Tear diluents in the treatment of keratoconjunctivitis sicca

To determine the optimum solution concentration for lowering elevated tear film osmolarity in keratoconjunctivitis sicca (KCS), tear osmolarity was measured in four KCS patients before and after instillation of either an isotonic saline solution or one of four hypotonic saline solutions (range, 75-225 mOsm/L). Average tear osmolarity one minute after instillation was significantly lower with the hypotonic solutions than with the isotonic saline (mean +/- SEM, 290 +/- 3 mOsm/L vs. 317 +/- 1 mOsm/L, P less than 0.0005). Solutions 150 mOsm/L or less were most effective in lowering osmolarity; the 75 mOsm/L solution was occasionally associated with irritation. In 16 KCS patients, we then compared the therapeutic efficacy of the 150 mOsm/L solution with that of an otherwise identical isotonic solution in a two-week, double-masked, crossover study. The 150 mOsm/L solution was superior for symptom relief by nearly 2:1 (P = 0.01).

The efficacy of cellulosic ophthalmic inserts for treatment of dry eye

Fourteen patients with dry eye signs and symptoms were treated with a cellulosic ophthalmic insert and conventional artificial tear drops in a cross-over study. Each subject rated symptoms before the study and after each treatment period. At the conclusion of the study, subjects chose which of the two treatments they preferred. Thirteen people preferred the artificial tear drops, and more symptoms were alleviated by them. Tear breakup time was not significantly changed by either treatment. The insert was not well received due to subjective blurring of vision and ocular irritation. Other studies have shown patient preference for the insert, but this may be due to patient selection.

[Chronic increase of amylase in primary sicca syndrome]

Pancreatitis had been erroneously diagnosed in a 50-year-old female patient with primary sicca syndrome with chronic salivary-gland-caused increase of amylase of 5 years' standing. Differentiation of amylase into isoenzymes showed clearly increased salivary amylase with normal pancreatic amylase. Little is known on the increase of amylase in Sjögren's syndrome. Unresolved increase of amylase of non-pancreatic origin should thus also lead to consideration of sicca syndrome.

Treatment of xerophthalmia with retinol, tretinoin, and etretinate

Topical retinol, tretinoin (all-trans-retinoic acid) and etretinate (a synthetic retinoid) were used in rabbits to treat experimental xerophthalmia due to vitamin A deficiency. Both 0.2% retinol and 0.1% and 0.2% tretinoin effectively reversed abnormal corneal epithelial keratinization within one to two days and restored corneal clarity within two to four days following topical application three times per day. Etretinate was ineffective in the concentration used (0.2%). In addition, application of tretinoin to one eye effectively reversed xerophthalmic changes in the other eye. Retinol did not have an effect on the other eye.

Slow-release artificial tear inserts in the treatment of dry eyes resulting from the oculomucocutaneous syndrome

Patients with dry eyes resulting from the practolol syndrome present a therapeutic challenge. Very frequent instillation of preservative-free drops are the only therapy in most cases. Using an entirely new agent--a hydrophilic polymer in insert form--we have provided in this open study an alternative therapy which shows some subjective and objective advantages. Few patients experienced problems, and none left the study because of failure of retention of the insert. Some patients preferred the cooling, soothing effects of frequent drops. The problems in mounting a clinical trial of this sort are discussed.

Treatment of corneal xerophthalmia with topical retinoic acid

Retinoic acid 0.1% in arachis oil was applied to one eye and arachis oil alone to the other eye, of each of 19 patients with equivalent degrees of corneal xerophthalmia in the fellow eyes. Even with concomitant systemic vitamin A therapy, topical retinoic acid was associated with more rapid healing of corneal lesions in a substantial proportion of cases. Application of retinoic acid three times a day produced no significant side effects; application five times a day, however, resulted in moderate to severe conjunctival injection and increased corneal vascularization and scarring.

Goblet cell response to vitamin A treatment for corneal xerophthalmia

In 11 patients with active corneal xerophthalmia, conjunctival biopsies were obtained at various intervals after massive-dose systemic vitamin A therapy. Goblet cells began to repopulate the inferonasal quadrant of the conjunctivas after two weeks, and they reached normal concentrations after one month. Corneal healing proceeded much more rapidly than that, suggesting that a full complement of mucus-secreting conjunctival goblet cells is not essential for restoration and maintenance of normal corneal appearance.

Conjunctival appearance in corneal xerophthalmia

We studied the appearance of conjunctiva in 50 consecutive cases of vitamin A-responsive conjunctival xerosis (X1) and 162 consecutive cases of nutritional keratopathy (corneal xerosis [X2] and stromal loss [X3]). conjunctival xerosis, most extensive at or shortly after the onset of frank corneal involvement, was present in 101 (95%) of 106 eyes of cases of X2 but in only 99 (64%) of 155 ulcerated/necrotic eyes (X3A and X3B). Forty-four percent of involved eyes were inflamed, the percentage increasing with the severity of corneal disease. In 20 patients with nutritional keratopathy, conjunctival xerosis was monocular: inflammation was more prevalent and corneal involvement more severe in the nonxerotic eyes. In patients with precipitous deterioration of vitamin A status, clinically recognizable alterations of the cornea sometimes developed before any changes appeared in the conjunctiva.

Protein deficiency and treatment of xerophthalmia

In a controlled clinical trial of massive-dose vitamin A therapy for xerophthalmia, holo-retinol-binding protein (holo-RBP) response was related to baseline protein status. Corneal healing was more commonly delayed or transient in children with protein-energy malnutrition (PEM), despite the vast majority achieving holo-RBP levels incompatible with severe corneal destruction. Correction of PEM is essential to ensuring a sustained clinical cure, and repeated massive vitamin A therapy is advisable until that occurs.

Corneal xerophthalmia and keratomalacia

Detailed examinations were conducted on 162 consecutive children with nutritional keratopathy. Surface changes ranged from mild haziness through generalized xerosis and formation of thickened keratinized plaques. Diffuse stromal edema occured early in the disease. Stromal loss took two forms: relatively small, sharply demarcated, eccentric, noninfiltrated cylindrical ulcers of varying depth; and localized or generalized, usually full-thickness necrosis. All forms of involvement were sometimes present in the same individual or even the same eye. Traumatic separation of a keratinized plaque, or decompensation of a dellen, accounted for some instances of stromal baring. In other cases, stromal melting appeared to progress below an intact epithelium. Focal areas of necrosis healed rapidly, as adherent leukomas; larger lesions sloughed, forming extensive descemetoceles. With therapy, the vast majority of children retained central corneal clarity.

["Dry eye" and artificial tear solutions (author's transl)]

Seventeen patients in whom "dry eye" had been diagnosed each tried four coded commercial artificial tear solutions for one week, in random sequence. The correlation of the function tests (Schirmer test, break-up tie, goblet cell count in conjunctival biopsy) did not permit a grouping of the patients. A tendency to a correlation between break-up time and goblet cell count was noted. It was not possible to show a preference on the part of certain patients for particular products; thus, with the current function tests available, a precise therapeutic classification of "dry eye" patients does not seem possible.

Tear production in vitamin A-responsive xerophthalmia

Schirmer tests showed decreased tearing (less than 15 mm of wetting) in 32 of 54 eyes (59%) of a representative group of patients with corneal xerophthalmia but in only four of 60 eyes (7%) of age-, sex-, and neighborhood-matched controls (P less than .001). The occurrence of decreased tearing was directly related to protein status: eight of 18 eyes (44%) of children with serum transferrin levels below 50 mg/100 ml but only 13 of 62 eyes (21%) of children with higher levels produced less than 15 mm of wetting (P less than .01). Among otherwise well-nourished children, the occurrence of decreased tearing was directly related to the severity of xerophthalmia and thus to vitamin A status. We found decreased tearing in eight of 86 eyes (9%) of a group of unpaired controls, in nine of 38 eyes (24%) of children with conjunctival xerosis, and in 17 of 62 eyes (27%) of children with corneal involvement (P less than .01).

Clinical trial of bromhexine in Sjögren's syndrome

Tear secretion and lysozyme tear content were measured in 30 patients with Sjögren's syndrome after treatment with oral bromhexine, 32 mg/day. In 21 patients (70%) there was a marked increase in tear secretion and in lysozyme content. In patients with keratoconjunctivitis sicca (KCS) good results in clarifying the mucoid eye discharge were obtained. A remarkable amelioration of xerostomia was also noted. Six other patients, serving as controls, were given a placebo and bromhexine. The placebo had no influence on the rate of tear secretion, while bromhexine caused it to increase in 70% of the controls. This side effects of bromhexine treatment encountered in the present study were negligible and transient. We consider bromhexine to be the drug of choice in the treatment of Sjögren's syndrome.