[Usefulness of oral pilocarpin therapy in the treatment of xerostomia and xerophthalmia in patients with primary Sjögren's syndrome]

BACKGROUND AND OBJECTIVE

We aimed to asses the efficacy of pilocarpine tablets as a symptomatic treatment for dry mouth and dry eyes in patients with primary Sjögren's syndrome (SS).

PATIENTS AND METHOD

We included 40 patients with SS (38 women and 2 men), mean age 49.2 years (range, 35-68), with severe xerostomia and xerophthalmia. Objective tests (salivary scintigraphy, Schirmer's test, break-up time, Rose Bengal staining) and subjective tests (symptoms' questionnaire) were carried out before starting treatment and 6 months later to evaluate any glandular function improvement.

RESULTS

All patients initially received 15 mg daily of pilocarpine. Twelve (30%) patients received 20 mg daily. Dry mouth-related symptoms improved in 57.5% of patients and dry eyes-related ones improved in 35%. Scintigraphic studies demonstrated an objective improvement of the glandular function in 35% patients. Ocular tests showed an improvement in 30% cases.

CONCLUSIONS

Pilocarpine therapy is useful to improve xerostomia and xerophthalmia in SS patients with moderate and severe glandular involvement. However, we have not observed a good correlation between subjective improvement of symptoms and the objective test results.

Traitements actuels de la xérophtalmie dans le syndrome de Gougerot-Sjögren

PURPOSE

To describe the large variety of treatments currently used in Sjögren's syndrome for one of its major manifestations, keratoconjunctivitis sicca or xerophthalmia.

CURRENT KNOWLEDGE AND KEY POINTS

Sjögren's syndrome causes a diffuse immunoinflammatory disturbance of main lacrimal glands and the whole ocular surface. Dry eye syndrome is responsible for chronic and deep impairment of quality of life. Many different tear substitutes have been widely developed that are poorly efficient for relieving patients from their complaints. Tear substitutes of various viscosity from standard artificial tears to synthetic gels may be used. Hyaluronic acid is currently the most promising tear substitute, but all eye drops and gels are only efficient in mild to moderate dry eyes and keratoconjunctivitis sicca mostly resists to lubricants. Moreover, the latter may increase patients' complaints when they are associated to preservatives, antiseptic drugs that have widely demonstrated their toxic or irritating potential. Preservatives are, therefore, to be avoided whenever possible in keratoconjunctivitis sicca, by using monodose disposable packaging or specific bottle filtering or eliminating the preservative. Stimulation of lacrimal and salivary secretions with systemic pilocarpine, or obturation of lacrimal puncta in order to limit the drainage of tears in lachrymal ducts may be useful in most severe forms of Sjögren's syndrome. However, the development of topical cyclosporine and other immunomodulating agents is the most relevant progress in the treatment of keratoconjunctivitis sicca in Sjögren's syndrome.

PERSPECTIVES

The future for treating Sjögren's syndrome is most likely to pass through the use of new drugs capable of treating the disease or at least its mechanisms, and not only to try to relieve symptoms with poorly efficient tear substitutes.

Treatment of chronic graft-versus-host disease with anti-CD20 chimeric monoclonal antibody

We reviewed the clinical outcome of 8 patients with steroid-refractory chronic graft-versus-host disease (GVHD) who received an anti-CD20 chimeric monoclonal antibody (rituximab). Rituximab was given by intravenous infusion at a weekly dose of 375 mg/m(2) for 4 weeks. All patients had received extensive treatment with various immunosuppressive agents; 6 patients had also received extracorporeal photopheresis. All patients had extensive chronic GVHD with diffuse or localized sclerodermoid GVHD and xerophthalmia. Other extracutaneous involvements included cold agglutinin disease with the Raynaud phenomenon, membranous glomerulonephritis, and restrictive or obstructive lung disease. Four patients responded to treatment with ongoing resolution or improvement ranging from 265 to 846 days after therapy, despite recovery of B cells in 3 patients. Rituximab seems to have significant activity in the treatment of refractory chronic GVHD and should be considered for further study in patients with early disease. This study suggests a participating role of B cells in the pathogenesis of chronic GVHD.

National immunisation days and vitamin A distribution in Mali: has the vitamin A status of pre-school children improved?

OBJECTIVES

The impact on vitamin A status of the distribution of vitamin A during national immunisation days (NIDs) has not been well established despite strong promotion by international agencies and donors. Using a pre-post design, the change in prevalence of vitamin A deficiency was examined in pre-school children in Mali.

DESIGN

Two cross-sectional surveys were conducted in Mopti region, the first in March 1997 before this strategy was adopted and the second in March 1999, four-and-a-half months after a mass distribution of vitamin A during NIDs.

SUBJECTS AND SETTING

We compared the vitamin A status of children aged 12 to 66 months targeted in 1999 by NIDs with the status of children in the same age group in 1997. Infectious events of the previous two weeks were concurrently recorded. Within the 1999 sample, the status of recipient and non-recipient children was also compared.

RESULTS

In 1997, the prevalence of xerophthalmia (defined by the presence of night blindness and/or Bitot spots) was 6.9% (95% confidence interval (CI) 5.1-9.2) and the modified retinol dose response (MRDR) test proved abnormal in 77.8% of 12-66-month-old children (95% CI 68.27-85.17). In 1999 this picture had improved significantly, both for xerophthalmia prevalence, 3.3% (95% CI 2.1-5.2), and abnormal MRDR test response, 63.1% (95% CI 54.25-71.23). The infectious morbidity rates between 1997 and 1999 tended to decrease. No significant improvement was found among children older than those targeted by NIDs. In 1999, children who received vitamin A had a lower risk for xerophthalmia (3.0% for recipients vs. 8.7% for non-recipients) and experienced fewer infectious events.

CONCLUSIONS

The clinical and biological vitamin A status of pre-school children improved between 1997 and 1999. Mass distribution of vitamin A appears to reduce the occurrence of xerophthalmia and would seem to be associated with a decrease in other related illnesses. Vitamin A supplementation during NIDs should be given a high priority when vitamin A deficiency remains a public health problem.

A pilot study to test the efficacy of oral administration of interferon-alpha lozenges to patients with Sjögren's syndrome

BACKGROUND

Complications from Sjögren's syndrome-induced xerostomia may cause a significant disruption in daily routines such as speech and eating habits. In addition, the reduction in salivary output may lead to increased incidence of caries, oral ulcers, sialadenitis, periodontal problems, and Candida infections. Interferon-alpha has been suggested as an effective drug therapy to increase salivary output.

OBJECTIVE

The objective was to test the efficacy of interferon-alpha lozenges in relieving the symptoms of dry mouth and dry eyes when administered orally to patients with Sjögren's syndrome in double-blind placebo-controlled and open-label trials.

STUDY DESIGN

Twelve patients with a diagnosis of primary Sjögren's syndrome were provided an Institutional Review Board-approved, written informed-consent form. During the double-blind placebo-controlled study they were randomized to receive 150 IU of interferon-alpha (8 patients) or placebo (4 patients) for 24 weeks with 6-week reevaluations. Five patients who received interferon-alpha in the double-blind placebo-controlled trial were treated in an open-label study for another 24 weeks. Whole saliva was measured during each visit, and symptoms were assessed by questionnaires and visual analog scales. The Wilcoxon signed rank test was used to detect significant changes for each variable.

RESULTS

The results indicated that, by the end of 24 weeks, patients who received interferon-alpha had a statistically significant improvement in unstimulated salivary flow rate (P < .05), and statistically significant changes were observed in the median ocular dryness visual analog scale (P < .05) and oral dryness visual analog scale (P < .05). No significant changes were observed among the placebo patients. By the end of 48 weeks, medicated patients had better results than they had at the end of the double-blind placebo-controlled study and showed improvements in whole stimulated salivary flow rate, conditions of throat, and swallowing dry food.

CONCLUSION

Oral administration of 150 IU interferon-alpha 3 times a day for the patients with primary Sjögren's syndrome improved saliva production, relieved symptoms of xerostomia and xerophthalmia, and was well tolerated by the patients.

Vitamin A supplementation on child morbidity

OBJECTIVE

To determine the impact of vitamin A supplementation on child morbidity and nutritional status.

DESIGN

A community based follow-up (interventional) in nature.

SETTING

Two randomly selected Weredas (districts) of Tigray, North Ethiopia were studied between 1996 and 1997.

SUBJECTS

Four thousand seven hundred and seventy children aged between six and 72 months, selected using a multi-stage sampling procedure were enrolled and clinically assessed for xerophthalmia and nutritional status. A sub-sample of these children (n = 281) was further assessed for their serum retinol levels.

MAIN OUTCOME MEASURES

The pre and post intervention data on xerophthalmia, morbidity, nutritional status and serum retinol levels were compared.

RESULTS

Vitamin A capsule coverage of 87% in all the villages of the Weredas and a statistically significant (p < 0.05) reduction in the prevalence of Bitot's spot (from 1.5 to 0.5), fever (from 29.8 to 14.2), diarrhoea (from 30.2 to 18.2), oedema (from 9.2 to 3.2), measles (from 14.0 to 6.2), conjunctivitis (from 10.2 to 3.0), stunted (from 64.2 to 42.7), wasted (from 12.8 to 2.5) and underweight (from 46.2 to 24.2). The proportion of children with normal serum retinol concentration (> 0.7 micromole/L) has also improved significantly (from 36.8 to 56.2).

CONCLUSION

In conclusion, the significant improvement in morbidity and nutritional status that followed the intervention programme although encouraging, it still indicates the importance of coupling periodic provision of Vitamin A capsules with nutrition education.

Control of vitamin A deficiency in Vietnam: achievements and future orientation

Vitamin A deficiency is one of the major nutritional deficiencies in Vietnam. The first survey, conducted in 1985-1988 showed that the prevalence of severe xerophthalmia was seven times higher than the cutoff point established by the World Health Organization (WHO) to define vitamin A deficiency as a public health problem. The result of this survey strongly convinced the government to launch a program to control vitamin A deficiency, which started in 1988. The program strategies included nutrition education, universal distribution of high-dose vitamin A capsules to children aged 6 to 36 months in combination with national immunization days, and promotion of production and consumption of vitamin A-rich foods at the family level. The implementation network was set up based on the existing preventive health structure at all administrative levels. Organizations such as the women's union and other social sectors have participated actively in the program. Surveys conducted in 1994 and 1998 showed that the prevalence of clinical xerophthalmia was significantly lower than that identified in the baseline survey and below the WHO criteria for a public health problem. The achievements of our program have demonstrated that an effective vitamin A supplementation program can be implemented successfully by the preventive health network with active community participation. In the coming years, it will be important for our program to develop approaches other than vitamin A supplementation in order to maintain the past achievements.

Rapid assessment and delivery of Vitamin A to slum children by using National Immunization Day in Chandigarh

This study was done with the objective to see the feasibility of using National Immunization Days (NIDs) for rapid assessment, and delivery of Vitamin A solution to about 27,600 children dwelling in 26 slums in Union Territory of Chandigarh. The assessment of Vitamin A deficiency (VAD) was done in a stratified random sample of 1304 children during third round of Intensified Pulse Polio Immunization (IPPI) and delivery of Vitamin A solution was done during fourth round of IPPI in 1999-2000 covering 27,642 children in the age group of 1-5 years. An additional team of two persons per centre delivered age specific doses of Vitamin A solution through 72 centres and operational problems were recorded. IPPI staff provided supervision and same tally sheets as of IPPI were used. The prevalence rate of VAD was 24.6%, with conjunctival xerosis, bitot's spot and corneal xerosis as 23.7%, 0.6% and 0.2% respectively. 27,275 (98.7%) children out of 27,642 were administered Vitamin A solution, with no major operational problem. Only five parents (0.01%) refused Vitamin A solution. No case of side effect or toxicity due to Vitamin-A was reported. The strategy to assess and deliver Vitamin A during NID's was found to be feasible and successful and could be a basis for launching similar initiatives in other areas of India and other countries where VAD is a public health problem.

[Two patients with xerophthalmia]

BACKGROUND

Xerophthalmia, the eye manifestation of vitamin A deficiency, is one of the main reasons of blindness in developing countries but is rare in industrial countries.

PATIENTS

We report on 2 cases of night blindness and conjunctival and corneal xerosis because of hypovitaminosis A. One patient developed vitamin A deficiency due to short bowel syndrome resulting from gastroschisis. The other patient suffered from primary hypovitaminosis A because of malnutrition due to inadequate dietary intake. Electroretinograms were consistent with vitamin A deficiency. Their symptoms quickly improved after vitamin A substitution.

CONCLUSION

Although rare in developed countries, ophthalmologists should consider xerophthalmia as differential diagnosis in night blindness and conjunctival and corneal xerosis. Early diagnosis and adequate treatment can prevent permanent visual loss.

Hypovitaminosis A in metropolitan Adelaide

Hypovitaminosis A is a well-recognized condition in many developing countries. However, in the developed world the diagnosis is frequently missed or delayed because of its rarity. A 67-year-old man from metropolitan Adelaide presented to us with gradual but severe bilateral visual loss. He had marked punctate epithelial keratopathy in both eyes. Hypovitaminosis was suspected because of his bizarre dietary habit, and this was confirmed by a combination of impression cytology of the ocular surface and biochemical testing of his venous blood. His vision responded dramatically to vitamin A supplementation. Hypovitaminosis A should be suspected in severe cases of 'dry-eye', especially in those patients with unusual dietary habit or malabsorption.

Malnutrition and xerophthalmia in rural communities of Ethiopia

OBJECTIVE

To determine the level of malnutrition and xerophthalmia in pre-school children.

DESIGNS

Non-randomised community based study.

SETTINGS

Four different administrative regions: Harari, Tigray, Southern Nation Nationalities and people region (SNNPR) and Oromiya, with different eco-zones, were studied from May to June 1996.

SUBJECTS

Fifteen thousand and eighty seven children, aged between six and 71 months, examined for clinical symptoms and signs of xerophthalmia. Anthropometry and blood samples were taken from every 20 children (n = 634) of same age, for serum retinol and nutritional determination. INTERVENTION MEASURES: Disease targeted approach of vitamin A supplementation was employed in the regions.

RESULTS

The overall prevalence rates of night blindness and Bitot's spots exceeded WHO cut-off point for xerophthalmia as a public health problem, with higher prevalence rates in males (53%) than females (26%). The proportion of children with deficient serum retinol concentrations (SRC), and Bitot's spot were observed to be higher in Oromiya and Harari regions followed by Tigray, than SNNPR administrative regions. Most of the affected children were aged between 36 and 72 months. The greatest low SRC was also observed in the same age group of children in all regions. There was higher prevalence rate of stunting (60.1%) than wasting (12.2%) with an additional (8.8%) of children both stunted and wasted. The proportion of stunted children was high in Tigray followed by Oromiya, SNNPR and Harari regions.

CONCLUSION

The high level of stunting and Bitot's spot, together with the low level of serum retinol concentrations found in these regions, indicates the need to strengthen this intervention strategy further with universal vitamin A capsule distribution, nutrition education and promotion of horticulture activities.

Vitamin A deficiency disorders

The major cause of blindness in children worldwide is xerophthalmia caused by vitamin A deficiency. In addition it has other adverse effects, including increased mortality and the term vitamin A deficiency disorders (VADD) has been introduced to cover the whole clinical spectrum of disease. The ocular manifestations of xerophthalmia have been classified and a set of prevalence criteria for the detection of a problem of public health magnitude has been in use for more than two decades. The global prevalence of VADD is now well documented and World Health Organisation (WHO) receives information continuously for updating its data base on the subject. The pathogenesis of the disease is still imperfectly understood, it is not at all clear precisely why certain subjects in vulnerable communities develop xerophthalmia, while the majority are spared. A schedule for treatment of the established case has been available for a long time, but at both clinic and hospital level concentrated sources of vitamin A for treatment are frequently not available. More emphasis needs to be laid on prevention and a choice of methods consisting of large dose supplementation, fortification of food, control of precipitating infections and dietary improvement. The advantages and drawbacks of each are discussed.

Comparison of the efficacy and safety of two eye gels in the treatment of dry eyes: Lacrinorm and Viscotears

PURPOSE

To compare the efficacy and safety of two carbomer 940 eye gels in the treatment of dry eyes: Lacrinorm (also called GelTears), a recently introduced eye gel, and Viscotears (also called Vidisic or Lacrigel), used as a reference gel. The main difference between the two gels is in the preservative, respectively benzalkonium chloride and cetrimide.

METHODS

A double-masked, randomised, parallel-group study was conducted in 16 centres in four European countries. A total of 179 patients suffering from aqueous-deficient dry eye were enrolled, of whom 92 were randomised to treatment with Lacrinorm and 87 to the reference gel. Gel was instilled four times a day for a period of 30 days.

RESULTS

After 30 days of treatment, subjective symptoms (the combined scores of foreign body sensation, ocular dryness, burning or pain, and photophobia) had improved by 50% in the Lacrinorm group and by 45% in the reference gel group, and objective test results (break-up time, fluorescein test, Schirmer test, Lissamine Green test) by 35-36% in the Lacrinorm group and 25-45% in the reference group. The improvements were significant in both treatment groups (p < 0.001), with no significant differences between the treatment groups. Subjective local tolerability upon instillation on day 30 was rated 'good' or 'very good' by 91% of patients in both treatment groups. Adverse events were reported for 21 patients in the Lacrinorm group and 17 in the reference group, the most frequent being discomfort, blurred vision, hyperaemia, burning and itching. The frequency and descriptions of adverse events did not differ significantly between the two treatment groups. No serious adverse events were reported.

CONCLUSIONS

Over the period of study, Lacrinorm eye gel was as effective and safe as Viscotears/Lacrigel in the treatment of dry eye.

N-linked glycoside and glucuronide conjugates of the retinoid, acitretin, are biologically active in cornea and conjunctiva

The purpose of this study was to test two water-soluble, synthetic retinoids, glucoseamido acitretin and glucuronamido acitretin, for biological activity in cells of the cornea and conjunctiva. Vitamin A-deficient, xerophthalmic rats were treated topically with these retinoids, and corneas were examined histologically for effects on epithelial keratinization. The effect of these retinoids on the proliferation of rabbit conjunctival fibroblasts in culture was also investigated. Glucoseamido acitretin treatment restored a normal cornea after eight to nine days of treatment, while no improvement was observed in the vehicle-treated corneas. Likewise, glucuronamido acitretin application restored a normal corneal surface and reversed keratinization after eight to ten days of treatment. These retinoids caused no irritation of the eye or ocular adnexa. In culture, exposure of conjunctival fibroblasts to glucoseamide acitretin inhibited cell proliferation. Cultures exposed to glucoseamido acitretin at 10(-8) M or 10(-6) M had cell densities 77.3% and 51.9% of control, respectively, after seven days. Glucuronamido acitretin also inhibited cell proliferation. Cultures exposed to glucuronamido acitretin at 10(-8) M had a cell density of 69.2% of control at day seven, while at 10(-6) M this retinoid completely inhibited cell proliferation. These results show that glucoseamide acitretin and glucuronamido acitretin are biologically active in the cornea and conjunctiva, and may be considered for ophthalmic use in diseases involving abnormalities of ocular surface cell differentiation or hyperproliferation of fibroblasts.

Child feeding and care behaviors are associated with xerophthalmia in rural Nepalese households

The study examined caregiver-child interactions, intrahousehold food allocation and general child care behaviors and their effect on children's xerophthalmia status in the rural Terai region of Nepal. Seventy-eight households with a child having a history of xerophthalmia (cases) were matched with 78 households with a child of the same age having no history of xerophthalmia (controls). Seven day-long continuous monitoring observations were performed in each household (over 15 months) by trained Nepali observers, focusing on feeding and care of a focus child and his/her younger sibling. Nineteen different behavioral variables were operationalized, including serving method, second helpings, serving refusals, encouragement to eat, request intensity, meal serving order, food channeling, food sharing, positive social behaviors, negative social behaviors, and positive health behaviors. Automatic serving and request intensity were strongly negatively correlated, especially among younger siblings. Children who serve themselves receive less encouragement to eat. Those children who are refused in their requests for food tend to ask for food more frequently, for a longer time, and be less likely to self-serve. Children who eat from a shared plate are less likely to interact with a food server and more likely to self-serve. Negative social behavior towards children is associated with the child having to request food more frequently and a greater likelihood of being refused food. Children who receive positive health care from their caregivers are also more frequently asked if they would like food by the server and are encouraged to eat. Several caregiver child feeding behaviors were related to a child's risk of having past vitamin A deficiency. Controls were much more likely to be served food automatically. Cases were more likely to serve themselves food and have multiple servings of food. Cases were nearly two times more likely than controls to be treated with neglect or harshly, and much less likely than controls to have their health needs receive attention. Examining intrahousehold behavior is critical for understanding the causes of vitamin A deficiency in rural Nepalese children, and has great potential for identifying and improving interventions to improve children's diets and care.

Association of xerophthalmia, flecked retina, and pseudotumor cerebri caused by hypovitaminosis A

PURPOSE

To report an unusual case of hypovitaminosis A with bilateral papilledema and flecked retina that regressed after restoration of vitamin A deficiency.

METHOD

Case report. A 27-year-old woman had undergone a biliopancreatic bypass for obesity in 1990. In 1995, she presented with bilateral xerophthalmia, bilateral papilledema, and bilateral flecked retina.

RESULTS

Laboratory tests demonstrated low serum levels of vitamin A (0.8 micromol/l) and vitamin E (8.54 micromol/l). Xerophthalmia, papilledema, and flecked retina disappeared after restoration of normal vitamin A blood levels.

CONCLUSION

Hypovitaminosis A after biliopancreatic bypass for obesity may be associated with xerophthalmia, pseudotumor cerebri, and flecked retina.

Effects of vitamin A on growth of vitamin A-deficient children: field studies in Nepal

Inconsistencies have been observed in the impact of vitamin A (VA) supplementation on early child growth. To help clarify this issue, a cohort of 3377 rural Nepalese, nonxerophthalmic children 12-60 mo of age were randomized by ward to receive vitamin A [60,000 microg retinol equivalents (RE)] or placebo-control (300 RE) supplementation once every 4 mo and followed for 16 mo. VA had no impact on annual weight gain or linear growth. However, arm circumference (AC) and muscle area (MA) growth improved in VA recipients, by 0.13 cm and 25 mm2, respectively, over controls. Growth of children with xerophthalmia, who were treated with >/= 120, 000 RE at base line, was also compared to that of nonxerophthalmic children, stratified by initial wasting status, and adjusted for sex, baseline age and measurement status. Among initially nonwasted children (AC >/= 13.5 cm), VA-treated xerophthalmic children (n = 86) gained 0.7 cm more in linear growth than nonxerophthalmic children. Among initially wasted children (AC < 13.5 cm), VA-treated children (n = 34) gained additional weight (672 g), height (approximately 1 cm), muscle (76 mm2) and fat (79 mm2) areas, and subscapular skinfold (1.3 mm) compared to changes observed in nonxerophthalmic children. Relative increments in soft tissue growth occurred within 4 mo of VA treatment, while the effect on linear growth was gradual. Moderate-to-severe VA deficiency, marked by xerophthalmia, is likely to impair normal physical growth, but milder stages of deficiency may not have this effect in rural South Asia.