The value of biopsies in the evaluation of chronic progressive conjunctival cicatrisation

BACKGROUND

Chronic progressive conjunctival cicatrisation is poorly understood, and therapy of this condition remains difficult. This study assessed the value of immunohistochemical investigations in the evaluation of patients who present with chronic cicatrising conjunctivitis similar to cicatricial pemphigoid (CP).

METHODS

Bulbar conjunctival biopsies from 36 patients with acute (n = 5), subacute (n = 13) and chronic (n = 18) ocular disease were studied. The biopsy was retaken in 7 patients to evaluate the present immunological findings in comparison with a biopsy more then 5 years ago. All the specimens were investigated for the presence of immunoglobulins and complement at the epithelial basement membrane, and the phenotype of the inflammatory cellular infiltrate was analysed. Twenty-nine patients were evaluated for the presence of circulating IgG-anti-basement membrane zone antibodies.

RESULTS

CP was confirmed by immunoglobulins and/or complement deposition at the epithelial basement membrane in 11 patients (31%). IgA was found to be the most frequent deposit. Eleven CP patients, mainly those with active or "burnt-out" disease, showed absence of immunoglobulins and/or complement at the conjunctival basement membrane. In 14 of 36 patients, conjunctival cicatrisation was subsequently felt to be caused by conditions other than CP. The cellular phenotype in the subepithelial conjunctiva was unspecific, but in CP the disease activity was reflected by the number of neutrophils and macrophages. Circulating IgG antibodies were found in none of the patients' serum.

CONCLUSION

Immunoglobulin and/or complement deposition at the epithelial basement membrane confirms the diagnosis of mucous membrane pemphigoid. Their absence, however, does not rule it out and is a frequent feature in very active conjunctival disease or after immunosuppressive treatment. The analysis of the cellular phenotype in mucous membrane pemphigoid may be useful in the assessment of disease activity but does not help in determining the underlying disease process causing the cicatrising conjunctivitis.

Occlusion therapy for strabismic amblyopia

OBJECTIVE

To assess the outcome of occlusion therapy in strabismic amblyopia.

METHODS

The case notes of 369 children requiring strabismus surgery were reviewed.

RESULTS

Of 369 children requiring surgical correction for strabismus, 109 had strabismic amblyopia. All of these patients were treated with occlusion. Seventy-eight per cent (85 of 109) had improvement of their visual acuity to within one Snellen line of the other eye. Another 11% (12 of 109) of patients genuinely failed to achieve equal acuity in both eyes despite occlusion and 11% (11 of 109) failed to improve due to poor compliance.

CONCLUSIONS

Occlusion for six hours per day, every day, produced an effective and rapid response in most patients. There was no occlusion amblyopia. Admission to hospital for occlusion was effective in some refractory cases.

Aetiology of severe visual impairment and blindness in microphthalmos

Microphthalmos occupies a spectrum from a normal, but small globe, to a globe with multiple anterior and posterior segment abnormalities. This study examines 54 eyes of 27 patients who had bilateral microphthalmos and severe visual impairment or blindness. Congenital cataract was the commonest cause of severe visual impairment (44%), followed by presumed retinal or optic nerve dysplasia (30%) and chorioretinal coloboma (22%). Lensectomy was followed by phthisis bulbi in 3/23 cases and retinal detachment in 2/23 cases. There were no cases of angle closure glaucoma. The three clinical conditions associated with a poor prognosis were cataract, chorioretinal coloboma, and a markedly reduced corneal diameter. A corneal diameter of 6 mm or less was associated with a visual acuity of no perception of light in 81% (21/26) compared with 4% (1/28) of those with larger corneas.

The immunological features and pathophysiology of ocular cicatricial pemphigoid

Ocular cicatricial pemphigoid is an uncommon but severe and potentially blinding systemic disease. It shares many pathophysiological features with the other bullous skin diseases such as dermatitis herpetiformis, bullous pemphigoid and pemphigus vulgaris. All of these diseases have circulating antibodies that bind to the basement membrane of mucous membranes. The individual diseases differ by each having a specific component of the basement membrane complex as its antigen. In acute ocular cicatricial pemphigoid, the conjunctiva is infiltrated with neutrophils, macrophages, Langerhans cells and CD8+ and CD4+ T-cells while in the chronic disease the conjunctiva is infiltrated mainly by CD8+ T-cells. There is evidence of activation of these T-cells as CD4+ cells as shown by expression of the interleukin-2 receptor and increased expression of major histocompatibility class II antigens within the tissue. The aetiology of the fibrosis is unknown but increased amounts of several fibrogenic growth factors are demonstrable by immunohistochemistry.

A clinicopathologic study of in vitro sensitivity testing and Acanthamoeba keratitis

PURPOSE

To examine the extent of any correlation between the in vitro sensitivity and the clinical outcomes of Acanthamoeba keratitis.

METHODS

The clinical outcomes were correlated with the in vitro sensitivity of 23 isolates of 23 patients with culture-positive Acanthamoeba keratitis. The laboratory assay assessed the amoebicidal and cysticidal efficacy of 13 drugs.

RESULTS

Most agents were effective against the trophozoites in vivo. Polyhexamethylene biguanide (PHMB) and chlorhexidine were the most successful cysticidal agents, followed by sepazonium and propamidine. Clotrimazole, paramomycin, and ketoconazole were cysticidal in a few specimens, but usually in high concentrations. Neomycin was ineffective against cysts in vivo. Nineteen patients were treated with topical propamidine and neomycin, and a medical cure was obtained in nine (47%). There was poor correlation between the clinical outcomes of individual cases and the in vitro sensitivity testing. The medical failures were treated with topical PHMB and propamidine and eight of ten (80%) of these were medically cured. Two patients, however, were still culture positive after 28 and 41 weeks of treatment. PHMB has an excellent in vitro sensitivity profile, but the two cases of failure were sensitive to the drug and resistance had not developed.

CONCLUSIONS

In vitro sensitivity testing has been important in the screening of new agents, although disappointing in the management of individual cases in this set of studies.

Leber congenital amaurosis and its association with keratoconus and keratoglobus

Leber congenital amaurosis has been associated with keratoconus and it has been postulated that this is due to eye rubbing, the oculo-digital sign, because of poor vision. Six schools for the blind were visited, and 174 children with a visual acuity of less than 3/60 examined. Thirty-five children had Leber amaurosis, and 10 of these had keratoconus (29%) and one had keratoglobus (3%). The six pedigrees of the cases with Leber amaurosis and keratoconus are presented in detail. Only 3 of the 139 other blind children had keratoconus (P < .05) and 1 had keratoglobus. Keratoconus seems specifically associated with Leber amaurosis, probably due to genetic factors, rather than poor visual acuity per se.

Congenital glaucoma in the West Bank and Gaza Strip

This study presents the results of all patients with congenital glaucoma who were managed at St John Ophthalmic Hospital, Jerusalem from 1981 to 1990. This involved 118 eyes, 174 surgical procedures, and 460 examinations under anaesthesia. All procedures showed decreasing success rates with time. However, trabeculectomy was clearly the most successful in the hands of general ophthalmologists. Careful, long term follow up with particular regard to both intraocular pressure and detection and treatment of amblyopia are emphasised.

Childhood blindness in the West Bank and Gaza Strip: prevalence, aetiology and hereditary factors

A study of all the schools for the blind in the West Bank and Gaza Strip was undertaken during 1991-2. Two hundred and five children had a complete ophthalmic examination. This represented 94% of all children aged 5-15 years attending schools for the blind. According to WHO categories of visual loss, 63% were blind and 21% had severe visual impairment. The main causes of blindness and severe visual loss were retinal (52%), optic atrophy (12%), glaucoma (9%) and cataract (7%). Common retinal diseases included degenerative myopia, Leber's congenital amaurosis, cone dystrophy and retinitis pigmentosa. Depending on the locality, 44-85% of these children were the product of a consanguineous marriage and a positive family history was present in 57%. The minimum prevalence of childhood blindness was estimated to be 0.32/1000 children. A reduction in the prevalence of blindness requires a reduction in consanguineous marriages, genetic counselling for affected families and public health measures to ensure early referral for management of cataract and glaucoma.

Penetrating eye injuries in children of the West Bank and Gaza strip

A retrospective study was carried out on 118 children with penetrating eye injuries. Fifty-three per cent of those without an intraocular foreign body (50/94) achieved a final visual acuity of 6/12 or better, whilst 13% (14/108) required an enucleation. Mixed corneoscleral wounds, vitreous haemorrhage and retinal detachment were bad prognostic features. Important principles of management are discussed.

Mersilene mesh and fascia lata in brow suspension: a comparative study

I retrospectively compared 34 brow suspension procedures: 17 using Mersilene mesh and 17 using stored, irradiated fascia lata. Good results were obtained with both materials. Since Mersilene mesh is inexpensive, easy to prepare and work with, and can be sterilized and guaranteed free of infectious diseases, it is an acceptable alternative if fascia lata is unavailable.

Paediatric dacryocystorhinostomy

The results of 95 dacryocystorhinostomy procedures in 78 paediatric patients are reviewed. The success rate was 77%. Factors influencing success and failure are discussed.

Diazepam and its effects on visual fields

A patient who experienced severe visual field loss whilst taking 100 mg of diazepam that reverted to normal on cessation of the drug is described. Diazepam affects GABA inhibitory neurones and the physiology of this in the retina and visual cortex is reviewed.

A clinicopathological study of loop recession in strabismus

This communication reports the histological structure of loop recessions of extraocular muscles from seven patients. In all cases the loops formed pseudotendons in which the typical histological structure was well established by four months. Subsequently, moulding of these pseudotendons occurred with improved alignment of collagen and decrease in vascularity. By three and a half years after the operation the pseudotendon had acquired a very close resemblance to true tendon.

Five-year follow-up of clear cornea trabeculectomy

A five-year follow-up of a prospective trial of 21 eyes with clear cornea trabeculectomy is reported. The procedure had a 56% success rate at five years.

Bone implants after enucleation

A method of preparing antigen-free cancellous bone for use as an orbital implant is described together with the surgical technique for its use in enucleation. The results of 52 patients with follow-up spanning 10 years is reported. In the first four years, five implants had to be removed, all due to infection following breakdown of Tenon's capsule in the early postoperative period. However, with more careful closure of Tenon's capsule, there have been no extrusions during the last six years.

Prevention of bony fluorosis in aluminum smelter workers. A 15-year retrospective study of fluoride excretion and bony radiopacity among aluminum smelter workers -- Pt. 4

1. Fifty six aluminum smelter workers with 10 to 43 years' occupational exposure, and who had been previously studied medically, were re-x-rayed. Average urinary fluoride concentrations since 1960 were estimated to range from 2.78 mg/liter preshift and 7.71 mg/liter postshift. 2. Roentgenographic studies in 1960-66 and 1974 failed to reveal any evidence of fluoride associated bony change. 3. Although these workers represent a self-selected group, their magnitude and duration of exposure far outweighs any other group working at present or in the past at this plant. The implication that they have uniformly self-selected as fluoride resistant individuals is improbable. 4. These data indicate that group post-shift ur a long period is not associated with enhanced risk of bony fluorosis. If preshift urinary fluoride concentrations are less than 4 mg/l, the same results appears to apply.