[Treatment with pilocarpine hydrochloride for sicca symptoms in Sjögren's syndrome]

We studied the efficacy of oral pilocarpine hydrochloride (9 mg/day, three times daily) on sicca symptoms in 21 patients with Sjögren's syndrome (SS) of the patients, 19 continued the treatment for at least one month, and subjective improvement of dry mouth and dry eye was observed in 10 patients (53%) and 5 patients (26%), respectively. As adverse effects, diaphoresis was most frequently recognized, but it was generally mild and tolerable. In the four patients who have been taking pilocarpine for 12 months, any severe side effects have not been observed. Since the incidences of clinical improvement of sicca symptoms and adverse effects were comparable with the other studies reported from US or Europe, our treatment protocol using pilocarpine hydrochloride (9 mg/day) was considered as appropriate for Japanese SS patients.

Ocular findings in cystic fibrosis patients receiving vitamin A supplementation

BACKGROUND

Vitamin A deficiency with eye symptoms has been reported in patients with cystic fibrosis who received the recommended daily intake of vitamin A.

METHODS

We measured serum retinol, dark adaptation, contrast sensitivity, and dry eye status in 35 adult cystic fibrosis patients to ascertain whether they had ocular signs or symptoms.

RESULTS

Median serum retinol concentration was 1.95 mumol/l, range 1.08-4.01 mumol/l, with no values indicating vitamin A deficiency. Retinal light sensitivity was normal. Nineteen patients had reduced contrast sensitivity. Conjunctival imprints all showed plenty of goblet cells, but were characteristic of dry eye in 42% of patients (n = 14). Decreased tear film stability was found in 49% (n = 17), tear production was low in 31% (n = 11), and 23% (n = 8) showed an increased amount of dying epithelial cells. Nine patients (26%) had keratoconjunctivitis sicca according to the Copenhagen criteria.

CONCLUSION

Our patients had no biochemical or clinical signs of vitamin A deficiency. We speculate that the high incidence of dry eye could be a primary manifestation of cystic fibrosis.

Epidemiology of xerophthalmia in Nepal. A pattern of household poverty, childhood illness, and mortality. The Sarlahi Study Group

A case-control study of xerophthalmia (120 cases, two with corneal disease; 3377 children without xerophthalmia, 12 to 60 months of age) was conducted in the rural plains of Nepal. Relative household wealth (ownership of animals and goods, house quality) and social standing (parental education, nondaily laboring, more affluent castes) were inversely related to risk of xerophthalmia. Mothers of cases were more likely to have had children die than mothers of controls (odds ratio, 1.85; 95% confidence interval, 1.22 to 2.78); case households were more likely to have had a young child die in the past year (odds ratio, 2.85; 95% confidence interval, 1.43 to 5.67). Children with xerophthalmia were more wasted and stunted than controls, although these associations largely disappeared after adjusting for socioeconomic influences. Frequency of breast-feeding was highly protective against xerophthalmia in a dose-response manner (odds ratio, 0.32 for 1 to 10 times a day, 0.12 for > 10 times a day) after adjusting for age and other factors. The risk of xerophthalmia rose directly with reported duration of dysentery in the previous week (odds ratio, 2.13 and 5.81 for durations of 1 to 6 days and > or = 7 days, respectively, vs none). Mild xerophthalmia is reflective of a lower, local standard of living within which child health, nutrition, and survival are compromised.

Changing prevalence of xerophthalmia in Indonesia, 1977-1992

OBJECTIVE

The primary objective of this analysis was to determine if the prevalence of xerophthalmia in Indonesia has changed over the period 1977-78 to 1992.

DESIGN

The design was two cross-sectional prevalence surveys conducted in the same rural sample locations 14 years apart.

SETTING

The studies were conducted in 15 provinces of Indonesia using a stratified random selection of villages.

SUBJECTS

All persons in selected villages < 6 years of age were eligible for participation. Children were recruited during a door-to-door census of villages and invited to present for an eye examination at a central point in the village. A total of 19,032 subjects were included in the 1977-78 and 18,508 children in the 1992 survey.

RESULTS

Overall, the prevalence of active xerophthalmia among preschool children declined by 75% (1.33% in 1977-78 to 0.34% in 1992). Active corneal disease declined by 95% (1/1000 in 1977-78 to 0.05/1000 in 1992). While the overall declines were dramatic and highly significant (P < 0.0001), selected provinces continued to show rates higher than the WHO criteria for a problem of public health significance.

CONCLUSIONS

The prevalence of xerophthalmia has declined significantly over the past 14 years in Indonesia. The specific reasons for this decline cannot be ascribed to any particular intervention due to the multitude of health and social changes that have occurred during this period.

The treatment of sicca features in Sjögren's syndrome: a clinical review

Patients with SS often suffer considerable distress due to sicca symptoms and the complications of mucosal dryness. Although there are many topical treatments available, the literature on their use is scant. This paper describes the treatments available and suggests a rationale for the choice of product.

A priming dose of oral vitamin A given to preschool children may extend protection conferred by a subsequent large dose of vitamin A

A randomized trial tested whether a priming dose of vitamin A would extend the protection of a subsequent 60,000-micrograms retinol equivalent (RE) oral dose. Seventy-five xerophthalmic and 74 age- and neighborhood-matched non-xerophthalmic preschool children were randomized to one of three oral regimens of vitamin A, receiving peanut oil only (Group A), 7500 micrograms RE (Group B) or 60,000 micrograms RE (Group C), followed in all instances by 60,000 micrograms RE 1 wk later. Serum retinol was measured 2, 4, 6 and 12 mo following the second dose by technicians unaware of the children's treatment status. Among xerophthalmic children, mean values differed across treatment groups at 2 mo (C > A) and tended to be different at 12 mo (C > A and B > A). Among non-xerophthalmic children mean retinol concentrations differed across treatment groups at 6 mo, but not in a consistent way (A > C > B), and at 12 mo (C > A and B > A). Xerophthalmic children reverted to biochemical deficiency faster than non-xerophthalmic children. A small or large priming dose may extend the protection conferred by a 60,000-micrograms RE dose, supporting the use of repeated, spaced doses of vitamin A for treating xerophthalmia. Similar retinol concentrations in Groups B and C at 12 mo suggest the 60,000-micrograms RE prophylactic dose currently recommended by the World Health Organization need not be increased.

Vitamin A supplementation in northern Ghana: effects on clinic attendances, hospital admissions, and child mortality. Ghana VAST Study Team

Although most studies on the effect of vitamin A supplementation have reported reductions in childhood mortality, the effects on morbidity are less clear. We have carried out two double-blind, randomised, placebo-controlled trials of vitamin A supplementation in adjacent populations in northern Ghana to assess the impact on childhood morbidity and mortality. The Survival Study included 21,906 children aged 6-90 months in 185 geographical clusters, who were followed for up to 26 months. The Health Study included 1455 children aged 6-59 months, who were monitored weekly for a year. Children were randomly assigned either 200,000 IU retinol equivalent (100,000 IU under 12 months) or placebo every 4 months; randomisation was by individual in the Health Study and by cluster in the Survival Study. There were no significant differences in the Health Study between the vitamin A and placebo groups in the prevalence of diarrhoea or acute respiratory infections; of the symptoms and conditions specifically asked about, only vomiting and anorexia were significantly less frequent in the supplemented children. Vitamin-A-supplemented children had significantly fewer attendances at clinics (rate ratio 0.88 [95% CI 0.81-0.95], p = 0.001), hospital admissions (0.62 [0.42-0.93], p = 0.02), and deaths (0.81 [0.68-0.98], p = 0.03) than children who received placebo. The extent of the effect on morbidity and mortality did not vary significantly with age or sex. However, the mortality rate due to acute gastroenteritis was lower in vitamin-A-supplemented than in placebo clusters (0.66 [0.47-0.92], p = 0.02); mortality rates for all other causes except acute lower respiratory infections and malaria were also lower in vitamin A clusters, but not significantly so. Improving the vitamin A intake of young children in populations where xerophthalmia exists, even at relatively low prevalence, should be a high priority for health and agricultural services in Africa and elsewhere.

[Dry eye syndrome in patients with biliary cirrhosis]

Ophthalmic state of 18 women patients between 40 and 69 years of age with primary biliary cirrhosis (PBC) was studied. Tear secretion was studied by Schirmer I., break up time and conjunctival and corneal bengal rose staining tests. In 15 cases serious degree of keratoconjunctivitis sicca has been revealed. Xanthelasma of the lid was found in three patients. Visual functions were intact. Kayser-Fleischer ring was absent in every case. There was no connection between the duration or laboratory characteristics of the PBC and the severity of the keratoconjunctivitis sicca. In nine patients of the cases requiring tear substitution eye drops of methylcellulosum available in Hungary were insufficient. Hydroxypropyl-methylcellulosum drops of eye gel containing peptides of low molecular weight eliminated the symptoms in these cases. The authors emphasize that PBC should be considered as a possible underlying disease in women over 30 years with severe dry eye syndrome.

The importance of the precorneal tear film for the quality of optical imaging

The optical function of the eye critically depends on the presence of an intact precorneal tear film. Abnormalities of the tear film such as those occurring in the dry eye syndrome or in otherwise irritated eyes may interfere with vision. In 30 patients with dry eyes artificial tears were found to produce statistically significant improvement of vision (p less than 0.001) while no significant changes were seen in the untreated partner eyes. Static perimetry in another 30 patients using the 'macular programme' of the automatic Humphrey 620 perimeter showed artificial tears to increase mean thresholds significantly (p less than 0.001) whereas no significant differences were seen in the untreated partner eyes.

Xerophthalmia in malnourished Sudanese children

Two hundred and thirteen Sudanese children (4-60 months old) with malnutrition were examined for signs of xerophthalmia. Sixty-three (29%) of these children were found to have varying stages of xerophthalmia. These included 35 (56%) patients with conjunctival xerosis, 12 (19%) with Bitot's spots, seven (11%) with corneal xerosis, seven (11%) with corneal ulceration and two (3%) with corneal scar. Direct questioning of the parents of these children revealed evidence of night blindness in nine (4%) of all patients. All nine patients had signs of xerophthalmia which showed good response to vitamin A therapy.

Pulmonary complications from ophthalmic preparations

Topical beta-adrenergic blocking agents are commonly used to treat glaucoma. Exacerbations of asthma and bronchospasm caused by topical beta-adrenergic ophthalmic preparations are well known. We describe a 67-year-old woman who had aspiration pneumonitis characterized by a nodular infiltrate in the right middle lobe of the lung and nocturnal coughing after beginning topical application of an ointment (Lacri-Lube) for treatment of xerophthalmia. Bronchial washing demonstrated lipid-laden pulmonary alveolar macrophages. After the use of Lacri-Lube was discontinued, her cough and the chest roentgenographic abnormality totally disappeared. We postulate that the topical ophthalmic preparation, which contains mineral oil and petrolatum, drained into the nasopharynx, trachea, and bronchial tree through the nasolacrimal duct and caused lipoid pneumonitis from aspiration of the oil contents. To our knowledge, this is the first report of pulmonary complications caused by Lacri-Lube. We briefly review the pulmonary complications, including pulmonary edema, apnea from paralysis of respiratory muscles, bronchospasm from non-beta-adrenergic blocking drugs, and electrolyte abnormalities, attributable to topically and systemically administered ophthalmic medications.

A comparative study of two preservative-free tear substitutes in the management of severe dry eye

Between mid-May and mid-July 1987 we performed a prospective crossover study of two unit-dose preservative-free artificial tear solutions, 1.4% polyvinyl alcohol (Refresh) and 0.1% sodium hyaluronate (Hylorin) in 14 female patients with severe dry eye syndrome. The patients were examined before treatment and after each of two trials with both products. A significant reduction in the mean score for dry-eye-induced keratitis (p = 0.001) and for mucous strands (p = 0.03) was observed following the second of two trials with sodium hyaluronate. A significant reduction in the mean score for burning and irritation was observed with both solutions (p = 0.009). We believe that the elimination of preservatives from artificial tear preparations may substantially reduce the iatrogenic effects of these frequently applied medications.

Avoidable blindness

The vast majority of the world's 42 million blind are needlessly impaired. Epidemiologic studies are providing important insights into the cause of cataracts and provision of surgical services; ecologic approaches to the control of trachomatous corneal scarring; treatment and prevention of onchocerciasis; and early diagnosis and treatment of xerophthalmia among others. Continued research and application of existing knowledge can have a dramatic impact on the sight and lives of millions of people.

Topical tretinoin: indications, safety, and effectiveness

Topical tretinoin has been used for a number of years to treat patients with acne vulgaris. This paper reviews some of the newer uses of tretinoin, including treatment of patients with photoaging of the skin, premalignant lesions, dry-eye disorders, and its use after dermabrasion.

Treatment of corneal xerophthalmia in rabbits with micromolar doses of topical retinoic acid

Several reports have appeared on the efficacy of topically applied 0.01% or 0.1% all-trans retinoic acid (0.04-0.4 millimolar) for treatment of xerophthalmia, conjunctival squamous metaplasia, and corneal epithelial erosions in humans and animals. An observation common to many of these studies is the occurrence of an adverse reaction to retinoic acid in the form of lid margin hyperemia and blepharoconjunctivitis. Since retinoic acid is biologically active at micromolar to nanomolar concentrations, it may be possible to reduce side effects while maintaining therapeutic effectiveness by reducing the retinoic acid concentration in ophthalmic formulations. In the present study, topical 0.005% retinoic acid in petrolatum ointment reversed corneal keratinization in xerophthalmic, vitamin A-deficient rabbits in 3-4 days while 0.0005% (2 micromolar) retinoic acid ointment was effective in 4-6 days. Further clinical trials of topical retinoic acid for treatment of ocular surface disease should be conducted using micromolar concentrations of retinoic acid which are expected to maintain a therapeutic effect while reducing adverse reactions.

A case of eye disease due to dietary vitamin A deficiency in Glasgow

A 22 year old Caucasian girl living in Glasgow presented with eye disease due to Vitamin A deficiency. There was no evidence of liver disease or malabsorption and the vitamin deficiency was found to be due to her bizarre dietary habit.

Effect of osmolarity of artificial tear drops on relief of dry eye symptoms: BJ6 and beyond

Patients with clinically well defined keratoconjunctivitis sicca (KCS) participated in two trials of hypo-osmolar tear substitutes. The trials were double masked, single crossover studies with computer generated random order allocation and were conducted by postal questionnaire. In the first trial a hypo-osmolar formulation using polyvinylpyrrolidone and hydroxyethyl cellulose was compared with the patients' usual treatment (BJ6 or hypromellose) and found to be inferior, especially in respect of blurring and stickiness caused by higher viscosity. In the second trial hypo-osmolar preparations of BJ6 and hypromellose were compared with their iso-osmolar equivalents and found not to be significantly different in their effects. Hypo-osmolarity alone does not seem to guarantee relief of symptoms in KCS. Other factors including viscosity and colloid osmotic pressure may be more significant.

Effect of sodium hyaluronate (0.1%) on break-up time (NIBUT) in patients with dry eyes

We evaluated the effect of 0.1% sodium hyaluronate (unpreserved) in 10 patients with dry eyes. The precorneal tear film break-up time was assessed by the non-invasive technique, and the severity of symptoms was recorded before and after treatment on a 0 to +3 scale. It was found that the tear film stability was significantly increased (p less than 0.05) in eyes treated with sodium hyaluronate. The symptoms of grittiness and burning were also significantly alleviated in the treated eyes.

The efficacy of retinoic acid ointment for treatment of xerophthalmia and corneal epithelial wounds

In previous studies of topical application of retinoic acid to the eye, retinoic acid in an oil vehicle has been used. An all-trans-retinoic acid (Tretinoin, USP) formulation in a petrolatum-based ophthalmic ointment vehicle has now been developed which is chemically stable for at least one year. The ointment is effective at retinoic acid concentrations of 0.01-0.1% in reversing corneal keratinization in vitamin A-deficient, xerophthalmic rabbits. At 0.1% it also stimulates the healing rate of corneal epithelial wounds in rabbits and monkeys. Retinoic acid ointment may prove to be valuable clinically in the treatment of xerophthalmia, corneal epithelial erosions, and related ocular surface abnormalities.

Topical retinoid treatment for various dry-eye disorders

We evaluated the clinical efficacy of treating various dry-eye disorders using 0.01% and 0.1% (weight/weight) topical all-trans retinoic acid ointment. Twenty-two patients were selected and classified into four major groups: keratoconjunctivitis sicca (6 patients; 11 eyes), Stevens-Johnson syndrome (9 patients; 17 eyes), ocular pemphigoid or drug-induced pseudopemphigoid (3 patients; 6 eyes), and surgery or radiation-induced dry eye (4 patients; 4 eyes), based on the criterion that they remained symptomatic even under maximum tolerable conventional medical and/or surgical therapies. The results indicated that squamous metaplasia with mucin deficiency secondary to goblet cell loss and keratinization may be the basis for the development of clinical symptoms and morbidities, as these epithelial abnormalities were invariably present before treatment. After treatment, all patients demonstrated clinical improvements in symptoms, visual acuity, rose Bengal staining, or Schirmer test. Most importantly, this topical vitamin A treatment caused the reversal of squamous metaplasia as evidenced by impression cytology. Therefore, this treatment may represent the first nonsurgical attempt to treat these disorders by reversing diseased ocular surface epithelium.