Immunity to a corneal antigen in Fuchs' heterochromic cyclitis patients

Immunity to a major corneal antigen was studied in 28 Fuchs' heterochromic cyclitis patients and compared with the response of 44 patients with other types of uveitis and 19 healthy controls. The highest incidence of immune response was found in patients with anterior segment involvement only (anterior uveitis and Fuchs') whereas the frequency of anti-corneal immune response in patients with posterior segment involvement only was low and not significantly different from that of healthy controls. Cellular immunity to corneal antigens was found in the majority of Fuchs' heterochromic cyclitis patients, and in one-third of the anterior uveitis patients. No correlation could be established in these patients between a positive cellular response and the chronicity of the disease or the presence of keratic precipitates. Humoral immunity to the corneal antigen was also the highest in patients with anterior segment involvement, but there was no difference in response between Fuchs' and non-Fuchs' anterior uveitis patients. This study suggests that anti-corneal immunity may be triggered in inflammatory diseases of the anterior segment, especially in Fuchs' heterochromic cyclitis.

Circulating monocyte migration inhibitory factor in serum of Graves' ophthalmopathy patients: a parameter for disease activity?

A factor which inhibits the random migration of monocytes in vitro was found in the serum of nearly half of Graves' ophthalmopathy patients. This factor was found in serum of only 4% of the healthy controls. When the Graves' ophthalmopathy patients were subdivided, on clinical criteria (pain, redness, swelling and impaired function), into patients with active disease and patients with inactive disease, the serum factor was found in 61% of the patients with active inflammatory disease and only in 14% of the patients with inactive disease. Furthermore this factor was also found in the serum of patients with an acute episode of uveitis, suggesting that it may be a useful marker for assessment of a localized inflammatory process.

Clinical presentation of Graves' ophthalmopathy

The eye findings of Graves' ophthalmopathy were prospectively recorded in 90 consecutive untreated patients (66 females, 24 males; mean age 44.5 years) according to the 1977 NOSPECS classification. Soft-tissue involvement was observed in 90%, proptosis greater than or equal to 23 mm in 30%, eye muscle involvement in 60%, corneal involvement in 9% and sight loss in 34%. No differences in the distribution of eye changes between right and left eye were found. Values for proptosis (mean +/- SD, 20.2 +/- 3.6 mm) had a near-normal distribution. Orbital computed tomography (CT) scanning (performed in 80 cases) demonstrated enlargement of inferior rectus in 60%, medial rectus in 50%, superior rectus in 40% and lateral rectus in 22%. Unilateral eye disease was present in 13 patients (14%); in 4 of these patients the CT scan showed eye muscle enlargement also in the fellow eye and in 2 patients bilateral eye disease subsequently developed. The distribution of age, sex and NOSPECS classes in patients with unilateral eye disease was similar to that in patients with bilateral eye disease, but the interval between the onset of thyroid and eye disease was much shorter in cases of unilateral than in cases of bilateral eye disease. Patients without clinically evident thyroid disease (n = 20, 22%) were not different from patients with thyroid disease in age, sex or ophthalmological presentation. The various data suggest: (1) the 1977 NOSPECS classification under-represents significant proptosis in 12% of cases; (2) the age and sex distribution of patients with Graves' ophthalmopathy is similar to that of cases with thyroidal Graves' disease, and (3) unilateral Graves' ophthalmopathy may represent an early stage of the disease, that as a rule already is or develops shortly afterwards into a bilateral disease.

High incidence of corneal epithelium antibodies in Fuch's heterochromic cyclitis

Sera obtained from 26 patients with Fuchs' heterochromic cyclitis were examined for the presence of autoantibodies directed against the anterior segment of the eye by means of immunofluorescence techniques. Antibodies against human iris tissue could not be detected, whereas autoantibodies against corneal epithelium were found in almost 90% of cases. This is the first report describing the presence of autoantibodies in patients with Fuchs' heterochromic cyclitis and it provides a further clue that immunological mechanisms might play an important role in the aetiology of Fuchs' heterochromic cyclitis.

Temporal relationship between onset of Graves' ophthalmopathy and onset of thyroidal Graves' disease

The temporal relationship between the onset of Graves' ophthalmopathy and the onset of thyroidal Graves' disease was evaluated in 125 consecutive patients with Graves' ophthalmopathy. Thyroidal Graves' disease--past or present--was clinically evident in 99 patients (79%): hyperthyroidism in 3 cases. Thyroid disease preceded the eye disease in 37 patients, it occurred simultaneously with the eye disease in 39 patients, and it developed after the eye disease in 23 patients (in 16 cases within one yr after the onset of eye disease). The age at the onset of thyroid disease (38.7 +/- 12.9 yr) was lower than the age at the onset of ophthalmopathy (41.8 +/- 12.5 yr; p less than 0.001). Among the 26 clinically euthyroid patients (21%) laboratory evidence of thyroidal Graves' disease was found in 14 cases (11%): abnormal TRH test, n = 9; normal TRH test but abnormal T3-suppression test, n = 4; normal TRH and T3-suppression tests but positive thyroid stimulating antibodies, n = 1). We conclude that Graves' ophthalmopathy as a rule develops at a time when thyroid autoimmunity also exists. This strongly suggests a common factor in the pathogenesis of thyroidal and ocular expressions of Graves' disease.

Immunological responses in the eyelid and orbit

Immunological responses in the eyelid and the orbit are reviewed: (1) A local immune response is dependent on the presence of lymphoid tissue in an organ. Lymphoid tissue is found in the conjunctival fornices and in the lacrimal gland but not in the orbit. The eyelids also have lymphatic drainage into the local lymph nodes. A local immune response is found in the palpebral conjunctiva and in the lacrimal gland, measureable both as immunoglobulin or specific antibody levels in tears or as immunoglobulin producing cells within the tissue. No local immunity has been demonstrated in the orbit. (2) The other type of immune response found in the eyelids, the lacrimal gland and the orbit is the involvement of these tissues in systemic diseases. Systemic diseases with an immunological basis, which affect the above mentioned tissues are: atopic diseases of the skin, autoimmune diseases, immunodeficiency diseases and lymphoproliferative diseases. (3) Finally, it is possible that the extraocular muscles and the lacrimal gland have tissue specific antigens and therefore may be target tissues for organ specific autoimmune processes.

Therapeutic outcome of prednisone medication and of orbital irradiation in patients with Graves' ophthalmopathy

Response to treatment was evaluated prospectively in 58 patients with Graves' ophthalmopathy. Prednisone, administered to 44 patients, resulted in a favourable response in 29 patients (66%): excellent in 3, good in 10 and fair in 16 subjects; 15 patients (34%) did not respond. Orbital irradiation was administered to 39 patients of whom all except 4 had been treated previously with steroids. Six months later, 25 patients (64%) had responded favourably (excellent in 0, good in 9 and fair in 16 subjects) and 14 patients had not responded (36%). A favourable response to prednisone or irradiation was reflected in a general shift to lower grades in each of the classes 2-6 of the NOSPECS system. Responders were not different from non-responders with regard to age, sex, NOSPECS classification, ophthalmopathy index, interval between the onset of eye disease (or of thyroid disease if present) and the start of treatment, or the presence of thyroid disease. In conclusion, (1) the ratio of responders to non-responders is 2:1 for both prednisone treatment and orbital irradiation in Graves' ophthalmopathy, (2) the response is seen in all classes of the NOSPECS system, and (3) the response is not dependent on age, sex, severity or duration of eye disease, or the presence of thyroid disease.

The influence of high molecular weight sodium hyaluronate (Healon) on the production of migration inhibitory factor

The effect of sodium hyaluronate on the production of migration inhibitory factor (MIF) was studied in a two step MIF-assay. High molecular weight sodium hyaluronate (100 micrograms/ml), added during the inductory step of the MIF-assay, inhibited the production of MIF. The inhibitory effect did not appear to be due to physical factors such as steric hindrance, which may prevent mitogen binding, since cells preactivated with phytohemagglutinin A (PHA) did not produce MIF when incubated in the presence of sodium hyaluronate. The inhibitory effect was still measurable when the sodium hyaluronate was added upto two hours after stimulation of the mononuclear cells with PHA. Inhibition was also found when the cells were preincubated with sodium hyaluronate, and washed prior to mitogen stimulation. Sodium hyaluronate could only be removed from the cells by incubation with hyaluronidase or by incubation of the cells for at least two hours in culture medium, whereafter the cells could be stimulated to the same extent as normal untreated cells to produce MIF. This inhibitory effect on cytokine production may explain the reduced inflammatory reactions found both in vivo and in vitro in the presence of sodium hyaluronate.

Humoral and cellular immune responsiveness to human S-antigen in uveitis

Purified human retinal S-antigen (S-ag) was used to investigate the occurrence of humoral and cellular autoimmune reactions against S-ag in uveitis patients. With a sensitive ELISA method anti-S-ag antibodies could be detected in the sera of 28% of the uveitis patients. No difference was found between patients with posterior or panuveitis (31 out of 117 positive) and patients with anterior or intermediate uveitis (16 out of 52 positive). Similar frequencies and levels of anti-S-ag autoantibodies were also found among healthy controls (6/20) and patients who had undergone cataract surgery (6/17). Immunoblotting with purified S-ag and with whole human retinal extract confirmed the presence of anti-S-ag antibodies in uveitis and control sera. Moreover, antibodies against various other retinal proteins could also be demonstrated in patients and controls, without being particularly enhanced in uveitis. The cellular immune responsiveness was tested by measuring the production of migration inhibitory factor (MIF) during overnight culture of peripheral mononuclear cells with the antigen. None of 18 healthy controls responded, whereas 17 positive reactions were observed in the group of 44 uveitis patients. The highest frequencies were found in patients with posterior (5/12) or pan- (7/12) uveitis, while of the responders with anterior (2/8) or intermediate (3/12) uveitis, three had disorders affecting the retina. Thus, cellular autoimmune responsiveness to S-ag is apparently associated with posterior and pan-uveitis, and might also occur in non-uveitic retinal disorders, whereas the occurrence of anti-S-ag antibodies is probably not at all pathognomic for uveitis.

The relationships between serum T3 index, thyroid volume, and thyroid stimulating, TSH receptor binding and thyroid growth stimulating antibodies in untreated Graves' disease

This study represents an international double-blind collaborative study of abnormal immunoglobulin activity in untreated Graves' disease. Laboratories in two countries participated in a comparison of thyrotrophin binding inhibiting (TBII), thyroid stimulating (TSAb), and growth stimulating (TGI) immunoglobulins with clinical data, including ultrasonically measured thyroid size. The correlation between TGI and thyroid volume (n = 25, Rs = 0.54, P less than 0.05) and the fact that 9 of 10 patients with high range TGI values had large goitres establish the relationship between TGI and goitre, confirming that the in-vitro activity of these antibodies is related to an in-vivo action. In addition, both TBII and TSAb correlated with serum free T3 indices (TBII: n = 60, Rs = 0.46, P less than 0.001, and TSAb: n = 60, Rs = 0.64, P less than 0.001). Moreover, both TBII and TSAb correlated with thyroid volume (TBII: n = 60, Rs = 0.37, P less than 0.01, and TSAb: n = 60, Rs = 0.41, P less than 0.01) suggesting that these antibodies are also important in development of goitre in Graves' disease. Finally, some correlation between the antibodies was observed. TBII correlated with TSAb (n = 60, Rs = 0.47, P less than 0.001), and in the 16 patients with positive TGI results, this activity correlated with TBII (Rs = 0.54, P less than 0.05), but not with TSAb. Also some cases were found with corresponding high range TBII and TGI, while negative for TSAb, suggesting a close relationship between the in-vitro measurement of TSH binding and TGI.

Clinical and experimental studies concerning circulating antibodies to corneal epithelium antigens

Corneal epithelium antibodies were detected in patients with corneal melting disease (55%), uveitis (42%), corneal transplantation (42%) and marginal furrow disease (20%). These antibodies were not found in herpetic keratitis patients. In control groups, consisting of ocular surgery patients (glaucoma, retinal detachment and cataract) and persons without a history of ocular disease, approximately 4% of the subjects had these antibodies. To investigate the possible role of trauma to the cornea as an initiator of corneal epithelium antibodies, these antibodies were determined in rabbits after alkaline burns were made on the cornea. These antibodies were detected one week later and disappeared after six weeks. Serum from three patients with corneal melting disease and corneal transplantation containing a high antibody titre against corneal epithelium were used to isolate corneal epithelium antigens. A 54 kD and a 17 kD corneal epithelium antigen were isolated. The incidence of autoantibodies directed against these antigens was investigated in patients with corneal melting disease, uveitis and corneal transplantation using an ELISA. 50% of the sera positive in the immunofluorescence test were positive in the ELISA.

Autoimmunity against corneal antigens. I. Isolation of a soluble 54 Kd corneal epithelium antigen

Corneal epithelium antibodies were detected in patients with corneal melting disease and uveitis using an immunofluorescence technique with cryostat sections of corneas obtained from various species (man, guinea pig, rabbit, mouse, rat, cow, pig). No differences in results were found using these various substrates, indicating that the autoimmune response is directed against common non-species specific corneal epithelium antigens. The serum of a patient with corneal melting disease, containing a high antibody titer against corneal epithelium was used to identify and isolate one of the bovine corneal antigens. A 54,000 dalton protein was isolated, which was shown to be the major protein present in the corneal epithelium. Absorption studies with other tissues taken from human eyes showed that cornea epithelium, cornea devoid of epithelium, ciliary body and retina contained material which cross-reacted with the isolated bovine corneal epithelium antigen, whereas iris and sclera showed no detectable cross-reaction. The incidence of autoantibodies directed against this antigen was investigated in patients with corneal melting disease, corneal transplantion and in uveitis patients using an ELISA and comparing the results with those obtained with the immunofluorescence assay on rabbit cornea sections. A positive ELISA was always associated with a positive immunofluorescence test. The presence of antibodies against the 54 Kd antigen as detected by the ELISA could be confirmed by immunoblotting in 7 out of 9 positive sera tested. A large number of sera showed a positive immunofluorescence test but a negative ELISA against the 54 Kd corneal epithelium antigen.(ABSTRACT TRUNCATED AT 250 WORDS)

IgG and IgA immune response against klebsiella in HLA-B27-associated anterior uveitis

Enteric infections with Gram-negative bacteria are thought to play an important part in HLA-B27-associated disease such as Reiter's syndrome and reactive arthritis. But the role of bacterial infections in HLA-B27-positive ankylosing spondylitis (AS) and acute anterior uveitis (AU) is still controversial. A special interest has recently been devoted to the role of klebsiella infection in HLA-B27-associated disease. We studied the humoral immune response against a 'cross-reactive' strain of Klebsiella pneumoniae in 62 patients with anterior uveitis and 33 healthy controls. The anterior uveitis patients were subdivided into 25 HLA-B27-negative patients without AS (B27- AU+ AS-), 17 HLA-B27-positive patients without ankylosing spondylitis (B27+ AU+ AS-), and 19 HLA-B27-positive patients with ankylosing spondylitis (B27+ AU+ AS+). Total serum IgA was higher in patients than in controls in both the B27+ AU+ AS+ and B27+ AU+ AS- patients but not in the B27- AU+ AS- group. No abnormalities were observed in the total serum IgG levels. The level of both the IgG and IgA klebsiella antibodies did not differ in the various patient groups tested as compared with the controls. Comparisons between the patient groups showed that the IgG anti-klebsiella response was higher in B27-positive patients patients without AS than in those with AS. These results suggest that stimulation of mucosal surfaces may play a role in HLA-B27-associated anterior uveitis. Whether klebsiella organisms are involved in this stimulation remains unclear.

Circulating antibodies to corneal epithelium in patients with uveitis

We investigated the incidence of circulating corneal epithelium antibodies in patients with uveitis. A high percentage of the patients (42%) were positive, whereas only 4% of controls had these antibodies in their serum. Significantly more patients with anterior and diffuse uveitis had corneal epithelium antibodies than did those with posterior uveitis. Subdivision of anterior uveitis into HLA-B27 positive versus negative patients showed a higher incidence of the antibodies in the HLA-B27 positive group. A previous history of uveitis may play a role in the pathogenesis of peripheral corneal thinning diseases, for which an autoimmune aetiology has been suggested.

Expression of HLA-B27 antigens on mononuclear leucocytes in ankylosing spondylitis

Differences in expression of HLA-B27 antigens on immune competent cells might play a role in the susceptibility to environmental factors which may be responsible for the initiation of ankylosing spondylitis (AS). Using a quantitative complement-mediated lymphocytotoxity assay we determined the expression of HLA-B27 antigens on the membranes of mononuclear cells obtained from 20 patients with AS, four patients with other seronegative arthropathies and eight healthy controls. The variation in expression of B27 between individuals was quite extensive, but there was no significant difference in the mean titration curves obtained for each of the three groups. These findings suggest that the expression of HLA-B27 antigens on the membrane of mononuclear leucocytes does not play a role in the pathogenesis of AS.

Lymphoid proliferations in the orbit: malignant or benign?

Clinical, pathological, and immunological analysis of 20 patients with ocular adnexal lymphoid disease has demonstrated several parameters which are useful for distinguishing malignant from benign lesions. Patients in the fourth or fifth decade of life presenting with an acute history of pain, oedema, epiphora, double vision, and ptosis, with a mass localised in the lacrimal gland area, are more likely to have a pseudolymphoma or a chronic inflammatory lesion than a true non-Hodgkin lymphoma (NHL). It is not possible to obtain a definite diagnosis without surgical intervention, because only three out of nine patients with orbital NHL had evidence of a monoclonal B cell population in peripheral blood on admission to the Orbital Centre. Furthermore it was confirmed that the identification of the various orbital lymphoid infiltrates becomes more distinct when immunological techniques are added to the clinical and histopathological methods of investigation. Multidisciplinary cooperation leads to further improvement of diagnosis and treatment of ocular adnexal lymphoproliferative disease.

Acute anterior uveitis (AAU) and HLA-B27

A group of 30 consecutive HLA-B27 positive acute anterior uveitis (AAU) patients was compared to 30 consecutive HLA-B27 negative AAU patients. The B27 positive group was characterized by male preponderance, earlier age of onset, unilateral uveitis and favourable outcome with therapy. It is concluded that HLA-B27 typing is a useful diagnostic discriminant in AAU.

Circulating antibodies against corneal epithelium and hookworm in patients with Mooren's ulcer from Sierra Leone

A relationship between the occurrence of Mooren's ulcer and hookworm infections was suggested by Kuriakose in 1963. Sixteen patients with clinical diagnosis of Mooren's ulcer and 15 local controls from Sierra Leone were tested with respect to serum immunoglobulin levels, circulating antibody to hookworm, circulating antibodies to corneal epithelium, stool smears, and eosinophil and lymphocyte levels. Both patients and healthy controls had circulating antibodies to corneal epithelium and to hookworm. In the controls the titres of hookworm antibodies were significantly lower than in the patients, though in both groups most people had intestinal parasite infestations as detected by the stool smear. Further investigation failed to demonstrate any other significant immune alteration in the patients as compared with local controls.

Serologic aspects of IgG4 antibodies. I. Prolonged immunization results in an IgG4-restricted response

Labeled antigen-binding tests were used to determine quantitatively the contribution of IgG4 antibodies to the total IgG antibody response in humans. In agreement with literature, we found no IgG4-restricted antibody responses with tetanus toxoid or streptococcal carbohydrate. In the serum of individuals immunized for several years with phospholipase (PLA) from honey bee venom, grass pollen allergen, or house dust mite allergen, we often found that more than 50% of the total antigen-binding capacity was due to IgG4 antibodies. In the case of beekeepers, it could clearly be shown that during prolonged immunization a shift in the IgG4:IgG1 antibody ratio occurs that finally results in an IgG4-dominated antibody response. Evidence is provided that antigen-binding assays may even underestimate the contribution of IgG4 antibodies, because in contrast to IgG1 antibodies, IgG4 antibodies act as monovalent antibodies in being unable to cross-link immunosorbent-bound antigen and radiolabeled antigen.

Serologic aspects of IgG4 antibodies. I. Prolonged immunization results in an IgG4-restricted response

Labeled antigen-binding tests were used to determine quantitatively the contribution of IgG4 antibodies to the total IgG antibody response in humans. In agreement with literature, we found no IgG4-restricted antibody responses with tetanus toxoid or streptococcal carbohydrate. In the serum of individuals immunized for several years with phospholipase (PLA) from honey bee venom, grass pollen allergen, or house dust mite allergen, we often found that more than 50% of the total antigen-binding capacity was due to IgG4 antibodies. In the case of beekeepers, it could clearly be shown that during prolonged immunization a shift in the IgG4:IgG1 antibody ratio occurs that finally results in an IgG4-dominated antibody response. Evidence is provided that antigen-binding assays may even underestimate the contribution of IgG4 antibodies, because in contrast to IgG1 antibodies, IgG4 antibodies act as monovalent antibodies in being unable to cross-link immunosorbent-bound antigen and radiolabeled antigen.

Chronic lymphocytic leukemia. Immunologic markers and functional properties of the leukemic cells

In 230 cases of chronic lymphocytic leukemia (CLL), marker analysis was performed with rosette techniques and a panel of xeno-antisera. A monoclonal B-cell proliferation was found in the majority of cases (94%). In most cases, the B-cells carried IgM, with or without IgD. Cytoplasmic immunoglobulin-inclusion bodies were seen in 7% of the cases of B-CLL. The number of patients with non-B/non-T-CLL was small (2%) in this series. In eight patients (4%), a proliferation of T-cells was established. These patients had a different clinical presentation and marker analysis of the lymphocytes, together with functional studies, showed that this group represented a mixture of different disease processes. Functional analysis of the B-CLL cells in 19 cases showed a poor or absent mitogen response and in nine cases the absence of the capacity to differentiate in vitro into plasma cells and/or to produce immunoglobulins.

Antibody dependent cell mediated cytotoxicity (ADCC) and complement dependent cytotoxicity (CDC) in 229 sera from human renal allograft recipients

Comparison between CDC and ADCC in a human allogeneic model using the same cytotoxicity marker, i.e. 51Cr release from labelled target cells, provided a better definition of the optimal technical conditions for revealing ADCC. Testing 229 sera from human renal allograft recipients after transplantation, we found that CDC is detected only during rejection (43% of cases) whereas ADCC can be found both in those recipients tolerating their grafts and in those undergoing rejection, more frequently in the former than in the latter (39% vs. 21%, p less than 0.05). These in vivo results and other in vitro experiments support the assumption that two distinct varieties of antibody can mediate the in vitro ADCC phenomenon, some directed against the A, B and C HLA loci and having a deleterious effect on the graft, and others capable of exerting a protective effect and which could be directed against D related HLA determinants.