Are cytokine patterns in aqueous humour useful in distinguishing corneal graft rejection from opacification due to herpetic stromal keratitis?

PURPOSE

Intra-ocular cytokine profiles were determined to study the immunological mechanisms of corneal graft opacification due to rejection and/or herpetic stromal keratitis (HSK).

METHODS

Sera and aqueous humour (AH) were sampled shortly after the onset of corneal graft opacification, group I (n=18). In eyes with clear grafts, samples were taken 5 months after transplantation, group II (n=59). Samples of non-inflamed eyes, prior to cataract surgery, were used to determine baseline cytokine levels, group III (n=49). Total protein (TP) levels were measured with Bradford reagent and interleukin (IL)-6, IL-10, IL-4 and interferon (IFN)-gamma with ELISAs.

RESULTS

All patients who's corneal grafts showed clinical evidence of graft opacification due to rejection and/or HSK were sampled. In the AH-samples of group I, increased levels of TP were found in 60% (9/15), IL-6 in 79% (11/14), IL-10 in 39% (7/18) and IL-4 in none (0/12). IFN-gamma was detected in 19% (3/16), in the case of HSK only. In contrast, samples obtained from patients with clear grafts in group II showed increased levels of TP in 36% (20/55), IL-6 in 14% (8/57) and IL-10, IL-4 or IFN-gamma in none (n=58).

CONCLUSIONS

During corneal graft rejection and/or HSV-infection, increased levels of TP and IL-6 in AH confirmed anterior chamber inflammation with breakdown of the blood-aqueous barrier. Based on the data presented, cytokine patterns in the AH do not appear to distinguish corneal opacification due to graft rejection from that due to herpes keratitis.

Detection of herpes simplex virus type 1, 2 and varicella zoster virus DNA in recipient corneal buttons

AIM

To study the value of polymerase chain reaction (PCR) analysis, to detect viral DNA in recipient corneal buttons taken at the time of penetrating keratoplasty (PKP) in patients with an initial diagnosis of herpetic stromal keratitis (HSK). Since HSK has a tendency to recur, an accurate diagnosis of previous HSK could be the reason to start antiviral treatment immediately, thereby possibly decreasing the number of graft failures due to recurrent herpetic keratitis.

METHODS

Recipient corneal buttons and aqueous humour (AH) samples were obtained at the time of PKP from HSK patients (n=31) and from other patients (n=78). Eye bank corneas were also used (n=23). Herpes simplex virus type 1 (HSV-1), type 2 (HSV-2), and varicella zoster virus (VZV) infection were assessed by PCR and antibody detection.

RESULTS

The clinical diagnosis HSK could be confirmed by PCR for HSV-1 in 10/31 (32%). In these corneal buttons HSV-2 DNA was detected in 1/31 (3%) and VZV DNA in 6/31 (19%). Intraocular anti-HSV antibody production was detected in 9/28 AH samples tested (32%). In the other patient derived corneas HSV-1 DNA was detected in 13/78 (17%), including eight failed corneal grafts without clinically obvious herpetic keratitis in the medical history. In clear eye bank corneas HSV-1 was detected in 1/23 (4%).

CONCLUSIONS

PCR of HSV-1 on corneal buttons can be a useful diagnostic tool in addition to detection of intraocular anti-HSV antibody production. Furthermore, the results were suggestive for the involvement of corneal HSV infection during allograft failure of corneas without previous clinical characteristic signs of herpetic keratitis.

Effect of macrophage depletion on immune effector mechanisms during corneal allograft rejection in rats

PURPOSE

In rats, corneal allograft rejection is delayed for at least 100 days by clodronate liposomes. These liposomes selectively deplete macrophages. To investigate the immunologic basis for absence of graft rejection in treated rats, the effect of these liposomes on the generation of cytotoxic T lymphocytes (CTLs) and antibody production after orthotopic corneal allotransplantation was determined.

METHODS

Transplantations of corneal buttons from PVG rats were performed in AO rats. After surgery, one group received clodronate liposomes subconjunctivally at five time points, and the other group remained untreated. On postoperative day (POD) 3, 7, 12, or 17, rats were killed, the presence of CTLs was investigated at three different anatomic locations, and antibodies against donor antigens were tested.

RESULTS

No significant differences were found between the groups tested 3 and 7 days after surgery. But on POD 12 (the time of onset of rejection in the untreated group) and on POD 17, the CTL activities detected in the submandibular lymph nodes (P < or = 0.008) and the spleen (P < or = 0.009) were significantly less in the treated groups compared with the untreated groups. In the untreated groups complement-independent antibodies were present only on POD 17, whereas no antibodies were found in the treated rats.

CONCLUSIONS

Local treatment with clodronate liposomes was shown to downregulate local and systemic CTL responses and to prevent the generation of antibodies. Local depletion of macrophages in the initiation phase of the immune response appears to lead to a less vigorous attack on the grafted tissue and therefore to promote graft survival.

Delayed graft rejection in pre-vascularised corneas after subconjunctival injection of clodronate liposomes

PURPOSE

To test the effects of clodronate liposomes on graft survival and neovascularisation after transplantation in pre-vascularised recipient corneas.

METHODS

Corneal neovascularisation was induced in F344 rats by injecting heat inactivated rabbit serum intrastromally. After 4 weeks F344 rats were orthotopically grafted with corneal buttons from DA rats. Directly after transplantation and on 2, 4, 6 and 8 days postoperatively clodronate liposomes were administrated subconjunctivally in one group, whereas the other group remained untreated. For 60 days grafts were observed for signs of graft rejection and neovascularisation.

RESULTS

Graft survival was significantly prolonged, but not prevented in clodronate liposome treated rats compared to untreated rats ( p =.004). Also clodronate liposome administration delays growth of corneal neovascularisation after transplantation.

CONCLUSIONS

Previous studies revealed that clodronate liposomes prevent corneal graft rejection and reduce neovascularisation in orthotopic corneal allotransplantation in rats. This study shows that also in pre-vascularised recipient corneas subconjunctival administration of clodronate liposomes seems to delay corneal graft rejection and reduces neovascularisation.

Changes in cytokine mRNA levels in experimental corneal allografts after local clodronate-liposome treatment

PURPOSE

Corneal allograft rejection in rats can be prevented by subconjunctival injections of liposomes containing dichloromethylene diphosphonate (clodronate-LIP), which selectively eliminate macrophages. In this study, the effect of clodronate-LIP treatment on cytokine mRNA levels in corneal allografts was examined.

METHODS

AO rats received corneal grafts of PVG rats. Rats were either not treated or injected subconjunctivally with clodronate-LIP on the day of transplantation and on postoperative days (PODs) 2, 4, 6, and 8. RNA was isolated from the graft and rim of corneas at different times after transplantation and from normal controls. Interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1RA), IL-2, IL-4, IL-6, IL-10, IL-12p40, tumor necrosis factor (TNF)-alpha, TNF-beta/lymphotoxin (LT), interferon (IFN)-gamma, monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 2 (MIP-2) mRNA levels were analyzed by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Corneal rejection, observed in all untreated rats by POD 12, was associated with increased mRNA levels of all cytokines investigated in grafts and rims. Clodronate-LIP treatment prevented allograft rejection and strongly decreased the levels of IL-1beta, IL-1RA, IL-2, IL-4, IL-6, IL-10, IFN-gamma, TNF-beta/LT, MCP-1, and MIP-2 mRNA in grafts and IL-1 beta, IL-2, IL-4, IL-6, and IFN-gamma mRNA in rims. Interleukin-12p40 mRNA levels were unaltered in clodronate-treated rats, except for a transient increase in grafts at POD 3. TNF-alpha mRNA levels were increased by clodronate-LIP in grafts and rims early after transplantation (PODs 3 and 7). Despite a normal appearance, long-term accepted corneal grafts (POD 100) contained mRNA for IL-10, IL-12p40, TNF-alpha, MCP-1, and MIP-2.

CONCLUSIONS

Clodronate-liposome treatment markedly altered the mRNA levels of all cytokines investigated in corneal allografts. These results may explain in part the mechanism by which clodronate-LIP treatment prevents corneal allograft rejection.

Experimental autoimmune keratitis induced in rats by anti-cornea T-cell lines

PURPOSE

Idiopathic inflammation of the cornea, keratitis, has been proposed to result from an autoimmune process, but thus far no convenient animal model of keratitis exists. An attempt was made to establish an animal model for keratitis, to investigate possible autoimmune mechanisms.

METHODS

T-cell lines were established from lymph node cells removed from rats immunized with bovine corneal epithelium (BCE) extract. After restimulation in vitro with BCE or a specific corneal antigen, the cells were transferred by intraperitoneal injection into naive rats, rats subjected to total body irradiation, or rats in which only one eye was irradiated.

RESULTS

Neither direct immunization with corneal antigens nor transfer of activated anti-corneal T-cells into naive rats gave any signs of keratitis. Irradiation alone did not induce corneal inflammation. Transfer of corneal-specific activated T cells into irradiated rats produced keratitis starting around day 4 and culminating around day 8. The disease was self-limiting and the severity dependent on the dose and site of radiation. Keratitis was characterized by corneal haze, conjunctival and episcleral hyperemia, episcleral hemorrhages, chemosis, corneal infiltrates, and vascularization. Immunohistochemistry showed T-cell and macrophage infiltration of epithelium and stroma in the affected corneas.

CONCLUSIONS

Thus, keratitis may be produced by T cells reactive to corneal antigens, provided that the target tissue has been made susceptible by irradiation. The effectiveness of T-cell vaccination in preventing adoptive keratitis suggests that systemic as well as local tissue factors may regulate the disease process.

Differential expression of two pro-opiomelanocortin mRNAs during temperature stress in common carp (Cyprinus carpio L.)

Pro-opiomelanocortin (POMC) is the precursor of a number of biologically active peptides, including adrenocorticotropic hormone, alpha-melanocyte-stimulating hormone and beta-endorphin, which are released by the pituitary glands of fish as well as mammals. To quantify the levels of expression of the two POMC mRNAs relative to one another during the response of the common carp to temperature-induced stress, we used reverse transcriptase PCR combined with capillary electrophoresis and laser-induced fluorescence detection. The ratio of POMC-I mRNA to POMC-II mRNA determined in wild-type and four isogenic carp strains was found to be strain-dependent and influenced by temperature. In strain E20xR8, the ratio had altered in favour of POMC-I from 1:3.2 (POMC-I:POMC-II) in fish adapted to 24 degreesC to 1:1.2 in fish adapted to a decrease of 9 degreesC in ambient temperature. A rapid drop in temperature from 24 to 15 degreesC decreased the POMC mRNA ratio at the expense of POMC-I from 1:1.9 in the control fish (strain E4xR3R8) to 1:4.2 3 h after the temperature drop of 9 degreesC. We conclude that both POMC genes are expressed in the common carp and that their expression ratio is strain-dependent and changes in response to ambient temperature.

Vascular expression of endothelial antigen PAL-E indicates absence of blood-ocular barriers in the normal eye

The endothelium-specific antigen PAL-E is expressed in capillaries and veins throughout the body with the exception of the brain, where the antigen is absent from anatomical sites with a patent blood-brain barrier. In this study we determined vascular endothelial staining for PAL-E in the normal eye in relation to the ocular blood-tissue barriers. Immunohistochemical staining of frozen tissue sections of eyes from 22 cornea donors and a number of normal animal autopsy eyes was performed for the PAL-E antigen and the blood-brain barrier marker glucose transporter 1. In normal human and animal eyes, endothelial PAL-E staining was absent from the microvasculature in iris, ciliary muscle, optic nerve and retina. In a few normal human eyes, some weakly stained capillaries were observed in the retina and nerve fiber layer, mostly in the peripapillary area. Marked staining of capillaries and venules with PAL-E was observed in the conjunctiva, episclera, sclera, ciliary processes, choriocapillaris and optic nerve head. In general, the endothelial antigen PAL-E is absent from microvessels involved in the blood-ocular and the blood-retinal barriers. PAL-E may therefore be a useful marker to identify pathological breakdown of blood-ocular barriers.

Cytokine mRNA expression during experimental corneal allograft rejection

Allograft rejection is the main cause of corneal graft failure. T lymphocytes and macrophages have been implied to be involved in corneal rejection, but little is known about the molecular mechanism in this process. In this study, cytokine mRNA expression in the cornea was analysed during experimental corneal transplantation. The donor and acceptor corneas of two groups of rats were studied after receiving an allo- (PVG to AO rat) or autograft (AO rat). For controls, central buttons and peripheral corneal rings of the non-transplanted contralateral eyes were used. At different post-operative days (1, 3, 7, 12 and 19), the corneas were removed and subjected to mRNA isolation. All corneal samples underwent semi-quantitative reverse transcriptase-polymerase chain reaction analysis for interleukin-1 beta, interleukin-1, receptor antagonist, interleukin-2, interleukin-4, interleukin-6, interleukin-10, tumor necrosis factor-alpha, interferon-gamma, monocyte chemotactic protein-1 and macrophage inflammatory protein-2 mRNA expression. Corneal rejection, characterized by opaque corneas with prominent neovascularization, was always diagnosed around day 12. Contralateral, non-grafted corneas showed constitutive mRNA expression for interleukin-1 receptor antagonist and in a few samples also monocyte chemotactic protein-1 and macrophage inflammatory protein-2 mRNA was found. Both allo- and autografts expressed mRNA for the cytokines found in contralateral, non-grafted tissue, as well as for interleukin-1 beta, interleukin-6, interleukin-10 and tumor necrosis factor-alpha. In allografts, the mRNA levels for these cytokines remained constant throughout all post-operative days, with increased interleukin-6 mRNA expression after post-operative day 12. The analysis of the autografts revealed high cytokine mRNA levels until post-operative day 3 or 7, which decreased from then on, except for interleukin-1 receptor antagonist. mRNA for interleukin-2, interleukin-4 and interferon-gamma was not observed in autografts at any time point and in allografts, until post-operative day 12. Interleukin-2 and interferon-gamma mRNA showed maximal expression on POD 12, while in autografts, a marked decrease was observed after POD 3. IL-10 mRNA levels decreased immediately after POD 1 in autografted eyes. For TNF-alpha, an increased mRNA expression starting on POD 7 was found in recipient rings of allografted eyes, while in autografts a weak expression was seen in some samples. MIP-2 transcription increased on PAD 12, while in autografts, its expression was not markedly different from that detected in the contralateral, non-grafted peripheral cornea.

Genetic and clinical determinants for the T cell mediated immune response against the cornea specific protein BCP 54

T cell mediated immune responses against the cornea specific protein BCP 54 have been observed in patients with uveitis, Fuchs' heterochromic cyclitis, and corneal disease. The pathophysiological role of this anti-BCP 54 response in corneal disease is not known. In order to ascertain whether the presence of such an immune response is related to the corneal disease itself or related to genetic influences, the anti-BCP 54 response was determined in 104 patients with severe corneal disease, using a monocyte migration inhibition assay. The results were compared with the presence of a variety of ocular parameters as well as with the distribution of HLA antigens in these patients. While only 7% of healthy controls responded to BCP 54, 37% of the patients showed a positive response (p = 0.002); in particular, patients with previous graft rejection, non-herpetic keratitis, and bullous keratopathy reacted against BCP 54. No relation with known risk factors for corneal transplantation, such as corneal neovascularisation, was observed. No significant association with the presence of any of the HLA antigens was observed. It was concluded that the main inducer of an anti-BCP 54 response is corneal disease itself, and that the presence of corneal disease is able to break the immunological privilege typical of normal corneas.

Circulating cornea-specific antibodies in corneal disease and cornea transplantation

In order to establish the significance of circulating cornea-specific antibodies, we determined the presence of anti-corneal antibodies in the serum of 100 patients with corneal disease and in 50 healthy controls, and subsequently followed the pattern of antibody reactivity in 46 patients who underwent corneal transplantation. An indirect immunofluorescence test on cryostat sections of rabbit corneas was used for screening. The reactivity against two known bovine corneal epithelial proteins was also tested: a 54-kD protein (BCP 54) and an 11-kD protein (BCP 11/24). No significant difference in the presence and specificity of anti-corneal antibodies was observed between the group of patients with corneal disease, taken as a whole, and the healthy controls. Patients with keratoconus or non-immunological graft failure, however, were significantly more often positive for anti-corneal antibodies. Neither the presence of antibodies prior to corneal transplantation nor their appearance post-transplantation had a predictive value for corneal graft survival.

Does autoimmunity to S-antigen play a role in Fuchs' heterochromic cyclitis?

Autoimmunity directed against retinal or choroidal antigens has been suggested to play a role in the chorioretinal lesions observed in patients with Fuchs' heterochromic cyclitis. This hypothesis was addressed and patients with Fuchs' heterochromic cyclitis were tested for cellular immunity (migration inhibitory factor assay) against human retinal S-antigen. A significantly higher percentage of patients with Fuchs' heterochromic cyclitis had a positive cellular autoimmune response to S-antigen than healthy controls and other patients with anterior uveitis. This finding is remarkable since Fuchs' heterochromic cyclitis is generally classified as an anterior uveitis and patients with Fuchs' heterochromic cyclitis without chorioretinal lesions also had a positive test. In view of these results and a sensitisation against a corneal antigen reported earlier in Fuchs' heterochromic cyclitis, it is suggested that a chronic low grade grade anterior uveitis or chorioretinitis of unknown origin may cause the release of potent autoantigens in these patients.

Site-dependent distribution of macrophages in normal human extraocular muscles

PURPOSE

Clinical data indicate that extraocular muscles have different susceptibilities for some orbital immune disorders depending on their anatomic location. The resident immunocompetent cells may be important mediators in the local pathogenesis of such disorders so the distribution of these cells was studied in extraocular muscles obtained from normal human donors. For comparison skeletal muscles were studied.

METHODS

The cell distributions were analyzed quantitatively in cryostat cross-sections subjected to a two-step immunoperoxidase method using monoclonal antibodies against T cells, B cells, macrophages and several other markers for cell differentiation or activation. The macrophage distribution was analyzed in more detail using on-line semiautomatic image analysis equipment (VIDAS, Kontron, Elektronik GmbH, Eching, Germany).

RESULTS

Extraocular muscles contain numerous macrophages, fewer human leukocyte antigenD-related (HLA-DR) positive cells and T cells, whereas B cells are absent. The numeric density of all cell types, and macrophages in particular, is much higher in extraocular muscles than in skeletal muscles. In extraocular muscles the majority of T cells are positive for the CD8 antigen (suppressor/cytotoxic), in skeletal muscle CD4 positive T cells (helper) predominate.

CONCLUSIONS

Extraocular muscles contain many more CD8-positive cells and macrophages per square millimeter than skeletal muscles. Of all the cell types studied, only the macrophage distribution differs significantly among the normal extraocular muscles: the medial and inferior recti muscles contain about twice as many macrophages as the lateral rectus and superior oblique muscles. Their mean sizes (area) or shape distributions however, appear to be similar.

Site-dependent effects of experimental hypo- and hyperthyroidism on resident macrophages in extraocular muscles of rats: a quantitative immunohistochemical study

It has been suggested that the effects of dysthyroidism on resident immunocompetent cells of the extraocular muscles may play a role in the pathogenesis of Graves' ophthalmopathy. The distribution of such cells was therefore studied in extraocular muscles of rats that were made hyper- or hypothyroid by the oral administration of thyroxine or propylthiouracil respectively. Skeletal muscles were studied for comparison. The cell distributions were analysed in cryostat cross-sections subjected to a two-step immunoperoxidase method using well-characterized monoclonal antibodies against T cells, B cells, macrophages and MHC class II antigens. The extraocular muscles of control (euthyroid) rats contained numerous macrophages, fewer MHC-II positive cells and T cells and no B cells. Differences in the distribution of immunocompetent cells were found in control rats, between skeletal and extraocular muscles as well as within the various recti eye muscles. This particular tissue distribution resembles that previously reported for human extraocular and skeletal muscles. Quantitative analysis showed that experimental dysthyroidism only affected cell populations in the extraocular muscles. Significant effects on the number of macrophages were observed in the inferior rectus muscle of both hypo- and hyperthyroid rats, this was most pronounced in the orbital layer of the muscles. Both hyper- and hypothyroidism appear to affect local cell distributions in a tissue-specific manner. The presently observed site-dependent effects of dysthyroidism on local immunocompetent cell populations may have relevance for the differential involvement of muscular tissues in Graves' ophthalmopathy.

Corneal autoimmunity in Cogan's syndrome? Report of two cases

Autoimmune reactivity against corneal antigens is described in two patients with Cogan's syndrome, a nonsyphilitic deep interstitial keratitis with vestibuloauditory symptoms. In both cases corneal antibodies were found at the beginning or during an exacerbation of the disease. After administration of high doses of corticosteroids the corneal antibodies diminished. Interstitial keratitis can generally be controlled by local or systemic corticosteroids. The effect of corticosteroid therapy on the audiovestibular symptoms is variable. The possibility of an autoimmune pathogenesis of Cogan's syndrome is discussed.

Distribution of the nuclear thyroid-hormone receptor in extraocular and skeletal muscles

The correlation between the occurrence of Graves' ophthalmopathy and Graves' hyperthyroidism may indicate a role for tri-iodothyronine (T3) hormone in the pathogenesis of Graves' ophthalmopathy. In Graves' ophthalmopathy the recti eye muscles are greatly enlarged whereas skeletal muscles seem unaffected. The distribution of the nuclear T3 receptor was studied in normal human and rat eye and skeletal muscles with immunohistochemistry using mouse (monoclonal) antibodies, and by in-situ hybridization for the detection of mRNA encoding the T3-receptor protein. Nuclear staining with T3-receptor antibodies was found in all types of tissues studied. Cytoplasmic staining occurred predominantly in the muscle fibres of the orbital layer of the eye muscles and was generally absent or very low in skeletal muscle fibres and hepatocytes. Immunostaining could be inhibited by preabsorbing the antibodies with bacterially expressed T3-receptor protein, implying specificity. The presence of nuclear and cytoplasmic hormone-free T3 receptor sites was indicated after preincubation of sections with T3 hormone; T3-receptor immunostaining decreased and T3-hormone staining increased. In-situ hybridization clearly revealed the presence of alpha-1 and beta-1 forms of the T3-receptor mRNA in liver, skeletal muscles, and orbital and intermediate layers of the eye muscles. The data demonstrate the presence of T3 hormone-receptor molecules in the extraocular and skeletal muscles. The different susceptibilities of these muscles to Graves' hyperthyroidism may relate to the quantitative differences in T3 hormone-receptor distribution.

Cellular and humoral anticorneal immune response in corneal transplantation

Immunologic responses play a role in the rejection process of corneal transplants. Both histocompatibility antigens and tissue-specific antigens may be potential targets for such an immune response. To identify relevant responses, the humoral immune response against corneal tissue and the cellular immune response against one specific corneal protein were determined in patients before and after corneal transplantation. The results were compared with known risk factors for corneal transplantation, but no correlations were observed. A conversion from negative to positive in cellular immune response against the cornea-specific protein was seen in patients who had experienced an inflammatory episode during the time interval between measurements. The anticorneal protein response may therefore be the result of an intraocular inflammatory response, but not a prognostic factor to help predict the patients at risk for rejection.

HLA-DR4 associated response to corticosteroids in Graves' ophthalmopathy patients

Fifty-seven patients with severe Graves' ophthalmopathy were treated with corticosteroids. Therapeutic outcome was assessed according to predetermined criteria as response (n = 37) or non-response (n = 20) to therapy. Patients were typed for HLA-A, -B, -C, -DR and -DQ. HLA-DR4 was completely absent in the 20 non-responder patients (corrected p value = 0.042). In the responder group 14 of the 37 patients were HLA-DR4 positive. This study shows that in Graves' ophthalmopathy patients the presence of HLA-DR4 is associated with a good response to corticosteroid therapy. The frequency of HLA-DR4 in the Graves' ophthalmopathy population as a whole, however, was not different from normal (25% versus 26%). But as reported previously, the frequency of HLA-DR3 was significantly increased in the Graves' ophthalmopathy patients when compared to healthy blood donors (47% versus 24%, corrected p value = 0.02). No significant deviations were found in the HLA-A, -B, or -C loci.

Effect of abnormal thyroid function on the severity of Graves' ophthalmopathy

Many clinicians have the impression that treatment of thyroid dysfunction ameliorates ophthalmopathy in Graves' disease. The aim of our study was to relate thyroid function to the severity of Graves' ophthalmopathy. We studied 90 patients with Graves' ophthalmopathy and Graves' hyperthyroidism in whom severity of Graves' ophthalmopathy and thyroid function (regardless of antithyroid treatment) were assessed when referred to our institution. Patients were assigned to four groups (A through D) with increasingly severe Graves' ophthalmopathy using Total Eye Score based on the NOSPECS classification. The percentage of dysthyroid patients in each group was determined: group A had 23% dysthyroid patient (5); group B, 32% (9); group C, 61% (14); and group D, 47% (8). More dysthyroid patients were in the groups with severe Graves' ophthalmopathy. We also compared the severity of Graves' ophthalmopathy between euthyroid (n = 54) and dysthyroid (n = 36) patients: euthyroid patients had less proptosis (19.9 +/- 3.5 vs 20.8 +/- 3.4 mm), better visual acuity (0.93 +/- 0.17 vs 0.88 +/- 0.18), and lower Total Eye Score (8.6 +/- 6.6 vs 10.6 +/- 6.6). We conclude that dysthyroidism is associated with more severe Graves' ophthalmopathy. Our findings suggest that meticulous control of thyroid function also during antithyroid treatment is important in the management of Graves' ophthalmopathy.

Orbital decompression for Graves' ophthalmopathy by inferomedial, by inferomedial plus lateral, and by coronal approach

To test the efficacy and safety of orbital decompression for Graves' ophthalmopathy, the authors studied the records of 60 consecutive patients who were operated on for dysthyroid optic neuropathy or for rehabilitative purposes. Patients decompressed for neuropathy were older, had less proptosis, and a shorter duration of eye disease than patients operated on for disfigurement. The authors compared the results of three surgical procedures including the inferomedial, the inferomedial plus lateral, and the coronal approach. Regarding improvement of visual function, no difference was found between the three techniques. Patients in whom vision failed to recover had a high prevalence of diabetes mellitus. Proptosis reduction varied from 1 to 9 mm, depending on the number of walls decompressed. There was no net change in the prevalence of diplopia. Persistent complications were seen in less than 5% of all decompressions. The authors conclude that orbital decompression for Graves' ophthalmopathy is safe and efficacious, regardless of surgical procedure. However, the coronal approach gives the best cosmetic results.

Graves' ophthalmopathy: what is the evidence for extraocular muscle specific autoantibodies

Graves' ophthalmopathy is thought to be an autoimmune disease. Whether this disease is organ specific or one of the manifestations of the closely linked Graves' thyroid disease is still a matter of speculation. Many papers describe autoimmunity to orbital antigens, in particular to extraocular muscles, in patients with Graves' ophthalmopathy. In this paper we have tried to give an overview of the evidence for circulating antibodies against extraocular muscle antigens and to discuss their significance in relation to the immunopathogenesis of the disease.

Human tumor and normal tissue reactivity of the anti-(breast cancer) monoclonal antibody BA-Br-3 and its similarity to the anti-(epithelial membrane antigen) monoclonal antibody E29

A mouse monoclonal antibody (BA-Br-3) raised against the breast carcinoma cell line CAMA-1 was previously shown to react with a greater than or equal to 300-kDa globule-like glycoprotein from human milk fat also expressed in the cytoplasm and on the surface of human carcinoma cells of different histological types. In this report the reactivity of this mAb with a large number of normal and malignant human tissues was analyzed using immunoperoxidase techniques. When tested on sections of both fresh-frozen tissues and formalin-fixed, paraffin-embedded tissues, BA-Br-3 reacted with a formalin-resistant antigenic determinant expressed by normal and malignant epithelial cells. Preferential reactivity was observed at the apical portion of ductal epithelial cells in normal breast and in glandular epithelia distributed in several other organs. Reactivity with mucin-like secretions in the lumina of ducts was also found. BA-Br-3 reacted mostly in heterogenous staining patterns with 88% of 49 breast carcinoma specimens tested, regardless of their histological type or whether they were primary or secondary neoplasms. Testing of epithelial malignant tumors other than breast carcinomas with this antibody showed that 127 of 151 (84%) were also reactive. mAb BA-Br-3 and E29 (a commercially available anti-(epithelial membrane antigen) shared very similar staining patterns and distributions of reactivity with breast and other epithelial tumors. However, BA-Br-3 showed a significantly higher percentage of reactivity with melanoma (33% versus 6%, P = 0.003) and a trend toward a higher percentage of reactivity with sarcoma (55% versus 27%, P greater than 0.05). This antibody, therefore, defines a molecule that is a member of the mucin-like epithelial membrane antigen family. Further studies are warranted to determine its usefulness in antibody-directed cancer diagnosis, prognosis, and immunotherapy.

Prednisone and cyclosporine in the treatment of severe Graves' ophthalmopathy

It is uncertain what is the most appropriate medical therapy for patients with severe Graves' ophthalmopathy. Therefore, we carried out a single-blind, randomized clinical trial to compare the efficacy of prednisone with that of cyclosporine in 36 patients who had been euthyroid for at least two months. The two groups, each consisting of 18 patients, were similar in age, sex, and the duration and severity of ophthalmopathy. The initial dose of cyclosporine was 7.5 mg per kilogram of body weight per day, and that of prednisone was 60 mg per day, which was subsequently tapered to 20 mg per day. During the 12-week treatment period, 11 prednisone-treated and 4 cyclosporine-treated patients responded to therapy (61 percent vs. 22 percent; P = 0.018); response was manifested by decreases in eye-muscle enlargement and proptosis and improved visual acuity and total and subjective eye scores. There were no differences at base line between the patients who later responded and those who did not. Prednisone was tolerated less well than cyclosporine. After 12 weeks, patients who did not respond were treated for another 12 weeks with a combination of cyclosporine and a low dose of prednisone. Among the 9 patients who initially received prednisone, the addition of cyclosporine resulted in improvement in 5 (56 percent); among the 13 patients who received cyclosporine initially, 8 (62 percent) improved after the addition of prednisone. Combination therapy was better tolerated than prednisone treatment alone. We conclude that single-drug therapy with prednisone is more effective than cyclosporine in patients with severe Graves' ophthalmopathy. The combination can be effective in patients who do not respond to either drug alone.

Clinical criteria for the assessment of disease activity in Graves' ophthalmopathy: a novel approach

Patients with serious inflammatory Graves' ophthalmopathy should be treated with anti-inflammatory drugs or radiotherapy to prevent complications like fibrosis, while those with non-inflammatory ophthalmopathy may be treated by surgery immediately. It is often difficult, however, to distinguish inflammatory from non-inflammatory Graves' disease. We therefore present a simple clinical classification here to differentiate between these two conditions. This classification is based on the classical signs of inflammation--pain, redness, swelling, and impaired function. After two consecutive clinical examinations an 'activity score' can be determined, ranging from 0 to 10 points. In a retrospective study testing the efficacy of this classification we found that patients with an activity score of 3 or more at the beginning of therapy responded well to anti-inflammatory drugs, while those with a lower activity score mostly did not. Comparing the pretreatment activity score with the degree of enlargement of the extraocular muscles on the CT scan, we found a significant correlation between these two parameters: the higher the activity score, the more the enlargement of the muscles. We conclude that this classification facilitates the proper selection of patients for treatment.

Immunity to a corneal antigen in Fuchs' heterochromic cyclitis patients

Immunity to a major corneal antigen was studied in 28 Fuchs' heterochromic cyclitis patients and compared with the response of 44 patients with other types of uveitis and 19 healthy controls. The highest incidence of immune response was found in patients with anterior segment involvement only (anterior uveitis and Fuchs') whereas the frequency of anti-corneal immune response in patients with posterior segment involvement only was low and not significantly different from that of healthy controls. Cellular immunity to corneal antigens was found in the majority of Fuchs' heterochromic cyclitis patients, and in one-third of the anterior uveitis patients. No correlation could be established in these patients between a positive cellular response and the chronicity of the disease or the presence of keratic precipitates. Humoral immunity to the corneal antigen was also the highest in patients with anterior segment involvement, but there was no difference in response between Fuchs' and non-Fuchs' anterior uveitis patients. This study suggests that anti-corneal immunity may be triggered in inflammatory diseases of the anterior segment, especially in Fuchs' heterochromic cyclitis.

Circulating monocyte migration inhibitory factor in serum of Graves' ophthalmopathy patients: a parameter for disease activity?

A factor which inhibits the random migration of monocytes in vitro was found in the serum of nearly half of Graves' ophthalmopathy patients. This factor was found in serum of only 4% of the healthy controls. When the Graves' ophthalmopathy patients were subdivided, on clinical criteria (pain, redness, swelling and impaired function), into patients with active disease and patients with inactive disease, the serum factor was found in 61% of the patients with active inflammatory disease and only in 14% of the patients with inactive disease. Furthermore this factor was also found in the serum of patients with an acute episode of uveitis, suggesting that it may be a useful marker for assessment of a localized inflammatory process.

Clinical presentation of Graves' ophthalmopathy

The eye findings of Graves' ophthalmopathy were prospectively recorded in 90 consecutive untreated patients (66 females, 24 males; mean age 44.5 years) according to the 1977 NOSPECS classification. Soft-tissue involvement was observed in 90%, proptosis greater than or equal to 23 mm in 30%, eye muscle involvement in 60%, corneal involvement in 9% and sight loss in 34%. No differences in the distribution of eye changes between right and left eye were found. Values for proptosis (mean +/- SD, 20.2 +/- 3.6 mm) had a near-normal distribution. Orbital computed tomography (CT) scanning (performed in 80 cases) demonstrated enlargement of inferior rectus in 60%, medial rectus in 50%, superior rectus in 40% and lateral rectus in 22%. Unilateral eye disease was present in 13 patients (14%); in 4 of these patients the CT scan showed eye muscle enlargement also in the fellow eye and in 2 patients bilateral eye disease subsequently developed. The distribution of age, sex and NOSPECS classes in patients with unilateral eye disease was similar to that in patients with bilateral eye disease, but the interval between the onset of thyroid and eye disease was much shorter in cases of unilateral than in cases of bilateral eye disease. Patients without clinically evident thyroid disease (n = 20, 22%) were not different from patients with thyroid disease in age, sex or ophthalmological presentation. The various data suggest: (1) the 1977 NOSPECS classification under-represents significant proptosis in 12% of cases; (2) the age and sex distribution of patients with Graves' ophthalmopathy is similar to that of cases with thyroidal Graves' disease, and (3) unilateral Graves' ophthalmopathy may represent an early stage of the disease, that as a rule already is or develops shortly afterwards into a bilateral disease.

High incidence of corneal epithelium antibodies in Fuch's heterochromic cyclitis

Sera obtained from 26 patients with Fuchs' heterochromic cyclitis were examined for the presence of autoantibodies directed against the anterior segment of the eye by means of immunofluorescence techniques. Antibodies against human iris tissue could not be detected, whereas autoantibodies against corneal epithelium were found in almost 90% of cases. This is the first report describing the presence of autoantibodies in patients with Fuchs' heterochromic cyclitis and it provides a further clue that immunological mechanisms might play an important role in the aetiology of Fuchs' heterochromic cyclitis.

Temporal relationship between onset of Graves' ophthalmopathy and onset of thyroidal Graves' disease

The temporal relationship between the onset of Graves' ophthalmopathy and the onset of thyroidal Graves' disease was evaluated in 125 consecutive patients with Graves' ophthalmopathy. Thyroidal Graves' disease--past or present--was clinically evident in 99 patients (79%): hyperthyroidism in 3 cases. Thyroid disease preceded the eye disease in 37 patients, it occurred simultaneously with the eye disease in 39 patients, and it developed after the eye disease in 23 patients (in 16 cases within one yr after the onset of eye disease). The age at the onset of thyroid disease (38.7 +/- 12.9 yr) was lower than the age at the onset of ophthalmopathy (41.8 +/- 12.5 yr; p less than 0.001). Among the 26 clinically euthyroid patients (21%) laboratory evidence of thyroidal Graves' disease was found in 14 cases (11%): abnormal TRH test, n = 9; normal TRH test but abnormal T3-suppression test, n = 4; normal TRH and T3-suppression tests but positive thyroid stimulating antibodies, n = 1). We conclude that Graves' ophthalmopathy as a rule develops at a time when thyroid autoimmunity also exists. This strongly suggests a common factor in the pathogenesis of thyroidal and ocular expressions of Graves' disease.

Immunological responses in the eyelid and orbit

Immunological responses in the eyelid and the orbit are reviewed: (1) A local immune response is dependent on the presence of lymphoid tissue in an organ. Lymphoid tissue is found in the conjunctival fornices and in the lacrimal gland but not in the orbit. The eyelids also have lymphatic drainage into the local lymph nodes. A local immune response is found in the palpebral conjunctiva and in the lacrimal gland, measureable both as immunoglobulin or specific antibody levels in tears or as immunoglobulin producing cells within the tissue. No local immunity has been demonstrated in the orbit. (2) The other type of immune response found in the eyelids, the lacrimal gland and the orbit is the involvement of these tissues in systemic diseases. Systemic diseases with an immunological basis, which affect the above mentioned tissues are: atopic diseases of the skin, autoimmune diseases, immunodeficiency diseases and lymphoproliferative diseases. (3) Finally, it is possible that the extraocular muscles and the lacrimal gland have tissue specific antigens and therefore may be target tissues for organ specific autoimmune processes.

Therapeutic outcome of prednisone medication and of orbital irradiation in patients with Graves' ophthalmopathy

Response to treatment was evaluated prospectively in 58 patients with Graves' ophthalmopathy. Prednisone, administered to 44 patients, resulted in a favourable response in 29 patients (66%): excellent in 3, good in 10 and fair in 16 subjects; 15 patients (34%) did not respond. Orbital irradiation was administered to 39 patients of whom all except 4 had been treated previously with steroids. Six months later, 25 patients (64%) had responded favourably (excellent in 0, good in 9 and fair in 16 subjects) and 14 patients had not responded (36%). A favourable response to prednisone or irradiation was reflected in a general shift to lower grades in each of the classes 2-6 of the NOSPECS system. Responders were not different from non-responders with regard to age, sex, NOSPECS classification, ophthalmopathy index, interval between the onset of eye disease (or of thyroid disease if present) and the start of treatment, or the presence of thyroid disease. In conclusion, (1) the ratio of responders to non-responders is 2:1 for both prednisone treatment and orbital irradiation in Graves' ophthalmopathy, (2) the response is seen in all classes of the NOSPECS system, and (3) the response is not dependent on age, sex, severity or duration of eye disease, or the presence of thyroid disease.

The influence of high molecular weight sodium hyaluronate (Healon) on the production of migration inhibitory factor

The effect of sodium hyaluronate on the production of migration inhibitory factor (MIF) was studied in a two step MIF-assay. High molecular weight sodium hyaluronate (100 micrograms/ml), added during the inductory step of the MIF-assay, inhibited the production of MIF. The inhibitory effect did not appear to be due to physical factors such as steric hindrance, which may prevent mitogen binding, since cells preactivated with phytohemagglutinin A (PHA) did not produce MIF when incubated in the presence of sodium hyaluronate. The inhibitory effect was still measurable when the sodium hyaluronate was added upto two hours after stimulation of the mononuclear cells with PHA. Inhibition was also found when the cells were preincubated with sodium hyaluronate, and washed prior to mitogen stimulation. Sodium hyaluronate could only be removed from the cells by incubation with hyaluronidase or by incubation of the cells for at least two hours in culture medium, whereafter the cells could be stimulated to the same extent as normal untreated cells to produce MIF. This inhibitory effect on cytokine production may explain the reduced inflammatory reactions found both in vivo and in vitro in the presence of sodium hyaluronate.

Humoral and cellular immune responsiveness to human S-antigen in uveitis

Purified human retinal S-antigen (S-ag) was used to investigate the occurrence of humoral and cellular autoimmune reactions against S-ag in uveitis patients. With a sensitive ELISA method anti-S-ag antibodies could be detected in the sera of 28% of the uveitis patients. No difference was found between patients with posterior or panuveitis (31 out of 117 positive) and patients with anterior or intermediate uveitis (16 out of 52 positive). Similar frequencies and levels of anti-S-ag autoantibodies were also found among healthy controls (6/20) and patients who had undergone cataract surgery (6/17). Immunoblotting with purified S-ag and with whole human retinal extract confirmed the presence of anti-S-ag antibodies in uveitis and control sera. Moreover, antibodies against various other retinal proteins could also be demonstrated in patients and controls, without being particularly enhanced in uveitis. The cellular immune responsiveness was tested by measuring the production of migration inhibitory factor (MIF) during overnight culture of peripheral mononuclear cells with the antigen. None of 18 healthy controls responded, whereas 17 positive reactions were observed in the group of 44 uveitis patients. The highest frequencies were found in patients with posterior (5/12) or pan- (7/12) uveitis, while of the responders with anterior (2/8) or intermediate (3/12) uveitis, three had disorders affecting the retina. Thus, cellular autoimmune responsiveness to S-ag is apparently associated with posterior and pan-uveitis, and might also occur in non-uveitic retinal disorders, whereas the occurrence of anti-S-ag antibodies is probably not at all pathognomic for uveitis.

The relationships between serum T3 index, thyroid volume, and thyroid stimulating, TSH receptor binding and thyroid growth stimulating antibodies in untreated Graves' disease

This study represents an international double-blind collaborative study of abnormal immunoglobulin activity in untreated Graves' disease. Laboratories in two countries participated in a comparison of thyrotrophin binding inhibiting (TBII), thyroid stimulating (TSAb), and growth stimulating (TGI) immunoglobulins with clinical data, including ultrasonically measured thyroid size. The correlation between TGI and thyroid volume (n = 25, Rs = 0.54, P less than 0.05) and the fact that 9 of 10 patients with high range TGI values had large goitres establish the relationship between TGI and goitre, confirming that the in-vitro activity of these antibodies is related to an in-vivo action. In addition, both TBII and TSAb correlated with serum free T3 indices (TBII: n = 60, Rs = 0.46, P less than 0.001, and TSAb: n = 60, Rs = 0.64, P less than 0.001). Moreover, both TBII and TSAb correlated with thyroid volume (TBII: n = 60, Rs = 0.37, P less than 0.01, and TSAb: n = 60, Rs = 0.41, P less than 0.01) suggesting that these antibodies are also important in development of goitre in Graves' disease. Finally, some correlation between the antibodies was observed. TBII correlated with TSAb (n = 60, Rs = 0.47, P less than 0.001), and in the 16 patients with positive TGI results, this activity correlated with TBII (Rs = 0.54, P less than 0.05), but not with TSAb. Also some cases were found with corresponding high range TBII and TGI, while negative for TSAb, suggesting a close relationship between the in-vitro measurement of TSH binding and TGI.

Clinical and experimental studies concerning circulating antibodies to corneal epithelium antigens

Corneal epithelium antibodies were detected in patients with corneal melting disease (55%), uveitis (42%), corneal transplantation (42%) and marginal furrow disease (20%). These antibodies were not found in herpetic keratitis patients. In control groups, consisting of ocular surgery patients (glaucoma, retinal detachment and cataract) and persons without a history of ocular disease, approximately 4% of the subjects had these antibodies. To investigate the possible role of trauma to the cornea as an initiator of corneal epithelium antibodies, these antibodies were determined in rabbits after alkaline burns were made on the cornea. These antibodies were detected one week later and disappeared after six weeks. Serum from three patients with corneal melting disease and corneal transplantation containing a high antibody titre against corneal epithelium were used to isolate corneal epithelium antigens. A 54 kD and a 17 kD corneal epithelium antigen were isolated. The incidence of autoantibodies directed against these antigens was investigated in patients with corneal melting disease, uveitis and corneal transplantation using an ELISA. 50% of the sera positive in the immunofluorescence test were positive in the ELISA.

Autoimmunity against corneal antigens. I. Isolation of a soluble 54 Kd corneal epithelium antigen

Corneal epithelium antibodies were detected in patients with corneal melting disease and uveitis using an immunofluorescence technique with cryostat sections of corneas obtained from various species (man, guinea pig, rabbit, mouse, rat, cow, pig). No differences in results were found using these various substrates, indicating that the autoimmune response is directed against common non-species specific corneal epithelium antigens. The serum of a patient with corneal melting disease, containing a high antibody titer against corneal epithelium was used to identify and isolate one of the bovine corneal antigens. A 54,000 dalton protein was isolated, which was shown to be the major protein present in the corneal epithelium. Absorption studies with other tissues taken from human eyes showed that cornea epithelium, cornea devoid of epithelium, ciliary body and retina contained material which cross-reacted with the isolated bovine corneal epithelium antigen, whereas iris and sclera showed no detectable cross-reaction. The incidence of autoantibodies directed against this antigen was investigated in patients with corneal melting disease, corneal transplantion and in uveitis patients using an ELISA and comparing the results with those obtained with the immunofluorescence assay on rabbit cornea sections. A positive ELISA was always associated with a positive immunofluorescence test. The presence of antibodies against the 54 Kd antigen as detected by the ELISA could be confirmed by immunoblotting in 7 out of 9 positive sera tested. A large number of sera showed a positive immunofluorescence test but a negative ELISA against the 54 Kd corneal epithelium antigen.(ABSTRACT TRUNCATED AT 250 WORDS)

IgG and IgA immune response against klebsiella in HLA-B27-associated anterior uveitis

Enteric infections with Gram-negative bacteria are thought to play an important part in HLA-B27-associated disease such as Reiter's syndrome and reactive arthritis. But the role of bacterial infections in HLA-B27-positive ankylosing spondylitis (AS) and acute anterior uveitis (AU) is still controversial. A special interest has recently been devoted to the role of klebsiella infection in HLA-B27-associated disease. We studied the humoral immune response against a 'cross-reactive' strain of Klebsiella pneumoniae in 62 patients with anterior uveitis and 33 healthy controls. The anterior uveitis patients were subdivided into 25 HLA-B27-negative patients without AS (B27- AU+ AS-), 17 HLA-B27-positive patients without ankylosing spondylitis (B27+ AU+ AS-), and 19 HLA-B27-positive patients with ankylosing spondylitis (B27+ AU+ AS+). Total serum IgA was higher in patients than in controls in both the B27+ AU+ AS+ and B27+ AU+ AS- patients but not in the B27- AU+ AS- group. No abnormalities were observed in the total serum IgG levels. The level of both the IgG and IgA klebsiella antibodies did not differ in the various patient groups tested as compared with the controls. Comparisons between the patient groups showed that the IgG anti-klebsiella response was higher in B27-positive patients patients without AS than in those with AS. These results suggest that stimulation of mucosal surfaces may play a role in HLA-B27-associated anterior uveitis. Whether klebsiella organisms are involved in this stimulation remains unclear.

Circulating antibodies to corneal epithelium in patients with uveitis

We investigated the incidence of circulating corneal epithelium antibodies in patients with uveitis. A high percentage of the patients (42%) were positive, whereas only 4% of controls had these antibodies in their serum. Significantly more patients with anterior and diffuse uveitis had corneal epithelium antibodies than did those with posterior uveitis. Subdivision of anterior uveitis into HLA-B27 positive versus negative patients showed a higher incidence of the antibodies in the HLA-B27 positive group. A previous history of uveitis may play a role in the pathogenesis of peripheral corneal thinning diseases, for which an autoimmune aetiology has been suggested.

Expression of HLA-B27 antigens on mononuclear leucocytes in ankylosing spondylitis

Differences in expression of HLA-B27 antigens on immune competent cells might play a role in the susceptibility to environmental factors which may be responsible for the initiation of ankylosing spondylitis (AS). Using a quantitative complement-mediated lymphocytotoxity assay we determined the expression of HLA-B27 antigens on the membranes of mononuclear cells obtained from 20 patients with AS, four patients with other seronegative arthropathies and eight healthy controls. The variation in expression of B27 between individuals was quite extensive, but there was no significant difference in the mean titration curves obtained for each of the three groups. These findings suggest that the expression of HLA-B27 antigens on the membrane of mononuclear leucocytes does not play a role in the pathogenesis of AS.

Lymphoid proliferations in the orbit: malignant or benign?

Clinical, pathological, and immunological analysis of 20 patients with ocular adnexal lymphoid disease has demonstrated several parameters which are useful for distinguishing malignant from benign lesions. Patients in the fourth or fifth decade of life presenting with an acute history of pain, oedema, epiphora, double vision, and ptosis, with a mass localised in the lacrimal gland area, are more likely to have a pseudolymphoma or a chronic inflammatory lesion than a true non-Hodgkin lymphoma (NHL). It is not possible to obtain a definite diagnosis without surgical intervention, because only three out of nine patients with orbital NHL had evidence of a monoclonal B cell population in peripheral blood on admission to the Orbital Centre. Furthermore it was confirmed that the identification of the various orbital lymphoid infiltrates becomes more distinct when immunological techniques are added to the clinical and histopathological methods of investigation. Multidisciplinary cooperation leads to further improvement of diagnosis and treatment of ocular adnexal lymphoproliferative disease.

Acute anterior uveitis (AAU) and HLA-B27

A group of 30 consecutive HLA-B27 positive acute anterior uveitis (AAU) patients was compared to 30 consecutive HLA-B27 negative AAU patients. The B27 positive group was characterized by male preponderance, earlier age of onset, unilateral uveitis and favourable outcome with therapy. It is concluded that HLA-B27 typing is a useful diagnostic discriminant in AAU.

Circulating antibodies against corneal epithelium and hookworm in patients with Mooren's ulcer from Sierra Leone

A relationship between the occurrence of Mooren's ulcer and hookworm infections was suggested by Kuriakose in 1963. Sixteen patients with clinical diagnosis of Mooren's ulcer and 15 local controls from Sierra Leone were tested with respect to serum immunoglobulin levels, circulating antibody to hookworm, circulating antibodies to corneal epithelium, stool smears, and eosinophil and lymphocyte levels. Both patients and healthy controls had circulating antibodies to corneal epithelium and to hookworm. In the controls the titres of hookworm antibodies were significantly lower than in the patients, though in both groups most people had intestinal parasite infestations as detected by the stool smear. Further investigation failed to demonstrate any other significant immune alteration in the patients as compared with local controls.

Serologic aspects of IgG4 antibodies. I. Prolonged immunization results in an IgG4-restricted response

Labeled antigen-binding tests were used to determine quantitatively the contribution of IgG4 antibodies to the total IgG antibody response in humans. In agreement with literature, we found no IgG4-restricted antibody responses with tetanus toxoid or streptococcal carbohydrate. In the serum of individuals immunized for several years with phospholipase (PLA) from honey bee venom, grass pollen allergen, or house dust mite allergen, we often found that more than 50% of the total antigen-binding capacity was due to IgG4 antibodies. In the case of beekeepers, it could clearly be shown that during prolonged immunization a shift in the IgG4:IgG1 antibody ratio occurs that finally results in an IgG4-dominated antibody response. Evidence is provided that antigen-binding assays may even underestimate the contribution of IgG4 antibodies, because in contrast to IgG1 antibodies, IgG4 antibodies act as monovalent antibodies in being unable to cross-link immunosorbent-bound antigen and radiolabeled antigen.

Serologic aspects of IgG4 antibodies. I. Prolonged immunization results in an IgG4-restricted response

Labeled antigen-binding tests were used to determine quantitatively the contribution of IgG4 antibodies to the total IgG antibody response in humans. In agreement with literature, we found no IgG4-restricted antibody responses with tetanus toxoid or streptococcal carbohydrate. In the serum of individuals immunized for several years with phospholipase (PLA) from honey bee venom, grass pollen allergen, or house dust mite allergen, we often found that more than 50% of the total antigen-binding capacity was due to IgG4 antibodies. In the case of beekeepers, it could clearly be shown that during prolonged immunization a shift in the IgG4:IgG1 antibody ratio occurs that finally results in an IgG4-dominated antibody response. Evidence is provided that antigen-binding assays may even underestimate the contribution of IgG4 antibodies, because in contrast to IgG1 antibodies, IgG4 antibodies act as monovalent antibodies in being unable to cross-link immunosorbent-bound antigen and radiolabeled antigen.

Chronic lymphocytic leukemia. Immunologic markers and functional properties of the leukemic cells

In 230 cases of chronic lymphocytic leukemia (CLL), marker analysis was performed with rosette techniques and a panel of xeno-antisera. A monoclonal B-cell proliferation was found in the majority of cases (94%). In most cases, the B-cells carried IgM, with or without IgD. Cytoplasmic immunoglobulin-inclusion bodies were seen in 7% of the cases of B-CLL. The number of patients with non-B/non-T-CLL was small (2%) in this series. In eight patients (4%), a proliferation of T-cells was established. These patients had a different clinical presentation and marker analysis of the lymphocytes, together with functional studies, showed that this group represented a mixture of different disease processes. Functional analysis of the B-CLL cells in 19 cases showed a poor or absent mitogen response and in nine cases the absence of the capacity to differentiate in vitro into plasma cells and/or to produce immunoglobulins.

Antibody dependent cell mediated cytotoxicity (ADCC) and complement dependent cytotoxicity (CDC) in 229 sera from human renal allograft recipients

Comparison between CDC and ADCC in a human allogeneic model using the same cytotoxicity marker, i.e. 51Cr release from labelled target cells, provided a better definition of the optimal technical conditions for revealing ADCC. Testing 229 sera from human renal allograft recipients after transplantation, we found that CDC is detected only during rejection (43% of cases) whereas ADCC can be found both in those recipients tolerating their grafts and in those undergoing rejection, more frequently in the former than in the latter (39% vs. 21%, p less than 0.05). These in vivo results and other in vitro experiments support the assumption that two distinct varieties of antibody can mediate the in vitro ADCC phenomenon, some directed against the A, B and C HLA loci and having a deleterious effect on the graft, and others capable of exerting a protective effect and which could be directed against D related HLA determinants.