The Features and Treatment Effects on Keratoepitheliopathy for Meibomitis-Related Keratoconjunctivitis

Meibomitis-related keratoconjunctivitis (MRKC) is characterized by meibomitis with corneal epithelial abnormalities, and can be divided into two types: MRKC accompanied with phlyctenular keratitis, and MRKC accompanied with keratoepitheliopathy that is similar to superficial punctate keratopathy (SPK). The purpose of this retrospective study was to investigate the characteristic features of keratoepitheliopathy and treatment outcomes for MRKC. This study involved 27 eyes of 18 MRKC patients (3 males and 15 females). National Eye Institute (NEI) scores and visual acuity were compared at pre and post treatment. All subjects were treated with a small-dose administration of clarithromycin. Keratoepitheliopathy characteristic to MRKC, yet different in appearance from SPK, was noted in 24 of the 27 eyes. Fluorescein staining revealed granular epithelial lesions generally larger than SPK that coexisted with small dark spots. In 17 eyes, keratoepitheliopathy was located within the pupillary zone, and the visual acuity in 12 eyes was less than 1.0. Our findings showed significant improvement in the NEI score in MRKC (p < 0.0001) and in visual acuity (p = 0.0157) post treatment, and the characteristic features of keratoepitheliopathy in MRKC that are often associated with decreased visual acuity were elucidated. The treatment of clarithromycin was found to be effective for MRKC with keratoepitheliopathy.

Effectiveness of Single-Dose Oral Pilocarpine Administration in Patients with Sjögren's Syndrome

In this study, we evaluated the effectiveness of a single-dose oral pilocarpine administration on tear film (TF), as well as dry eye and dry mouth symptoms, in 53 eyes of 27 Sjögren syndrome (SS) patients who were experiencing dry mouth. To evaluate the changes in tear volume, a digital video-meniscometer was used to measure the radius of the lower central tear meniscus curvature (R, mm) of each eye at prior to the administration of 5 mg oral pilocarpine, and at 15 (R:(15)), 30 (R:(30)), and 60 (R:(60)) minutes after administration. The fluorescein breakup time (FBUT, seconds) and ocular and oral dryness symptoms were evaluated before and at 60 min after administration using a visual analogue scale (VAS, mm). A significant increase in R was observed at 15 and 30 min after administration compared to that at prior to administration. FBUT showed significant improvement at 60 min after administration, and the VAS score for ocular and oral dryness symptoms was found to have decreased significantly at 60 min after administration. A single-dose administration of 5 mg oral pilocarpine had a beneficial effect on TF, as well as on ocular and oral dryness symptoms, in patients with SS.

Eye Pain Caused by Epithelial Damage in the Central Cornea in Aqueous-Deficient Dry Eye

In this study, the severity of eye pain (EP) and associated objective findings were evaluated in aqueous-deficient dry eye (ADDE) patients using PainVision®, a quantitative pain-measuring device. This study involved 53 eyes of 53 ADDE patients (6 males and 47 females; mean age: 64.4 ± 13.4 [mean ± SD] years). Of those, 18 eyes of 18 patients underwent punctal occlusion, and EP and objective findings in those patients were evaluated before and after treatment. In all patients, the severity of EP as measured by PainVision® was assessed using the Pain Degree (PD). The median PD for the 53 patients was 30.6 µA/µA (interquartile range, 16.9-93.2), and the nasal and central corneal staining score and the upper lid-wiper epitheliopathy score were significantly correlated with PD (R = 0.33, 0.33, and 0.28, respectively) (all: p < 0.05). Using the least squares method, the central corneal staining score most significantly affected PD. In the 18 cases that underwent punctal occlusion, PD was significantly reduced (median PD: 24.8 to 7.1 µA/µA; p < 0.0001). Using the least squares method, the central corneal staining score and tear meniscus radius were significantly more influential as factors contributing to PD before and after treatment, and central corneal epithelial damage was the factor most associated with ADDE-related EP.

Effect of Punctal Occlusion on Blinks in Eyes with Severe Aqueous Deficient Dry Eye

Punctal occlusion (PO) is considered to improve both tear-film instability and increased friction during blinking and may consequently affect blinks. The purpose of this study was to investigate the effect of PO on blinks. This study involved 16 eyes of 16 severe aqueous deficient dry eye (ADDE) patients (mean age: 65.7 years). In all eyes, tear meniscus radius (TMR), spread grade (SG) of the tear-film lipid layer (i.e., SG 1-5: 1 being the best), fluorescein break-up time (FBUT), corneal epithelial damage score (CED), conjunctival epithelial damage score, corneal filament (CF) grade, lid-wiper epitheliopathy (LWE) grade, and superior limbic keratoconjunctivitis (SLK) grade were evaluated at before and at more than 1-month after PO. Moreover, using a custom-made high-speed blink analyzer, palpebral aperture height, blink rate, upper-eyelid closing-phase amplitude/duration/maximum velocity, and upper-eyelid opening-phase amplitude/duration/maximum velocity were measured at the same time point. After PO, TMR, SG, FBUT, CED, and the CF, LWE, and SLK grades were significantly improved, and upper-eyelid opening/closing-phase amplitude and maximum velocity significantly increased (all p < 0.04). The findings of this study suggest that PO improves ocular surface lubrication and that blink-related parameters can reflect the friction that occurs during blinking in eyes with severe ADDE.

The Relationship between Subjective Symptoms and Quality of Life in Conjunctivochalasis Patients

The purpose of this study was to evaluate the differences in subjective symptoms between patients with conjunctivochalasis (CCh) and dry eye (DE), and examine the relationship between subjective symptoms and quality of life (QOL). In 75 eyes of 75 CCh patients and 122 eyes of 122 DE patients, 12 subjective symptoms classified into four groups depending on the mechanisms associated with symptoms (ITF: instability of tear film, IF: increased friction, R: reflex, and DTC: delayed tear clearance) were evaluated by use of a visual analogue scale (VAS). Fifteen items related to DE symptoms and their influence on daily life were evaluated by use of the dry eye-related quality-of-life score (DEQS) questionnaire, with overall degree of QOL impairment calculated as a QOL score. The correlation between the Total VAS score and QOL score were evaluated. Between the CCh and DE patients, significant differences in subjective symptoms were found in eye dryness, pain, tearing sensitivity to light, and heavy eyelids, while tearing was higher in CCh. A significant strong correlation was found between QOL score and Total VAS score, ITF, and IF in CCh patients. The QOL of CCh patients is strongly determined by decreased tear-film stability and increased friction during blinking.

A new surgical approach for punctal occlusion using fibrous tissue from under the lacrimal caruncle

Purpose

Surgical punctal occlusion is indispensable for the treatment of severe dry eye in cases where punctal-plug insertion is not applicable due to an enlarged or deformed punctum. However, permanent punctal occlusion is difficult in some cases. In our aim to establish a more reliable punctal occlusion, we have devised a new surgical approach for punctal occlusion.

Patients and methods

This study involved 20 puncta of 12 eyes of 12 patients (1 male and 11 females; mean age: 65.2 years) with severe aqueous-tear-deficient dry eye. A new surgical procedure for punctal occlusion using fibrous tissue from under the lacrimal caruncle into the diathermy-induced deepithelialized canaliculus as supporting tissue for punctal closure was performed. In all patients, the assessment of eye symptoms, as well as the condition of punctal occlusion by slit-lamp biomicroscopy, tear volume (tear-meniscus radius [TMR] measurement by meniscometry), the condition of precorneal tear film (graded by interferometry [IG]), measurement of fluorescein breakup time (FBUT), and scoring of ocular surface staining (fluorescein score of area [FSA] and density [FSD], and lissamine green score [LGS]) were performed, and the preoperative and 6-month-postoperative values were compared.

Results

In regard to the postoperative improvement of symptoms, 11 patients showed remarkable improvement, 1 patient showed improvement, and no reopening of the closed punctum was found in any patient. Test values were all significantly improved post surgery (all: P<0.05) as compared to those prior to surgery (respective values [mean ± SD], and the pre- and postoperative P-values were: TMR (mm) [0.18±0.08; 0.56±0.28, P=0.002], IG [4.3±0.9; 2.7±0.8, P=0.009], FBUT [0.4±0.6; 4.1±2.9, P=0.004], FSA [1.6±0.7; 0.7±0.9, P=0.03], FSD [2.7±0.7; 0.6±0.7, P=0.003], and LGS [5.1±2.7; 1.1±2.1, P=0.005]). Moreover, no postoperative complications were observed.

Conclusion

The findings of this study showed that our novel surgical procedure for punctal occlusion is highly successful and that it results in improved and more complete punctal occlusion.

Meibomian Gland Physiology in Pre- and Postmenopausal Women

Purpose

The purpose of this study was to assess the change of meibomian gland physiology during the menstrual cycle and compare its physiology among pre- and postmenopausal women and men.

Methods

This study involved 18 healthy subjects: 6 premenopausal women with a regular 28- to 30-day menstrual cycle, 6 postmenopausal women, and 6 men who were age-matched to the premenopausal women. All subjects measured basal body temperature every day at home and were seen once weekly for 5 weeks, and the menstrual state of the premenopausal subjects was masked until after the investigation. At each visit, the meibomian gland orifice (MGO) diameter, lid margin meibum level as meibometry value, meibomian gland morphology, and fluorescein breakup time (F-BUT) of tear film were evaluated, and serum samples were obtained for analysis of sex steroid hormones.

Results

The meibomian gland physiology showed cyclic change during the menstrual cycle. The MGO diameter and meibometry value of the meibomian glands decreased in the latter half of the luteal phase until menstruation, correlating well with a shortening of F-BUT. The MGO diameter and meibometry value were significantly higher in postmenopausal women and men than in premenopausal women; however, F-BUT was significantly longer in men than in pre-/postmenopausal women.

Conclusions

The findings of this study show that meibomian glands exhibit a cyclic change in premenopausal women, as well as sex- and age-related physiologic differences.

The association of sleep quality with dry eye disease: the Osaka study

PURPOSE

To investigate the association of dry eye disease with sleep quality.

METHODS

In 2011, a cross-sectional survey was conducted among all the employees, mainly young and middle-aged Japanese office workers, who used visual display technology, at a company in Osaka, Japan (N=672; age range =26-64 years). The participants were classified according to the Japanese dry eye diagnosis criteria by dry eye examination results including the Schirmer test, fluorescein and lissamine green staining, tear film break-up time, and symptom questionnaire into three groups as follows: definite dry eye disease, probable dry eye disease, and no dry eye disease. To determine sleep quality, Japanese version of the Pittsburgh Sleep Quality Index (global score) was implemented. The global score (range =0-21) was calculated by summing seven sleep variable scores (scale, 0-3); scores ≥5.5 indicated poor sleep.

RESULTS

The total mean global score was 5.1±2.3 (completed N=383); 45% of the dry eye disease participants reported having poor sleep quality, while 34% of the no dry eye disease participants did so, with a significant difference found in the global score (P=0.002). Furthermore, a statistically significant association was observed between the global score and dry eye disease (P=0.005).

CONCLUSION

Poor sleep quality is associated with dry eye disease, especially with dry eye symptoms.

Three percent diquafosol ophthalmic solution as an additional therapy to existing artificial tears with steroids for dry-eye patients with Sjögren's syndrome

PURPOSE

To investigate the long-term results of 3% diquafosol ophthalmic solution as an alternative therapy to existing ophthalmic solutions, including topical immunosuppression, for the treatment of dry eye in patients with Sjögren's syndrome.

METHODS

This study involved 14 female dry-eye patients (mean age: 62.4 years) with Sjögren's syndrome who insufficiently responded to their current therapy. In all patients, 3% diquafosol ophthalmic solution was administered six times daily for 12 months in substitution for artificial tears and sodium hyaluronate ophthalmic solution. Their use of corticosteroid eye drops remained unchanged from that prior to the treatment with diquafosol sodium. The subjective symptoms assessed, and ocular signs including tear meniscus radius and the tear film breakup time, and ocular-surface epithelial damage score were examined at 1, 2, 3, 4, 5, 6, 9, and 12 months after initiating treatment.

RESULTS

Among the subjective symptoms, significant improvement was obtained in dryness at 2 months post treatment, in eye fatigue at 1, 2, 3, 4, and 12 months post treatment, and in pain at 1, 2, 6, and 12 months post treatment. Difficulty in opening the eye, foreign body sensation, and redness were also significantly ameliorated at various time-points. The tear meniscus radius and the tear film breakup time were significantly improved throughout the observation period, and the corneal epithelial staining scores were significantly decreased at 3 months post treatment.

CONCLUSIONS

In dry-eye patients with Sjögren's syndrome, treatment with 3% diquafosol ophthalmic solution improved both symptoms and signs, and that effectiveness was maintained for 12 months.

Associations between subjective happiness and dry eye disease: a new perspective from the Osaka study

Importance

Dry eye disease has become an important health problem. A lack of concordance between self-reported symptoms and the outcome of dry eye examinations has raised questions about dry eye disease.

Objective

To explore the association between subjective happiness and objective and subjective symptoms of dry eye disease.

Design

The study adopted a cross-sectional design.

Setting

All the employees of a company in Osaka, Japan.

Participants

672 Japanese office workers using Visual Display Terminals (age range: 26–64 years).

Methods

The dry eye measurement tools included the Schirmer test, conjunctivocorneal staining, the tear film break-up time, as well as the administration of a dry eye symptoms questionnaire. Happiness was measured by the Subjective Happiness Scale.

Main Outcome Measures

Dry eye examination parameters, dry eye symptoms questionnaires, and the Subjective Happiness Scale score.

Results

Of the 672 workers, 561 (83.5%) completed the questionnaires and examinations. The mean Subjective Happiness Scale score was 4.91 (SD = 1.01). This score was inversely correlated with the dry eye symptom score (r = -0.188, p < 0.001), but was not associated with objective findings which include conjunctivocorneal staining, low Schirmer test score, or low tear film break-up time. The level of subjective happiness was the lowest in the group without objective results, but reported subjective symptoms of dry eyes (p < 0.05).

Conclusions and Relevance

There is evidence of the relationship between subjective happiness and self-reported symptoms of dry eyes. Findings of this study revealed a new perspective on dry eye disease, including the potential for innovative treatments of a specific population with dry eye disease.

The Association between Dry Eye Disease and Physical Activity as well as Sedentary Behavior: Results from the Osaka Study

Purpose. To assess the association of dry eye disease (DED) with physical activity and sedentary behavior. Methods. The cross-sectional survey conducted included Japanese office workers who use visual display terminals (n = 672). DED was assessed according to the Japanese Dry Eye Diagnostic Criteria, and participants were categorized into "definite DED," "probable DED," or "non-DED" groups based on the results of DED examinations. Physical activity and sedentary behavior of participants were assessed using the International Physical Activity Questionnaire (IPAQ), and physical activity level was calculated in metabolic equivalent units per week (MET, min/week). Participants were classified as having a high, moderate, or low level of physical activity. Results. Participants with abnormal tear break-up time (BUT) (≤5 s) were involved in sedentary behavior for significantly longer duration than those with normal BUT (P = 0.035). Non-DED participants (14.5%) tended to have higher levels of physical activity than definite DED participants (2.5%). Participants with definite DED had significantly lower MET scores than those with non-DED (P = 0.025). Conclusions. Our findings suggest that a lower level of physical activity and sedentary behavior are associated with DED; however, longitudinal/intervention studies with large groups of participants are needed to validate these findings.

Alteration of tear mucin 5AC in office workers using visual display terminals: The Osaka Study

IMPORTANCE

There are limited reports on the relationship between mucin 5AC (MUC5AC) concentrations in tears, working hours, and the frequency of ocular symptoms in visual display terminal (VDT) users. This investigation evaluated these relationships among patients with dry eye disease (DED) and individuals serving as controls.

OBJECTIVE

To determine the relationship between MUC5AC concentration in the tears of VDT users based on the diagnosis of DED and frequency of ocular symptoms.

DESIGN, SETTING, AND PARTICIPANTS

An institutional, cross-sectional study was conducted. Participants included 96 young and middle-aged Japanese office workers. Both eyes of 96 volunteers (60 men and 36 women) were studied. Participants working in a company that used VDTs completed questionnaires about their working hours and the frequency of ocular symptoms. Dry eye disease was diagnosed as definite or probable, or it was not present. Tear fluid was collected from the inferior fornix after instillation of 50 μL of sterilized saline. The MUC5AC concentration was normalized to tear protein content and expressed as MUC5AC (nanograms) per tear protein (milligrams). The differences in MUC5AC concentration between DED groups, between VDT working hours (short, intermediate, and long), and between symptomatic and asymptomatic groups were evaluated with 95% CIs based on nonparametric Hodges-Lehmann determination.

MAIN OUTCOMES AND MEASURES

Ocular surface evaluation, prevalence of DED, and MUC5AC concentration.

RESULTS

The prevalence of definite and probable DED was 9% (n = 9) and 57% (n = 55), respectively. The mean MUC5AC concentration was lower in the tears of VDT users with definite DED than in those with no DED (P = .02; Hodges-Lehmann estimator, -2.17; 95% CI, -4.67 to -0.30). The mean MUC5AC concentration in tears was lower in the group that worked longer hours than in the group that worked shorter hours (P = .049; estimated difference, -1.65; 95% CI, -3.12 to 0.00). Furthermore, MUC5AC concentration was lower in participants with symptomatic eye strain than in asymptomatic individuals (P = .001; estimated difference, -1.71; 95% CI, -2.86 to -0.63).

CONCLUSIONS AND RELEVANCE

The data obtained in the present study suggest that office workers with prolonged VDT use, as well as those with an increased frequency of eye strain, have a low MUC5AC concentration in their tears. Furthermore, MUC5AC concentration in the tears of patients with DED may be lower than that in individuals without DED.

[Treatment progress of large-size puncta and clinical investigation of the extrusion rate and other complications associated with large-size punctal plugs]

PURPOSE

One complication of punctal plug occlusion (PPO) is enlargement of the punctum. The purpose of the present study was to investigate large-size (over 1.0 mm) puncta after punctal plug extrusion.

SUBJECTS AND METHODS

This study involved the treatment progress of 74 large-size (over 1.0 mm) puncta in 55 eyes of 46 patients who underwent PPO. The extrusion rate and other complications of the total 133 punctal plugs used for those puncta were investigated.

RESULTS

Of the 74 puncta, 33 (44%) achieved occlusion by PPO alone, 20 (27%) achieved perfect occlusion of granulation, and 21 (29%) required surgical punctal occlusion. Although larger or longer punctal plug sizes have been used for PPO, the average elapsed time until extrusion was 143.5 +/- 217.0 (mean +/- SD) days, and the time until 50% of the plugs were extruded was 50 days. No significant extrusion rate was found among the punctal plugs, and there was 0% migration rate. Granulation was observed in 20.3% of the plugs, yet no soft whitish material was seen around the plugs.

CONCLUSION

The findings of this study show that large-size puncta can successfully be occluded for a fixed period of time following PPO.

[Clinical investigation of extrusion rate and other complications associated with Punctal Plug F]

PURPOSE

To investigate the effectiveness, extrusion rate and other complications of Punctal Plug F (PPF) compared with Punctal Plug (PP), Super-Flex plug (SFP) and SuperEagle plug (SEP).

SUBJECTS AND METHODS

This study involved 31 eyes of 24 dry-eye patients treated with PPF at the dry-eye clinic of Kyoto Prefectural University of Medicine, Kyoto, Japan. Intracanalicular migration rate, extrusion rate, granulation rate, accumulation of soft whitish material and enlargement of punctum size after punctal-plug extrusion were investigated and compared with previously published results of PP, SFP and SEP.

RESULTS

No migration was observed in the PPF cases at the time of insertion. The extrusion rate was 43.5% during follow-up periods. The average time to extrusion was 158.2 +/- 175.7 (mean +/- SD) days, and the time until 50% of plugs were extruded was 234 days, longer than that in the SFP cases (p = 0.0012). Granulation was seen in 4.3% of the eyes, but the frequency was lower than in the PP(19%, p = 0.015) and SEP cases (34.5%, p < 0.0001). No soft whitish material was seen around the PPF-cases' plugs yet significant, post-extrusion punctum size (mm) enlargement (0.78 +/- 0.14) was observed compared to pre-insertion(0.61 +/- 0.18, p < 0.001).

CONCLUSION

Our findings show that insertion of the PPF was easy and without intracanalicular migration, harder to extrude, similar to the PP, yet less susceptible to granulation formation compared with the PP.

Dry-eye screening by using a functional visual acuity measurement system: the Osaka Study

PURPOSE

We determined whether functional visual acuity (VA) parameters and a dry eyes (DEs) symptoms questionnaire could predict DEs in a population of visual terminal display (VDT) users.

METHODS

This prospective study included 491 VDT users from the Osaka Study. Subjects with definite DE, diagnosed with the presence of DE symptoms, tear abnormality (Schirmer test ≤ 5 mm or tear breakup time [TBUT] ≤ 5 seconds), and conjunctivocorneal epithelial damage (total staining score of ≥3 points), or probable DE, diagnosed with the presence of two of them, were assigned to a DE group, and the remainder to a non-DE group. Functional VA was assessed, and DE questionnaires were administered. We assessed whether univariate and discriminant analyses could determine to which group a subject belonged. Sensitivity and specificity were assessed.

RESULTS

Of 491 subjects, 320 and 171 were assigned to the DE and non-DE groups, respectively. No significant differences were observed between DE and non-DE groups in Schirmer test value and epithelial damage, but TBUT value (3.1 ± 1.5 vs. 5.9 ± 3.0 seconds). The sensitivity and specificity of single test using functional VA parameters were 59% and 49% in functional VA, 60% and 50% in visual maintenance ratio, and 83% and 30% in frequency of blinking, respectively. According to a discriminant analysis using a combination of functional VA parameters and a DE questionnaire, six variables were selected for the discriminant equation, of which area under the curve (AUC) was 0.735. Sensitivity and specificity of diagnoses predicted by the discriminant equation were 85.9% and 45.6%, respectively.

CONCLUSIONS

The discriminant equation obtained using functional VA measurement combined with a symptoms questionnaire may suggest the possibility for the first step screening of DE with unstable tear film. Since the questionnaire has an overall poor sensitivity and specificity, further amelioration may be necessary for the actual utilization of this screening tool.

Dry eye disease and work productivity loss in visual display users: the Osaka study

PURPOSE

To estimate the impact of dry eye disease (DED) on work performance and productivity in office workers using visual display terminals (VDTs).

DESIGN

Cross-sectional study.

METHODS

Six hundred seventy-two Japanese young and middle-aged office workers using VDTs completed a questionnaire that was designed to measured at-work performance deficits and productivity losses using the Japanese version of the Work Limitations Questionnaire, completed by e-mail. Using the Japanese dry eye diagnostic criteria, respondents were classified into 3 groups: definite DED, probable DED, and non DED.

RESULTS

Of the 672 office workers, 553 subjects (82.3%), including 366 men and 187 women, completed the questionnaire and underwent clinical evaluation. As for the total workplace productivity loss, the non DED group demonstrated a loss of 3.56%, those with probable DED demonstrated a loss of 4.06%, and those with definite DED demonstrated a loss of 4.82%, indicating significantly worse performance and productivity (P = .014, trend test). For the 4 subscales, DED was associated with significantly lower on-the-job time management (P = .009, trend test) and combined mental performance and interpersonal functioning (P = .011, trend test). After controlling for age, sex, VDT working hours, and diagnosis of DED, time management, physical demands, and mental and interpersonal functioning showed a significant relationship to DED (each P > .05). Annual DED productivity losses were estimated to be $6160 per employee when measured by total production and $1178 per employee calculated by wage.

CONCLUSIONS

This study indicated that there is a significant impact of DED on the total productivity of Japanese VDT users.

Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study

PURPOSE

To investigate tear function and prevalence of dry eye disease (DED) in visual display terminal (VDT) users.

DESIGN

Cross-sectional study.

METHODS

Six hundred and seventy-two young and middle-aged Japanese office workers who used VDT completed questionnaires and underwent dry eye testing. We estimated the prevalence of DED using logistic regression analysis to examine associations between DED and possible risk factors. The ocular surface feature, prevalence of DED, and risk factors were evaluated.

RESULTS

Of the 672 workers, 561 (83.5%, mean age: 43.3 ± 9.1 years) completed the questionnaire. The percentage of women with a composite outcome of definite DED or probable DED was 76.5%, which was higher than that among men (60.2%; odds ratio [OR] = 2.00; 95% confidence interval [CI], 1.29-3.10, P = .002). Workers over 30 years of age had a higher risk of DED (OR = 2.22; 95% CI, 1.06-4.66), as did workers using a VDT >8 hours per day (OR = 1.94; 95% CI, 1.22-3.09). Average Schirmer value was 18.7 ± 11.7 mm and tear break-up time (TBUT) was 4.0 ± 2.5 seconds (78.6% of study participants had TBUT ≤5 seconds).

CONCLUSIONS

DED is prevalent among young to middle-aged Japanese VDT users. Ophthalmic findings revealed short TBUT and corneal staining accompanied by normal Schirmer test values. Increased risk for DED was noted for women aged over 30 years and prolonged VDT use. Measures to modify the adverse impact of VDT use on the ocular surface may provide a positive impact on public health and quality of life for office workers using VDTs.

[Clinical investigation of the extrusion rate and other complications of the SuperEagle plug]

PURPOSE

Punctal occlusion using a silicone plug is reported as an effective way of treating severe dry eye. The purpose of this study is to investigate the migration, extrusion rate and complications of the SuperEagle plug (Eagle Vision)

SUBJECTS AND METHODS

This study involved 148 puncta in 64 eyes of 85 patients (13 eyes of 10 men, 72 eyes of 54 women; mean age: 57.8 +/- 16.6 years [mean +/- standard deviation]) with severe dry eye who underwent punctual occlusion using a SuperEagle plug during the period of May 2009 to September 2010 at our dry eye clinic. We investigated the intracanalicular migration rate, extrusion rate, granulation rate, accumulation of soft whitish material and enlargement of punctum size after extrusion.

RESULTS

The migration rate was 0%. The extrusion rate was 57.4% during follow up periods. The average time to extrusion was 92.4 +/- 82.2 days, and the time until 50% of plugs were extruded was 154 days. Granulation was seen in 34.5% of the eyes. 52.9% of puncta that granulation was formed was completely occluded by granulation after extrusion. The accumulation of soft whitish material was not seen in any of the puncta. There was no significant change in the size of the puncta before insertion or after extrusion.

CONCLUSION

The insertion of the SuperEagle plug was easy and without intracanalicular migration. Complete punctual occlusion by granulation after extrusion occurred.

[Clinical characteristics of short tear film breakup time (BUT) -type dry eye]

PURPOSE

To evaluate the clinical characteristics and management of short tear film breakup time (BUT) -type dry eye.

METHODS

Clinical background and post-treatment changes of symptoms in 77 patients with short BUT -type dry eye were investigated. Treatment consisted of artificial-tear eye-drop instillation and, if necessary, the addition of a low-density-level steroid, hyaluronic acid, a low-density-level cyclopentolate prepared by ourselves and punctal plugs inserted into the upper and lower lacrimal puncta.

RESULTS

There were three times more women than men among the patients, and the peak age of occurrence was in the twenties in the men and in the sixties in the women. Our findings show that visual display terminal (VDT) work, contact lens (CL) wear, and changes in the sex hormones may initiate subjective symptoms. Some patients had simultaneous conjunctivochalasis, allergic conjunctivitis, and meibomian gland dysfunction. Nineteen patients (24.7%) were effectively treated with eye-drop instillation alone. Thirty-seven patients (48.1%) required punctal-plug insertion, which was completely effective in only 8 of them (21.6%).

CONCLUSION

Mainly young men and menopausal women contract short BUT -type dry eye. Changes in sex hormones, VDT work and CL wear may be causal, and the disease cannot be controlled by eyedrop and punctal-plug treatment alone.

[Eyelid surgery for refractory filamentary keratitis]

PURPOSE

Cases of filamentary keratitis that are unresponsive to conventional medical treatment methods are often encountered in the clinical setting. Here we report on cases of filamentary keratitis that showed no recurrence for long periods after performing eyelid surgery.

SUBJECTS AND METHODS

Enrolled were 17 eyes of 13 patients with filamentary keratitis who had eyelid surgery (4 men and 9 women ranging in age from 54-89 years; mean age: 73.6 years). Ptosis operations were performed with blepharoptosis (14 eyes of 11 patients) and entropion operations were performed on cases with filamentary keratitis but without entropion (3 eyes of 2 patients).

RESULTS

Following blepharoptosis, the filamentary keratitis disappeared in all cases except in one which experienced a recurrence of filamentary keratitis probably due to the recurrence of ptosis. However, the filamentary keratitis in that case also disappeared following reoperation for the blepharoptosis. After entropion surgery, the keratitis disappeared in all cases with eye drops.

CONCLUSION

The satisfactory, long-term postoperative results obtained in this study suggest that eyelid surgery is an effective treatment for filamentary keratitis unresponsive to conventional medical treatment methods.

Transforming growth factor-β decreases the cancer-initiating cell population within diffuse-type gastric carcinoma cells

Stem cells in normal tissues and cancer-initiating cells (CICs) are known to be enriched in side population (SP) cells. However, the factors responsible for the regulation of expression of ABCG2, involved in efflux of dyes, in SP cells have not been fully investigated. Here, we characterized the SP cells within diffuse-type gastric carcinoma, and examined the effects of transforming growth factor-β (TGF-β) on SP cells. Diffuse-type gastric carcinoma cells established from four independent patients universally contained SP cells between 1 and 4% of total cells, which displayed greater tumorigenicity than non-SP cells did. TGF-β repressed the transcription of ABCG2 through direct binding of Smad2/3 to its promoter/enhancer, and the number of SP cells and the tumor-forming ability of cancer cells were decreased by TGF-β, although ABCG2 is not directly involved in the tumor-forming ability of SP cells. Cancer cells from metastatic site expressed much higher levels of ABCG2 and included a greater percentage of SP cells than parental cancer cells did. SP cells are thus responsible for the progression of diffuse-type gastric carcinoma, and TGF-β negatively contributes to maintain the CICs within the cancer.

Transforming growth factor-β decreases the cancer-initiating cell population within diffuse-type gastric carcinoma cells

Stem cells in normal tissues and cancer-initiating cells (CICs) are known to be enriched in side population (SP) cells. However, the factors responsible for the regulation of expression of ABCG2, involved in efflux of dyes, in SP cells have not been fully investigated. Here, we characterized the SP cells within diffuse-type gastric carcinoma, and examined the effects of transforming growth factor-β (TGF-β) on SP cells. Diffuse-type gastric carcinoma cells established from four independent patients universally contained SP cells between 1 and 4% of total cells, which displayed greater tumorigenicity than non-SP cells did. TGF-β repressed the transcription of ABCG2 through direct binding of Smad2/3 to its promoter/enhancer, and the number of SP cells and the tumor-forming ability of cancer cells were decreased by TGF-β, although ABCG2 is not directly involved in the tumor-forming ability of SP cells. Cancer cells from metastatic site expressed much higher levels of ABCG2 and included a greater percentage of SP cells than parental cancer cells did. SP cells are thus responsible for the progression of diffuse-type gastric carcinoma, and TGF-β negatively contributes to maintain the CICs within the cancer.

Radio frequency ion source operated with field effect transistor based radio frequency system

Characteristics of radio frequency (RF) plasma production are investigated using a field effect transistor inverter power supply as an RF wave source. With the frequency of around 0.3 MHz, an electron density over 10(18) m(-3) is produced in argon plasma. Although lower densities are obtained in hydrogen plasma, it drastically increased up to 5x10(18) m(-3) with an axial magnetic field of around 100 G applied in the driver region. Effects of the magnetic field and gas pressure are investigated in the RF produced plasma with the frequency of several hundred kilohertz.

Retention of reversibly thermo-gelling timolol on the human ocular surface studied by video meniscometry

PURPOSE

To investigate the retention of reversibly thermo-gelling timolol (TG-timolol) on the human ocular surface using video meniscometry.

METHODS

The study population consisted of 14 healthy volunteers with no external eye disease. Fifteen microl TG-timolol were instilled into one eye of each subject and the same volume of aqueous, timolol ophthalmic solution was instilled in the fellow eye, in a masked fashion. Tear meniscus curvature was monitored at the center of the lower meniscus in each eye, using a newly-developed video meniscometer, before and at one-minute intervals for ten minutes after, the instillation. The radius of meniscus curvature (R) was calculated from printed video-images using the concave mirror formula. The change in R with time after instillation was compared for the two groups.

RESULTS

The change in meniscus radius with time t [defined as deltaR(t) = R(t) - R(0)] showed a significant exponential regression in both the TG-timolol and the timolol groups. There was a significant difference in the value of deltaR(5) and deltaR(10) between eyes with TG-timolol [deltaR(5) = 0.29 mm, deltaR(10) = 0.18mm] and eyes with timolol only [deltaR(5) = 0.10mm, deltaR(10) = 0.06 mm] [deltaR(5): P < 0.001, deltaR(10): P < 0.001]. The area under each regression curve of deltaR(t), an indicator of vehicle retention, was greater in the eyes treated with TG-timolol than in those receiving timolol only (2.09 vs. 0.56, P < 0.001).

CONCLUSIONS

The present study demonstrated that the reversibly thermo-gelling timolol was better retained at the ocular surface than conventional, aqueous timolol.

New Instruments for Dry Eye Diagnosis

Several non-invasive techniques for dry eye diagnosis have been developed in the past decade. These include quantitative assessment of tear volume, tear film stability, tear dynamics, and integrity of ocular surface epithelium. A combination of meniscometry and interferometry is useful for proving focal dry eye, by confirming whether or not tears at the meniscus have an effect on the ocular surface. Interferometer is also useful to evaluate tear dynamics on soft contact lenses. Fluorophotometry is useful for assessing the severity of dry eye from the view point of corneal epithelial barrier function and measuring the tear turnover rate. Both video-meibography and meibometry are useful for screening meibomian gland dysfunction. The advances in these techniques accumulate knowledge regarding pathophysiology of dry eye and allow precise diagnosis of dry eye. More targeted treatment will become feasible based on the clearer pathophysiology.

[Clinical investigation of the extrusion rate and other complications of the new Super Flex Plug punctal plug and other plugs]

PURPOSE

Currently, there are only three punctum plugs available for use in Japan [EaglePlug (EP), Eagle Flex Plug (FP), and Punctal Plug (PP)]. This study investigated the effectiveness of the newly marketed Super Flex Plug (SFP).

SUBJECTS AND METHODS

This study involved 291 eyes of 224 severe dry eye patients treated at the dry eye clinic of Kyoto Prefectural University of Medicine, Kyoto, Japan. For the SFP, EP, FP, and PP, this study compared the extrusion rate of each plug and other complications, including enlargement of the size of the punctum after extrusion, granulation, and the accumulation of soft whitish material around the plugs.

RESULTS

During the evaluation periods, the elapsed times until extrusion were significantly longer for SFP than for EP and FP(p<0.001). In all cases, there was a significant enlargement of the size of the punctum (mm) after extrusion of the SFP [0.74 +/- 0.13 (mean +/- SD)] as compared to that before insertion [0.62 +/- 0.14 (p < 0.0001)]. Granulation formed in 1.7% of the SFP cases, but the frequency was lower than that in PP cases (19%). No soft whitish material around the plug was seen in SFP-inserted eyes.

CONCLUSION

The SFP was harder to extrude, and was found to cause granulation. After extrusion of the SFP, the punctum was likely to be enlarged.

A Newly Developed Video-Meibography System Featuring a Newly Designed Probe

PURPOSE

To demonstrate the usefulness of a video-meibography system featuring our newly designed probe.

METHODS

This study utilized a newly designed probe featuring an obliquely inclined, T-shaped head containing 16 windows in the portion of the probe applied for emitting infrared light. The transilluminated structure of the meibomian gland is conducted to a highly sensitive, infrared charge-coupled device video camera and recorded digitally. The utility of the new probe was compared with the intraocular illumination probe traditionally used for meibography, both being applied to the eyelids of ten healthy volunteers and ten patients with meibomian gland dysfunction. The results were then analyzed.

RESULTS

The newly designed probe facilitated eyelid eversion and transilluminated the meibomian gland structure effectively. Moreover, subjects experienced no irritation and only limited invasiveness when the new probe was applied.

CONCLUSIONS

Our meibography system featuring the newly designed probe provided greater ease of use, an improved visualization of the meibomian gland structure, and increased comfort for patients during the examination.

Establishment of a cultivated human conjunctival epithelium as an alternative tissue source for autologous corneal epithelial transplantation

PURPOSE

The corneal epithelium is essential for maintaining corneal transparency, and efforts have been made to develop improved techniques for corneal epithelial transplantation in patients with total limbal failure. We evaluated the suitability of transplanted cultivated human conjunctival epithelium (HCjE) as a corneal epithelium replacement in rabbits with total corneal and limbal deficiency.

METHODS

HCjE cells, cultivated on human amniotic membrane (AM) to confluence and exposed to an air-liquid interface (air-lifted), were transplanted onto denuded rabbit corneas and monitored for 2 weeks. The cultivated HCjE sheet and the engrafted epithelium were analyzed by immunohistochemistry and transmission electron microscopy (TEM).

RESULTS

The transplanted HCjE remained transparent, smooth, and without epithelial defects during the follow-up period. Both the cultivated HCjE cells and the engrafted epithelium manifested five to six layers of stratified squamous epithelium similar in morphology to normal corneal epithelium. The basal cells expressed the putative stem cell markers (ABCG2 and P63) and hemidesmosome and desmosome component proteins. The cytokeratins (CK4, CK13, CK3, and CK12) and MUC4 were found in the engrafted epithelium. However, MUC5AC was not expressed. The results indicate that HCjE cultivated on AM has the potential to be used as an alternative corneal epithelium.

CONCLUSIONS

The transplantation of cultivated HCjE sheets is a promising technique for the treatment of eyes with limbal failure.

Clusters of Corneal Epithelial Cells Reside Ectopically in Human Conjunctival Epithelium

PURPOSE

The ocular surface is covered by two biologically distinct epithelia: corneal and conjunctival. The expression of keratin12 (K12) is currently considered a hallmark of cornea-type differentiation. In the current study, the biological features of K12-positive cells in human bulbar conjunctival epithelium were examined.

METHODS

Human conjunctival tissues were subjected to investigate the K12-positive cells in conjunctiva by immunostaining, in situ hybridization, Western blot analysis, reverse transcriptase-polymerase chain reaction (RT-PCR), and fluorescence-activated cell sorting (FACS). Gene expression profiling of these cells was performed with introduced amplified-fragment length polymorphism (iAFLP). To determine the presence of stem- or progenitor cells, immunostaining and colony-forming assays were performed.

RESULTS

Western blot analysis, RT-PCR revealed that K12 was expressed in conjunctival epithelium. Immunostaining analysis showed that K12-positive cells reside mainly in clusters in conjunctival epithelium. FACS analysis showed that 0.2% to 1.7% of conjunctival epithelial cells collected from the inferior bulbar conjunctiva were K12 positive. iAFLP analysis revealed that the gene expression patterns of these cells were highly similar to that of corneal epithelial cells. p63 and ABCG2 were expressed beneath the K12-positive cells. Some colony-forming cells expressed K12.

CONCLUSIONS

The K12-positive cells appear to be ectopically residing, self-maintaining corneal epithelial cells in the conjunctival epithelium.

Clinical Impact of Conjunctivochalasis on the Ocular Surface

PURPOSE

To report the clinical impact of conjunctivochalasis on the ocular surface by evaluating the effect of a new concept of conjunctivochalasis operation on the resolution of patients' symptoms and corneal epithelial damage. Also, the association of inflammation with conjunctivochalasis is examined.

PATIENTS AND METHODS

A total of 168 eyes of 131 conjunctivochalasis patients with (50 eyes) or without (118 eyes) dry eye who received the newly designed conjunctivochalasis operation were enrolled. All patients had prominent conjunctivochalasis at the lower tear meniscus and their ocular symptoms were not sufficiently controlled by the usual eyedrop therapy. Subjective symptoms of patients were assessed before and after the operation by questionnaires. Scores of corneal fluorescein staining were evaluated before and after the operation in patients with dry eye. Four samples of the lower part of conjunctiva from non-dry eye conjunctivochalasis patients were investigated by immunostaining and compared with samples from 4 normal conjunctiva and 3 conjunctiva showing inflammation due to Mooren ulcer, ocular cicatricial pemphigoid, and alkali burn.

RESULTS

The most frequent chief subjective symptoms before the operation were irritation (51.7%) and lacrimation (31.4%) in conjunctivochalasis patients without dry eye and irritation (80.0%) in those with dry eye. Improvement of the chief symptoms was obtained in 88.2% and 78.0% of these 2 patient groups, respectively. Furthermore, in patients with dry eye, corneal fluorescein staining scores (mean+/-SD) were significantly improved after the operation compared with before the operation: A (area), 0.6+/-0.7 and D (density), 0.8+/-0.9 versus A, 1.3+/-0.5 and D, 1.9+/-0.9; P<0.0001. Based on the immunostaining study, conjunctival samples from eyes with conjunctivochalasis and normal eyes showed negligible inflammation compared with those from inflamed conjunctiva.

CONCLUSIONS

This study suggests that conjunctivochalasis has a great clinical impact on the ocular surface, and the newly developed operation is very effective in resolving patient complaints and also ocular surface damage in conjunctivochalasis with dry eye. It may also be suggested that the conjunctivochalasis has a negligible association with conjunctival inflammation.

Pathological keratinisation in the conjunctival epithelium of Sjögren's syndrome

Our previous gene expression analysis suggested that conjunctival epithelial cells of Sjögren's syndrome (SS) are inclined to hyper-proliferation and keratinisation status. The goal of this study is to elucidate whether such pathological situations really exist in the conjunctival epithelium of SS. Also, involvement of inflammatory cytokines in this disease was investigated. Conjunctival tissues or cells obtained from 12 SS patients and 13 normal subjects were subjected to indirect immunostaining to analyse expression of transglutaminase 1 (TGase1), involucrin, keratins 1, 4, 10 and 13. The number of proliferative cells was also analysed by immunostaining of Ki67 antigen. Additionally, changes in gene expression of TGase1 and involucrin after stimulation by IL-1 or IFN-gamma were quantified by real-time RT-PCR. TGase1 and involucrin were up-regulated in the conjunctival epithelium of SS patients. Although not statistically significant, Ki67 positive proliferative cells were slightly increased in SS patients. IFN-gamma stimulation significantly up-regulated TGase1 and unexpectedly repressed involucrin gene expression. IL-1 did not render any significant changes in the expression of these genes. These results suggest the existence of pathological keratinisation in the conjunctival epithelium of SS and also support our hypothesis that inflammatory cytokines may be involved in the ocular surface pathological changes in SS.

[Study of change of size of the punctum before insertion and after extrusion of a punctal plug and selection of an appropriate plug for reinsertion]

PURPOSE

In cases when the reinsertion of punctal plugs is considered, enlargement of the punctum is often experienced and a larger punctal plug is sometimes required for reinsertion. We therefore investigated the change in the size of the punctum before insertion and after extrusion of a punctal plug and the selection of an appropriate punctal plug for reinsertion.

SUBJECTS AND METHODS

There were 70 cases where punctal plugs were reinserted (37 eyes from 32 patients) because of extrusion of the plugs. A retrospective study was performed with regard to the change in the size of the punctum before insertion and after extrusion of the punctal plugs, and with regard to the type of plug reinserted.

RESULTS

There were significant changes in the size of the punctum before insertion [0.70 +/- 0.09 (mean +/- standard deviation) mm] and after extrusion (0.78 +/- 0.07 mm) of the punctal plug (p < 0.001). In 22 cases of 23 cases which experienced extrusion of the 0.8 mm Eagle plug (EP; Eagle Vision), Punctal plugs (PP; FCI) of M size were selected for reinsertion, because there are no EPs larger than 0.8 mm available for reinsertion.

DISCUSSION

After extrusion of the punctal plug, the punctum is likely to be enlarged, resulting in the need to select a larger punctal plug. Therefore, cases which experienced extrusion of an EP were likely to eventually have the EP replaced by a PP during follow-up treatment.

Relationship between tear volume and tear meniscus curvature

OBJECTIVE

To investigate the relationship between tear volume and tear meniscus curvature by means of the video meniscometer.

METHODS

Eleven eyes of 11 patients with severe dry eye were studied (all female; mean +/- SD age, 66.2 +/- 7.7 years; 7 left eyes and 4 right eyes), each of whose puncta had been therapeutically occluded. Four instillations of balanced salt solution were given at intervals of 1 minute in each studied eye, with the concentration increasing in 5-microL steps from 5 to 20 microL. Before and after the instillation of balanced salt solution, tear meniscus changes were recorded by video meniscometer and radius of the meniscus was calculated from the printed images by means of the concave mirror formula.

RESULTS

The mean radius of the meniscus increased linearly with increased drop volume (r(2) = 0.65, P<.001), with mean +/- SD radius values of 0.24 +/- 0.08 mm at baseline and 0.48 +/- 0.13, 0.62 +/- 0.13, 0.84 +/- 0.26, and 1.00 +/- 0.32 mm after separate instillations of 5, 10, 15, and 20 microL of balanced salt solution, respectively. For each subject, a significantly different slope defining the relationship between instilled volume and meniscus radius was seen (0.016-0.063 mm/ microL; mean +/- SD, 0.039 +/- 0.015 mm/ microL), which was thought to depend on the difference in capacity of the fluid reservoir over the ocular surface.

CONCLUSIONS

This study confirmed that the volume of instilled eyedrops is linearly related to the resulting radius of the tear meniscus, suggesting that this radius is a useful measure in monitoring the tear volume. This is likely to have implications both for dry eye diagnosis and for confirming the efficacy of punctal occlusion in this condition.

[New surgical methods for punctal occlusion of severe tear-deficient dry eye and its outcome]

PURPOSE

Although several surgical methods for punctal occlusion have been reported, it is difficult to obtain complete punctal occlusion in all cases since recanalization of the punctum often occurs after the operation. In this report, new surgical procedures to obtain sufficient occlusion of punctum are introduced and the outcome of the present method is compared with that of previous methods.

SUBJECTS AND METHODS

Subjects were 33 severe tear-deficient dry eye patients (4 males and 29 females; mean age: 54.3 yrs.) and they were considered as candidates for punctal occlusion of both upper and lower puncta. The previous surgical punctal occlusion method had been performed in 12 cases (group A: 10 females and 2 males) and the newly-developed method was applied to 21 cases (group B : 19 females and 2 males). Corneal epithelial damage(scored with AD classification; A : area, D : density, scored from 0 to 3) was compared before and after the treatment and the control-lability of dry eye with only an artificial tear preparation was compared between the previous and the new methods. The newly-developed surgical procedures include the following steps: (1) diathermy of the epithelium of the canaliculus using a newly-designed electric needle for diathermy, (2) full removal of the epithelium of the canaliculus using a hand motor drill, (3) cutting the punctum at two opposite points parallel to the lid margin, (4) suturing the punctum to close the cut punctum with 10-0 nylon or 8-0 absorbable sutures.

RESULTS

In group A, corneal epithelial damage improved a little from A, D : 2.4, 2.1 to A, D: 1.8, 1.9 during an average of 7.2 months of alone follow-up, and only 2 of the 12 cases obtained control with eye drops. In group B, the corneal epithelial damage improved significantly from A, D : 2.1, 2.2 to A, D : 1.0, 1.3 during an average of 8.2 months of follow-up, and all cases obtained control with eye drops alone.

CONCLUSION

The new surgical methods are regarded as a more complete way of performing surgical punctal occlusion compared to previous methods.

Non-invasive methods of assessing the tear film

The interaction between the tear film and the ocular surface epithelium is crucial for the maintenance of ocular surface health; interference with this relationship may cause dry eye. Several diagnostic techniques have been developed to assess the tear film and diagnose dry eye but many of these tests are invasive and modify the parameter which they are designed to measure. Non-invasive or minimally invasive tests may overcome this problem and provide more reproducible and objective data. One test of this kind is meniscometry, which is particularly useful in assessing tear volume indirectly by measuring tear meniscus radius. The newly developed video-meniscometer, which enables calculation of the meniscus radius digitally, is useful for the diagnosis of tear-deficient dry eye. Video-meniscometry also has other applications, to the study of tear and eye drop turnover, determining the indication for punctal plugs and in demonstrating dysfunction of the tear meniscus. Interferometry of the tear film lipid layer is useful in screening and evaluating dry eye severity and in selecting dry eye candidates for punctal occlusion. It is also useful for analysing tear lipid layer pathophysiology more clearly, especially in combination with meniscometry. Meibometry is a minimally invasive technique to quantify the amount of meibomian lipid on the lid margin. Lipid is blotted onto a plastic tape and the change in optical density is used to calculate lipid uptake. Laser meibometry has increased the scope of this technique for the assessment of meibomian gland dysfunction; also, the delivery of lipids from the lid reservoir to the preocular tear film can be analysed using interferometry and laser meibometry. The present report reviews the application of these techniques to the study of tear film physiology and dry eye.

[Clinical investigation of extrusion of a new punctal plug(Flex Plug)]

PURPOSE

Punctal occlusion using punctal plugs is very effective for the treatment of tear-deficient dry eye. We compared the newly marketed Flex Plug (FP, Eagle Vision Co., Ltd.) and the Eagle Plug (EP, Eagle Vision Co., Ltd.).

SUBJECTS AND METHODS

The subjects were patients with severe tear-deficient dry eye who were treated in our dry eye clinic. FP plugs in 8 patients (9 eyes) and EP plugs in 29 patients (35 eyes) were compared during over 4 months of observation with regard to the time until extrusion and the possibility for re-insertion of the plugs.

RESULTS

During the 4 months after insertion of the plugs, the EP plugs were extruded from 35 of 51 puncta (68.6%) and the FP plugs were extruded from 4 of 13 puncta (30.8%). In the 35 EP extrusions and in the 4 FP extrusions, re-insertion was possible. The time period until extrusion was longer for FP than for EP. In all cases, for both EP and FP, pyogenic granuloma was not observed.

DISCUSSION

The extrusion rate for EP plugs was much greater than for FP plugs (68.6% to 30.8%). Pyogenic granuloma was not observed in any instance for both types of punctal plugs.

[Age-related changes in the mucocutaneous junction and the conjunctivochalasis in the lower lid margins]

PURPOSE

We investigated the age-related changes in the mucocutaneous junction and the conjunctivochalasis at the lower lid margin, and whether there is a correlation between the two or not.

SUBJECT AND METHODS

Sixty eyes of sixty patients without ocular surface disorders were examined and they were divided into six groups by age (20-29, 30-39, 40-49, 50-59, 60-69 and 70-79 years old) and sex(five males and five females in each age group). The lower lid margins were divided into three parts(the temporal third, the middle third, and the nasal third) and the anteroplacement of the mucocutaneous junction and the conjunctivochalasis were graded 0, 1, 2 and 3.

RESULT

In each part of the lower lid margins, there were significant age-related increases in both parameters(p < 0.005, p < 0.0001 respectively). Also, the grade of the anteroplacement of mucocutaneous junction increased with the grade of conjunctivochalasis.

CONCLUSION

These findings suggest that there is a relationship between the anteroplacement of the mucocutaneous junction and the conjunctivochalasis with aging.

[Comparison of extrusion rate for two different design of punctal plugs]

PURPOSE

Punctal occlusion using a silicone plug is an effective treatment for severe tear-deficient dry eye. At present, plugs from two companies are available in Japan [Eagle plug(EP); Eagle Vision, Punctal plug(PP); FCI]. We compared the extrusion rate between EP and PP in our dry eye clinic.

SUBJECTS AND METHODS

Subjects were 20 eyes of 18 patients for EP [5 eyes from 5 males, 15 eyes from 13 females, age: 58.1 +/- 17.5(mean +/- standard deviation)] and 76 eyes of 51 patients for PP (6 eyes from 5 males, 70 eyes from 46 females, age: 58.6 +/- 13.4), 62 eyes from 44 patients with Sjögren syndrome, 34 eyes from 25 patients with non-Sjögren syndrome with severe tear-deficient dry eye treated for the period of November 1996 to February 2002 in our dry eye clinic. We compared the extrusion rate for each plug and necessity of reinsertion of the plug.

RESULTS

In the examination for EP, 72.2% plugs were extruded during the follow-up periods, and the average period(59 days) until the extrusion was significantly shorter than for PP(p < 0.0001). In the examination for PP, 55.9% were extruded, and the average period until the extrusion was 287 days. Significant improvement of corneal epithelial damage was seen with PP after insertion of the plug. For the PP, reinsertion of plugs was sometimes impossible, probably because of the granulation formed inside the canaliculus, while for EP, reinsertion of the plugs was possible for all cases.

DISCUSSION

EP becomes extruded more easily than PP, and PP is seems for to form granulation more easily.

Propofol pharmacokinetics in a dwarfism patient

Pharmacokinetic information is important to control anesthetic depth. However, there are few available pharmacokinetic data of propofol in dwarfism patients. We anesthetized a dwarfism patient who underwent spinal decompression, and investigated the pharmacokinetics of propofol. The patient was a 40-year-old man suffering from muscle weakness and numbness in the arms. The operation consisted of two stages; anterior approach in the supine position and posterior approach in the prone position. We also obtained arterial blood for pharmacokinetic analysis. Distribution volume at steady-state and clearance in the supine position was 180 and 0.92 l min- 1, respectively, and in the prone position 127 and 0.74 l min- 1, respectively, in spite of a continuous infusion of dopamine. The data in the supine position were well predicted by Gepts' parameters (used in Diprifusor Zeneca Ltd, Cheshire, UK), which means the target-controlled infusion (TCI) technique can be available in the supine position, while attention is necessary to avoid overdosing when a patient is placed in the prone position.

New surgical treatment for superior limbic keratoconjunctivitis and its association with conjunctivochalasis

PURPOSE

To introduce a new surgical procedure for treating superior limbic keratoconjunctivitis (SLK) and to suggest the association of SLK with conjunctivochalasis.

DESIGN

Interventional case series.

METHODS

Six eyes of five patients with long-standing severe ocular irritation unresponsive to treatment with topical steroid and artificial tears were operated on using our new procedure. This technique consists of four steps as follows: (1) Rose bengal (RB) staining is used to localize the abnormal conjunctival area; (2) an arc-like conjunctival incision is placed from the 2 to the 10 o'clock position adjacent and distal to the RB-stained area; (3) the conjunctiva is resected to form a crescent using the arc-like incision as the base; the size of the resection is determined by conjunctival redundancy after removal of the subconjunctival connective tissue; and (4) the crescent conjunctival opening is closed with interrupted sutures. In two eyes, the new surgical procedure was performed together with surgery for inferior bulbar conjunctivochalasis.

RESULTS

In all operated eyes, RB staining had disappeared by the end of the second postoperative week; recovery from symptoms and loss of inflammation were recorded by 1 month after treatment. In the case with the longest follow-up (14 months), there was cytologic evidence of goblet cell recovery at 3 months after the operation. In another, there was normalization of the nucleo/cytoplasmic ratio of conjunctival cells without the appearance of goblet cells.

CONCLUSIONS

Our treatment very effectively resolved symptoms associated with SLK, even in eyes unresponsive to conventional therapy with eye drops. Considering that we did not address the diseased part of the conjunctiva but rather the adjacent conjunctival redundancy, we propose that superior bulbar conjunctivochalasis is involved in the pathogenesis of SLK.

Influence of latanoprost on the corneal epithelial barrier function in glaucoma patients

AIM

To evaluate the influence of topically administered latanoprost, a prostaglandin F(2alpha) analog, on the corneal epithelial barrier function.

PATIENTS AND METHODS

Twenty-four patients suffering from a glaucoma were enrolled. Ten patients without prior topical antiglaucoma medication received topical latanoprost (0.005%, once daily) for 30 days (monotherapy group); 14 patients receiving topical antiglaucoma medication also received latanoprost (0.005%, once daily) for 180 days (combination treatment group). Before and 30 days after treatment (monotherapy group) and before and 30 and 180 days after treatment (combination group), the corneal epithelial barrier function was measured by a fluorophotometric technique.

RESULTS

The fluorescein uptakes in the monotherapy group were 54.6 +/- (SE) 7.5 and 57.1 +/- 11.0 ng/ml before and 30 days after treatment, respectively (p = 0.81). In the combination group, the uptakes were 101.0 +/- 18.3 and 118.9 +/- 25.9 ng/ml (p = 0.38) and 93.4 +/- 17.5 ng/ml (p = 0.58) before and 30 and 180 days after treatment, respectively.

CONCLUSION

The corneal epithelial barrier function remained intact following the instillation of latanoprost in both groups.