IgG4-related cerebral pseudotumor with perineural spreading along branches of the trigeminal nerves causing compressive optic neuropathy: A case report

RATIONALE

Immunoglobulin G4-related disease (IgG4-RD) is characterized by tumor-like lesions, a dense lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. IgG4-RD has been described in a variety of organ systems; however, it rarely involves the central nervous system.

PATIENT CONCERNS

A 17-year-old woman visited our clinic with a complaint of blurred vision for the past 5 months. She also reported a painless right submandibular mass that had been present for 1 year. Her best-corrected visual acuity (BCVA) was 2.0 LogMAR, with an almost total visual field defect in the right eye.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed lobulated parasellar tumors with perineural spreading along branches of the trigeminal nerves causing right optic nerve compression. A craniotomy with tumor removal and submandibular gland biopsy was performed. Histopathological analysis of the tumor revealed stromal fibrosis with atypical lymphoid infiltrations. Histopathological and immunohistochemical analysis of the submandibular gland confirmed the diagnosis of IgG4-RD.

INTERVENTIONS

The patient was administered 500mg/d of pulse methylprednisolone for 3 days, 500mg of intravenous rituximab every 2 weeks (for a total of 2 doses), and 500mg of intravenous pulse cyclophosphamide every month (for a total of 3 doses).

OUTCOMES

Two months after the initiation of immunosuppressive therapy, the patient's BCVA returned to 0.1 LogMAR with visual field defect recovery. The follow-up MRI showed the almost complete disappearance of the previously contrast-enhanced lesions.

LESSONS

Herein, we report a rare case of IgG4-RD presenting as a parasellar tumor and present a review of the related literature. Based on the case report, we propose that aggressive therapy with glucocorticoid, rituximab, and cyclophosphamide may potentially be useful for treating such cases.

Positive Auto-Antibody Activity With Retina and Optic Nerve in Smokers and Non-Smokers: The Controversy Continues

Auto-antibodies assist with the diagnosis of ocular paraneoplastic syndromes and autoimmune ocular conditions; however, the frequency of positive test results as a possible precursor to future disease is unknown. The frequency of positive antibodies in heavy smokers who may be at risk for autoimmune-related retinopathy and optic neuropathy was evaluated. Serum antibody activity was evaluated through the use of Western blot reactions from pig retina and optic nerve extract. Fifty-one patients were included: 35 patients were smokers (average: 40.9 pack-year history) and 26 patients had no past smoking history. None of the patients had any visual complaints or known eye disease. Of the patients studied, 76.5% (39 patients: 18 smokers, 21 non-smokers) had positive antiretinal antibodies, and 19.6% (10 patients: 3 smokers, 7 non-smokers) had positive antioptic nerve antibodies. Anti-retinal antibodies were seen in a majority of randomly selected patients with and without a past smoking history. Anti-optic nerve bodies were less common, but more prevalent in those who never smoked. The specificity of these antibodies remains greatly uncertain and clinical correlation is warranted.

The association between glaucoma and immunoglobulin E antibody response to indoor allergens

PURPOSE

To evaluate the association between sensitization to indoor allergens and glaucoma in participants of the National Health and Nutrition Examination Survey (NHANES).

DESIGN

Retrospective cross-sectional study.

METHODS

This study examined the association between serum immunoglobulin E (IgE) levels for a panel of common indoor allergens and glaucoma for 2005-2006 NHANES participants. The exposures of interest were serum IgE levels to a panel of common indoor allergens. The outcome of interest was a clinical diagnosis of glaucoma based on the Rotterdam criteria. Logistic regression modeling was performed to assess the association between each type of IgE and glaucoma, while controlling for age, ethnicity, and steroid use. All estimates were weighted based on the multistage NHANES sampling design.

RESULTS

Among a weighted total of 83 308 318 participants, the overall prevalence of glaucoma was 3.2% (95% confidence interval [CI]: 2.8%, 3.6%). The majority of patients were non-Hispanic white (n = 10 547 654; 77.1%). The American dust mite antigen had the highest proportion of participants with positive IgE values (n = 12 093 038; 14.5%). In the full model including all allergen-specific IgE subtypes as predictors, there were statistically significant associations between IgE subtypes and glaucoma for the cockroach (odds ratio [OR] = 2.78; 95% CI = 1.34, 5.76), cat (OR = 3.42; 95% CI = 1.10, 10.67), and dog (OR = 0.24; 95% CI = 0.06, 0.96) antigens.

CONCLUSIONS

In NHANES, participants with glaucoma had significantly higher odds of sensitization to the cockroach and cat allergens compared to those without glaucoma. These findings indicate the need for further research to elucidate the role of chronic indoor allergen exposure in the development of glaucomatous optic neuropathy.

Chiasmitis caused by Mycobacterium haemophilum in an immunocompromised adult

We report a case of chiasmitis caused by a rare nontuberculous mycobacterium in an immunocompromised patient. A 44-year-old man with a history of AIDS presented with recurrent vision loss and headache. Magnetic resonance imaging (MRI) demonstrated an enhancing mass involving the optic chiasm. Histopathologic and microbiological evaluation revealed infection with Mycobacterium haemophilum. While combination antimicrobial and steroid therapy contributed to improvement in his vision, the patient's symptoms recurred. Follow-up MRI showed extension of infection to the hypothalamus and leptomeninges, indicative of basilar meningitis. MRI is a valuable tool for early diagnosis of chiasmitis as well as for monitoring infection progression and treatment response.

[The current conception about the pathogenic mechanisms of the diabetic optical neuropathy development]

Diabetic Optical Neuropathy (DON) is the optical nerve damage induced by the Diabetes Mellitus. Optical nerve sufferings in Diabetes Mellitus were studied much less compare to the retinal changes. But according to the literature data, the DON has been detected in 7 to 24.3% of Diabetes Mellitus patients. That's why the investigators great interest refers to the optical nerve pathological changes pathways in Diabetes Mellitus studying. This article was focused to the up-to-date scientific views of the DON pathogenesis summarizing. Two basic ways of the DON pathogenesis were demonstrated: metabolic and vascular. The metabolic pathway was connected with the neural tissue damage induced by the diabetic changed metabolism. The vascular pathway was connected with the ischemia and endoneural blood flow malfunction.

[Paraneoplastic retinopathy and optic neuropathy]

Paraneoplastic retinopathy including cancer-associated retinopathy (CAR) and melanoma-associated retinopathy (MAR), and paraneoplastic optic neuropathy (PON) are visual disorders associated with systemic cancer. Patients with CAR typically present with progressive loss of vision and photopsia, which are related to dysfunction of both cones and rods in photoreceptors. The triad of photosensitivity, ring scotoma, and a reduced caliber of the retinal arteriole along with undetectable signals in electroretinogram (ERG) are specific manifestations of CAR. CAR is associated most commonly with small-cell lung cancer (SCLC) and occasionally with gynecologic tumors, and it is usually caused by autoantibodies against recovering, which is a calcium-binding photoreceptor protein that participates in the transduction of light. MAR is characterized by shimmering, flickering, or pulsating photopsias, and usually occurs in the patients with a cutaneous melanoma. MAR differs from CAR in terms of visual acuity and color vision and is associated with a characteristic pattern detected in ERG. Autoantibodies against the bipolar cells of the retina have been identified in patients with MAR. Patients with PON frequently present with progressive visual loss and optic disc edema, or with other paneoplastic neurologic syndromes related to SCLC, such as paraneoplastic encephalomyelitis or retinitis, ophthalmoplegia, and subacute cerebellar syndrome. Autoantibodies against collapsin-responsive mediator protein-5 (CRMP-5, also called anti-CV2) are considered to be as the causative factor. Treatments with corticosteroids, plasma exchange, and intravenous immune globulin as well as treatment of the tumor itself, occasionally improves these paraneoplastic visual syndromes. However, the prognosis depends on their underlying malignancy.

MRI in experimental inflammatory and mitochondrial optic neuropathies

MRI is a powerful tool for evaluating structural and functional alterations in the optic nerve in experimental animal models of human disease. MRI-histopathological correlations have provided important insights into the pathogenesis of disease. Paramagnetic contrast agents have been used to serially visualize the foci and severity of disruption of the blood-optic nerve barrier and physiological neuronal alterations in living animals. Here I review the experience of our group in optic nerve imaging of experimental autoimmune encephalomyelitis and neurodegeneration induced by genetic manipulation of respiratory chain enzymes.

[Role of immune system in glaucomatous optic nerve degeneration]

Glaucoma is a chronic neurodegenerative disease characterized by progressive loss of retinal ganglion cells and optic nerve axons, and accompanying loss of visual field sensitivity. With the development of immunology, compelling evidence obtained suggests the involvement of immune system regulation in glaucomatous optic nerve degeneration. Despite the neuroprotective features of immune system, an autoimmune component resulting from a failure to properly control aberrant and stress-induced immune response likely lead to the progression of neurodegeneration in glaucoma. A better understanding of the diverse roles of the immune system in all forms of glaucomatous optic nerve degeneration will facilitate the development of effective neuroprotective strategies in glaucoma. The effect of immune system on glaucomatous neuropathy is reviewed in this article.

Modulating the immune system: a vaccine for glaucoma?

Glaucomatous neuropathy, like other neurodegenerative diseases, is a multi-dimensional disease in which various molecular and cellular factors contribute to the pathological process. These factors, while not initially causative, are key elements in disease progression and may continue to contribute even after the primary pathology is alleviated. An entire field of research of neuroprotection and restoration has opened up as part of the search for additional ways of slowing disease progression. We have proposed, on the basis of experimental evidence, that a vaccine could be a means of recruiting the immune system to help eliminate many of the factors associated with glaucomatous neurodegeneration and thus prevent disease progression, though not its onset. This immune defence involves lymphocytes, resident and infiltrating innate immune cells, the microglia, and macrophages. The antigens of choice are synthetic antigens, such as glatiramer acetate, that weakly cross-react with self-antigens in the retina and optic nerves. The vaccine induces a beneficial immune response that recruits immune effector cells to counteract or neutralize many of the compounds and factors that contribute to ongoing destruction, and in addition supports cell renewal and repair.

Sarcoidosis of the nervous system

Although sarcoidosis is rarely confined to the nervous system, any neurological features that do occur frequently happen early in the course of the disease. The most common neurological presentation is with cranial neuropathies, but seizures, chronic meningitis and the effects of mass lesions are also frequent. The diagnostic process should first confirm nervous system involvement and then provide supportive evidence for the underlying disease; in the absence of any positive tissue biopsy, the most useful diagnostic tests are gadolinium enhanced MRI of the brain and CSF analysis, although both are non-specific. The mainstay of treatment is corticosteroids, but these often have to be combined with other immunosuppressants such as methotrexate, hydroxychloroquine or cyclophosphamide. There is increasing evidence that infliximab is a safe treatment with good steroid sparing capacity.

Mechanisms of immune system activation in glaucoma: oxidative stress-stimulated antigen presentation by the retina and optic nerve head glia

PURPOSE

Evidence supports the immune system activity accompanying glaucomatous neurodegeneration. This study aimed to determine the in vitro effects of reactive oxygen species (ROS) on the phenotype and antigen-presenting function of the retina and optic nerve head glia.

METHODS

Cultures of rat retina and optic nerve head glia were treated with a mixture of ROS-generating compounds for 24 and 48 hours. Pretreated glial cells were then coincubated with syngeneic CD4(+) T cells for 48 hours. ROS generation and cell viability were assessed with the use of dihydroethidium and calcein assays, respectively. Flow cytometry and immunocytochemistry were used to determine major histocompatibility complex (MHC) class II molecules. In addition, functional experiments were performed to determine the proliferation and cytokine secretion of T cells using [(3)H]-thymidine incorporation and TNF-alpha assays, respectively.

RESULTS

MHC class II molecules were upregulated on glial cells exposed to ROS. Compared with the control glia, glial cells in ROS-generating systems were found to be more potent inducers of T-cell activation in a cell density- and time-dependent manner, as assessed by increased T-cell proliferation (approximately threefold) and TNF-alpha secretion (approximately sixfold; P < 0.01). When an ROS scavenging treatment was applied, MHC class II upregulation on glial cells persisted, but antigen-mediated T-cell activation was significantly decreased (P < 0.01), indicating an additional costimulatory function of ROS during antigen presentation.

CONCLUSIONS

These in vitro findings support that ROS regulate the immune response by stimulating the antigen-presenting ability of glial cells and functioning as costimulatory molecules for antigen presentation.

The immune system and glaucoma

PURPOSE OF REVIEW

Compelling evidence obtained from studies over the last decade strongly suggests the involvement of immune system regulation in cell fate decisions in glia and retinal ganglion cells that lead to glaucomatous optic nerve degeneration.

RECENT FINDINGS

Recent studies reveal seemingly conflicting roles of the immune system in glaucomatous optic nerve degeneration. T cells directed against specific antigens may have a beneficial effect to protect neurons from the consequences of axonal injury. However, the immune response in glaucoma also has the capacity to cause neuronal injury. The balance between the benefit of protective immunity and the risk of inducing an autoimmune neurodegenerative disease is critical. The immunoregulatory function of glial cells and the presence of tissue stress seem to be important factors that determine the balance between diverse roles of the immune system in glaucomatous optic nerve degeneration. Thus, the net effect of immunoregulation may be either neuroprotective or neurodestructive.

SUMMARY

Despite the neuroprotective features of the immune system, an autoimmune component, resulting from a failure to properly control aberrant, stress-induced immune response, likely accompanies the progression of neurodegeneration in glaucoma in some patients. A better understanding of the diverse roles of the immune system in all forms of glaucomatous optic nerve degeneration will facilitate the development of effective neuroprotective strategies in glaucoma. The basis of a sustainable neuroprotective strategy is to harness immunoregulation of glial and retinal ganglion cell fate to maximize beneficial effects, while minimizing negative sequelae, for therapeutic gain.

[Neuro-ophthalmologic aspects in antiphospholipid syndrome]

Antiphospholipid syndrome is the one autoimmune noninflammatory syndrome affecting all blood vessels at any vascular segment, irrespective of the vascular size and topography. Defined in 1983 by Hughes, this syndrome represents the actual research theme in practically all medical fields, therefore the importance of antiphospholipid syndrome is recognized. The major aim of this article is to describe the neuro-ophthalmologic manifestations of the antiphospholipid syndrome, emphasizing the latest news about this syndrome and its impact on the retina and central nervous system.

Neuroprotection as a treatment for glaucoma: pharmacological and immunological approaches

Primary open-angle glaucoma is a chronic, progressive optic neuropathy associated with a gradual decline in visual function, which may lead to blindness. In most cases, the optic neuropathy is associated with increased intraocular pressure. It is now generally accepted, however, that normalization of pressure, although necessary, is often not-sufficient as a remedial measure. This is because of the existence of additional factors, some of which emerge as a consequence of the initial damage. This situation is reminiscent of the response to a traumatic axonal insult, in which some of the damage is immediate and is caused by the insult itself, and some is secondary and is caused by a deficiency of growth-supportive factors as well as by toxic factors derived from the damaged tissue. Accordingly, the author has suggested that glaucoma may be viewed as a neurodegenerative disease and consequently amenable to any therapeutic intervention applicable to neurodegenerative diseases. There is evidence that neuroprotection can be achieved both pharmacologically and immunologically. Pharmacologic intervention neutralizes some of the effects of the nerve-derived toxic factors and possibly increases the ability of the remaining healthy neurons, at any given time, to cope with the stressful conditions. Immunologic intervention boosts the body's repair mechanisms for counteracting the toxicity of physiologic compounds acting as stress signals.

[Current concepts in the pathogenesis of glaucomatous optic neuropathy]

On the basis of review of available literature, the concept of vascular dysregulation, excitotoxicity in the pathogenesis of glaucoma, and influence of intraocular pressure and immunology system on mechanism of glaucomatous optic neuropathy was described.

Neurobiology of glaucomatous optic neuropathy: diverse cellular events in neurodegeneration and neuroprotection

Although glaucomatous optic nerve degeneration is a leading cause of worldwide blindness, neither the precise cellular mechanisms underlying neurodegeneration in glaucoma, nor effective strategies for neuroprotection are yet clear. This review focuses on diverse cellular events associated with glaucomatous neurodegeneration whose balance is critical for determination of ultimate cell fate. An improved understanding of the site of primary injury to optic nerve, the mediator pathways of apoptotic cell death and intrinsic protection mechanisms in retinal ganglion cells, the role of glial activation on the survival and death of retinal ganglion cell bodies and their axons, and the protective and destructive consequences of immune system involvement can facilitate development of effective neuroprotective strategies in glaucoma.

[Inflammatory optic neuropathies]

Diagnosis of inflammatory optic neuropathy is very likely in a young adult presenting acute, unilateral and painful visual loss. Relative afferent pupillary defect is a very sensitive and specific sign of optic neuropathy. Ophthalmological exam is mandatory to estimate severity of visual loss, appearance of optic disks and check for another eye disease. Magnetic resonance imaging is indicated to rule out a compressive optic neuropathy and to quantify the inflammatory lesion index, which is the best prognostic indicator of multiple sclerosis development (MRI is abnormal at entry in about 50% of patients with isolated optic neuritis). Spontaneous outcome of optic neuropathies is favourable. Corticosteroids have demonstrated efficacy only in shortening length of evolution and by using parenteral high doses. Clinical benefit from introducing beta-interferons treatment after a first episode of isolated optic neuritis remains to be evaluated. Secondary inflammatory optic neuritis (infection, vasculitis, sarcoïdosis) are rare and usually present atypical evolution or other symptoms.

[Immune disorders in patients with dystrophic conditions of the posterior segment of the eye and chronic alcoholism]

A total of 193 patients with chronic alcoholism aged 30-65 years were examined. Optic nerve abnormalities were detected in 30 (15.5%) and degenerative condition of the retina in 42 (21.8%) patients. Ocular diseases were detected in 72 (37.3%) examined chronic alcoholics. Disorders of total and local immunity of the eye contribute to the development of the above diseases. These changes were more pronounced in chronic alcoholics with visual analyzer abnormalities. These data can be useful in development of pathogenetic therapy of ocular diseases.

Paraneoplastic optic neuropathy and cerebellar ataxia with small cell carcinoma of the lung

Bilateral optic neuropathy and subacute cerebellar ataxia were manifestations of a paraneoplastic neurologic disorder in a woman found to have small cell carcinoma of the lung. Serologic tests revealed a neuronal autoantibody specific for CRMP-5, a 62-kd member of the collapsin response-mediating protein family. Unexplained optic neuropathy in the setting of subacute cerebellar ataxia should cause suspicion of a paraneoplastic disorder and prompt testing for this autoantibody, especially in patients at risk for lung carcinoma.

Neuroprotection as a treatment for glaucoma: pharmacological and immunological approaches

PURPOSE

Primary open-angle glaucoma is a chronic, progressive optic neuropathy associated with a gradual decline in visual functions, which may lead to blindness.

METHODS

In most cases, the optic neuropathy is associated with increased intraocular pressure. However, it is now generally accepted, that normalization of pressure, although necessary, is often not sufficient as a remedial measure. This is because of the existence of additional risk factors, some of which emerge as a consequence of the initial damage. This situation is reminiscent of the response to a traumatic axonal insult: some of the damage is immediate and is caused by the insult itself, while some is secondary and is caused by a deficiency of growth-supportive factors as well as by toxic factors derived from the damaged tissue. Accordingly, we have suggested that glaucoma may be viewed as a neurodegenerative disease and consequently is amenable to any therapeutic intervention applicable to these diseases.

CONCLUSIONS

There is evidence that neuroprotection can be achieved both pharmacologically and immunologically. Pharmacological intervention (e.g. by using selective alpha-2 adrenergic receptor agonists) neutralizes some of the effects of the nerve-derived toxic factors and possibly increases the ability of the remaining healthy neurons, at any given time, to cope with the stressful conditions. Immunological intervention boosts the body's own repair mechanisms for counteracting the toxicity of physiological compounds acting as stress signals.

Physiological Approaches to Neuroprotection

In glaucoma, as in other degenerative diseases of the central nervous system (CNS), there are some neurons which, although susceptible to degeneration, are amenable to neuroprotection. Until very recently, attempts to attenuate the spread of damage after CNS trauma or in neurodegenerative diseases did not include recruitment of the immune system, because it was assumed that in the CNS any immune activity, particularly autoimmune activity, would be harmful. Using the injured optic nerve of the rat as a model, we recently showed, however, that this 'secondary degeneration' can be slowed down by a well-controlled adaptive immune response, which is mediated by T cells against CNS self-antigens, such as myelin basic protein (MBP), and can be achieved either by passive transfer of MBP-activated T cells or by active immunization with MBP. Accordingly, we suggested that autoimmune T cells can be neuroprotective. We further showed that the neuroprotective autoimmunity is a physiological response to the injury, perhaps insufficient in its natural state, but amenable to boosting. The neuroprotective activity of these T cells probably depends on their reactivation by their specific antigen after they are targeted to the injured nerve. As nerve degeneration is initiated and sustained by many factors, it would probably best be counteracted by a comprehensive type of therapy rather than treatment that addresses only some aspects of nerve damage. T cell therapy, being physiological rather than pharmaceutical in nature, may provide a global answer. However, since the neuroprotective immune response is directed against the self, it must be rigorously regulated to avoid inducing an autoimmune disease. We showed that the synthetic copolymer Cop-1 can passively or actively evoke T cell-mediated neuroprotection, probably by cross-reacting with MBP. Safe synthetic peptides that resemble self-antigens and are cross-activated by CNS-associated self antigens may be a useful starting point for the development of anti-self immunity for neuroprotective purposes.

[Autoimmune mechanisms in molecular pathology of glaucomatous optic neuropathy]

BACKGROUND

Glaucomatous optic neuropathy is characterized by loss of retinal ganglion cells and their axons, excavated appearance of the optic nerve head, and progressive loss of visual field sensitivity. In terms of pathology of the glaucomatous optic neuropathy, observations suggest retinal ganglion cell death by apoptosis. Deprivation of neurotrophic factors, ischemia, chronic elevation of glutamate, and disorganized nitric oxide metabolism have been suspected to be mechanisms triggering apoptosis. Another recent suggestion is that autoantibodies directed toward retinal antigens may be involved in facilitating apoptotic cell death in some glaucoma patients.

METHOD

We summarized previous reports dealing with the relationship between glaucoma etiology and autoimmune responses, and investigated the contribution of autoimmune factors in glaucomatous optic neuropathy using electrophysiological and biochemical methods.

RESULTS

We found serum anti-neuron specific enolase(NSE) antibody in approximately 20% of our glaucoma patients. In primary open angle glaucoma, maximum and mean intraocular pressures in antibody positive patients were significantly or relatively lower than pressures in antibody negative patients. In addition, we also found that apoptotic cell death of retinal ganglion cells was induced in rat eyes by intravitreal administration of purified anti-NSE antibody.

CONCLUSION

As suggested by previous reports, autoimmune response is one of the mechanisms related to glaucoma etiology and NSE may have an important function as an autoantigen.

Macrophage migration inhibitory factor in the cerebrospinal fluid of patients with conventional and optic-spinal forms of multiple sclerosis and neuro-Behçet's disease

Macrophage migration inhibitory factor (MIF) is becoming increasingly recognized as an important regulator of immune and inflammatory responses. It is released by activated T lymphocytes and macrophages and up-regulates the proinflammatory activity of these cells. MIF is required for antigen- and mitogen-driven T cell activation, and stimulates macrophages to release cytokines and nitric oxide. On the basis of the recent suggestion that pharmacological modulation of MIF production and neutralization of its activity may have important implications for treatment of a variety of autoimmune or inflammatory conditions, we determined the level of MIF in the cerebrospinal fluid (CSF) of patients with conventional-form multiple sclerosis (C-MS) and optic-spinal form multiple sclerosis (OpS-MS), and neuro-Behçet's disease (NBD). As control, the CSF of patients with non-inflammatory neurological diseases (NIND) was used. The concentration of MIF in CSF samples was significantly elevated in relapsed cases of C-MS (4.13+/-1.07 ng/ml) (mean+/-S.D.) compared with control samples (2.38+/-0.60 ng/ml) (P<0.0001), whereas MIF in the CSF of C-MS patients in remission was not elevated (2.65+/-0.67 ng/ml). The concentration of MIF in the CSF of OpS-MS patients in relapse (5.53+/-1.74 ng/ml) was higher than that of patients with C-MS in relapse (P<0.05). In NBD patients, the concentration of MIF in CSF was significantly elevated (7.47+/-5.61 ng/ml) compared with control samples (P<0.01) and correlated well with cell count in these samples (r=0.910, P<0.005). These results suggest that MIF may play a pivotal role in immune-mediated diseases of the central nervous system, and that MIF may be useful in the study of differences between C-MS and OpS-MS.

T cell immunity to copolymer 1 confers neuroprotection on the damaged optic nerve: possible therapy for optic neuropathies

We recently reported that the posttraumatic spread of degeneration in the damaged optic nerve can be attenuated by the adoptive transfer of autoimmune T cells specific to myelin basic protein. However, it would be desirable to obtain immune neuroprotection free of any possible autoimmune disease. In an attempt to obtain disease-free immune neuroprotection, we used the synthetic four-amino acid polymer copolymer 1 (Cop-1), which is known not to be encephalitogenic despite its cross-reactivity with myelin basic protein. We show here that active immunization with Cop-1 administered in adjuvant, as well as adoptive transfer of T cells reactive to Cop-1, can inhibit the progression of secondary degeneration after crush injury of the rat optic nerve. These results have implications for the treatment of optic neuropathies.

Is there a role for the immune system in glaucomatous optic neuropathy?

Glaucoma and immunity are not traditionally perceived as being causally related. Recently, however, compelling observations have provided insight into a potential role for the immune system in the development of glaucomatous optic neuropathy. In this article, it is proposed that the role of the immune system in glaucoma is two-fold. In some patients, there is evidence that an autoimmune mechanism may be responsible for eliciting damage to the optic nerve, resulting in glaucomatous injury. Autoimmune damage to the optic nerve may occur directly by autoantibodies, or indirectly by way of a "mimicked" autoimmune response to a sensitizing antigen which, in turn, injuries retinal ganglion cells. We suggest that autoimmune-mediated glaucoma injury occurs most often, but not exclusively, in patients in whom the intraocular pressure has never been found to be elevated. A second role of the immune system in glaucoma is likely one of surveillance, in which signal pathways of the immune system regulate cell death in response to conditions that stress retinal neurons in glaucoma. These might include mechanical stress from high intraocular pressure, ischemia, excessive excitatory amino acids, or toxic products resulting from excessive nitric oxide synthase production in either neurons or glial fibers that surround the optic nerve as it exits the eye. In these cases, we propose that the immune system acts as an "arbiter" to help determine whether a neuronal cell will ultimately survive, or succumb to, those stressors that are perceived as injurious. It is conceivable that such surveillance and cell death regulation by the immune system is important in determining the fate of retinal neurons in both the more common "high-pressure" forms of glaucoma, such as primary open-angle glaucoma, and in cases in which the intraocular pressure appears within normal range.

The 22-kDa antigen in optic nerve and retinal diseases

OBJECTIVE

Patients with unexplained visual loss were evaluated for the possibility of immunologic involvement. Antibody reactions were sought that might identify a common indication of retinal hypersensitivity.

METHODS

The enzyme-linked immunosorbent assay (ELISA) and Western blot analysis were used to identify autoantibody reactions with retina and optic nerve components. Comparisons were made with the autoantibody reaction of normal subjects and patients with recognized forms of retinal decay: macular degeneration, retinitis pigmentosa, diabetic retinopathy, and paraneoplastic retinopathy.

RESULTS

Eight patients, one man and seven women, were found to produce an autoantibody reaction with retina and optic nerve, including a novel 22-kDa neuronal antigen present within the retina and optic nerve. One of the eight had retinopathy associated with melanoma (MAR Syndrome). Seven of the eight patients had electroretinogram abnormalities, varying from mild to severe. Six displayed features of optic atrophy. One patient with progressive visual loss had visual function stabilized after immunosuppressive therapy.

CONCLUSIONS

In the eight cases described, unexplained visual loss was associated with autoantibody reactions with retina and optic nerve, including a common antibody reaction with a 22-kDa neuronal antigen found in the retina and optic nerve. All the patients had either an abnormal electroretinogram or optic atrophy. Six patients had both. The 22-kDa immunologic marker may not be directly involved in the patient's vision loss, but rather may be related to a nonspecific destruction of retina and optic nerve. However, the marker may be useful in identifying a specific subgroup of patients for further analysis.

Bilateral optic neuropathy with IgGkappa multiple myeloma improved after myeloablative chemotherapy

A 49-year-old woman with immunoglobulin GK multiple myeloma developed progressive visual loss with bilateral upper and lower central arcuate scotomas. Funduscopic and electrophysiologic studies indicated bilateral optic neuropathy. The immunoglobulin G fraction of the patient's serum reacted with retinal ganglionic cells in bovine retina. The visual abnormalities remitted after myeloablative chemotherapy and disappearance of the paraprotein.

Paraneoplastic optic neuropathy and autoantibody production in small-cell carcinoma of the lung

A 59-year-old woman presented with acute-onset, bilateral, painless loss of vision, dysarthria, and ataxia. Ophthalmoscopy showed bilateral optic disc edema. A magnetic resonance scan of the head was normal. Chest radiography showed mediastinal adenopathy. Mediastinoscopy and biopsy identified small-cell carcinoma of the lung. An autoantibody to optic nerve and retina was demonstrated in the patient's serum. An electroretinogram was normal. The patient was diagnosed with a paraneoplastic optic neuropathy and paraneoplastic cerebellar syndrome. After treatment for her lung cancer, the patient remains stable from a visual and neurologic standpoint.

[Western blot study of sera from patients with epidemic neuropathy]

The immune response of a group of patients with epidemical neuropathy and of controls was studied by the immunoblotting technique against proteins of the Coxsackie virus and the proteins of slow effect isolated in our laboratory. 13 sera of patients with epidemical neuropathy and 9 sera of controls were studied. Of the 13 sera studied, 8 (61.5%) recognized protein VPI and 2 sera (15.3%) protein VP0 of the strain 47.93. Of the 9 controls studied, 4 (44.4%) recognized protein VPI and 3 (33.3%) protein VP0 only. With the antigen prepared from the slow effect strain it was obtained a specific signal in 5 (38.5%) sera of patients and in 2 sera (22.5%) of controls. It should be stressed that in this last case the protein observed had a molecular weight of 41,300 D, and that its size was smaller than that of the preceding protein detected against the strain 47.93 was of 45,000 D.

[Mechanism of Enterovirus participation in epidemic neuropathy. Physiopathological hypothesis]

During the epidemic neuropathy occurred in Cuba from 1992 to 1993, viral isolations antigenically connected with Coxsackie viruses were obtained from the cerebrospinal fluid of patients. Virological, epidemiological, toxicologic, nutritional, immunological and histopathological investigations were made. Though the disease was related to toxic and nutritional factors, it has been impossible to identify the cause of the epidemic. Taking into consideration the results of the different investigations, we have formulated a comprehensive and multifactorial hypothesis to explain the physiopathological mechanism of the participation of the isolated viruses as mediators in a process of autoimmunity of the pathogeny of the disease.

Anti-Ro/SS-A positivity and heat shock protein antibodies in patients with normal-pressure glaucoma

PURPOSE

To describe the clinical and laboratory findings in 10 patients with normal-pressure glaucoma and anti-Ro/SS-A positivity by enzyme-linked immunosorbent assay (ELISA) and to determine whether that positivity may be related to an autoimmune mechanism for the optic neuropathy.

METHODS

In this prospective study, we evaluated ocular and systemic clinical findings of 10 patients with normal-pressure glaucoma and anti-Ro/SS-A positivity by ELISA, including sicca complex features. Oüchterlony immunodiffusion was performed to confirm the presence of antibodies for Ro/SS-A, and the presence of other serum antibodies and their possible cross-reactivities with Ro/SS-A were investigated.

RESULTS

None of the 10 patients with normal-pressure glaucoma and anti-Ro/SS-A positivity (by ELISA) had clinical or laboratory signs of Sjögren syndrome or other connective tissue diseases. Only one of 10 patients had evidence of anti-Ro/SS-A antibodies by Oüchterlony immunodiffusion. All patients demonstrated serum immunoreactivity to bacterial heat shock protein 60 (hsp60) by Western blotting. Cross-reactivity between bacterial hsp60 and Ro/SS-A was demonstrated by Western blotting. Immunoreactivity to bacterial hsp60 by ELISA was significantly elevated in the sera of patients with normal-pressure glaucoma. Furthermore, patients with either normal-pressure or primary open-angle glaucoma had increased serum immunoreactivity to human hsp60.

CONCLUSIONS

Anti-Ro/SS-A positivity by ELISA in 10 patients with normal-pressure glaucoma was associated with a high level of serum immunoreactivity to bacterial hsp60, which may indicate that their glaucomatous optic neuropathy involves an as yet unidentified autoimmune mechanism. The identification of autoantibodies that react with human hsp60 in patients with normal-pressure and primary open-angle glaucoma may signify a common finding associated with the glaucomatous optic neuropathy process in some patients and appears to be unrelated to intraocular pressure levels.

[Neuro-ophthalmologic complications of disseminated lupus erythematosus]

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystemic inflammatory disease of unknown etiology. Physiopathology includes small vessel occlusion and auto-antibody production. Neuro-ophthalmic complications can be detected in 10-30% of SLE cases. Further, some patients can present with neuro-ophthalmic complications prior to diagnosis of SLE.

PATIENTS AND METHODS

We report seven cases of neuro-ophthalmic complications of SLE demonstrating lesions from the retina to the brain. The other possible manifestations of SLE will be reviewed.

RESULTS

Two cases were not yet diagnosed with SLE when neuro-ophthalmic disease occurred. Anti-double stranded DNA antibodies were detected at a very high titer, suggesting SLE, later confirmed by rheumatologists.

CONCLUSIONS

Ophthalmologists should be aware of the unusual patient presenting with a neuroophthalmic disorder prior to the diagnosis of SLE. In such cases, autoantibodies should be sought. Antinuclear antibodies are very sensitive but non specific for SLE. Anti-double stranded DNA antibodies are specific for SLE and elevated titer should raise the suspicion of undiagnosed SLE.

Anticardiolipin antibodies in Japanese patients with multiple sclerosis

We evaluated circulating anticardiolipin antibodies (aCL) in 38 Japanese patients who fulfilled the criteria of clinically definite multiple sclerosis (MS), using a newly developed EIA system with aCL-cofactor. Two of 38 patients (5.3%) had a aCL-cofactor-dependent positive serology, and differences compared with findings in controls were statistically significant. The 2 aCL-positive patients had similar clinical features with acute transverse myelopathy (ATM), optic neuropathy (OPN), normal cranial MRI and negative oligoclonal IgG bands (OCBs) in the cerebrospinal fluid (CSF). Among the 38 patients, 3 had ATM, OPN, normal cranial MRI and negative OCBs, hence, in a significant number of the patients (2/3; 67%) with these distinctive features, serology for aCL was positive. Therefore, they may have another condition associated with aCL, masquerading as MS. Serological testing for aCL with aCL-cofactor is recommended for the patients with clinical diagnosis of MS, especially for those showing OPN and ATM during the clinical course, and in Asian peoples where the incidence of ATM and OPN is relatively high among the patients with diagnosis of MS.

Ocular thrombosis associated with antiphospholipid antibodies

Four patients with isolated acute ocular ischemic syndromes also had circulating antiphospholipid antibodies. Two patients had vaso-occlusive retinopathy and two, anterior ischemic optic neuropathy (which was successive in one). Extensive clinical laboratory evaluation identified vascular risk factors in two patients. One patient had essential thrombocytosis, confirmed by bone marrow biopsy; the other had stable hypertension and a history of coronary artery disease. These cases suggest that small vessel thrombosis in situ may be a mechanism for antiphospholipid-associated ocular and cerebral ischemia.

Antiphospholipid antibodies in the aetiology of ischaemic optic neuropathy

The involvement of antiphospholipid antibodies in the mediation of acute anterior ischaemic optic neuropathy (AION) was studied, in the light of recent associations between these autoantibodies and other vascular events. A strong association between IgG anticardiolipin antibodies and AION secondary to biopsy proven giant cell arteritis was identified, which did not exist with the 'non-arteritic', biopsy negative form of AION. The possible implications of this finding on the aetiology, diagnosis, and treatment of giant cell arteritis are discussed.

[Pathogenetic mechanisms of optic nerve lesions in acute vascular optic neuropathies]

The authors analyze the findings of histomorphologic and immunomorphologic studies of 20 cadaver optic nerves from subjects with a history of acute vascular optic neuropathies due to atherosclerosis, eventuating in optic nerve atrophy: 13 atrophic optic nerves and 7 pair nerves from clinically normal eyes of the same patients were examined. The blood sera of 30 patients suffering from acute vascular optic neuropathies were tested. Noteworthy that vascular optic neuropathy associated with atherosclerosis is a bilateral process. Vascular insufficiency due to sclerotic changes in vessels of various diameters undoubtedly contributes to the pathogenesis of the optic nerve impairments in the involved and clinically healthy eyes. The developing immune status disorders and autoimmune processes also contribute to the genesis of sclerotic shifts in the vessels and optic nerve atrophy in both eyes.

Ocular manifestation of temporal arteritis. Immunological studies

Since immunological mechanisms may be involved in the pathogenesis of temporal arteritis, serum samples of 15 patients with ocular manifestations of temporal arteritis were investigated for the presence of circulating immune compleses (CICs) and antinuclear antibodies (ANAs). In addition, the serum levels of IgG, IgA, IgM, and the complement components C3 and C4 were determined. In none of our patients could CICs be detected. Serum samples of two of the patients were positive for ANA. The values for IgG, IgM, C3, and C4 were within normal limits. Our data indicate that circulating C1q-binding immune complexes and ANAs are not the cause of ocular manifestation of temporal arteritis. This does not exclude the possibility that other forms of circulating immune complexes or the local formation of immune complexes might play a role in the pathogenesis of this disease.

[Immunopathogenesis of the Vogt-Koyanagi-Harada syndrome]

Regarding immunopathogenesis of the Vogt-Koyanagi-Harada syndrome (VKHS), peripheral blood lymphocytes of a female patient with this disease were tested for sensitization against several antigens such as myelinic basic protein (BP) and uveoretinal, brain and spleen tissue homogenates. For comparison, cells of seven patients with chorioretinitis only and cells of six patients with encephalitis of unknown etiology were also tested. Cells of healthy donors served as controls. The electromobility test and the leucocyte migration test were used as in vitro test systems for cell-mediated immunological reactivity. The results show a strong sensitivity against BP and uveoretinal and brain tissue homogenates in VKHS. In the patients suffering from chorioretinitis, a strong reactivity against uveoretinal homogenate only was found, while in patients with encephalitis, responses to brain antigens only were observed. Reactions towards spleen tissue homogenate were negative in all experiments. The extent to which this tissue-specific immunological reactivity, which is different from the monoreactivity in chorioretinitis or encephalitis, might be a characteristic phenomenon of the VKHS is discussed.

Experimental immunogenic proliferative retinopathy in monkeys

When a small amount of bovine serum albumin (BSA) was injected into the posterior vitreous body of a sensitized monkey, an immunogenic response occurred in the major blood vessels of the optic disk. In nonsensitized monkeys, the same phenomenon appeared after repeated intravitreal injections of small amounts of BSA. Focal leaks of fluorescein from the optic disk vessels were demonstrated by fluorescein angiography. Correlative light and electron microscopy revealed infiltration of acute and chronic inflammatory cells from the vessels of the optic disk into the vitreous body. When larger amounts of BSA were injected in sensitized monkeys, in addition to optic nerve involvement, there were scattered retinal vascular hemorrhagic and exudative lesions throughout the posterior pole. Immunologic mechanisms can result in preferential optic disk involvement with formation of proliferative lesions during the healing phase of the immunogenic inflammation.