules displayed a thick spongeous polymer coating around the oily nanodroplets. The corneal levels of CyA were up to 5 times higher for the encapsulated CyA than for the oily solution of CyA. In addition, these levels remained significantly higher than those of the control group (oily solution) for up to 3 days. Furthermore, the area-under-the-curve (AUC) values were significantly increased for the encapsulated CyA (319.98) with respect to the oily control (74.34).

CONCLUSIONS

The CyA-loaded nanocapsules are shown to be interesting vehicles for the improvement of the ocular penetration of CyA.

Phlyctenular keratoconjunctivitis a potentially blinding disorder

Phlyctenular keratoconjunctivitis, a delayed hypersensitivity reaction to foreign proteins (i.e., bacterial products), occurs more often in children and young adults sensitized to Staphylococcus aureus inhabiting the lid margins. Clinical manifestations occur on the conjunctiva and/or the cornea. Management strategies used to treat a 14-year-old girl with a long history of keratoconjunctivitis with severe corneal involvement and secondary lacrimal gland enlargement included a complete ocular examination, blood workups, cultures, vigorous lid hygiene, topical antibiotics and steroids, and systemic doxycycline. Phlyctenular keratoconjunctivitis was diagnosed, and Streptoccocus viridans was found colonizing the lid margins and fornices. Subsequent treatment quieted the active inflammation and the secondary lacrimal gland enlargement. However, the residual corneal scarring permanently compromised visual acuity. This patient demonstrates the potentially blinding consequences of untreated phlyctenular keratoconjunctivitis. Moreover, Streptoccocus viridans is not frequently associated with this disorder. To our knowledge hypertrophy of the lacrimal gland, as a secondary complication of this disorder, has not been reported previously.

Experimental model of allergic conjunctivitis to ragweed in guinea pig

An experimental model of ocular allergy was developed in the guinea pig by exposing these animals to ragweed through topical contact on nasal and conjunctival mucosae, followed by subsequent challenge with ragweed contact on the conjunctiva. Animals developed clinical and histological signs of allergy with and without the use of interleukin 4 as adjuvant. This model mimics human hay fever conjunctivitis more naturally than do animal models previously reported, and it may be subsequently more valuable in the study of the response of allergic conjunctivitis to different therapeutic approaches.

Inducible nitric oxide synthase in human lymphomononuclear cells activated by synthetic peptides derived from extracellular matrix proteins

Synthetic peptides with sequences present in extracellular matrix proteins are capable of causing the expression of the inducible form of nitric oxide synthase (iNOS), detected by immunocytochemistry, and the release of NO by human lymphomononuclear cells incubated in their presence. Active peptides are 15-mers containing a characteristic 2-6-11 motif in which the amino acid residue at position 2 is Leu, Ile, Val, Gly, Ala or Lys; the residue at position 6 is always Pro; and residue 11 is Glu or Asp. The induction of iNOS in human monocytes and macrophages could be involved in the cytotoxicity against tumor cell lines also elicited by these peptides.

Calcareous corneal degeneration: report of two cases

Band keratopathy, calcium salts in Bowman's membrane, is the most classic form of corneal calcification seen in clinical practice. However, calcareous degeneration, calcium deposition involving the full corneal thickness, is rare. We reviewed the clinical and histopathological records of two patients with severe dry eyes and calcareous corneal degeneration. In each case, complete ophthalmic examination and histopathological study were performed. Both patients had severe dry eyes, case 1 secondary to graft-versus-host disease and case 2 secondary to rheumatoid arthritis, and a persistent epithelial defect and anterior segment chronic inflammation. Both patients underwent repeated penetrating keratoplasties. Histological examination of the corneal buttons showed that calcareous corneal degeneration and band keratopathy were coincident in both cases. Both patients received postoperative medications for high-risk grafting. The mechanisms of corneal calcification may be the same in calcific band keratopathy and calcareous corneal degeneration.

Isolation and partial characterization of nigrin b, a non-toxic novel type 2 ribosome-inactivating protein from the bark of Sambucus nigra L

The bark of Sambucus nigra L. contains a non-toxic novel type 2 ribosome-inactivating protein that we named nigrin b. In vitro, nigrin b strongly inhibited mammalian protein synthesis but did not affect plant nor bacterial protein synthesis. The protein (M(r) 58,000) contains two subunits, A (M(r) 26,000) and B (M(r) 32,000); linked by disulphide bridge(s). Nigrin b was found to be an rRNA N-glycosidase of the rRNA of intact mammalian ribosomes and shares a very good N-terminal amino-acid sequence homology with the anti-HIV-1 proteins TAP 29 and trichosanthin.

Ebulin 1, a nontoxic novel type 2 ribosome-inactivating protein from Sambucus ebulus L. leaves

A novel type 2 ribosome-inactivating protein (RIP) that we named ebulin 1 has been isolated from leaves of Sambucus ebulus L. (Caprifoliaceae). In vitro ebulin 1 strongly inhibited protein synthesis by rabbit reticulocyte lysates, rat brain, and rat liver cell-free systems but did not affect in vitro plant nor bacterial protein synthesis. Ebulin 1 is composed of two subunits, a catalytic A subunit (M(r) 26,000) and a D-galactose-binding lectin B subunit (M(r) 30,000). Amino-terminal amino acid sequence homology revealed the novelty that the ebulin 1 A-chain shares a high degree of homology not with the A-chain of other type 2 RIPs but rather with the Cucurbitaceae type 1 RIP briodin S and the anti-human immunodeficiency virus type I proteins trichosanthin and TAP 29. Upon treatment with acid aniline the rRNA from ebulin 1-treated rabbit reticulocyte ribosomes released the RNA fragment which is diagnostic of RIP catalytic action. Ebulin 1 was nontoxic to mice up to 2 mg/kg of body weight and did not inhibit protein synthesis in cultured NHC human epithelial cells which are highly sensitive to ricin.

Ocular surface alteration after long-term treatment with an antiglaucomatous drug

BACKGROUND

This study was undertaken to see whether long-term locally applied ocular medications produced any alterations in the ocular surface, and, in particular, whether it caused damage to the mucus layer of the tear film.

METHODS

The authors studied the ocular surface of 40 control subjects (group 1), 21 patients (group 2) chronically treated with a commercial preparation of 0.5% timolol maleate, and 20 previously untreated glaucomatous patients (group 3) in need of treatment with the same drug. Parameters studied were Schirmer's test, lacrimal meniscus height, break-up time, fluorescein and rose Bengal stains, conjunctival impression cytology, mucus staining, and the ferning test.

RESULTS

Patients in groups 2 and 3 showed a significant decrease (P less than 0.001) in the number of normal Schirmer's and break-up time tests. All had positive vital stains. Results showed a significant decrease (P less than 0.001) in goblet-cell density, mucus granules, and reticular sheets, and an increase (P less than 0.001) in pathologic crystallization patterns.

CONCLUSION

These results demonstrate that chronic application of a commercial preparation of timolol maleate damaged the ocular surface, especially the mucus layer of the tear film.

Epidermal growth factor and corneal wound healing. A multicenter study

A randomized, double-blind, placebo-controlled, multicenter clinical trial was conducted in five centers to assess safety, ocular tolerance, and efficacy of an ophthalmic solution of epidermal growth factor (EGF) for the treatment of traumatic corneal epithelial defects. One hundred four patients completed the study: 47 received EGF and 57 placebo (the drug vehicle). Mean epithelial healing time was significantly enhanced in the EGF-treated group (44.17 h) compared with the placebo-treated treated group (61.05 h) (p < 0.01). The number of epithelial defects completely healed at 24, 48, and 72 h after the onset of treatment was significantly greater in the EGF-treated group. Local tolerance was adequate in both groups. These results indicated that topical EGF is well tolerated and may be a significant addition to the ophthalmologist's armamentarium for treating corneal epithelial defects.

Management of corneal complications in xeroderma pigmentosum

Xeroderma pigmentosum is an uncommon, recessively inherited disorder characterized by hypersensitivity to ultraviolet (UV) radiation, with defective repair of DNA damage caused by short-wavelength radiation. Patients with this disease experience progressive and precancerous changes in sun-exposed areas of the skin and mucous membranes. Some patients develop progressive neurologic degeneration. Eye involvement includes lid, conjunctiva, and corneal disorders. We report clinical, histopathologic findings, and complex management strategies used for a 33-year-old woman with xeroderma pigmentosum and recurrent corneal ulcerations that required corneal transplantation, topical cyclosporin, perilimbic conjunctival resection followed by topical mitomycin C, and corneal dye-laser photocoagulation of neovascularization in the left eye.

Vascular permeability during the early and late phases of ocular anaphylaxis

The role of enhanced vascular permeability in a model of ocular anaphylaxis was investigated during both early- and late-phase reactions (EPR and LPR). Vascular permeability was assessed by measuring the extravascular retention of 125I-bovine serum albumin (125I-BSA) in ocular tissues. Ten groups of guinea pigs (n = 5-12 per group) were injected with dinitrophenylated (DNP) bovine gamma globulin emulsified in Freund's adjuvants and challenged after a 4-week interval by topical application of di-DNP-lysine to one eye and phosphate-buffered saline to the other eye. Thereafter, the eyes were examined and the animals were killed at different intervals after topical challenge. They were injected intravenously with 125I-BSA 0.5 hr before death. Retained radioactivity was measured separately in four tissues. The EPR (period between 0.5-1.5 hr after challenge) was characterized by enhanced retention of radioactivity in lids, conjunctiva, and orbital content. There was no significant retention of extravascular radioactivity in the globe and lacrimal gland. Thereafter (period between 2-3.5 hr after challenge), retained radioactivity was significantly diminished. The subsequent period, between 4.5-6.5 hr (LPR), was characterized by a smaller, although significant, increment of radioactivity retained in lids and conjunctiva but not in the other tissues examined. These findings indicate that enhanced microvascular permeability occurs during two phases in actively immunized guinea pigs challenged topically with di-DNP-lysine and that these phases correspond to the clinical signs that constitute the EPR and LPR of ocular anaphylaxis.

Early and late phases of ocular anaphylaxis in actively immunized guinea pigs

A model of ocular anaphylaxis with distinct early- and late-phase components was studied in actively immunized guinea pigs. Twenty guinea pigs were injected with dinitrophenylated (DNP) bovine gamma globulin emulsified in Freund's complete adjuvant and challenged topically with di-DNP-lysine. Clinical signs were monitored over a 48 h period. An early-phase reaction (EPR) characterized by conjunctival edema, conjunctival erythema, lid swelling, and lid redness was observed. This reaction peaked at 0.5 h after challenge and subsided to a low point at 3-4 h. Subsequently, a second episode of lid swelling and lid redness was observed at 4-8 h. All animals in both groups exhibited an EPR. In addition, 75% of the animals underwent an EPR and an LPR. No animals exhibited an isolated LPR. Of the animals that underwent a dual response, 47% were biphasic, 6% were prolonged and 47% were multiphasic. The development of an active model of ocular anaphylaxis exhibiting both EPR and LPR components will enable studies of mechanisms which regulate the frequency and magnitude of these ocular allergic responses.

Atopic keratoconjunctivitis

The clinical presentation and severe complications of atopic keratoconjunctivitis, a potentially blinding disorder, were characterized in a 9-year retrospective study of 45 patients seen at a large referral center. Twenty-six patients had subepithelial fibrosis, 13 with symblepharon and/or fornix fore-shortening. Thirty-four patients had severe keratopathy, which included neovascularization in 17 patients. Persistent epithelial defect was another major complication, occurring in 21 eyes and causing severe loss of vision. These patients required interdisciplinary therapeutic strategies; systemic antihistamine therapy and strict environmental controls were the keys to success in most cases.