The differences of tear function and ocular surface findings in patients with atopic keratoconjunctivitis and vernal keratoconjunctivitis

BACKGROUND

The pathogenesis of the ocular surface disease in atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) has not been fully understood. We tried to clarify the differences in the ocular surface status in patients with AKC, VKC, and healthy control subjects.

METHODS

Twenty-four eyes of 12 AKC patients, 12 eyes of six VKC patients, and 20 eyes of 10 normal control subjects were studied. The subjects underwent corneal sensitivity measurements, Schirmer test, tear film break-up time (BUT), vital staining of the ocular surface, conjunctival impression and brush cytology. Impression cytology samples underwent periodic acid Schiff staining for goblet cell density, squamous metaplasia grading, and immunohistochemical staining for MUC1, 2, 4, and 5AC. Brush cytology specimens underwent staining for inflammatory cell counting and Real Time PCR for MUC1, 2, 4, and 5AC mRNA expression.

RESULTS

The mean BUT, corneal sensitivity, and conjunctival goblet cell density values in AKC patients were significantly lower compared with VKC patients and control subjects. The squamous metaplasia grades in eyes with AKC were significantly higher compared to eyes with VKC and controls. The inflammatory cell response in brush cytology specimens was different between patients with AKC and VKC. Eyes with AKC showed significantly higher MUC1, 2 and 4 and lower MUC5AC mRNA expression compared to eyes with VKC.

CONCLUSIONS

Differences of the infiltrates, higher level of tear instability, lower corneal sensitivity, up-regulation of MUC1, 2, and 4, and down regulation of MUC5AC were important differential features of the ocular surface disease in AKC compared with VKC.

Amelioration of lacrimal gland inflammation by oral administration of K-13182 in Sjögren's syndrome model mice

Regulation of the adhesion of mononuclear cells to endothelial cells is considered to be a critical step for the treatment of inflammatory diseases, including autoimmune diseases. K-13182 was identified as a novel inhibitor for these adhesions. K-13182 inhibited the expression of vascular cell adhesion molecule-1 (VCAM-1, CD106) on human umbilical vein endothelial cells (HUVECs) and on mouse vascular endothelial cell line (MAECs) induced by tumour necrosis factor (TNF)-alpha. K-13182 also inhibited the adhesion of mononuclear cells to these HUVECs and MAECs, indicating that K-13182 suppressed these adhesions mediated by cellular adhesion molecules including VCAM-1. To evaluate the therapeutic effect in autoimmune disease model mice, K-13182 was orally administered to non-obese diabetic (NOD) mice as Sjögren's syndrome (SS) model mice. Severe destructive inflammatory lesions were observed in the lacrimal glands of vehicle-treated control mice; however, 8-week administration of K-13182 inhibited the mononuclear cell infiltration into the inflammatory lesions of the lacrimal glands. In K-13182-treated mice, the decrease in tear secretion was also prevented compared to the control mice. In addition, the apoptosis and the expression of FasL (CD178), perforin, and granzyme A was suppressed in the lacrimal glands of K-13182-treated mice. Therefore, K-13182 demonstrated the possibility of therapeutic efficacy for the inflammatory region of autoimmune disease model mice. These data reveal that VCAM-1 is a promising target molecule for the treatment of autoimmune diseases as a therapeutic strategy and that K-13182 has the potential as a new anti-inflammatory drug for SS.

Alterations of the ocular surface epithelial mucins 1, 2, 4 and the tear functions in patients with atopic keratoconjunctivitis

BACKGROUND

An increased understanding of the ocular surface alterations at the cellular level in the conjunctiva and the cornea, may help explain the pathogenesis and the subsequent clinical appearance of atopic ocular allergies, which may be potentially blinding.

PURPOSE

To investigate MUC 1, 2 and 4 alterations, tear function and the ocular surface disorder in patients with atopic keratoconjunctivitis.

METHODS

Twenty-eight eyes of 14 atopic keratoconjunctivitis patients as well as 22 eyes of 11 age-and sex-matched normal subjects were studied. The subjects underwent corneal sensitivity measurements, Schirmer's test, tear film break-up time (BUT), fluorescein and Rose Bengal staining of the ocular surface, conjunctival impression cytology and brush cytology. Impression cytology samples underwent periodic acid-Schiff and immunohistochemical staining with MUC 1, 2 and 4 antibodies. Brush cytology specimens underwent evaluation for inflammatory cell numbers and quantitative real-time-PCR for MUC 1, 2 and 4 mRNA expression. Patient eyes with fluorescein and Rose Bengal scores greater than four points were regarded to have significant epithelial disease in this study.

RESULTS

The mean corneal sensitivity and BUT values were significantly lower in atopic patients with significant epithelial disease, compared with patients with insignificant epithelial disease and controls (P < 0.01). Brush cytology specimens from patients with significant epithelial disease revealed significantly higher numbers of inflammatory cells (P < 0.01). Specimens from patient eyes showed positive staining for MUC 1, 2 and 4. MUC 1, 2 and 4 mRNA expressions were significantly higher in eyes with significant epithelial disease compared with eyes with insignificant epithelial disease and eyes of control subjects.

CONCLUSION

Ocular surface inflammation, decline in corneal sensitivity, tear film instability, changes in conjunctival epithelial MUC 1, 2 and 4 mRNA expressions were thought to be important in the pathogenesis of atopic ocular surface disease.

Foregut cyst of the oesophageal wall in a cynomolgus monkey (Macaca fascicularis)

Congenital oesophageal cysts of foregut origin are rare in animals and human beings. This report describes a case in a 4-year-old cynomolgus monkey with no clinical symptoms. The cyst, which was located within the oesophageal submucosal tissue near the mid-point of the oesophagus, was lined with pseudostratified ciliated epithelium and had a thin layer of submucosal tissue. The cyst was surrounded by a smooth muscle layer which was partly intermingled with the circular muscle layer of the oesophagus. The muscularis mucosae of the oesophagus was not shared with the cyst wall. Simple tubular glands were present, opening into the cyst lumen. No communication between the cyst lumen and the oesophagus was observed. Cartilaginous tissue, which is a diagnostic feature of bronchogenic cysts, was not identified in the cyst wall. On the basis of the histopathological features, a foregut cyst of the oesophagus was diagnosed.

Microkeratome assisted deep lamellar keratoprosthesis

AIMS

To establish a keratoprosthesis (Kpro) surgical technique that maintains an intact superficial corneal layer.

METHODS

A manual microkeratome (Moria LSK-1) was used to create a 130 mum flap of approximately 10 mm diameter in the right eye of Japanese white rabbits. The stoma beneath the flap area was dissected before the removal of a 5.0 mm stromal disc. A 5.0 mm collagen I immobilised poly(vinyl alcohol) (COL-PVA) disc was placed on the exposed posterior stroma close to Descemet's membrane. The flap was repositioned and fixed using 10-0 nylon sutures, which were removed 2 days following surgery. The corneas were followed clinically by slit lamp microscopy and photographs. Rabbits were sacrificed after 6 months, and the transplanted corneas were examined histologically by haematoxylin and eosin staining and immunohistochemistry against vimentin and alpha-smooth muscle actin (alpha-SMA).

RESULTS

The transplanted COL-PVA discs remained transparent throughout the study, with no complications related to the flap or overlying epithelium. The interface between COL-PVA and Descemet's membrane remained clear without signs of opacification caused by scarring or cellular deposition. Pathology revealed the intact COL-PVA polymer in the posterior stroma, with minimal cellular infiltration along the anterior and posterior interfaces. Immunohistology shows vimentin and alpha-SMA staining at levels comparable to lamellar keratoplasty control.

CONCLUSIONS

Microkeratome assisted deep lamellar keratoprosthesis may be a safe technique for the transplantation of artificial hydrogels for therapeutic purposes.

Elucidation of apoptosis induced by serum deprivation in cultured conjunctival epithelial cells

BACKGROUND/AIMS

The conjunctival epithelial cell line, CCL20.2 (CCL), requires the presence of 10% fetal calf serum (FCS) in the medium to survive. To elucidate the molecular mechanism underlying such cell death, including the death signal for these cells, the activities of several caspases in the CCL were measured, and the effects of caspase inhibitors and serum components on cell death were examined.

METHODS

CCL was grown in Medium 199 containing 10% FCS, and the medium was changed to Medium 199 with or without 10% FCS, or medium without 10% FCS but containing caspase inhibitors or serum components. After 24 hours' incubation, the enzyme activities of caspases 1, 3, 8, and 9 in the culture supernatants were measured, and the effects of caspase inhibitors and serum components-for example, growth factors, lactoferrin, retinoic acid, were investigated.

RESULTS

DNA fragmentation was induced by serum deprivation, confirming that serum deprivation induces apoptosis in CCL. While the activities of caspases 3 and 8 were found to be increased, those of caspases 1 and 9 were not detected in the apoptotic cells. Z-VAD completely suppressed the caspase 3 activation, and specific inhibitors of caspases 1, 8, and 9 partially suppressed the activation. Serum deprivation induced a decrease in the cellular viability, which, however, partially recovered in the presence of caspase inhibitors, epidermal growth factor and retinoic acid.

CONCLUSION

These results suggest that the apoptosis induced by serum deprivation involves caspases 1, 3, 8, and 9, and is suppressed by caspase inhibitors. EGF and retinoic acid have a key role in the maintenance of the ocular surface.

Preliminary repair of eyelids for the treatment of opaque corneas caused by burns

The treatment of opaque cornea as a result of a burn is challenging, because the cornea often re-opacifies even after transplantation. One of the main risk factors is the deformity of the eyelids, and we have developed a new treatment for this. Preliminary repair of the lower eyelid is done by an auricular composite graft before transplantation, so that the grafted materials can be safely protected by the eyelids. The results of treatment since have greatly improved. Preliminary repair of the eyelid is an effective way to secure successful transplantation.

Decreased tear lipocalin concentration in patients with meibomian gland dysfunction

BACKGROUND/AIM

Recent studies have demonstrated that tear lipocalin (TL) and phospholipids have a crucial role in maintaining tear film stability. The level of TL in patients with meibomian gland dysfunction (MGD) was examined and these data were correlated with the severity of their clinical disorder.

METHODS

12 patients with obstructive MGD, 12 patients with seborrhoeic MGD, and 12 age matched normal control subjects participated in this study. 3 mul of unstimulated tears were collected with a micropipette from the inferior tear meniscus in the right eye of all subjects. Tear samples were fractionated by high performance liquid chromatography, and TL concentrations were assayed with a bicinchoninic acid technique.

RESULTS

The mean concentration of TL in patients with obstructive and seborrhoeic MGD was significantly lower than in normal controls. TL concentration correlated positively with tear film break up time and negatively with fluorescein staining scores.

CONCLUSION

These results suggest that TL deficiency may be a predisposing factor for the manifestation of symptoms in MGD.

Transplantation of corneal endothelium with Descemet's membrane using a hyroxyethyl methacrylate polymer as a carrier

AIMS

To evaluate the histology and function of Descemet's membrane transplanted with intact endothelium.

METHODS

Japanese white rabbits and human eyebank eyes were used as donors and recipients of Descemet's membrane transplantation. Donor endothelium was hydrodissected by injecting indocyanine green from a limbal incision, and then processed as a corneal scleral button. A 6 mm diameter donor sheet was trephined, and folded in half using a 6 mm diameter polymer as a carrier. Recipient endothelium was also hydrodissected from the limbus using trypan blue to stain the Descemet's membrane. Continuous curvilinear descemetorhexis (CCD) was performed to remove a circular section of the Descemet's membrane using a 27 gauge cystotome. Donor tissue was inserted into the anterior chamber through a 5 mm limbal incision and apposed to the host stroma. Polymers were removed following transplantation. Similar surgical procedures were performed in both rabbits and eyebank eyes. Haematoxylin eosin stains were performed after 28 days in rabbits, and eyebank eyes were fixed immediately following surgery for endothelial cell counts.

RESULTS

Rabbit control eyes demonstrated stromal oedema caused by loss of Descemet's membrane, whereas transplanted eyes had clear corneas. The mean (standard deviation) pachymetry of operated eyes was 376.6 (SD 32.5) mum compared with 389.6 (SD 25.1) mum in the unoperated eye. Mean endothelial density immediately following surgery in eyebank eyes was 2749 (SD 288) cells/mm(2).

CONCLUSIONS

Transplantation of Descemet's membrane by CCD produces a functional graft with an optically clear interface similar to control cornea.

Development of a wearable computer system with a hands-free operation interface for the use of home health caregiver

We previously developed a network-based medical care support system called the Hyper Hospital, a computer network with an interface that is dedicated to patient care. In this study, we developed a wearable information system that is designed so that a caregiver can obtain information and control various support devices within the home-care environment. In our system, the wearable computer itself consists of a computer network built into a jacket. Each required function is implemented by a dedicated small computer connected to the in-jacket network. A new function may easily be added to the system by connecting additional computers. A network comprising such a set of single-function computers becomes a highly efficient information system when applied to health care support.

Inflammatory cells in brush cytology samples correlate with the severity of corneal lesions in atopic keratoconjunctivitis

BACKGROUND

Inflammatory cells infiltrating to the tarsal conjunctiva are thought to be involved in the pathogenesis of corneal lesions in severe allergic conjunctival diseases. The relation between such cells and the severity of corneal lesions was studied.

METHODS

Six patients with atopic keratoconjunctivitis (AKC) were enrolled in this study. Tarsal brush cytology findings and the severity of corneal damage at that point were recorded and analysed for correlation.

RESULTS

Four out of six patients exhibited correlation between eosinophils and corneal damage. Three out of six patients exhibited correlation between neutrophils and corneal damage. Two out of six patients exhibited correlation between both eosinophils and neutrophils and corneal damage. Analysis of all data from all patients taken together revealed that both eosinophils and neutrophils in brush cytology samples significantly correlated with corneal damage.

CONCLUSIONS

Inflammatory cells in brush cytology samples correlated with corneal damage. Evaluation of the relative percentages of inflammatory cells in brush cytology samples is a useful method of assessing disease activity in allergic conjunctival disease.

Efficacy of core vitrectomy preceding triple corneal procedure

AIMS

To evaluate the effectiveness of core vitrectomy preceding triple corneal procedure (penetrating keratoplasty, extracapsular cataract extraction, and intraocular lens (IOL) implantation).

METHODS

Thirty one consecutive eyes of 31 patients with indication for triple corneal procedure were randomly assigned to either triple procedure with core vitrectomy (vitrectomy group) or without vitrectomy (control group). The success rate of IOL implantation, IOL positioning, intraoperative and postoperative complications, endothelial cell loss, and best corrected visual acuity (BCVA) were compared. Follow up period was six months. Factors that may contribute to vitreous pressure elevation were also investigated in each case.

RESULTS

There was no statistically significant difference in each clinical parameter examined except a tendency of facilitating IOL implantation (p = 0.11). There were two cases of vitreous loss in the control group. Retinal detachment was not seen in any of the cases. The body mass index and age were related to higher vitreous pressure (p<0.05).

CONCLUSION

Core vitrectomy preceding triple corneal procedure is not necessary for all cases.

Salivary flow and its relationship to oral signs and symptoms in patients with dry eyes

OBJECTIVES

The aim of this study was to investigate oral symptoms and clinical parameters in dry eye patients. Subjective reports of the sensation of a dry mouth, salivary flow rates, and clinical parameters of oral disease related to three different types of dry eye patients were examined.

SUBJECTS AND METHODS

There were 224 individuals, including dry eye patients and control subjects. The dry eye patients were classified into three types: patients with Sjögren's syndrome (SS-DE), patients without SS-DE (non-SS-DE), and patients with Stevens-Johnson syndrome (SJS-DE). Salivary flow rates were measured using two kinds of sialometry. Subjective and objective oral symptoms and signs were also examined.

RESULTS AND CONCLUSION

Over half of the dry eye patients complained of a dry mouth. The flow rates of their stimulated whole saliva and parotid saliva were significantly lower than those of the control groups (P < 0.05, P < 0.01). The sensation of a dry mouth and changes in oral soft tissues, dental caries, and oral Candida frequently occurred in dry eye patients.

Albumin as a tear supplement in the treatment of severe dry eye

AIM

To determine the efficacy of using albumin tear supplements in the treatment of ocular surface disorders as a substitute for serum eye drops.

METHODS

The effects of albumin on the viability of serum deprived conjunctival cell were observed in vitro. The ability for albumin to compensate for serum was demonstrated by measuring the activity of the apoptosis related enzyme, caspase-3. In an animal study, corneal erosions were inflicted in 40 Japanese white rabbits. Rabbits were treated with 5% or 10% solutions of human albumin, and the decrease in epithelial defect size was compared with saline control and 0.3% sodium hyaluronate. A clinical case series trial of 5% albumin drops was conducted in nine patients with Sjögren's syndrome with severe dry eye.

RESULTS

The addition of albumin to serum deprived conjunctival cells inhibited caspase activity and increased cell viability, showing that albumin can compensate for some of the physiological properties of serum. Corneal erosions in rabbits healed significantly faster (p<0.05) in eyes treated with 10% albumin compared with control and sodium hyaluronate. Patients with Sjögren's syndrome used albumin drops showed statistically significant improvement in fluorescein and rose bengal scores, but not in tear break up time and subjective symptoms. No adverse effects of albumin were observed during the study.

CONCLUSIONS

The use of albumin as a protein supplement in artificial tear solutions is a viable approach in the treatment of ocular surface disorders associated with tear deficiency.

Autologous serum eye drops for the treatment of severe dry eye in patients with chronic graft-versus-host disease

We investigated the efficacy and safety of autologous serum eye drops for the treatment of severe dry eye after allogeneic haematopoietic stem cell transplantation (SCT). A total of 14 patients (four males and 10 females; median age, 31.0 years) with severe dry eye associated with chronic graft-versus-host disease (cGVHD) were enrolled in this study. All patients were refractory to treatment with conventional artificial tears. Autologous serum eye drops, a solution made of 20% autologous serum in sterile saline, were applied 10 times per eye per day. The patients were evaluated every 4 weeks according to visual acuity, corneal sensitivity, vital staining of the ocular surface, tear dynamics, and subjective assessments of symptoms (complaints scores). The median follow-up period was 19.4 months (range: 4-41 months). After 4 weeks of treatment, significant improvement was observed in both complaint scores (from 33.7+/-12.3 to 23.6+/-10.6 points; P<0.01) and fluorescein scores (from 5.8+/-2.0 to 2.4+/-0.9 points; P<0.005). Significant improvements were observed also in rose-bengal staining and tear break-up time. In seven of the 14 patients, the responses were maintained for 6-41 months (median:19.4+/-8.3 months), while six of the other seven patients required treatment with punctal plugs in addition to autologous serum eye drops. One of these other seven patients developed eczema around the eyelids, after which the treatment was discontinued. No serious adverse events were observed. We conclude that autologous serum eye drops are safe and effective for treating severe dry eye associated with cGVHD and that more efficient control of dry eye may be achieved by the combined use of autologous serum eye drops with punctal plugs.