Periocular inflammation in mice with experimental systemic lupus erythematosus. A new experimental blepharitis and its modulation

Experimental systemic lupus erythematosus (SLE) can be induced in mice by immunization with a human monoclonal anti-DNA Ab, bearing a major Id 16/6Id. Immunized mice initially produce Abs to 16/6Id, DNA and nuclear Ags, and subsequently develop various clinical manifestations including leukopenia and renal immune complex disease. MHC class I Ags play a critical role in the induction and progression of experimental SLE. The present study reports that ocular changes also occur in mice with experimental SLE. The ocular disease is characterized by bilateral subacute and chronic inflammation of the eyelids (blepharitis) with immune complex IgG deposition and hypertrophic meibomian glands. The severity of ocular changes was strain dependent: most severe in 129 mice, less intense in BALB/c animals and only minimal in C3H.SW mice. No blepharitis developed in mice deficient in MHC class I expression. Further, the disease was strongly inhibited in BALB/c mice treated with methimazole, an agent that has been shown to repress transcription of MHC class I. In these cases, there was no IgG deposition and a decreased infiltration of inflammatory cells in the eyelids. These observations thus suggest that, similar to the observation with experimental SLE, MHC class I is critical in the onset of this experimental autoimmune blepharitis. The new experimental eye disease described here provides an animal model for chronic blepharitis in humans, a common condition for which such a model has been sought.

[Morphology of the Meibomian lipid film. Results of Brewster angle microscopy]

Meibomian lipid layers were studied in the anterior mirror area by reflecting microscopy and interference microscopy. Using these techniques, it was not possible to correlate the biophysical and morphological data. Brewster angle microscopy provides direct observation of the spread Meibomian lipid layer with simultaneous registration of the surface pressure. It is based on the fact that He-Ne laser light, which is incident at a water surface under the Brewster angle, does not reflect visible light. After spreading of a lipid film, the angle of the incident light beam varies, causing reflection of light. The Meibomian lipid layer was studied in a Langmuir-type trough. At 5.0 mN/m the lipid layers are homogeneous and mobile, consisting of areas of higher and lower reflectivity. In patients with meibomitis the films are inhomogeneous and immobile. The thickness of the areas of lower reflectivity is 2 nm, the high reflectivity lipids are 8-10 nm thick. According to these results, Meibomian gland secretion can form monolayers under in vitro conditions.

[Isotretinoin administration in treatment of acne vulgaris. A prospective study of the kind and extent of ocular complications]

Isotretinoin (13-cis-retinoic acid) is commonly used for the treatment of acne vulgaris. In the skin this substance causes an atrophy of sebaceous gland acini and a decrease in sebum production. Systemic treatment also alters meibomian gland function and structure. These alterations seem to be responsible for ocular complications (dryness of the eye, blepharitis, conjunctivitis) during therapy with isotretinoin. We inspected 30 patients before, during and after therapy with isotretinoin with regard to ocular side effects. Examination included careful slit-lamp inspection, measurement of break-up time (BUT) and the Schirmer test. Conjunctival smears were taken from every patient. The most frequently observed side-effects were decreased tear break up time and alterations of the lid margin. In addition, an enormous increase of Staphylococcus aureus in conjunctival flora was noticed. However, all ocular complications of systemic treatment with isotretinoin were reversible after cessation of therapy.

Corneal vascularization and opacification during long-term use of dipivefrin

Dipivefrin hydrochloride is a lipophilic prodrug for epinephrine hydrochloride, allowing lower concentration of the drug to achieve the same intraocular pressure lowering effect and having also less harmful effects than epinephrine hydrochloride. However, harmful effects have been associated also with the use of dipivefrin and here we report of a case of corneal vascularization during long-term use of dipivefrin.

Piecemeal degranulation of mast cells in the inflammatory eyelid lesions of interleukin-4 transgenic mice. Evidence of mast cell histamine release in vivo by diamine oxidase-gold enzyme-affinity ultrastructural cytochemistry

We used light and electron microscopy to analyze the eyelid inflammation that develops in transgenic mice that overexpress interleukin-4 (IL-4; Tepper et al, Cell 62:457, 1990). Analysis of alkaline Giemsa-stained plastic sections examined by light microscopy (Dvorak et al, J Exp Med 132:558, 1970), as well as by routine transmission electron microscopy, indicated that the mast cells in the inflammatory eyelid lesions were undergoing piecemeal degranulation, a form of secretion in which the cells' cytoplasmic granules exhibit characteristic morphologic changes that are thought to be associated with the prolonged, vesicle-mediated release of the granules' constituents. Moreover, by using a newly reported enzyme affinity-gold method, which stains histamine based on binding to diamine oxidase-gold (Dvorak et al, J Histochem Cytochem 41:787, 1993), we show that these activated mast cells had released much of their histamine content. The eyelid lesions also exhibited increased numbers of mast cells; interstitial fibrosis, particularly around cutaneous nerves and blood vessels; activated fibroblasts; focal axonal damage; venules with endothelial cells containing numerous vesiculo-vacuolar organelles; and infiltrates of neutrophils and eosinophils. Our findings illustrate that overexpression of the IL-4 gene in vivo can result in eyelid lesions associated with piecemeal degranulation of mast cells, as well as tissue fibrosis and a variety of other pathologic changes. These results also represent the first direct morphologic evidence for histamine secretion by mast cells in vivo.

[Chronic unilateral keratoconjunctivitis in molluscum contagiosum of the upper eyelid margin]

PATIENT AND METHODS

Over a period of one year a 33-year-old married housewife, mother of two healthy children, complained of an initially recurrent, in the last 6 months persisting conjunctivitis, upper and lower lid edema, dacryorrhea and photophobia concerning the left eye. Neither topical derivates of cromoglycin acid, antibiotics nor steroids brought relief. Half a year ago the patient had noticed a "little nodule" of the lateral upper eyelid without tendency to grow. The visual acuity was 0.8 due to a punctate superficial keratopathy. In addition a marked follicular conjunctivitis was present. Our examination revealed a little whitish-rosy tumor with elevated edges and a central crater at the lateral margin of the upper lid. The right eye was completely normal. The tumor was totally excised preserving the lid margin. Our histopathological diagnosis was "molluscum contagiosum". Four weeks after surgery the keratoconjunctivitis had subsided without further medication.

CONCLUSION

In persisting unilateral conjunctivitis without amelioration after any topical therapy the eyelids should be checked carefully for a tumor to be excised. In older patients a sebaceous gland carcinoma must be ruled out. Considering the patient's personal history a chlamydial infection should be kept in mind as a differential diagnosis.

Necrotizing fasciitis of the eyelids

Necrotizing fasciitis is a destructive soft tissue infection that rarely involves the eyelids. Three cases of necrotizing fasciitis of the eyelids are described. Necrotizing fasciitis was preceded by minor forehead soft tissue trauma in two cases and occurred spontaneously in one. In two patients necrotizing fasciitis was bilateral and involved both the upper and lower eyelids. Review of these cases, in addition to 18 cases previously reported in the English literature, reveals a predominance in females, preceding minor local soft tissue trauma, frequent bilateral involvement, and an association with alcohol abuse and diabetes. In all of the patients, group A beta-hemolytic streptococci were cultured from the wound. Early recognition of the disease process, prompt surgical debridement of the necrotic tissue, aggressive antimicrobial therapy, and delayed skin grafting combine to minimize morbidity.

Experimental comparison of laser and cryosurgical cilia destruction

We compared cryosurgery with the argon and carbon dioxide lasers in a rabbit model to evaluate the permanence of eyelash destruction as well as the gross and histologic effects on the eyelid. Each modality was equally effective in preventing eyelash regrowth. Cryosurgery and the carbon dioxide laser produced the greatest acute soft tissue swelling; the carbon dioxide laser produced the most pronounced gross eyelid alterations. The argon laser produced minimal eyelid tissue change. Long-term histologic tissue alterations were not striking and were confined to eyelids treated with cryosurgery and the carbon dioxide laser. We conclude that, of the two lasers, the argon is the best suited to the clinical treatment of trichiasis: it is widely available, more precise in limiting contiguous tissue destruction when delivered through a slit lamp, and is safer for use near the eye.

[Unilateral chronic granulomatous blepharitis as a leading symptom of Oriental cutaneous leishmaniasis in Germany. Giesma stain as rapid diagnosis and initial description of systemic therapy with gamma-interferon]

Nine months after leaving the Lebanon, a four-year-old immigrant boy presented with a 5 months history of blepharitis. The lesion remained therapy-resistant for aminoglycoside antibiotics. Six months later, the patient presented with an indolent granulomatous necrotizing purulent blepharitis and follicular conjunctivitis. Diagnosis was made by Giemsa stain and histopathology, which revealed amastigotes in macrophages consistent with the diagnosis of oriental cutaneous leishmaniasis. Therapy with systemic recombinant gamma Interferon, which is described for the first time in this disease entity, resulted in a successful primary healing of the cutaneous lesion. Self-healing epithelial keratitis was the only side-effect observed. Ophthalmologists in Germany should be aware of the differential diagnosis of oriental cutaneous Leishmaniasis in patients suffering from chronic granulomatous lid lesions of patients from countries endemic/epidemic for Leishmaniasis. Laboratory diagnosis is simple. Insights into the immunology of infection have made possible novel therapeutic avenues using gamma-Interferon being effective without serve side-effects and allowing for a good primary healing of the cutaneous lesions.

Conjunctival cytologic features of primary Sjögren's syndrome

To determine whether there are specific cytologic features associated with primary Sjögren's syndrome (SS), the authors evaluated impression cytology specimens from three conjunctival sites (temporal bulbar [TB], inferior bulbar [IB], and inferior tarsal [IT]) from 38 SS eyes, 34 eyes of aqueous tear-deficient patients without SS, 35 eyes of seborrheic blepharitis patients, and 17 eyes of normal controls in a masked fashion. The following features were observed more frequently in SS eyes than in the eyes of the other groups: squamous metaplasia of the TB and IB (P less than 0.05), extensive (greater than 75%) goblet cell loss of the TB (P less than 0.05), mucous aggregates of the bulbar conjunctiva (P less than 0.05), and inflammatory cells intercalated with epithelial cells on the IT conjunctiva (P less than 0.06). The conjunctival inflammatory cell infiltrate correlated with the presence of extensive squamous metaplasia (P less than 0.01) in SS specimens. The inflammatory cells on the IT conjunctival epithelium were found to consist predominantly of T-lymphocytes by immunofluorescent staining of cytologic specimens from six eyes. Based on these findings, the authors speculated that conjunctival squamous metaplasia, in addition to aqueous tear deficiency, may be due to primary involvement of the dysfunctional immune system of SS.

Pathogenesis of blepharoconjunctivitis complicating 13-cis-retinoic acid (isotretinoin) therapy in a laboratory model

Systemic treatment of adult male New Zealand albino rabbits with 13-cis-retinoic acid (isotretinoin) resulted in a reduction in the size of the meibomian gland. Clinical signs of toxicity included weight loss, alopecia, dry skin and mild conjunctival erythema with crusting on the eyelid margin. Histopathologic findings included thickening of duct and ductule epithelium, decrease in acinar tissue, accentuation of basaloid cells and evidence of periacinar fibrosis. The model presents the first experimental data to indicate that systemic 13-cis-retinoic acid effects meibomian gland structure in a laboratory model. Future functional studies of this model may yield important insights into the relationships between meibomian gland morphology, function, the ocular surface and the pathogenesis of blepharo-conjunctivitis.

Acute fibrinopurulent blepharitis and conjunctivitis associated with Staphylococcus hyicus, Escherichia coli, and Streptococcus sp. in chickens and turkeys

Multiple outbreaks of acute severe fibrinopurulent lesions of the eyelids occurred in chickens and turkeys. Lesions began as tiny foci of epidermal necrosis and ulceration and spread to involve the entire eyelid. Scabs overlying the epidermis contained large gram-positive cocci; lesser numbers of small cocci and gram-negative bacilli were in more superficial areas. Staphylococcus hyicus was isolated from birds in all stages of the disease. Escherichia coli and Streptococcus sp. were isolated only during severe stages; no anaerobic bacterial pathogens were isolated. Vasculitis and perivascular lymphocytic infiltrates in deep layers of the dermis suggested that a staphylococcal toxin may have been involved. The disease was not reproduced by scarifying S. hyicus onto the eyelids or by intravenous inoculation of retrovirus-infected chickens.

Allergic blepharoconjunctivitis due to phenylephrine

Acute allergic blepharoconjunctivitis with mucopurulent discharge due to phenylephrine eye drops is reported. The reaction begins 3-4 hours after drug application, persists for 12 hours and regresses gradually within 72 hours. This clinical picture occurs with a phenylephrine concentration as low as 0.1%. Conjunctival biopsy of the inflamed eyes reveals marked infiltration by lymphocytes, plasma cells and eosinophiles, without predominance of any of these cells.

A rabbit model of staphylococcal blepharitis

Rabbits immunized with cell wall antigens of Staphylococcus aureus developed blepharitis after topical challenge with viable S aureus. The lids of these rabbits were thickened and erythematous. Crusting was found around the lashes, and the lids developed loss of lashes and hair. Histopathologic examination of lids from rabbits with blepharitis showed a dense leukocytic infiltrate and dilated blood vessels beneath an intact epidermis and palpebral conjunctival epithelium. The infiltrate contained neutrophils as well as mononuclear cells, including macrophages, plasma cells, and lymphocytes. The meibomian glands appeared normal. Gram's staining of lid sections did not show gram-positive cocci. The results of this study suggest that hypersensitivity to the S aureus cell wall, and particularly the ribitol teichoic acid that it contains, plays a role in the pathogenesis of staphylococcal blepharitis.

Dermis-fat graft for orbital reconstruction after subtotal exenteration

A surgical technique for reconstruction after subtotal orbital exenteration uses an autogenous dermis-fat graft. A musculocutaneous flap is advanced over the graft to provide the anterior vascular supply for the free dermis-fat graft. The periorbita and remaining orbital tissue provide the vascular supply posteriorly. This technique eliminates extensive skin grafting and delayed spontaneous healing. Wound healing is rapid and surgical morbidity is minimized. We have used this procedure in three patients with sebaceous gland adenocarcinoma, two patients with severe posttraumatic contracted sockets, and as a palliative procedure in one patient with a fungating choroidal melanoma and widespread metastasis.

[Necrotizing pseudomonas infection of the eyelids and lacrimal ducts with orbital involvement in a newborn infant]

A newborn boy presented with severe, bilateral, necrotic blepharitis and dacryocystitis caused by Pseudomonas aeruginosa. The possible etiology of this infection would be a transient neutropenia and a chemical blepharoconjunctivitis caused by Credé's prophylaxis. The relentless course of the necrosis could only be stopped by maximum-dose topical and systemic antibiotic therapy; the visual function of the right eye, however, was lost owing to a keratititis e lagophthalmo.

Surgical management of floppy eyelid syndrome

Four patients (five eyes) with the classic findings of floppy eyelid syndrome all had chronic irritative symptoms, with papillary conjunctivitis, and a soft, rubbery, floppy, and easily everted upper eyelid. All affected eyes were treated surgically by a full-thickness eyelid shortening procedure which produced immediate relief of symptoms. Histopathologic study of the resected eyelids showed only an inflammatory infiltrate in the conjunctiva, but failed to identify specific cause for the lax tarsus.

The diagnostic value of fungal autofluorescence

Many pathogenic and saprophytic fungi fluoresce under ultraviolet light. Autofluorescence usually persists even if the specimen has undergone fixation, paraffin embedding, and staining with hematoxylin and eosin. Thus, fluorescence microscopy can help to identify organisms in histopathologic sections of ocular and periocular tissue. It may reveal microorganisms that do not stain with hematoxylin and eosin, and it does not alter or adversely affect microscopic sections. We describe a case of periocular cutaneous blastomycosis which was misdiagnosed clinically and histologically as squamous cell carcinoma. Fluorescence microscopy of the initial hematoxylin and eosin stained section revealed microorganisms that were not appreciated on the first skin biopsy.

Sebaceous gland carcinoma. Review of 40 cases

The clinical and histopathologic features of 40 cases of sebaceous gland carcinoma include tumors that appeared as a localized lesion (15), diffuse chronic blepharoconjunctivitis (12), recurrent chalazion (eight), and caruncular tumors (two). In three older cases, specimens were submitted with insufficient clinical information. Chronic blepharoconjunctivitis were associated with "pagetoid" involvement of the conjunctive and lid margin. Despite the characteristic pathologic features of sebaceous gland carcinoma, correct diagnosis was given for only 22.5% of tumors on initial pathologic examination. The most common misdiagnoses were basal cell carcinoma (11) and squamous cell carcinoma (ten). Early recognition and diagnosis have substantially reduced tumor mortality. Six (24.0%) tumor deaths were encountered in 25 patients treated prior to 1970. No tumor-related mortality occurred in the 15 patients encountered after 1970.

Discoid lupus erythematosus of the eyelids

Discoid lupus erythematosus (DLE) is a chronic skin disease that may affect the eyelids. Unless suspected, these lid lesions may resemble chronic blepharitis and persist for years. We present the clinicopathologic features of DLE from the lids of seven patients, electron microscopic features of one case, and a review of 31 previously reported cases.

Cellulose acetate impressions of the ocular surface. Dry eye states

Cellulose acetate impressions of the ocular surface were obtained for normal eyes, eyes with blepharoconjunctivitis, eyes with keratoconjunctivitis sicca, and eyes with primary ocular surface disease. Normal eyes and eyes with blepharoconjunctivitis had morphologically normal epithelium and goblet cells on the bulbar and palpebral ocular surfaces. Eyes with primary ocular surface disease had abnormal ocular surface impressions (decreased, abnormal, or absent goblet cells with abnormal epithelial cells) on both the bulbar and palpebral ocular surfaces. Conversely, eyes with keratoconjunctivitis sicca had substantial abnormalities of the epithelium and goblet cells only on the bulbar ocular surface, suggesting an environmental role in this disease process.