Conjunctival impression cytology in contact lens wearers

Efficacy and safety of platelet-rich plasma and autologous-serum eye drops for dry eye in primary Sjögren's syndrome: a randomized trial

We compared the efficacy and safety of autologous-serum (AS) and platelet-rich plasma (PRP) eye drops for dry eye (DE) treatment in primary Sjögren's syndrome (SS). This prospective, randomized, double-blinded clinical study included patients diagnosed with primary SS DE. Thirty-eight participants were randomly assigned to the AS or PRP groups. Corneal and conjunctival staining scores, Schirmer I test, tear film break-up time (TBUT), and ocular surface disease index (OSDI) scores were evaluated at 4 and 12 weeks. Conjunctival impression cytology (CIC) metaplasia grade and goblet cell density grade at 12 weeks were compared with those at baseline. Corneal and conjunctival staining scores and TBUT significantly improved at 4 and 12 weeks in both groups (all p < 0.005). No significant difference between the AS and PRP groups was observed at 4 and 12 weeks. The Schirmer I values, OSDI scores, CIC metaplasia grade, and goblet cell density grade did not significantly change at 4 and 12 weeks in either group. Both AS and PRP eye drops are effective for primary SS DE without a significant difference. Considering that the preparation time of PRP is shorter than that of AS, PRP can be a good alternative treatment for primary SS DE.

Filaggrin Expression in the Lid Margin During Contact Lens Wear

AIM

To investigate the expression of the keratinization-related protein, filaggrin, in the lid margin epithelium of contact lens (CL) wearers compared with nonwearers.

METHODS

This was a cross-sectional study of 100 individuals with different exposures to CL wear: short, moderate, and long experience; previous CL wearers; and nonwearers as controls. Impression cytology samples were collected from the lid wiper (LW) area of the central upper lid margin. After fixing, an equal, random sample was selected from each group (n=13) for immunocytochemistry analysis using antihuman primary anybody (mouse filaggrin), then stained with secondary antibody (fluorescein isothiocyanate-conjugated donkey anti-mouse immunoglobulin G horseradish peroxidase) to detect filaggrin. Imaging was performed with the 3i-Vivo 2-photon microscope equipped with a Zeiss 20×-objective and SlideBook-reader software.

RESULTS

Sixty-five samples from 65 participants (37 women; mean age±SD: 25.1±4.1 years) were collected. Filaggrin was detected in all 65 randomly selected immunostained marginal epithelium samples. All samples were similar in showing patchy areas of filaggrin immunostaining, regardless of CL wear, symptoms or epithelium morphology. Because the filaggrin immunostaining showed similar patterns across almost all the observed samples, comparison between subject groups was impractical. The presence of filaggrin in the healthy LW was additionally confirmed by an independent laboratory.

CONCLUSION

Filaggrin expression seems to be a normal part of epithelial cell differentiation in the lid margin and may not be a useful keratinization/stress biomarker in the marginal epithelium. Investigating other keratinization biomarkers that are not detected in the normal mucocutaneous junction/LW may help to understand the keratinization nature of LW epithelium changes in CL wearers.

Impression cytology and meibomian glands in conjunctivochalasis

PURPOSE

To evaluate the tear parameters, meibomian glands and lid margin and tarsal conjunctival impression cytology in patients with conjunctivochalasis (CCH).

METHODS

The study included 57 patients diagnosed with CCH and 35 healthy volunteers. Tear break-up time (TBUT) was measured and Schirmer test was performed. Meibomian gland morphologies, dropout rates, and meiboscores were evaluated using meibography. Finally, impression cytology samples were taken by pressing the impression filters on the lower lid margin and lower tarsal conjunctiva. The samples were evaluated according to the Nelson grading system.

RESULTS

Schirmer test was longer and TBUT was shorter in the study group (p = 0.035 and p < 0.001, respectively). The median of meibomian gland dropout rate was 33.45% (Interquartile range [IQR]; 23.17%-49.75%) and 18.80% (IQR; 12.35%-26.50%) in the study and control groups, respectively (p < 0.001). There was no significant difference in terms of lid-margin cytology between the two groups (p = 0.481). In tarsal conjunctiva cytology, the median value of Nelson grade of the study group was 2 (IQR; 1-2) and that of the control group was 1 (IQR; 1-2) (p = 0.040). When Nelson grade-2 and above was accepted as the pathological limit, it was found that 27.5% of the study group and 15.2% of the control group showed pathological findings (p = 0.204).

CONCLUSIONS

In patients with CCH, damage occurs in the tarsal conjunctiva with the effects of redundant conjunctival folds. In these patients, atrophy occurs in the meibomian glands and tear stability is impaired. Therefore, CCH should not be overlooked in clinical practice.

Evaluation of corneal topography, tear film function and conjunctival impression cytology after long-term scleral contact lens wear in keratoconus patients

Purpose: To investigate the impact of long-term scleral contact lens (ScCL) wear on corneal curvature, corneal thickness, tear film function, and ocular surface in patients with keratoconus.Methods: Sixteen keratoconus patients wearing ScCLs for 6 months were enrolled in the study. Corneal topography, tear osmolarity test, Schirmer 1 test, tear film break-up time (TBUT) test, and impression cytology analysis were assessed at baseline and follow-up examinations.Results: There were no significant differences in visual acuity, keratometric and pachymetric values after 6 months of ScCL wear compared to baseline (p>0.05 for all). Tear osmolarity, Schirmer 1 test, and TBUT test results showed no significant change during follow-up (p>0.05 for all). Median goblet cell density and grade of squamous metaplasia did not differ significantly at 1-month. However, there was a gradual deterioration in goblet cell density and Nelson grade until the third-month visit compared to baseline (p for goblet cell, p=0.003; p for Nelson grade, p=0.003). These impaired cytological features observed at 3-month visit persisted at 6-month visit (p for goblet cell, p=0.008; p for Nelson grade, p<0.001).Conclusion: Six months of ScCL wear did not induce any changes in corneal curvature and thickness and also did not affect tear function tests in keratoconic eyes. The only significant changes observed were a decrease in goblet cell density and metaplastic changes in conjunctival epithelium in impression cytology analysis. Further investigations may be needed to better understand the cause of impairment in cytological features of ocular surface and its clinical implications.

Tear function and ocular surface changes following corneal collagen cross-linking treatment in keratoconus patients: 18-month results

PURPOSE

To investigate the long-term effects that CXL has on the tear function and ocular surface in keratoconus.

METHODS

Twenty-one consecutive patients (24 eyes) with progressive keratoconus scheduled for CXL were included. All patients underwent the following procedures: conjunctival impression cytology analysis, ocular surface disease index (OSDI) score, tear osmolarity test, Schirmer test, tear film breakup time (TBUT), ophthalmic surface fluorescein (Fl) staining, and topographical corneal evaluation before as well as 3 and 18 months after accelerated CXL.

RESULTS

There was no change in the median OSDI score, tear osmolarity test, Schirmer test, and the Fl staining score after CXL. The median TBUT increased from 9.00 s at baseline to 12.00 s at 18 months postoperative (P < 0.001). The cytological features of the temporal and superior bulbar conjunctiva deteriorated at 3 months post-CXL (P < 0.001). An improvement in impression cytology analysis of the temporal conjunctiva was noted at 18-month follow-up (P < 0.001). Significant improvements in the median maximum keratometry and mean keratometry (K-mean) readings were also noted 18 months after CXL (P < 0.001). The changes in the K-mean correlated significantly with the changes in TBUT levels at 18-month follow-up as compared to baseline (r =  - 0.688, P < 0.001).

CONCLUSIONS

The improvement in TBUT, conjunctival squamous metaplasia, and the goblet cell density indicates a favorable effect of CXL on the ocular surface and tear film in keratoconus, presumably due to the reduced corneal irregularity after CXL.

Evaluation of the Efficacy and Safety of A Novel 0.05% Cyclosporin A Topical Nanoemulsion in Primary Sjögren's Syndrome Dry Eye

Purpose: To evaluate the efficacy and safety of a novel topical cyclosporin A 0.05% nanoemulsion in comparison with a conventional emulsion in primary Sjögren's syndrome dry eyes.Methods: Prospective, randomized, double-blinded study was conducted.Results: Corneal and conjunctival staining score was improved in both groups, with a faster change noted in the nanoemulsion group at 12 weeks (p < 0.05). Tear film break-up time was significantly improved in the nanoemulsion group at 12 weeks (p < 0.05), while ocular surface disease index score was improved in both groups without a difference at 12 weeks. Schirmer I value and goblet cell grade did not change in both groups. IL-6 and MMP-9 were significantly decreased in both groups at 12 weeks.Conclusions: Both nanoemulsion and conventional cyclosporin A improved ocular signs, symptoms, and conjunctival inflammation. However, the novel cyclosporin A nanoemulsion showed faster improvement of ocular surface staining scores than the conventional emulsion.

Tear Function and Ocular Surface Alterations After Accelerated Corneal Collagen Cross-Linking in Progressive Keratoconus

OBJECTIVE

To investigate the alterations in the ocular surface and tear film parameters 3 months after accelerated corneal collagen cross-linking (A-CXL) in progressive keratoconus (KC) patients.

METHODS

Twenty-six patients (33 eyes total) with progressive KC were enrolled in this study. All patients were subjected to ophthalmic surface examination, such as OSDI (ocular surface disease index) scoring, the osmolarity tear test, Schirmer test, tear film breakup time (TBUT) analysis, rose bengal (RB) and fluorescein (Fl) ocular surface staining, and conjunctival impression cytology (IC) analysis, respectively. These tests were performed at baseline and 3 months after A-CXL. Nelson's grading system was used to evaluate the cell morphology and goblet cell density.

RESULTS

No statistically significant differences in the levels of tear osmolarity, TBUT, Schirmer test, OSDI scoring, and Fl and RB staining between pretreatment and 3 months postoperatively were observed (all P values >0.05). A statistically significant increase in superior (P=0.005) and temporal (P=0.006) IC grading was seen at the postoperative third month compared to pretreatment.

CONCLUSIONS

Only metaplastic changes and a reduction in the density of the goblet cells were seen in conjunctival IC, which is probably because of the toxicity of ultraviolet-A 3 months after A-CXL. However, these results do not lead to deterioration in TBUT. In this study, A-CXL has no adverse effect on ocular surface and tear function, which are important for visual quality.

Effects of the rigid gas permeable contact lense use on tear and ocular surface among keratoconus patients

PURPOSE

To investigate changes in tear and ocular surface of patients with keratoconus using rigid gas permeable contact lenses (RGPCL) and compare them against keratoconus patients who were not using lenses as well as a control group of healthy subjects.

METHODS

24 keratoconus patients using RGPCL (Group 1) 22 patients who were not using lenses (Group 3) and 21 healthy subjects (Group 3) were included in the study. Subjective complaints about the subjects' eyes have been investigated using the ocular-surface disease index (OSDI). After the control of best-corrected visual acuity, anterior chamber and fundus examinations were performed.

RESULTS

Schirmer (p-value=0.01) and tear break up mean comparison tests (p-value=0.002) revealed significant differences across different groups but tear osmolarity analysis did not (p-value >0.05). Oxford and OSDI scores were compatible with Schirmer and tear break up test comparisons. (for both p-value=0.001) Moreover, no statistical differences were seen in impression cytology measures between groups. (p-value >0.05) CONCLUSIONS: The erosion in the tear film stability is in line with the erosion in the ocular surface epithelium. Taking into account the statistical indifference between the impression cytology measures across groups, the break up time differences may be attributed to the collagen destruction in tear.

Tear film and ocular surface dysfunction in diabetes mellitus in an Indian population

Purpose:

Ophthalmic complications in diabetes such as retinopathy, cataract, and infections have been extensively studied. Recently, attention has been drawn toward ocular surface changes in diabetes mellitus (DM). This study has been carried out to investigate the tear film and ocular surface abnormalities in type II DM patients.

Materials and Methods:

A total of 83 participants (130 eyes) were enrolled: 53 diabetics (80 eyes) and 30 healthy controls (50 eyes). Of the 53 diabetics, 24 patients (42 eyes) had some diabetic retinopathy. The tear film and ocular surface were evaluated using Schirmer test, tear film break-up time (TBUT), keratoepitheliopathy score (KES), Rose Bengal Staining (RBS) test, and conjunctival impression cytology.

Results:

When compared with the healthy controls, diabetics showed significantly reduced Schirmer, TBUT measurements and the higher grades of KES and RBS test (P < 0.001). Impression cytology analysis showed goblet cell loss and conjunctival squamous metaplasia in diabetics.

Conclusion:

Tear film abnormality is a significant feature of diabetic ocular surface diseases. These abnormalities are likely on account of poor quality and function of tears, combined with the subnormal ocular surface. Therefore, all diabetic patients especially those with evidence of retinopathy changes should undergo routine early examination and follow-up of tear function and ocular surface parameters.

Non-invasive objective and contemporary methods for measuring ocular surface inflammation in soft contact lens wearers - A review

Contact lens wear is one of the primary risk factors for the development of ocular surface inflammatory events. The purpose of this review is to examine and summarize existing knowledge on the mechanisms of contact lens related ocular surface inflammation and the evidence for the effectiveness of current objective methods to measure ocular surface inflammation. Contact lens wear is postulated to trigger an inflammatory response on the ocular surface due to mechanical, chemical, hypoxic stress, or by the introduction of microbes and their toxins. Apart from the traditional signs of inflammation, such as swelling, oedema, redness and heat, on the ocular surface, other methods to measure ocular surface inflammation in sub-clinical levels include tear inflammatory mediator concentrations, conjunctival cell morphology, and corneal epithelial dendritic cell density and morphology. Tear inflammatory mediator concentrations are up- or down-regulated during contact lens wear, with or without the presence of associated inflammatory events. There is higher conjunctival cell metaplasia observed with contact lens wear, but changes in goblet cell density are inconclusive. Dendritic cell density is seen to increase soon after initiating soft contact lens wear. The long term effects of contact lens wear on dendritic cell migration in the cornea and conjunctiva, including the lid wiper area, require further investigation. Currently patient factors, such as age, smoking, systemic diseases and genetic profile are being studied. A better understanding of these mechanisms may facilitate the development of new management options and strategies to minimize ocular surface inflammation related to contact lens wear.

Conjunctival cytologic features in patients with unilateral primary acquired nasolacrimal duct obstruction

PURPOSE

To evaluate the cytologic features of conjunctival epithelium in patients with unilateral primary acquired nasolacrimal duct obstruction (PANDO) using impression cytology.

METHODS

Twenty-four patients with unilateral PANDO for at least 1 year were enrolled in this study. The healthy eyes of the patients are assessed as control group. All patients were subjected to ophthalmic surface examination with conjunctival impression cytology analysis. Squamous metaplasia and goblet cell density were graded according to Nelson grading system.

RESULTS

The mean age was 52.7 ± 16.3 (range 21-70) years. The mean period for complaints of epiphora was 3.2 ± 2.4 (range 1-8) years. The eye with PANDO had a mean squamous metaplasia grade of 2.38 ± 0.59 versus 1.91 ± 0.82 for control eyes (p = 0.011). The mean grade of goblet cell density was 2.0 ± 0.51 for eyes with PANDO and 2.38 ± 0.65 for control eyes (p = 0.013). There was no statistically significant correlation between conjunctival cytological features in terms of squamous metaplasia and goblet cell density grades and duration of epiphora complaint (r = -0.04, p = 0.82; r = 0.09, p = 0.66, respectively).

CONCLUSIONS

PANDO may cause alterations in conjunctival impression cytology. Successful dacryocystorhinostomy surgeries will help to protect ocular surface health.

Effect of three months of soft contact lens wear on conjunctival cytology

BACKGROUND

The purpose of this study was to investigate the effect of three months of soft contact lens wear on conjunctival goblet cell density and epithelial cell morphology.

METHODS

This was a longitudinal clinical trial. Conjunctival impression cytology was performed on the superior palpebral conjunctiva in fifty-four eyes of twenty-seven neophyte contact lens wearers before and after three months of contact lens wear. Goblet cell density was determined by optical microscopy and epithelial cell morphology was classified according to the Tseng classification. Changes in goblet cell density as well as epithelial cell grading were determined. The effects of lens material and wearing modality on cytological changes were also investigated.

RESULTS

Goblet cell density reduced significantly by 85 ± 151 cells/mm(2) (p < 0.001) after three months of contact lens wear. Reduction in goblet cell density was associated with lens materials; it was higher in conventional hydrogel lenses in comparison to silicone-hydrogel lenses (p = 0.008). The highest reduction in goblet cell density was found with Nelfilcon A lens wear (p = 0.002) and the lowest with Comfilcon A lens wear (p = 0.414). There was no statistically significant difference in grading of epithelial metaplasia before and after three months of contact lens wear (p = 0.075). Age was not correlated with the reduction in goblet cell density (r = -0.196, p = 0.160) but it was associated with the change in epithelial cell morphology (p = 0.036).

CONCLUSION

Three months of soft contact lens wear statistically significantly reduced goblet cell density; however, no significant changes were found in the grading of epithelial metaplasia. Contact lenses with lower oxygen permeability, higher Young modulus and higher thickness highly affected the conjunctival cytology.

Conjunctival impression cytology versus routine tear function tests for dry eye evaluation in contact lens wearers

Aims:

Prolonged contact lens wear is often accompanied by dryness of the eyes. The aim of this study was to compare conjunctival impression cytology (CIC) and tear film tests such as tear film break up time (TBUT) and Schirmer test for dry eye evaluation in contact lens wearers and measure their correlation with dry eye symptoms.

Setting:

A case control study was done at three referral eye centers.

Materials and Methods:

The eyes of 230 contact lens users were compared to 250 eyes of age- and sex-matched controls. Participants were recruited based on their response to a questionnaire of dry eye symptoms, (Dry Eye Scoring System, DESS^©) and measurements of TBUT, Schirmer test, and CIC was done. A correlation analysis between symptom severity and tear film tests was performed. Pearson's coefficient, R² > 0.5 was considered significant.

Results:

As compared to controls (r² = 0.010), Nelson grade correlated significantly with dry eye symptoms (r² = 0.765), among cases. However, there was moderate correlation between dry eye symptoms, Schirmer test, and TBUT (r² = 0.557 and 0.530, respectively) among cases and a weak correlation among controls (r² = 0.130 and 0.054, respectively). The sensitivity of TBUT was 86.4%, specificity was 82.4%, positive likelihood ratio (LR) was 4.50 [95% confidence interval (CI) 3.46-5.85)], and negative LR was 0.09. The sensitivity of the Schirmer test was 48.2%, specificity 88%, LR 2.12 (95% CI 1.48-2.96), and negative LR 0.83.

Conclusion:

CIC correlates better than Schirmer and TBUT with dry eye symptoms. It may be the most appropriate test for dry-eye evaluation in contact lens wearers.

Impression cytology diagnosis of ulcerative eyelid malignancy

OBJECTIVE

The utility of impression cytology in ocular diseases has predominantly been restricted to the diagnosis of dry eye, limbal stem cell deficiency and conjunctival neoplasias. Its role in malignant eyelid lesions remains largely unexplored. Although scrape cytology is more popular for cutaneous lesions, impression cytology, being non-traumatic, has an advantage in small and delicate areas such as the eyelid. The present study has been designed to evaluate its role in the diagnosis and management of malignant eyelid lesions.

METHODS

Thirty-two histopathologically proven malignant eyelid lesions diagnosed over a 2-year period, including 13 basal cell carcinomas, 11 sebaceous carcinomas, four squamous cell carcinomas, two malignant melanomas and two poorly differentiated carcinomas, formed the study group.

RESULTS

The results of impression cytology were compared with those of histopathology in the study group and with an age- and sex-matched group of benign cases as controls. The sensitivity of impression cytology was 84% (27/32) for the diagnosis of malignancy and 28% (9/32) for categorization of the type of malignancy.

CONCLUSIONS

Impression cytology is a simple, useful, non-invasive technique for the detection of malignant ulcerative eyelid lesions. It is especially useful as a follow-up technique for the detection of recurrences.

Assessing the human lid margin epithelium using impression cytology

PURPOSE

To establish if impression cytology combined with histochemical and immunocytochemical staining can be used to assess epithelium of the human upper lid margin.

METHODS

Following an initial eye examination of 40 healthy subjects (19 soft contact lens wearers and 21 non-contact lens wearers, aged 18-57 years), lid margin staining was assessed with lissamine green using slit lamp biomicroscopy and graded (grade 0-3). Impression cytology of the upper lid margin of both eyes was collected, fixed and stained with periodic acid Schiff (PAS) and haematoxylin for cell morphology analysis (Nelson grade) or for immunocytochemistry (keratinization-related proteins: filaggrin, transglutaminase1 (TGase1) and cytokeratin 1/10).

RESULTS

In 57% of all subjects, grade 0 lissamine green staining showed a thin line (the Marx line), just posterior to the meibomian gland ducts. Grade 2 or 3 lissamine green staining was observed in 17% of all subjects. There was no difference between contact lens and non-contact lens wearers for lid margin staining or Nelson grade (p = 0.4, Fisher's exact test). PAS/haematoxylin staining and immunocytochemistry showed transition in epithelial cell morphology, with marginal conjunctival epithelium, mucocutaneous junction and squamous epithelium, adjacent to meibomian gland ducts. This transition in epithelium was associated with differential expression of keratinization-related proteins (filaggrin, cytokeratin 1/10 and TGase1).

CONCLUSION

 Lid margin epithelium can be successfully sampled using impression cytology and further characterized using histochemistry and immunocytochemistry staining techniques. This approach can be applied to assess lid margin changes in conditions such as dry eye and meibomian gland dysfunction.

The wound healing effects of vitamin A eye drops after a corneal alkali burn in rats

PURPOSE

We investigated the wound healing effect of retinyl palmitate eyedrops following a corneal alkali burn in rats.

METHODS

A total of 160 Sprague-Dawley male rats were divided into two groups and central corneas were injured by contacting eyes with filter paper saturated with 0.01 m NaOH for 45 seconds. Vitamin A group was treated with retinyl palmitate and antibiotic (Cravit(®) : 0.5% levofloxacin) eye drops four times daily for 3 days and the control group with vehicle and antibiotic eye drops. Corneal wound healing by fluorescein staining and impression cytologic analysis were conducted at 0, 24, 48 and 72 hr after injury. Vascular endothelial growth factor A (VEGF-A), thrombospondin 2, matrix metalloproteinase 9 (MMP 9) and transforming growth factor-β (TGF-β) were measured in corneas by ELISA, immunofluorescent staining and real-time PCR.

RESULTS

Corneal wound healing was better in the vitamin A group than in the control group. Early sprouting of new vessel was observed in the control group at 72 hr, but not in the vitamin A group. Corneal thrombospondin 2 proteins in ELISA were higher in the vitamin A group, but VEGF-A, MMP 9 and TGF-β proteins were higher in the control group (p < 0.05). Similarly, thrombospondin 2 immunofluorescent staining was stronger, whereas VEGF-A, MMP 9 and TGF-β staining were weaker in the vitamin A group (p < 0.05). In addition, thrombospondin 2 mRNA levels were higher, whereas VEGF-A, MMP 9 and TGF-β mRNA levels were lower in the vitamin A group (p < 0.05).

CONCLUSIONS

Retinyl palmitate eye drops can inhibit VEGF-A and activate thrombospondin 2 and improve conjunctival impression cytologic findings. Furthermore, retinyl palmitate eye drops were found to promote corneal healing after an alkali burn in rats.

Changes in the tear film and ocular surface after cataract surgery

PURPOSE

To evaluate changes in corneal sensitivity, tear film function, and ocular surface stability in patients after cataract surgery.

METHODS

This hospital-based prospective randomized trial included 48 eyes from 30 patients who underwent phacoemulsification. Slit-lamp examination, Schirmer test 1 (ST1), and measurement of corneal sensitivity and tear film breakup time (BUT) were performed for all patients 1 day before and 1 day, 1 month, and 3 months after surgery. In addition, conjunctival impression cytology from the temporal region of the conjunctiva was simultaneously performed.

RESULTS

Corneal sensitivity at the center and temporal incision sites had decreased significantly at 1 day postoperatively (P = .021, P < .001). However, the sensitivity had returned to almost the preoperative level 1 month postoperatively. The mean postoperative ST1 results were no different from preoperative values. On the other hand, BUT results had decreased significantly at 1 day postoperatively (P = .01) but had returned to almost the preoperative level 1 month postoperatively. Mean goblet cell density (GCD) had decreased significantly at 1 day, 1 month, and 3 months postoperatively (P < .001). In addition, decrease in GCD and cataract operative time were highly correlated (r² = 0.65).

CONCLUSIONS

The decrease in GCD, which was correlated with operative time, had not recovered at 3 months after cataract surgery. Therefore, microscopic ocular surface damage during cataract surgery seems to be one of the pathogenic factors that cause ocular discomfort and dry eye syndrome after cataract surgery.

Goblet cells of the normal human bulbar conjunctiva and their assessment by impression cytology sampling

Goblet cells of the conjunctiva are the main source of mucus for the ocular surface. The objectives of this review are to consider the goblet cells as assessed by various histological, cytological and electron microscopy methods, and to assess the consistency of published reports (over more than 25 years) of goblet cell density (GCD) from impression cytology specimens from nominally healthy human subjects. Reported GCD values have been notably variable, with a range from 24 to 2226 cells/mm² for average values. Data analysis suggests that a high density of goblet cells should be expected for the healthy human conjunctiva, with a tendency toward higher values in samples taken from normally covered locations (inferior and superior bulbar conjunctiva) of the open eye (at 973 +/- 789 cells/ mm²) than in samples taken from exposed (interpalpebral) locations (at 427 +/- 376 cells/mm²). No obvious change in GCD was found with respect to age, perhaps because the variability of the data did not allow detection of any age-related decline in GCD. Analyses of published data from 33 other sources indicated a trend for GCD to be lower than normal across a spectrum of ocular surface diseases.

Contact lens wear and the goblet cells of the human conjunctiva-A review

PURPOSE

To review the reported effects of contact lens wear on the goblet cells of the human conjunctiva.

METHODS

A literature search was undertaken to identify reports on the conjunctival health after contact lens wear, principally as assessed using the conjunctival impression cytology (CIC) technique in which cells are examined ex vivo, after fixation and staining. Details of technique, data on duration of contact lens wear and then CIC outcome in terms of goblet cell density (GCD) were extracted.

RESULTS

Of 24 reports identified, 22 examined the bulbar conjunctiva and 2 examined the tarsal conjunctiva. A decrease in GCD was considered, directly or indirectly, to be a consequence of contact lens wear in 18 of the studies, but there was no obvious overall relationship between duration of lens wear and the GCD changes. Conversely, four reports indicated an increase in GCD or goblet cell-related mucins. Two reports concluded that there was no change in goblet cells or their mucin, a result however that is consistent with a recent conclusion that no statistically significant change in GCD was detectable in contact lens wearers assessed by in vivo imaging of the human conjunctiva by confocal microscopy.

CONCLUSIONS

The majority of published studies have concluded that contact lens wear results in a decrease in goblet cells in the conjunctiva. While there are reports that draw a very different conclusion, it should be noted that there has been limited consistency in technique or the method of reporting the results across the various studies.

Fluorescein punctate staining traced to superficial corneal epithelial cells by impression cytology and confocal microscopy

PURPOSE

The basis of fluorescein-associated superficial punctate staining in dry eyes is controversial. Prior explanations include fluorescein pooling in surface erosive defects, intercellular trapping of fluorescein, and intracellular staining in dead cells. In this study, the hypothesis that punctate erosions are individual cells with enhanced fluorescence was tested.

METHODS

Ten impression cytology membrane materials were compared, to optimize cellular yield in buccal mucosa and cornea. Clinicocytologic correlation of punctate fluorescent spots was performed in four dry eye patients. Individual punctate spots were localized by fiducial marks in photographs, before and after removal with impression membranes, and were traced in fluorescence microscopy and cytologic staining. Two-way contingency table analysis was used to determine the correlation of punctate spots with cells removed by the membrane. Clinicopathologic correlation of punctate spots was performed in 10 corneas removed in dry eye patients by transplantation for concurrent diseases. Punctate fluorescence was tracked in specimens by fiducial marks and epifluorescence. The distribution of fluorescent spots in specific cell layers of the cornea was determined by confocal microscopy.

RESULTS

Cellular yield was greatest with impressions from polytetrafluoroethylene (PTFE [Teflon]; BioPore; Millipore, Billerica, MA) membrane compared with its closest rival (P = 0.019). Punctate fluorescent spots, most of which disappeared after impression cytology (71%), correlated with cells on the membranes (P = 0.009). The punctate spots were more frequent in the superficial cell layers of the cornea (80%) compared with the deepest two layers (0%) (P < 0.00049).

CONCLUSIONS

Punctate epithelial erosions correspond to enhanced fluorescence in epithelial cells predominantly in superficial layers of the cornea and would be more aptly named fluorescent epithelial cells (FLECs).

Conjunctival mucin mRNA expression in contact lens wear

PURPOSE

To investigate the influence of the water content in non-ionic hydrogel contact lenses (HCL) on the mRNA levels of human conjunctival mucin genes (MUCs).

METHODS

Sixteen healthy subjects with no history of contact lenses wear were selected and randomized into two equal groups. Group 1 subjects wore low water content (38%, Soflens 38) non-ionic HCLs. Group 2 wore high water content (66%, Soflens 66) non-ionic HCLs. Conjunctival impression cytology was applied to the superior bulbar conjunctiva of both eyes before, 6 months, and 1 year after HCL fitting, and 15 days after discontinuation of wearing. Total RNA was isolated, retrotranscribed, and amplified by conventional polymerase chain reaction (PCR) and by quantitative real time PCR to study the mRNA levels of MUCs and to analyze variations during the study period. Time- and HCL-dependent variations in mRNA expression were analyzed using Student's test.

RESULTS

From the known MUCs, transcripts from MUC1, MUC2, MUC4, MUC5AC, MUC7, MUC13, MUC15, MUC16, and MUC17 genes were detected in all subjects before HCL fitting. Except for MUC2, the expression of some MUC genes significantly increased whereas others significantly decreased at either the 6- and 12-month period. Statistically significant differences between both HCL groups (p < 0.001) were found in the MUC4, MUC13, and MUC15 mRNA expression after 1 year of wear and after the 15 days without HCL wear. However, these differences were not clearly related to the water content of the lenses.

CONCLUSIONS

Low and high water content non-ionic HCLs induced different changes in the mRNA levels of several MUCs, but the water content was not related to the changes. Recovery to basal levels of conjunctival MUC mRNA expression after wearing HCL lenses for a year takes longer than 15 days for some MUCs.

Conjunctival impression cytology by using a thermosensitive adhesive: polymerized N-isopropyl acrylamide

PURPOSE

We aimed to evaluate a new technique using a thermosensitive glue coating for impression cytology of the ocular surface.

METHODS

We prepared plasma polymerized N-isopropyl acrylamide (pNIPAM)-coated parylene C (poly(monochloro-p-xylylene)) films to obtain cytological samples from the conjunctival surface. We compared this new technique with the conventional nitrocellulose paper method in regards to the quality of impression cytology and quantity of the cells in 30 postmenauposal women with dry eye complaints.

RESULTS

The cellular material was adequate for evaluation in 28 (93%) of 30 eyes in pNIPAM-coated parylene group and in 18 (60%) of 30 eyes in the nitrocellulose group (P = 0.0002). pNIPAM-coated parylene technique was superior to the nitrocellulose technique regarding the mean number of cells per microscopic field (P = 0.00003), integrity of the cells (P = 0.00001), and cellular preservation (P = 0.0002).

CONCLUSION

The number of cells and the quality scores were significantly higher in the pNIPAM-coated impression cytology technique than the nitrocellulose method.

Conjunctival impression cytology in trachoma

Trachoma is one of the leading causes of blindness and clinical examination remains the mainstay of diagnosis. However there is need to evaluate simple, inexpensive techniques which can be used for screening of trachoma in endemic regions. We report two cases where conjunctival impression cytology played a part in confirming the diagnosis of trachoma. We used a modified technique of obtaining conjunctival impressions, which not only met with better patient compliance and minimal ocular distress, but also provided better cellularity and morphology of cells for evaluation. The impression smears showed squamous metaplasia and loss of goblet cells. The cytoplasm of these cells had a hazy, moth eaten appearance and showed presence of intracytoplasmic inclusions. These basophilic inclusions were present singly and in clusters and were around 5 mum in diameter. A large number of these inclusions were present extracellularly as well. Conjunctival impression cytology is a simple procedure which needs to be evaluated for its potential to be used for screening trachoma in endemic areas.

A comparison of vitamin a and cyclosporine a 0.05% eye drops for treatment of dry eye syndrome

PURPOSE

To compare the efficacy of vitamin A (retinyl palmitate) and cyclosporine A 0.05% eye drops in treating patients with dry eye disease.

DESIGN

Prospective, randomized, controlled, parallel group study.

METHODS

A total of 150 patients with defined dry eye disease participated (50 in each treatment group). In 3 identical clinical trials, patients were treated twice daily with cyclosporine A 0.05%, or four times daily with retinyl palmitate 0.05%, or with neither cyclosporine or retinyl palmitate. Adjunctive treatment with preservative-free artificial tears was undertaken four times daily in all 3 groups. Corneal fluorescein staining results, Schirmer tear test (without anesthesia) results, tear film break-up time (BUT), dry eye symptom score, and impression cytologic analysis results were obtained before treatment and at the first, second, and third months after initiation of treatment.

RESULTS

Both vitamin A eye drops and topical cyclosporine A 0.05% treatments led to significant improvement in blurred vision, tear film BUT, Schirmer I score results, and impression cytologic findings in patients with dry eye syndrome (P < .05) compared to the control group treated with preservative-free artificial tears alone.

CONCLUSIONS

Both vitamin A eye drops and topical cyclosporine A 0.05% treatments are effective for the treatment of dry eye disorder.

Concordance between common dry eye diagnostic tests

AIM

Large variations in results of diagnostic tests for mild to moderate dry eye are widely recognised. The purpose of this study was to assess if there was concordance between common dry eye diagnostic tests.

METHODS

A total of 91 subjects were recruited to the study. The tear film and ocular surface were evaluated using the phenol red thread test (PRT), tear film break-up time (TBUT), biomicroscopic examination and impression cytological assessment of conjunctival goblet cells. Dry eye symptoms were assessed using McMonnies' dry eye questionnaire (MQ) and statistical correlations between all tests were assessed.

RESULTS

This study cohort did not include severe aqueous deficient dry eye patients as determined by the PRT. A statistically significant difference was noted between PRT results and all other tests (p

CONCLUSION

A correlation was found only between tests assessing lipid/mucous deficiency (Meibomian gland evaluation, goblet cell density, TBUT and MQ).

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Key Words

• correlation dry eye diagnostic tests

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Analysis of Variance
• Conjunctiva/pathology
• Diagnosis, Differential
• Diagnostic Techniques, Ophthalmological/standards
• Dry Eye Syndromes/diagnosis
• Female
• Humans
• Male
• Meibomian Glands/pathology
• Middle Aged
• Reproducibility of Results
• Tears/metabolism
• Young Adult

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Grants

• R01 EY019470 NEI NIH HHS

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Affiliation(s)

J E Moore Centre for Molecular Biosciences, University of Ulster, Cromore Road, Coleraine, Northern Ireland BT52 1SA, UK.
J E Graham
E A Goodall
D A Dartt
A Leccisotti
V E McGilligan
T C B Moore

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Conjunctival cytologic features in anophthalmic patients wearing an ocular prosthesis

PURPOSE

To evaluate the cytologic features of conjunctival epithelium in anophthalmic sockets with an ocular prosthesis, using an impression cytology technique and to determine the clinical factors associated with these changes.

METHODS

In a prospective case-controlled study, 40 consecutive unilateral anophthalmic patients who wore an ocular prosthesis were recruited. A questionnaire on the care of the prosthesis included total wearing period, frequency of cleaning, frequency of polishing, cleaning solution, and eye drop use. The degree of inflammation of the anophthalmic conjunctival socket was evaluated. Impression cytology specimens were taken from the upper tarsal conjunctiva, the bulbar conjunctiva, and the lower tarsal conjunctiva of each socket, and from the contralateral eye (to serve as an internal matched control). The goblet cell density and the nucleus-to-cytoplasm ratio of the epithelial cells were measured. The relevance of these conjunctival cytologic features to the various factors of prosthesis care or conjunctival inflammation was analyzed.

RESULTS

In the anophthalmic sockets, the conjunctiva showed squamous metaplasia at all 3 areas sampled. The goblet cell density was significantly decreased and the nucleus-to-cytoplasm ratio of the epithelial cells was significantly increased compared with the control eyes (p<0.05, on all 3 areas sampled, Wilcoxon signed rank test). These conjunctival cytologic changes were not significantly associated with total wearing time, frequency of polishing, cleaning solution, or eye drops use (p>0.05, Spearman's correlation test).

CONCLUSIONS

Squamous metaplasia with decreased goblet cell density and increased nucleus-to-cytoplasm ratio occurred in anophthalmic conjunctival sockets but was not associated with particular aspects of prosthesis care.

Conjunctival epithelial changes induced by cilia in patients with epiblepharon or entropion

PURPOSE

To evaluate the effect of mechanical trauma induced by cilia on the conjunctival epithelium in patients with epiblepharon or entropion and to evaluate changes in epithelium after surgical correction in patients with entropion.

DESIGN

Case-control study.

METHODS

One hundred and seven eyes of 61 patients were enrolled in this study and were divided into three groups: the epiblepharon group (n = 59), the entropion group (n = 17), and the age-matched control group for the epiblepharon group (n = 31). Impression cytologic specimens were obtained from nasal and temporal bulbar conjunctiva of the epiblepharon and control groups immediately after the induction of general anesthesia. In the entropion group, these were obtained before and one month after surgical correction. Conjunctival changes were graded using the Tseng method and goblet cell densities were compared.

RESULTS

Cytologic scores were significantly higher in the epiblepharon group than in the control group (P < .001), and goblet cell densities of nasal and temporal conjunctiva were significantly lower in the epiblepharon group than in the control group (P = .044 and P = .018, respectively). In the entropion group, postoperative scores were significantly lower than preoperative scores in both conjunctival areas (P = .033 and P = .003, respectively). No statistically significant difference was found between nasal and temporal conjunctiva in the three groups.

CONCLUSIONS

The persistent mechanical trauma by cilia in patients with epiblepharon or entropion can induce squamous metaplasia of the conjunctival epithelium. However, these conjunctival changes can be reversed by surgical correction.

Comparison of autologous serum and umbilical cord serum eye drops for dry eye syndrome

PURPOSE

To compare the therapeutic effect between autologous serum and umbilical cord serum eye drops in the treatment of severe dry eye syndrome.

DESIGN

Prospective case-control study.

METHODS

Ninety-two eyes of 48 patients with severe dry eye syndrome (34 eyes of 17 patients with Sjögren syndrome and 58 eyes of 31 patients with non-Sjögren syndrome) were treated with either 20% autologous serum (41 eyes of 21 patients) or umbilical cord serum eye drops (51 eyes of 27 patients). Symptom scoring, corneal sensitivity test, tear film break-up time (BUT), Schirmer test, tear clearance rate (TCR), corneal fluorescein staining, and conjunctival impression cytologic analysis were performed before and one month and two months after treatment.

RESULTS

Both autologous serum and umbilical serum treatments led to improvement in the symptom score, tear film BUT, keratoepitheliopathy score, and impression cytologic findings. Symptom and keratoepitheliopathy scores were lower at one month (P = .03 and P = .12) and two months (P = .04 and .02) for those treated with umbilical cord serum compared with those treated with autologous serum. In Sjögren syndrome patients, goblet cell density was higher at two months of umbilical cord serum treatment compared with autologous serum treatment (P = .04).

CONCLUSIONS

Umbilical cord serum eye drops were more effective in decreasing symptoms and keratoepitheliopathy in severe dry eye syndrome and increasing goblet cell density in Sjögren syndrome compared with autologous serum eye drops.

Interleukin-6 and tumor necrosis factor-alpha levels in tears of patients with dry eye syndrome

PURPOSE

To determine the levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in tears of patients with dry eye syndrome.

METHODS

IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay in tear samples obtained from 18 patients with dry eye (8 patients with Sjögren syndrome and 10 patients with non-Sjögren syndrome) and 14 control subjects. The correlation between IL-6 and TNF-alpha levels and tear film and ocular surface parameters was analyzed. The relative expression of these cytokines was evaluated in conjunctival impression cytology and conjunctival biopsy specimens by using immunohistochemical staining.

RESULTS

The mean levels of IL-6 and TNF-alpha were, respectively, 18.57 +/- 8.92 and 3.68 +/- 3.45 pg/mL in patients with dry eye and 3.59 +/- 3.38 (P < 0.01) and < 0.5 (P < 0.01) pg/mL in control subjects. IL-6 level was significantly increased in tears of patients with Sjögren syndrome compared with those with non-Sjögren syndrome (P < 0.01). IL-6 level correlated significantly with tear film breakup time (P = 0.04), Schirmer test (P < 0.01), tear clearance (P = 0.02), keratoepithelioplasty score (P < 0.01), and goblet cell density (P = 0.03), but not with corneal sensitivity (P = 0.08). There was no significant difference in TNF-alpha level between patients with non-Sjögren and Sjögren syndrome. TNF-alpha levels did not correlate with tear film and ocular surface parameters. Immunohistochemical staining showed positive staining for IL-6 in specimens from patients with dry eye, especially in specimens from patients with Sjögren syndrome.

CONCLUSION

IL-6 and TNF-alpha levels are elevated in tears of patients with dry eye syndrome. IL-6 level, but not TNF-alpha level, is associated with the severity of the disease and correlates with various tear film and ocular surface parameters.

The effect of contact lens wear on the ocular surface changes in keratoconus

PURPOSE

To investigate the effects of contact lens wear or the keratoconic shape itself on the changes in the ocular surface in keratoconus.

METHODS

Forty-two patients (84 eyes) were enrolled in this study and divided into four groups. Group 1 comprised 22 eyes with keratoconus that had been wearing rigid gas-permeable (RGP) contact lenses for an average of 5.54 +/- 2.11 years. Group 2 comprised 24 myopic eyes that had been wearing RGP contact lenses for 6.42 +/- 1.79 years. Group 3 comprised 20 eyes with keratoconus without any contact lens wear. Group 4 comprised 18 healthy eyes that were used as controls. The ocular surface changes were evaluated by determining the tear film breakup time and performing conjunctival impression cytology. The goblet cell densities, nucleus-to-cytoplasm ratio, and epithelial cell morphology in the four groups were compared with optical microscopy in the high-power field.

RESULTS

The tear film breakup times in groups 1 and 2 were significantly lower than those in groups 3 and 4. The goblet cell densities were 5.49 +/- 1.75 and 5.82 +/- 1.63 in groups 1 and 2, respectively, which were significantly lower (P < 0.05) than the 8.79 +/- 1.42 and 10.24 +/- 2.10 in groups 3 and 4, respectively. There were no statistically significant differences in the goblet cell densities, nucleus-to-cytoplasm ratios, and epithelial cell morphologies between groups 1 and 2 and groups 3 and 4.

CONCLUSIONS

The ocular surface changes in keratoconus may be directly related to contact lens wear and not to the keratoconic shape itself.

Application of Umbilical Cord Serum Eyedrops for the Treatment of Dry Eye Syndrome

PURPOSE

To investigate the efficacy of umbilical cord serum eyedrops for the treatment of severe dry eye syndrome.

METHODS

Fifty-five eyes of 31 patients with severe dry eye syndrome were treated with umbilical cord serum eyedrops. Symptom scoring, tear film break-up time (BUT), Schirmer test, corneal sensitivity test, and corneal fluorescein staining were performed before and 1 and 2 months after treatment, and conjunctival impression cytology was performed before and 2 months after treatment. The concentrations of epidermal growth factor (EGF), vitamin A, and transforming growth factor-beta (TGF-beta) in umbilical cord serum and normal peripheral blood serum were measured.

RESULTS

Two months after treatment, significant improvement was observed in symptom score (from 3.07 +/- 0.54 to 0.96 +/- 0. 58), BUT (from 3.96 +/- 1.56 to 5.45 +/- 2.54 seconds), and keratoepitheliopathy score (from 4.87 +/- 3.22 to 1.71 +/- 1.84) (P < 0.01). There was no statistically significant change in Schirmer and corneal sensitivity tests. In impression cytology, the grade of squamous metaplasia (from 2.35 +/- 0.72 to 1.44 +/- 0.69) and goblet cell density (from 80.91 +/- 31.53 to 154.68 +/- 43.06 cell/mm) improved significantly (P < 0.01). The mean concentrations of EGF, TGF-beta, and vitamin A were 0.48 +/- 0.09, 57.14 +/- 18.98, and 230.85 +/- 13.39 ng/mL in umbilical cord serum and 0.14 +/- 0.03, 31.30 +/- 12.86, and 372.34 +/- 22.32 ng/mL in peripheral blood serum, respectively.

CONCLUSION

Umbilical cord serum contains essential tear components, and umbilical cord serum eyedrops are effective and safe for the treatment of severe dry eye syndrome.

Changes of tear film and ocular surface in diabetes mellitus

This study was performed to investigate the changes of tear film and ocular surface in diabetic patients, as well as the ocular and systemic factors related to these changes. We assessed the scoring of keratoepitheliopathy, corneal sensitivity test, tear film break-up time (BUT), Schirmer test, and conjunctival impression cytology in 94 eyes of 47 patients with noninsulin-dependent diabetes mellitus and in 60 eyes of 30 normal subjects. The degree of keratoepitheliopathy was severe, and the corneal sensitivity, BUT, and tear secretion were significantly reduced in the diabetic patients. Conjunctival impression cytology showed a higher grade of conjunctival squamous metaplasia and lower goblet cell density in the diabetic patients. All parameters were related to the status of metabolic control, diabetic neuropathy, and stage of diabetic retinopathy. We think that diabetic patients with poor metabolic control, neuropathy, and advanced stage of retinopathy should be examined for tear film and ocular surface changes.

Effects of soft contact lenses on conjunctival surface

PURPOSE

To examine the effects of soft contact lenses on tear breakup time (TBUT), basal Schirmer test result, and the conjunctival surface in patients wearing contact lenses.

METHODS

In this study, conjunctival cytologic changes, TBUT, and Schirmer test function alterations of soft contact lens wearers were evaluated by impression cytology. The study included 100 eyes of 50 soft contact lens wearers who were followed up in the Department of Ophthalmology of Dicle University and 80 eyes of 40 subjects as a control group. After TBUT and basal Schirmer test, conjunctival surface epithelial morphology was investigated using impression cytology. After the materials were appropriately stained, they were evaluated according to the Nelson grading scale.

RESULTS

Contact lens wearers were divided into three groups according to the duration of contact lens wear. When these groups were evaluated according to the Nelson grading method, 21% of cases were grade 0; 32% were grade 1; and 28% were grade 3. There were statistically significant differences in epithelial cell morphology, goblet cell density, snakelike chromatin changes, TBUT, and basal Schirmer test result between the control and study groups.

CONCLUSIONS

We suggest that TBUT and Schirmer test result be carefully monitored in contact lens wearers. Impression cytology may be used as a safe, simple, and noninvasive method in the diagnosis of ocular surface alternations in patients with contact lens intolerance.

Ocular surface impression cytology

Impression cytology, either using cellulose acetate strips or the Biopore membrane device, is a simple, noninvasive technique that aids in the diagnosis of several disorders of the ocular surface. These disorders include ocular surface squamous neoplasia, dry eye syndrome, limbal stem-cell deficiency, specific viral infections, vitamin A deficiency, allergic disorders, conjunctival melanosis, and malignant melanoma. Another advantage is the preservation of limbal stem cells, which occur in the basal layer of the limbal epithelium and are responsible for renewal of the corneal epithelium. The Biopore membrane device is particularly user friendly, with little expertise required and adequate specimens obtained in a very high percentage of cases. The most common applications in diagnostic ocular pathology are:(i) primary diagnosis and follow-up of ocular surface squamous neoplasia, including after therapy with topical mitomycin C. The sensitivity is high (78-87%); and (ii) dry eye syndrome where squamous metaplasia and/ or hyperkeratosis are noted. Certain limitations of the technique for diagnosis of squamous neoplasia include the fact that dysplasias are often keratinizing and may yield very few or even no dysplastic cells with impression cytology. Secondly, no definite cytologic criteria reliably distinguish invasive SCC of ocular surface from in situ disease. Other applications include the rapid specific diagnosis of ocular surface infections with herpes simplex, adeno-, and varicella zoster viruses. Impression cytology samples may also be used to obtain mRNA, cells for phenotyping by flow cytometry, and proteins for Western blotting for research studies.