Conjunctival biopsy in scleroderma and primary Sjögren's syndrome

Ocular Involvement in Systemic Sclerosis: Updated Review and New Insights on Microvascular Impairment

Systemic sclerosis (SSc) is a chronic multisystemic disease characterized by immunological activation, diffuse vasculopathy, and generalized fibrosis exhibiting a variety of symptoms. A recognized precursor of SSc is Raynaud's phenomenon, which is part of the very early disease of systemic sclerosis (VEDOSS) in combination with nailfold videocapillaroscopy (NVC) impairment. The pathophysiology of ocular involvement, alterations in internal organs, and body integumentary system involvement in SSc patients are complicated and poorly understood, with multiple mechanisms presumptively working together. The most prevalent ocular symptoms of SSc are abnormalities of the eyelids and conjunctiva as well as dry eye syndrome, due to fibroblasts' dysfunction and inflammation of the ocular surface. In particular, lagophthalmos, blepharophimosis limitation of eyelid motion, eyelid telangiectasia, and rigidity or tightening of the lids may affect up to two-third of the patients. In addition, reduction in central corneal thickness, iris defects and higher rates of glaucoma were reported. In the first reports based on retinography or fluorescein angiography, about 50% of SSc patients showed signs of vascular disease: peripheral artery occlusion, thinning of retinal pigment epithelium and choroidal capillaries, ischemic areas surrounded by intraretinal extravasation and microaneurysms, and peripheral capillary non-perfusion. Successively, thanks to the advent of optical coherence tomography angiography (OCTA), several studies highlighted significant impairment of either the choriocapillaris and retinal vascular plexuses, also correlating with NVC involvement and skin disease, even in VEDOSS disease. Given the sensitivity of this technique, ocular micro-vasculopathy may act as a tool for early SSc identification and discriminate between disease stages.

Ocular Manifestation in Systemic Sclerosis-A Literature Review

Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disease that affects more than 2 million people worldwide. It manifests through vasculopathy, an abnormal immunological response, and fibrosis leading to dysfunction of the multiple organs. The disease is categorized into two subtypes: limited cutaneous SSc and diffuse cutaneous SSc. Scleroderma can affect vital organs with respiratory, cardiac, renal, ocular, and dermatological complications. The ocular manifestations of the disease can occur in the anterior and posterior segments of the eye. Changes in the anterior segment related to the disease include eyelid skin remodeling, dry eye syndrome, and conjunctival abnormalities. The disease's impact on the posterior segment of the eye mostly causes pathologies in the retinal microcirculatory system and abnormalities in the optic nerve. This review provides detailed insights into ocular complications associated with scleroderma.

The Autoimmune Rheumatic Disease Related Dry Eye and Its Association with Retinopathy

Dry eye disease is a chronic disease of the ocular surface characterized by abnormal tear film composition, tear film instability, and ocular surface inflammation, affecting 5% to 50% of the population worldwide. Autoimmune rheumatic diseases (ARDs) are systemic disorders with multi-organ involvement, including the eye, and play a significant role in dry eye. To date, most studies have focused on Sjögren's syndrome (one of the ARDs) since it manifests as two of the most common symptoms-dry eyes and a dry mouth-and attracts physicians to explore the relationship between dry eye and ARDs. Many patients complained of dry eye related symptoms before they were diagnosed with ARDs, and ocular surface malaise is a sensitive indicator of the severity of ARDs. In addition, ARD related dry eye is also associated with some retinal diseases directly or indirectly, which are described in this review. This review also summarizes the incidence, epidemiological characteristics, pathogenesis, and accompanying ocular lesions of ARD's related dry eye, emphasizing the potential role of dry eye in recognition and monitoring among ARDs patients.

Ocular manifestations in patients with systemic sclerosis

Systemic sclerosis (SSc) is a rare, chronic autoimmune disease with unknown etiology. Its prominent features are fibrosis, vasculopathy and impaired immune response. Disease can also affect eyes leading to various findings in ophthalmological examination.

The objective of this study was to determine the prevalence and type of ocular involvement in patients with SSc. A systematic literature review was conducted using electronic databases. A combination of following keywords was used: “systemic sclerosis” and ophthalmology-related search terms, including the keywords “eye”, “ocular” and “ophthalmic”.

In conclusion, eyelid and conjunctival abnormalities and dry eye disease are among the most common ocular manifestations of SSc. Their diversity is connected to complexity of the disease.

Association between objective signs and subjective symptoms of dry eye disease in patients with systemic sclerosis

The aim of this study was to evaluate the association between clinical signs and symptoms of dry eye disease (DED) in patients with systemic sclerosis (SSc). This cross-sectional observational study included 19 SSc patients and 19 normal subjects with no ocular symptoms or ocular surface disorders. Clinical parameters included tear film break-up time (tBUT), Schirmer I, lissamine green (LG) dye, and tear film osmolarity tests, tear production, and tear secretion flow. For assessment of the dry eye symptoms, the Ocular Surface Disease Index (OSDI) questionnaire was administered to all patients. The following mean values were found in SSc patients: OSDI 33.6 ± 19.86; osmolarity of the tear fluid 310.8 mOsmol/l ± 14.47; tBUT time 5.158 ± 2.328 s; Schirmer I test 5.395 mm/5 min; LG grading score 2.026 ± 0.8893; collected tear fluid volume 6.397 ± 2.761 µl. The calculated average tear velocity was 4.654 ± 1.963 µl/min. A significant correlation was found between the OSDI as a subjective parameter and disease duration. Early recognition of dry eye symptoms, a possible extra-intestinal manifestation of SSc, should be included in the check up of the disease to reduce ocular complications. The objective tear functional tests were strongly influenced by individual factors like age and disease duration.

An engineered human conjunctival-like tissue to study ocular surface inflammatory diseases

The aim of this study was to develop a three-dimensional model of the human conjunctiva that can be used to perform physiology and pathophysiology experiments. Fibrin-based matrices (derived from human plasma or plasma cryoprecipitate) were used as scaffolds, and primary cells were obtained from conjunctival tissue. Conjunctival constructs were analyzed by immunofluorescent staining and scanning electron microscopy and cell proliferation was measured with alamarBlue® assay. After characterizing the constructs, four different experimental conditions were analyzed in cryoprecipitate matrices: controls, air-lifted cultures (to increase cell stratification), partially desiccated cultures (to mimic dry eye disease), and IL-13-treated cultures (to mimic allergy). Constructs were stained with hematoxylin/eosin to observe changes in morphology. High molecular weight glycoconjugates were identified by HPA staining. MUC5AC and IL-6 secretion was evaluated by ELISA. The fibrin-based matrices supported conjunctival cell growth. Epithelial cells grew on the surface of the scaffolds and underwent stratification that increased over time. These cells had microvilli, which suggests cell polarization and functionality. Fibroblasts were integrated in the scaffold and showed elongated shape. Compared to controls, air-lifted construct had increased epithelial stratification and upregulated MUC5AC secretion. Increased MUC5AC secretion also occurred in partially desiccated and IL-13-treated cultures. The inflammatory status of cells was evaluated by IL-6 levels which were increased in air-lifted and partially desiccated cultures, but not in IL-13-treated ones. In conclusion, we have developed a new three-dimensional model of human conjunctiva that can be used to study ocular surface inflammatory diseases.

Sjögren's syndrome: An underdiagnosed condition in mixed connective tissue disease

OBJECTIVE

To determine the prevalence of sicca symptoms, dry eye, and secondary Sjögren's syndrome and to evaluate the severity of dry eye in patients with mixed connective tissue disease.

METHODS

In total, 44 consecutive patients with mixed connective tissue disease (Kasukawa's criteria) and 41 healthy controls underwent Schirmer's test, a tear film breakup time test, and ocular surface staining to investigate dry eye. In addition, the dry eye severity was graded. Ocular and oral symptoms were assessed using a structured questionnaire. Salivary gland scintigraphy was performed in all patients. Classification of secondary Sjögren's syndrome was assessed according to the American-European Consensus Group criteria.

RESULTS

The patients and controls had comparable ages (44.7±12.4 vs. 47.2±12.2 years) and frequencies of female gender (93 vs. 95%) and Caucasian ethnicity (71.4 vs. 85%). Ocular symptoms (47.7 vs. 24.4%) and oral symptoms (52.3 vs. 9.7%) were significantly more frequent in patients than in controls. Fourteen (31.8%) patients fulfilled Sjögren's syndrome criteria, seven of whom (50%) did not have this diagnosis prior to study inclusion. A further comparison of patients with mixed connective tissue disease with or without Sjögren's syndrome revealed that the former presented significantly lower frequencies of polyarthritis and cutaneous involvement than did the patients without Sjögren's syndrome. Moderate to severe dry eye was found in 13 of 14 patients with mixed connective tissue disease and Sjögren's syndrome (92.8%).

CONCLUSIONS

Sjögren's syndrome, particularly with moderate to severe dry eye, is frequent in patients with mixed connective tissue disease. These findings alert the physician regarding the importance of the appropriate diagnosis of this syndrome in such patients.

Evaluation of dry eye signs and symptoms in patients with systemic sclerosis

BACKGROUND

One of the most frequent ocular features of systemic sclerosis (SSc) is dry eye disease (DED), which has been identified to occur in 37-79% of patients. Although several studies have found weak or no correlations between symptoms and signs of dry eye, symptoms are often the motivation for seeking eye care, and are therefore a critical outcome measure when assessing treatment effect. The aim of this study is to evaluate the impact of symptoms of dry eye on vision-related quality of life in patients with systemic sclerosis, and to investigate the relation between clinical tests and symptoms of dry eye in these patients.

METHODS

In this cross-sectional study, 45 consecutive patients with SSc were enrolled. For evaluation of the symptoms the "Ocular Surface Disease Index (OSDI)" questionnaire was applied to all patients. After that, all individuals were submitted to a full ophthalmic examination, including the following tests: tear break-up time, Schirmer I, rose bengal staining. Patients were then grouped into dry eye and non-dry eye groups with regard to the diagnosis of dry eye. Mann-Whitney test was used to compare continuous variables, whereas the Fisher exact test was used to compare categorical data between groups. Spearman's correlation test was used to analyze the correlations between clinical tests and OSDI scores. P values <0.05 were considered significant.

RESULTS

Dry eye disease was diagnosed in 22 patients (48.9%). Other ocular surface abnormalities found were: blepharitis (40% of the patients), pterygium (15.6%), pinguecula (82.2%), and superficial punctate keratitis (26.7%). Among the 45 patients, 29 patients (64.4%) had symptoms of ocular surface disease. The mean OSDI score was 26.8 ± 25.8 (SD). There were no statistically significant differences in OSDI scores between DED and non-DED patients. No substantive correlations were found between OSDI scores and TBUT, Schirmer I, or rose bengal staining score, and none of the observed correlations reached statistical significance.

CONCLUSION

Symptoms of dry eye have a moderate impact on vision-related quality of life in patients with systemic sclerosis and do not correlate well with clinical findings.

Mucosal microvilli in dry eye patients with chronic GVHD

The ocular surface is a frequent target tissue of mucosal chronic GVHD (cGVHD). We investigated the histopathological features of the conjunctival microvilli in patients with cGVHD. Conjunctival tissue specimens from patients with cGVHD or Sjögren's syndrome (SS) or from healthy individuals were examined by light microscopy and EM, impression cytology, and immunohistochemistry. The cGVHD conjunctivae showed significantly more metaplasia and fewer goblet cells than the SS and normal conjunctivae. Abundant CD8(+) T cells infiltrated the basal epithelia in the cGVHD conjunctiva. The microvilli per standard epithelial unit and the secretory vesicles were counted by analyzing electron micrographs. The mean number of mucosal microvilli was significantly lower in the cGVHD than that in the SS or normal specimens, and the microvilli were significantly shorter, with a smaller height-width ratio. The mean number of secretory vesicles was also significantly lower, and the membrane-spanning mucin thinner, in the cGVHD compared with the SS and normal specimens. Thus, the conjunctival mucosal microvilli of cGVHD patients were significantly different in number and morphology from those of SS and normal subjects. These may be important factors affecting the stability of the tear-film layer and its contribution to cGVHD-related dry eye.

Evaluation of patients with dry eye for presence of underlying Sjögren syndrome

PURPOSE

To evaluate the rate of Sjögren syndrome (SS) in a cohort of patients with dry eye syndrome.

METHODS

Medical records of patients with a primary diagnosis of dry eye syndrome (International Classification of Diseases [ICD] code 375.15 or 370.33) were reviewed retrospectively. Patients who had 2 or more visits to a single dry eye center during a 2-year period (January 2004 to January 2006) were considered.

RESULTS

Two hundred twenty patients with dry eye syndrome were identified. A total of 57 patients (25.9%) had an underlying rheumatic condition: 25 patients (11.4%) had rheumatoid arthritis and 24 (10.9%) had primary Sjögren syndrome (PSS). Majority of the patients with rheumatoid arthritis (96%) carried the diagnosis at the time of presentation. Of all patients with PSS, only 33.3% (8/24) carried the diagnosis at the time of presentation. Fifty percent (12/24) were diagnosed as a result of the initial evaluation. Among those, only 66.6% (8/12) tested SSA (anti-Ro antibodies) or SSB (anti-La antibodies) positive. One third of patients (4/12) tested only antinuclear antibody positive at a titer of <1/320 and required minor salivary gland biopsy for definitive diagnosis. Additional 16.7% (4/24), who were initially serologically negative, eventually underwent minor salivary gland biopsy and became diagnosed with SS.

CONCLUSIONS

PSS seems to be underdiagnosed in patients with dry eye syndrome and should be the focus of diagnostic evaluations. A minor salivary gland biopsy might be required for a definitive diagnosis in a significant proportion of the patients with SS.

Ocular manifestations of scleroderma

Systemic sclerosis is a chronic multi-system disorder predominantly affecting the skin, musculoskeletal, gastrointestinal, pulmonary, and renal systems. Although the exact etiology is unknown, recent evidence suggests that immune activation play a pivotal role in the pathogenesis. Ocular involvement in systemic sclerosis has been documented; however, due to the rare nature of the disease, most papers have been single case reports or small case series. This review paper aims to consolidate the findings of previous papers with a view to providing a comprehensive review of the ocular manifestations of systemic sclerosis.

[Granulomatous uveitis and CREST syndrome: a case study]

PURPOSE

To report a case of recurrent granulomatous panuveitis associated with CREST syndrome.

OBSERVATION

A 74-year-old patient with CREST syndrome presented with unilateral granulomatous panuveitis in a pseudophakic eye. She had undergone cataract surgery 6 months before. The patient reported a vision loss that had been evolving for 1 month. Visual acuity was noted at 20/400. The initial clinical examination highlighted retrodescemetic precipitates and granulomatous precipitates on the IOL. A vitreous tyndall was noted. Funduscopic examination revealed papillary edema and cystoid macular edema, confirmed by fluorescein angiography.

RESULTS

Topical treatment consisting in corticosteroid eye drops associated with mydriatics controlled uveitis in a few weeks. Visual recovery was 20/30. No granulomatous uveitis etiology could be highlighted. The diagnosis of chronic endophthalmitis was also ruled out.

CONCLUSION

The diagnosis retained was uveitis associated with CREST syndrome. To our knowledge, this association has only been reported twice in the literature.

Ophthalmologic manifestations of rheumatic diseases

OBJECTIVES

Detailed review of the manifestations of eye involvement in the context of rheumatic diseases.

METHODS

An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors.

RESULTS

Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications.

CONCLUSIONS

The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.

Morphological and morphometric analysis on the rabbit conjunctival goblet cells in different hormonal conditions

An altered conjunctival mucous secretion was reported in pregnancy or oral contraceptive use. Four groups of rabbits (males, dioestrous females, oestrous females, pregnant) were studied to determine whether sex and/or different physiological conditions could influence conjunctival goblet cells structure and ultrastructure. Light microscopy, transmission electron microscopy, and morphometry were performed. In males and in oestrous females the intracytoplasmic secretory granules were filled with granular material, whilst in pregnant and dioestrous females the granules were formed by a more homogenous and dense secretory material. The number of goblet cells was not statistically different in the groups studied, whilst pregnant animals showed the largest mean diameter. As to the secretory granules, their mean area was larger in dioestrous females, whilst their optical density was highest in pregnant animals. These observations indicate that the morphology of conjunctival goblet cell may vary according to sex and to different physiological conditions: this may account for the peculiar mucous secretion demonstrated during pregnancy.