Suppression of experimental immune-mediated blepharoconjunctivitis in Brown Norway rats by topical application of FK506

BACKGROUND

Experimental immune-mediated blepharoconjunctivitis (EC) in Brown Norway (BN) rats, which is inducible by transfer of antigen-specific T cells, is a model for human allergic conjunctivitis. We investigated the possible inhibition of EC in BN rats by topical application of FK506, which is an immunosuppressive agent that mainly targets T cells.

METHODS

To induce EC by active immunization, ovalbumin (OVA) adsorbed to alum was injected into the hind footpads of BN rats. Three weeks after the initial immunization, rats were challenged with OVA by eye drops. Twenty-four hours later, lids including conjunctivas, lymph nodes (LNs), and sera were harvested for histology or reverse transcriptase PCR, proliferation assays, and measurement of IgE titer, respectively. For passive immunization, rats were intravenously injected with 10 million of in vitro-stimulated OVA-primed LN cells. Four days after the transfer, rats were challenged with OVA and evaluated as above. The rats were divided into two groups. One group received topical FK506 treatment three times per day from 15 to 21 days after active immunization or from 1 to 4 days after transfer. The other group was treated with vehicle as above.

RESULTS

FK506 treatment suppressed infiltration of both lymphocytes and eosinophils in the conjunctiva either by active or passive immunization (P<0.002). No differences were noted in antigen-specific cellular and humoral immune responses. Concerning cytokine expression in the conjunctiva, a prominent difference was noted only with IL-4, which was more abundantly detected in the vehicle-treated group.

CONCLUSION

Topical FK506 treatment suppressed EC in BN rats, possibly by inhibition of IL-4 in the conjunctiva.

[FK 506 ointment 0.1 % - A new therapeutic option for atopic blepharitis. Clinical trial with 14 patients]

BACKGROUND

Severe atopic blepharitis is difficult to treat, as topical steroids offer only a limited therapeutic benefit with increasing side effects by time. Topical FK 506 was found to be efficient and safe for treatment of atopic dermatitis in dermatologic studies. The use of topical FK 506 in atopic blepharitis has not been reported so far.

PATIENTS AND METHODS

Fourteen patients with severe atopic blepharitis were treated with topical FK 506 0.1 %. The ointment was applied twice daily on the eye lids. Ophthalmologic examinations were scheduled at two weeks, two months and five months after onset of treatment. A score was defined for the skin of the lid (edema, erythema, lichenification, oozing, excoriation and crusting) and for the eye lid margin (erythema, thickening, crusting) respectively. Every patient graded pruritus on a visual analogue scale.

RESULTS

The mean skin score prior to treatment was 25.6 +/- 5.8, after two weeks 7.9 +/- 4.8 (p < 0.001), after two months 5.8 +/- 5.0 (p < 0.001) and after five months 5.3 +/- 5.3 (p < 0.001). The mean score for the eye lid margin prior to treatment was 12.3 +/- 4.0, after two weeks 4.6 +/- 2.7 (p < 0.001), after two months 3.8 +/- 2.4 (p < 0.001) and after five months 4.3 +/- 2.6 (p < 0.001). The mean score for pruritus prior to treatment was 8.1 +/- 1.3, after two weeks 2.0 +/- 1.4 (p < 0.001), after two months 1.3 +/- 0.8 (p < 0.001) and after five months 0.8 +/- 0.7 (p < 0.001). All patients assessed the overall situation under therapy as markedly improved.

CONCLUSIONS

Topical FK 506 0.1 % ointment turns out to be an excellent therapeutic option for treatment of severe atopic blepharitis. Long-term efficacy and safety have to be evaluated in long-term follow-up studies.

Why the eye becomes dry: a cornea and lacrimal gland feedback model

PURPOSE

Many explanations have been offered for why a large segment of the population develops dry eye. The purpose of this paper is to describe a new unifying theory of dry eye that incorporates all of these causes.

METHODS

Data from the Department of Ophthalmology, University of Iowa Hospitals and Clinics was analyzed from 520 patients with dry eye, blepharitis and other conditions to assess the relationship between dry eye and blepharitis. This data was reviewed in terms of the relationship between dry eye, menopause, and aging. Also examined in detail were many of the proposed causes for dry eye in the literature.

RESULTS

A close relationship between corneal damage and lacrimal gland function is hypothesized. Not only does decreased lacrimal gland output damage the ocular surface, but also damage to the corneal surface creates a negative feedback loop and damage to the lacrimal gland. There are probably several mechanisms by which this feedback occurs. One mechanism results from interruption or damage to the sensory corneal nerves. Damage to the nerves within the lacrimal gland may be another mechanism. Alteration of growth factor levels in the lacrimal gland, which occurs following corneal damage, represents another possible mechanism. Contact lenses and corneal refractive surgery are additional elements that may create negative feedback to the lacrimal gland.

CONCLUSION

The ocular surface and the lacrimal gland functions as a tightly integrated unit. Dry eye conditions damage the ocular surface and this in turn leads to further damage to the lacrimal gland.

Experimental immune-mediated blepharoconjunctivitis in rats induced by immunization with ragweed pollen

BACKGROUND

A study was performed to compare the effects of immunization with ragweed pollen (RW) in two different adjuvants on the characteristics of a previously described model of experimental immune-mediated blepharoconjunctivitis (EC) in rats.

METHODS

Lewis or Brown Norway (BN) rats were immunized with 100 microg of RW in emulsion with aluminum hydroxide [Al(OH)3] or complete Freund's adjuvant (CFA). Three weeks later, the animals were challenged with eye drops containing RW in PBS. Twenty-four hours after topical challenge, eyes, blood, and lymph nodes were obtained for histology, measurement of antigen-specific antibodies, and proliferation or cytokine assays, respectively. In addition to active immunization, recipients of RW-primed lymph node cells were challenged and evaluated as above.

RESULTS

RW in both adjuvants induced infiltration with predominantly mononuclear cells in Lewis rats and eosinophils in BN rats. As well as active immunization, eosinophils were detected only in BN rats by adoptive transfer of cells. Lymphocyte proliferative responses to RW were high in immunized Lewis rats when CFA was used as an adjuvant. In contrast, proliferative responses in BN rats were higher when Al(OH)3 was used. RW-specific IgE was detected only in BN rats. There were no significant differences in RW-specific IgG1/IgG2a ratio among the four groups. Lewis rats had higher level of RW-specific interferon-gamma in the culture supernatant.

CONCLUSIONS

The characteristics of EC are different in Lewis and BN rats, dependent on the genetic background of the rat strains. The response to RW was similar to other previously used antigens, such as ovalbumin.

Herpes simplex virus virion host shutoff (vhs) activity alters periocular disease in mice

During lytic infection, the virion host shutoff (vhs) protein of herpes simplex virus (HSV) mediates the rapid degradation of RNA and shutoff of host protein synthesis. In mice, HSV type 1 (HSV-1) mutants lacking vhs activity are profoundly attenuated. HSV-2 has significantly higher vhs activity than HSV-1, eliciting a faster and more complete shutoff. To examine further the role of vhs activity in pathogenesis, we generated an intertypic recombinant virus (KOSV2) in which the vhs open reading frame of HSV-1 strain KOS was replaced with that of HSV-2 strain 333. KOSV2 and a marker-rescued virus, KOSV2R, were characterized in cell culture and tested in an in vivo mouse eye model of latency and pathogenesis. The RNA degradation kinetics of KOSV2 was identical to that of HSV-2 333, and both showed vhs activity significantly higher than that of KOS. This demonstrated that the fast vhs-mediated degradation phenotype of 333 had been conferred upon KOS. The growth of KOSV2 was comparable to that of KOS, 333, and KOSV2R in cell culture, murine corneas, and trigeminal ganglia and had a reactivation frequency similar to those of KOS and KOSV2R from explanted latently infected trigeminal ganglia. There was, however, significantly reduced blepharitis and viral replication within the periocular skin of KOSV2-infected mice compared to mice infected with either KOS or KOSV2R. Taken together, these data demonstrate that heightened vhs activity, in the context of HSV-1 infection, leads to increased viral clearance from the skin of mice and that the replication of virus in the skin is a determining factor for blepharitis. These data also suggest a role for vhs in modulating host responses to HSV infection.

A comparative study of bovine pericardium (periguard) and homologous sclera as lower eyelid spacer graft analogs in New Zealand white rabbits

PURPOSE

To compare bovine pericardium (Periguard; Bio-Vascular, Inc., St. Paul, MN, U.S.A.) and homologous sclera as spacer graft analogs in a rabbit model.

METHODS

A nonrandomized experimental animal study was conducted. Elliptical subconjunctival implants were placed in one lower eyelid each of 10 rabbits. Five rabbits received homologous sclera implants, and five received bovine pericardium implants. The rabbits were killed 7 weeks later, and the lower eyelids were examined clinically and histopathologically.

RESULTS

Rabbit eyelids implanted with Periguard had a more marked inflammatory reaction and more significant collagen lamellar disruption than eyelids implanted with homologous sclera, although clinically they appeared quite similar.

CONCLUSIONS

Although bovine pericardium elicited a more intense inflammatory response at the histopathologic level, both implants were similarly tolerated at the clinical level. These findings are consistent with animal and human investigations of bovine pericardium in other parts of the body, and warrant further studies into its potential use in the human eyelid.

Pyogranulomatous blepharitis in two dogs

Two cases of pyogranulomatous blepharitis (inflammation of the lid margins) in the dalmatian are described. The diagnosis was confirmed on biopsy of the lid lesions. Bacteriology performed in one case was negative. Both cases responded to treatment: one responded well to a course of systemic steroids (prednisolone 1 mg/kg at a decreasing dose over three weeks), while the other, which was negative on culture, responded to a six-week course of cephalexin (30 mg/kg twice daily). This second dog also presented with a localised lymphadenopathy; the owner had suffered a similar reaction three years previously as a result of a penetrating injury by a pyracantha thorn.

Bacterial conjunctivitis in Muc1 null mice

PURPOSE

In contrast to wild-type mice, genetically engineered Mucin1 (Muc1) null animals display a marked propensity for development of blepharitis and conjunctivitis. Molecular approaches confirmed the presence of Muc1 mRNA and protein in the conjunctival tissue of wild-type mice and identified the bacterial species in Muc1 null symptomatic mice.

METHODS

Muc1 null animals housed in a conventional facility were examined for visually apparent inflammation of the eye and surrounding tissue. Blood taken from overtly affected animals was assayed for antibodies to common murine viral agents. Swabs of infected eyes and whole eye preparations were used to detect and speciate bacterial pathogens. Frozen sections of whole eye, lid margin, and Harderian gland were immunostained with antibodies to Muc1 and cytokeratin 14, both epithelial cell markers. Northern blot analysis and reverse transcription-polymerase chain reaction (RT-PCR) were performed on RNA isolated from conjunctiva and Harderian gland of wild-type mice to compare relative levels of transcript.

RESULTS

Student's unpaired t-test performed on the eye inflammation frequency of Muc1 null mice confirmed a statistical significance (P < 0.01) when compared to wild-type background animals housed in the same room. Analysis of blood samples from affected Muc1 null animals detected no common murine viral pathogens. Bacterial analysis of conjunctival swabs and whole eye preparations demonstrated the presence of coagulase-negative Staphylococcus, Streptococcus type alpha, and Corynebacterium group G2. Muc1 antibody staining of wild-type sections revealed the presence of Muc1 on conjunctival goblet and non-goblet cells and on the epithelium of the Harderian gland. Serial sections stained with cytokeratin 14 antibody confirmed the epithelial nature of cells expressing the Muc1 protein. RNA from conjunctiva and Harderian gland subjected to RT-PCR and northern blot analysis showed an abundance of Muc1 transcript in these tissues.

CONCLUSIONS

Muc1 mRNA and protein are present in murine conjunctival and Harderian gland epithelia. Animals lacking Muc1 mRNA and protein are predisposed to developing eye inflammation when compared to wild-type animals with an intact Muc1 gene. Muc1 appears to play a critical protective role at the ocular surface, presumably by acting as a barrier to infection by certain bacterial strains.

Inhibitory effects of FK506 on the development of experimental allergic/immune-mediated blepharoconjunctivitis in Lewis rats by systemic but not by topical administration

BACKGROUND

FK506 has been used for treatment of cell-mediated immune disorders such as graft rejection in transplantation or Behçet disease. To evaluate the effectiveness of FK506 in another ocular disease model, we injected FK506 in rats with experimental allergic/immune-mediated blepharo conjunctivitis (EAC) the induction mechanism of which depends on cell-mediated immunity.

METHODS

Lewis rats were immunized with ovalbumin (OVA) in emulsion of complete Freund's adjuvant (CFA). We injected 2 (n = 6), 20 (n = 6) or 200 (n = 5) microg of FK506 intramuscularly daily from the day of immunization (day 0) to day 6. Control rats were not treated with FK506 (n = 4). In addition, we injected 200 microg of FK506 from day 7 to day 13 (n = 12) to compare the timing of FK506 administration (day 0 to day 6, n = 12; control, n = 12). Twenty-one days after immunization, all rats were challenged with OVA by eye drops, and 24 h later they were killed after clinical evaluation and their eyes, blood and draining lymph nodes were harvested for histology, antibody titers and proliferation assay or flow cytometric analysis. In another set of experiments, rats that had received OVA-primed lymph node cells did (n = 9) or did not (n = 9) receive additional FK506 by injection daily for 4 days. Four days after transfer, these rats were challenged with OVA and evaluated as mentioned. To investigate possible suppression of disease by topical administration of FK506, both actively immunized and passively immunized rats received OVA together with 0.3% (weight/volume) of FK506 (n = 16) or vehicle (n = 10) by eye drops and 24 h after challenge, rats were evaluated as mentioned.

RESULTS

Development of disease, induced by either active or passive immunization, was inhibited in the group treated with 200 microg of FK506, regardless of timing of administration. Cellular proliferative responses to OVA were inhibited only in this group. Flow cytometry demonstrated a decrease of about 20% in the proportion of all cells made up by CD4-positive T cells. Topical administration of FK506 inhibited the development of EAC, though not significantly.

CONCLUSIONS

Systemic treatment with 200 microg of FK506 either in the induction or the effector phase inhibits the development of EAC in Lewis rats. Topical administration is not so effective as systemic administration.

[Therapy refractory unilateral chronic blepharokeratoconjunctivitis as the chief manifestation of auto-aggression syndrome. Clinico-histopathologic findings]

Autoaggressive syndromes as causes of diseases underlying chronic blepharitis and keratoconjunctivitis that are refractory to treatment are often difficult to recognize.

PATIENTS

Three female patients (age 21, 25, 41 years) and one male patient (age 42 years) had suffered from a right-(4x) or left-(1x) handed treatment-refractory blepharokeratoconjunctivitis for 1, 2, 11 and 30 months prior to admission. In each case more than 5 ophthalmologists and 2-6 eye hospitals had been consulted, and extraocular surgery had been performed 1-4 times.

RESULTS

Patients presented with a visual acuity of 0.3 p (1x), 0.1 (1x), FC (1x), HM (1x). In three patients contact eczema of the facial skin and lids and a corneal pannus were observed; in two patients we saw purulent pseudomembranous and in two patients chronic cicatrizing keratoconjunctivitis. Conjunctival smears grew P. aeruginosa, and S. aureus; impression cytology showed infiltration with neutrophils and epithelial keratinization; histopathology indicated chronic inflammatory, partly purulent subepithelial and stromal conjunctival infiltrate with hyper- and parakeratosis fibrous strands and epithelial cell loss; the lower lids showed parakeratosis, focal necrosis, intercellular edema and a lymphohistiocytic round-cell infiltrate. Furthermore, multiple allergies to antibiotics and preservatives (4x), lacerations of the arms and legs (2x) and an irritative-toxic dermatitis (1x) were substantiated. In the patients who agreed to a psychiatric consultation, somatized-agitated longing for care combined with a dependent and infantile personality (1x) and reactive depression (2x) were verified.

CONCLUSIONS

In patients suffering from treatment-refractory unilateral chronic blepharokeratoconjunctivitis correlated with the hand, one must take into consideration the fact that other factors may be involved: possible exacerbation prior to examinations; multiple inpatient diagnostic and surgical procedures in different locations; histopathological mixed inflammatory patterns; and psychiatric syndromes.

Effects of eyelid scrubbing on the lid margin

PURPOSE

To compare the effects of eyelid scrubbing with an eyelid cleansing solution (ECS) to eyelid scrubbing with ECS and the addition of antibacterial or anti-inflammatory pharmaceuticals on the clinical appearance, microbial status, tissue histology, and the inflammatory cell profile of the normal eyelid margin.

METHODS

Eyelid scrubbing was performed twice daily using ECS; ECS with the antibacterial sulfacetamide (ECS+); and ECS with sulfacetamide and prednisolone acetate (ECS++) over a 21 day period on three groups of 16 rabbits with clinically normal eyelids.

RESULTS

Significant hyperemia of the margin occurred in all three groups over the 3 week period; however, the degree of hyperemia was less with ECS+ (P<0.05) and ECS++ (P<0.05). Chemosis, tearing, mucus discharge, and the microbial status were not significantly different than controls. There were no marked histologic differences in the tissues, except for increased red blood cell packing in the small vessels near the lid margins in scrubbed eyelids, consistent with hyperemia. The inflammatory cell profile showed minimal changes that were not statistically significant in any of the three groups, except that >50% of mast cells showed evidence of degranulation.

CONCLUSIONS

Use of ECS with an antibiotic, or an antibiotic and steroid solution, resulted in less inflammation than scrubbing with ECS alone.

Acute inflammation of the eyelid and cornea in Staphylococcus keratitis in the rabbit

PURPOSE

The inflammatory response during Staphylococcus keratitis was analyzed biochemically and histologically to determine the source of the neutrophils infiltrating the tear film and cornea.

METHODS

Rabbit eyes were swabbed and then examined by slit-lamp microscopy at 0, 5, 10, 15, 20, and 25 hours after intracorneal inoculation with Staphylococcus aureus. Bacterial colony-forming units were quantified in the cornea, eyelid, and acute inflammatory exudate. Myeloperoxidase activity of ocular swabs of acute inflammatory exudate, corneal homogenates, and eyelid homogenates was determined. Gross and microscopic examinations of corneas and eyelids were performed.

RESULTS

The colony-forming units per cornea exceeded 10(7) after 10 hours, whereas no bacteria were cultured from the eyelid until 15 hours postinfection. Slit-lamp examination revealed progressive pathology, and the myeloperoxidase activities of ocular swabs, corneas, and eyelids increased markedly by 15 hours postinfection. Corneas showed a wave of neutrophils moving from the tear film toward bacteria in the central corneal stroma and early neutrophil migration from the limbus into the stroma. In the eyelid, neutrophils migrated from the stromal vessels to the tear film.

CONCLUSIONS

Staphylococcus keratitis in the rabbit causes acute inflammation in the overlying eyelid. Neutrophils of the acute inflammatory exudate interact with the infected cornea, whereas neutrophils migrating through the cornea from the limbus remained distant from the site of infection.

Sterile peripheral keratitis following laser in situ keratomileusis

BACKGROUND

Sterile infiltrates have been reported as a possible complication following photorefractive keratectomy (PRK). They have not been reported following laser in situ keratomileusis (LASIK). We review a case of fleeting, sterile peripheral corneal infiltrates following LASIK.

METHODS

A 53 year old patient developed peripheral, sterile corneal infiltrates along the edge of the primary flap following LASIK. This was successfully managed with topical antibiotics and corticosteroids without permanent sequelae.

RESULTS

Sterile peripheral corneal infiltrates are now a known complication following LASIK. Pathogenesis is undetermined but may involve activation of marginal keratitis reminiscent of that following blepharitis or a mechanism similar to acute subepithelial infiltrative keratitis following PRK.

CONCLUSION

Fleeting, sterile peripheral corneal infiltrates can occur following LASIK. This undesired complication is poorly characterized but can be successfully managed with culturing of the infiltrates, topical corticosteroids, and antibiotics.

Persistence of herpes simplex virus type 1 DNA in chronic conjunctival and eyelid lesions of mice

Herpes simplex virus type 1 (HSV-1) causes chronic blepharitis and conjunctivitis as well as keratitis in humans. The pathogenesis of these inflammatory ocular and dermal lesions is not well understood. We have examined the persistence of HSV-1 DNA and its relationship to inflammatory lesions in the conjunctiva and eyelid skin of mice which were inoculated with HSV-1 by the corneal route. Viral DNA was detected by in situ PCR in the conjunctiva and eyelid tissue of infected mice at 5, 11, 23, and 37 days postinfection (p.i.). This DNA was localized in the epithelial cells of the conjunctiva and hair follicles and in the epidermal cells of the eyelid skin. Viral proteins were not detected in the conjunctiva or the eyelid skin after 5 days p.i., even though histopathological lesions were found at 23 and 37 days p.i. in both tissues. The DNA-containing cells were adjacent to sites of inflammation in the chronic lesions in both the conjunctiva and the eyelid skin. A similar temporal and spatial relationship between HSV-1 DNA and inflammatory lesions has been previously reported for the cornea. Our data suggest that the lesions in the cornea, conjunctiva, and eyelid skin progress similarly. Further studies are required to determine whether the long-term presence of HSV-1 is involved in the mechanism by which these chronic inflammatory lesions develop. The presence of HSV-1 DNA in these extraocular tissues for extended periods may constitute persistent viral infection of nonneuronal cells.

Characterization of the immunopathogenic responses to ovalbumin peptide 323-339 in experimental immune-mediated blepharoconjunctivitis in Lewis rats

PURPOSE

We recently reported the essential role of cellular immunity on the induction of experimental immune-mediated blepharoconjunctivitis (EC, formerly EAC) by using ovalbumin (OVA) as a model antigen in Lewis rats. The purpose of this study was to investigate the possible induction of EC by immunization with an OVA peptide (OVA 323-339).

METHODS

Lewis rats were immunized with various doses of OVA or OVA 323-339 in complete Freund's adjuvant. Three weeks later they were challenged with OVA or OVA 323-339 by eye drops; 24 h after challenge, eyes including lids, lymph nodes and blood were harvested after clinical evaluation. An OVA 323-339-specific cell line (S816) was established by periodical stimulation with this peptide. Pathogenicity of S816 was tested by adoptive transfer of S816 into syngeneic recipient rats after challenge with OVA or OVA 323-339.

RESULTS

All rats immunized with OVA 323-339 developed EC after challenge with OVA or OVA 323-339. Rats immunized with OVA 323-339 at doses as low as 0.01 microg had severe clinical scores. OVA-primed rats also developed EC after challenge with OVA 323-339. OVA-primed lymph node cells responded to OVA but not to OVA 323-339. OVA 323-339-primed lymph node cells responded to OVA 323-339 but not to OVA and produced IFN-gamma by stimulation with either OVA or OVA 323-339 (three- to fourfold more than with OVA-primed lymph node cells). Recipient rats of S816 developed severe EC after challenge with either OVA or OVA 323-339.

CONCLUSION

OVA 323-339 was identified as a potent pathogenic peptide in EC.

Adhesion molecules and relationship to leukocyte levels in allergic eye disease

PURPOSE

To evaluate the conjunctival expression of leukocyte cell adhesion molecules (CAMs) and their relationship to leukocyte patterns on the microvasculature in the different clinical subtypes of allergic eye disease.

METHODS

Immunohistochemical analysis, using appropriate monoclonal antibodies, was applied to glycolmethacrylate-embedded biopsies of bulbar and tarsal conjunctival tissue. The proportion of total blood vessels expressing a particular CAM was derived and related to individual cell types identified by cell-specific markers, such as mast cells, eosinophils, neutrophils, T cells, and macrophages. Statistical analysis was used to correlate adhesion molecule expression and, ultimately, cell type.

RESULTS

There was a basal expression of intercellular adhesion molecule-1 (ICAM-1) (21% bulbar, 18% tarsal), E-selectin (15% bulbar, 21% tarsal), and vascular cell adhesion molecule-1 (VCAM-1) (13% bulbar and tarsal) in normal controls. In seasonal and perennial (bulbar and tarsal conjunctival) allergic tissue, ICAM-1 and E-selectin were expressed in 40% to 78% of vessels; in chronic disease, they were expressed in 45% to 80% of vessels; and in vernal giant papillae, they were expressed in as many as 90% of vessels. There was also increased expression of endothelial VCAM-1 in all forms of allergic eye disease; the greatest values were found in vernal giant papillae (64%). Biopsies taken in winter from seasonal sufferers demonstrated a marked reduction in levels of all three CAMs compared with those taken in the pollen season. This is almost consistent with values found in normal conjunctiva. Positive correlations were found between the levels of ICAM-1 and E-selectin expression and the degree of granulocyte and lymphocyte infiltration, although VCAM-1 expression correlated most closely with eosinophil numbers.

CONCLUSIONS

Increased levels of cell adhesion molecules on the microvasculature and the factors that regulate them are likely to be responsible for the infiltration of cells bearing their ligands and may perpetuate inflammation in the chronic forms of allergic eye disease.

Granulomatous blepharitis as a sign of Melkersson-Rosenthal syndrome

OBJECTIVE

The objective of our study was to describe the ophthalmic features and histologic eyelid findings of Melkersson-Rosenthal syndrome.

DESIGN

Three patients with eyelid edema underwent eyelid biopsy to establish the diagnosis of Melkersson-Rosenthal syndrome.

RESULTS

Of the three patients, only one patient manifest the classic triad of facial edema, facial paralysis, and furrowed tongue. Histoloppgically, the eyelid skin in all patients showed characteristic perilymphatic granulomas with marked dermal edema.

CONCLUSIONS

The histopathologic features assist in establishing the diagnosis of Melkersson-Rosenthal syndrome in oligo- and monosymptomatic patients. Melkersson-Rosenthal syndrome should be considered in patients presenting with eyelid edema of unknown etiology and biopsy performed.

Local injections of corticotropin releasing factor reduce doxorubicin-induced acute inflammation in the eyelid

PURPOSE

Doxorubicin chemomyectomy is an effective alternative treatment option for patients with blepharospasm and hemifacial spasm. One side effect of the use of doxorubicin in localized injections is the development of acute inflammation and skin injury at the injection site. Corticotropin releasing factor (CRF) was reported to reduce inflammation after acute inflammatory injuries due to other causes and at other sites. This study was performed to assess the potential of CRF to prevent the development of skin injury and eyelid soreness after local doxorubicin injection.

METHODS

Rabbits received lower eyelid injections of either 75 or 150 micrograms CRF followed by injection of either 0.5, 1, or 2 mg doxorubicin or doxorubicin alone. Eyelids were assessed for changes in acute inflammation by immunohistochemical localization of macrophages and monocytes using anti-CD11, an antibody specific for these cell types. Short-term alterations in vascular permeability were assessed using an Evans blue assay. Additional eyelids were followed daily for changes in the skin over the injection site to determine day of onset of skin injury and the total duration of skin injury. After 1 month, the eyelids were processed histologically for morphometric analysis of muscle fiber loss. Monkey eyelids also were examined for the effect of CRF and doxorubicin injections.

RESULTS

Doxorubicin alone produced an acute inflammatory reaction in the treated eyelids, with a large influx of macrophages and monocytes throughout the connective tissue at 1 and 2 days. Corticotropin releasing factor pretreatment significantly reduced this influx of inflammatory cells into the connective tissue. Doxorubicin produced a large increase in vascular permeability in the treated eyelids, with resultant edema. Corticotropin releasing factor did not alter this change in vascular permeability, indicating that CRF appears to have a specific effect on migration of inflammatory cells rather than just a generalized effect on vascular permeability. Corticotropin releasing factor and doxorubicin cotreatments delayed the onset of skin injury and decreased the total duration of injury to the skin compared to doxorubicin alone. The effectiveness of doxorubicin chemomyectomy was maintained; muscle loss was significant at all doses of CRF combined with doxorubicin.

CONCLUSIONS

Corticotropin releasing factor dramatically decreased the acute inflammatory reaction that results in the eyelid from local doxorubicin injections. Not only did CRF reduce the acute influx of monocytes and macrophages, but it protected the skin overlying the injection site, substantially reducing the extent of skin injury. The efficacy of doxorubicin-induced muscle toxicity was maintained. A treatment protocol that combines myotoxicity with antiinflammatory activity in the treated eyelids may lead to a more effective patient treatment by increasing patient acceptance. The potential should be explored that CRF may be of clinical use in limiting tissue injury when administered immediately after extravasation during cancer chemotherapy.

Assessment of the tear film with tandem scanning confocal microscopy

PURPOSE

To evaluate the confocal microscopic appearance of the tear film by correlating the interference pattern created by the lipid surface with physiologic measurements of tear function and with clinic diagnosis.

METHODS

A series of 53 patients was examined with a battery of tests to evaluate the tear film and with confocal microscopy to evaluate the interference pattern created by the lipid surface of the tear film. Assessment of the tear-film appearance involved five nonparametric scales: degree of debris in the tear film, variability of the interference pattern over time, linearity of the interference pattern, number of dry spots seen, and relative thickness of the lipid layer. For 10 other subjects, the confocal appearance of the tear film and evaporation from the ocular surface was tested for before and after meibomian gland expression.

RESULTS

The confocal appearance correlated with multiple physiologic variables and clinical diagnosis. Patients with seborrheic meiboman gland dysfunction had a thicker lipid layer, greater variability, and more debris than did patients with obstructive meibomiam gland dysfunction. After meibomian gland expression, lipid thickness and linearity increased, whereas pattern variability and evaporation decreased significantly. The mean reduction in evaporation was 48%.

CONCLUSIONS

Confocal microscopy can be used to examine the tear film, and its appearance correlates significantly with physiologic variables in normal-individuals and in disease states. The confocal appearance of the lipid interference patterns and evaporation from the ocular surface are altered after lipid expression from meibomian glands.

Acute and chronic conjunctivitis due to over-the-counter ophthalmic decongestants

OBJECTIVE

To describe patterns of conjunctivitis caused by ophthalmic decongestants.

DESIGN

Case series.

SETTING

Outpatient eye clinic.

PATIENTS

We selected patients with conjunctival inflammation who were using nonprescription decongestant eyedrops, who had no other cause for conjunctivitis, and whose conditions improved after discontinuing the incriminated preparations.

MAIN OUTCOME MEASURES

Clinical characteristics of conjunctival inflammation and time to resolution of symptoms and signs after discontinuing the use of eyedrops.

RESULTS

Seventy patients (137 eyes) were identified. Preparations containing the vasoconstrictors naphazoline, tetrahydrozoline, or phenylephrine were associated with 3 clinical patterns of conjunctivitis: conjunctival hyperemia (50 cases), follicular conjunctivitis (17 cases), and eczematoid blepharoconjunctivitis (3 cases). Decongestants were used daily for a median of 3 years (range, 8 hours to 20 years) prior to presentation. The median time to resolution of symptoms and signs was 4 weeks (range, 1-24 weeks), and patients remained asymptomatic for a median follow-up of 6 months (range, 0-12 years).

CONCLUSION

Nonprescription decongestant eyedrops can produce acute and chronic forms of conjunctivitis by pharmacological, toxic, and allergic mechanisms. Once recognized, conjunctival inflammation often takes several weeks to resolve.

Noninfectious inflammatory response to gold weight eyelid implants

We describe three patients with noninfectious inflammatory reactions to gold weight eyelid implants, a complication not previously reported. Eyelid edema and erythema developed gradually in each patient, and maximal inflammation that prompted treatment was present at 12, 3, and 5 weeks, respectively, after surgery in the three patients. Management involved removal of the implant in the first patient, oral corticosteroids followed by replacement of the implant by a platinum weight in the second patient, and a local corticosteroid injection with retention of the implant in the third. Histopathological features included a thick eosinophilic coagulum at the tissue-gold interface and an intense, predominantly lymphocytic infiltrate in the collagenous capsule that surrounded the implants. Gold weight eyelid implants can elicit a gradually progressive inflammatory response. In at least some cases, local corticosteroid injection may suppress the inflammation and permit retention of the implant.

Analysis of mast cell activation using diamine oxidase-gold enzyme-affinity ultrastructural cytochemistry

We review a new technique--diamine oxidase (DAO)-gold ultrastructural enzyme-affinity labeling--which we developed to localize histamine in subcellular sites of mast cells. The DAO-gold method showed that isolated human lung mast cells contained abundant histamine in their cytoplasmic granules, a conclusion which was verified by a large number of specificity controls. We also studied mast-cell-rich eyelid lesions which developed in interleukin-4 transgenic mice. The DAO-gold method demonstrated histamine in the electron-dense granules of mast cells in these lesions, but little or no histamine was detected in the swollen, empty granules of mast cells undergoing piecemeal degranulation. This new enzyme-affinity-gold method has permitted the first ultrastructural localization of histamine in subcellular sites of routinely prepared electron microscopy samples. The method has also permitted the first morphological studies of histamine secretion in vivo and has demonstrated that such secretion can be associated with the ultrastructural changes of piecemeal degranulation.