Advances in imaging of the lacrimal gland in Sjögren's syndrome: A narrative review

Due to lymphocytic infiltration of the salivary and lacrimal glands, Sjogren's syndrome (SS), a systemic autoimmune illness that mostly affects the exocrine glands, causes dry mouth (xerostomia) and dry eyes (xerophthalmia). Additionally, SS is associated with various comorbidities such as cardiovascular diseases, infections, musculoskeletal diseases, and cancers. Among patients with SS, xerophthalmia frequently arises as a complication, leading to insufficient tear production or rapid tear evaporation, thereby causing discomfort, irritation, and a gritty sensation in the eyes. This article aims to examine recent advancements in the imaging of the lacrimal gland in Sjögren's syndrome and briefly discusses the utilization of various imaging examinations for the lacrimal gland in this particular disease.

Acupuncture promotes tear secretion by up-regulating VIP/cAMP/PKA/AQP5 signaling in guinea pigs with aqueous tear deficiency dry eye

OBJECTIVES

To observe the effect of acupuncture on the ocular surface symptoms and the protein expression of vasoactive intestinal peptide (VIP) / cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) / aquaporin 5(AQP5) signaling pathway in lacrimal gland tissue of aqueous tear deficiency (ATD) type dry eye model, so as to investigate its mechanism underlying improvement of ATD.

METHODS

British shorthair guinea pigs were randomly divided into blank control, model, acupuncture, sham-acupuncture and medication group, with 8 guinea pigs in each group. The ATD model was established by subcutaneous injection of scopolamine hydrobromide (0.6 mg/dose, 4 times/d for 10 days). For guinea pigs of the acupuncture group, filiform needles were inserted into bilateral "Jingming"(BL1), "Cuanzhu"(BL2), "Sizhukong"(TE23), "Taiyang"(EX-HN5), and "Tongziliao"(GB1) for 15 min. For guinea pigs of the sham-acupuncture group, a blunt filiform needle was used to repeatedly prick (not pierce) the skin of the same acupoints mentioned above. The treatment in the above two groups was conducted once daily for 14 days. The guinea pigs in the medication group received administration of sodium hyaluronate eye drops in both eyes, three times a day for 14 days. The objective tests of tear film break-up time (BUT), corneal fluorescein staining score (FLS) and phenol red thread (PRT) test were conducted before and after modeling and after the intervention. After the intervention, the lacrimal index (weight of lacrimal gland/body weight) was calculated. Histopathological changes of the lacrimal gland were observed after H.E. staining. The expression of AQP5 in the lacrimal gland were detected by immunofluorescence, and the contents of VIP and AQP5 in the lacrimal gland were measured by ELISA, the protein expression levels of VIP, cAMP, PKA, p-PKA and AQP5 in the lacrimal gland were detected by Western blot.

RESULTS

In comparison with the blank control group, the PRT, BUT, lacrimal index, AQP5 immunoactivity, contents of VIP and AQP5, and protein expression levels of VIP, cAMP, PKA, p-PKA and AQP5 were significantly decreased(P<0.01, P<0.05), and FLS was obviously increased (P<0.01) in the model group . Compared to the model group, the PRT, BUT, lacrimal index, AQP5 immunoactivity, contents of VIP and AQP5, and expression levels of VIP and AQP5 in both acupuncture and medication groups, and the expression levels of cAMP, PKA, p-PKA in the acupuncture group were considerably increased (P<0.01, P<0.05), while the FLS was markedly decreased in both acupuncture and medication groups (P<0.01, P<0.05). Compared with the medication group, the acupuncture group had increased PRT (P<0.05).

CONCLUSIONS

Acupuncture intervention is effective in reducing ocular surface damage and promoting tear secretion in guinea pigs with ATD, which may be related to its function in activating VIP/cAMP/PKA signaling, and promoting the expression of AQP5 in the lacrimal gland.

Defining the Role of Monocytes in Sjögren's Syndrome

Sjögren's syndrome is one of the most prevalent autoimmune diseases after rheumatoid arthritis, with a preference for middle age, and is characterised by exocrine glandular involvement leading to xerostomia and xerophthalmia. It can have systemic implications with vascular, neurological, renal, and pulmonary involvement, and in some cases, it may evolve to non-Hodgkin's lymphoma. For a long time, B- and T-lymphocytes have been the focus of research and have been considered key players in Sjögren's syndrome pathogenesis and evolution. With the development of new technologies, including omics, more insights have been found on the different signalling pathways that lead to inflammation and activation of the immune system. New evidence indicates that a third actor linking innate and adaptive immunity plays a leading role in the Sjögren's syndrome play: the monocyte. This review summarises the recent insights from transcriptomic, proteomic, and epigenetic studies that help us to understand more about the Sjögren's syndrome pathophysiology and redefine the involvement of monocytes in this disease.

Bilateral keratomalacia secondary to xerophthalmia

INTRODUCTION

Vitamin A deficiency leads to a wide spectrum of ocular manifestations ranging from conjunctival xerosis to corneal ulceration and perforation. Penetrating keratoplasty along with vitamin A supplementation can save the eye and useful vision.

CASE

A 10-year-old boy presented with decreased vision in both eyes for 3 months. Slit-lamp examination with diffuse light revealed bilateral corneal thinning with iris prolapse at inferior aspect of cornea. He underwent therapeutic penetrating keratoplasty in both eyes. Vitamin A supplementation was given as per national protocol. Till 1 year postoperatively visual acuity in RE was 6/18 and LE was pre-phthisical.

CONCLUSION

Vitamin A deficiency is potentially a sight threatening condition, which may lead to keratomalacia and corneal perforation if neglected. Timely management with Vitamin A supplementation and penetrating keratoplasty can save the eye and vision.

Powered air-purifying respirator use in healthcare: Effects on thermal sensations and comfort

Twelve subjects wore an N95 filtering facepiece respirator (N95 FFR), one tight-fitting full facepiece powered air-purifying respirator (PAPR), two loose-fitting PAPRs, and one elastomeric/PAPR hybrid for 1 hr each during treadmill walking at 5.6 km/hr while undergoing physiological and subjective response monitoring. No significant interaction (p ≥ .05) was noted between the five respirators in heart rate, respiratory rate, oxygen saturation, transcutaneous carbon dioxide, and perceptions of breathing effort or discomfort, exertion, facial heat, and overall body heat. Respirator deadspace heat/humidity were significantly greater for the N95 FFR, whereas tympanic forehead skin temperatures were significantly greater for the hybrid PAPR. Temperature of the facial skin covered by the respirator was equivalent for the N95 FFR and hybrid PAPR, and both were significantly higher than for the other three PAPRs. Perception of eye dryness was significantly greater for a tight-fitting full facepiece PAPR than the N95 FFR and hybrid PAPR. At a low-moderate work rate over 1 hr, effects on cardiopulmonary variables, breathing perceptions, and facial and overall body heat perceptions did not differ significantly between the four PAPRs and a N95 FFR, but the tight-fitting, full facepiece PAPR increased perceptions of eye dryness. The two loose-fitting PAPRs and the full facepiece tight-fitting PAPR ameliorated exercise-induced increases in facial temperature, but this did not translate to improved perception of facial heat and overall body heat.

[Preliminary observation the correlation between lid-wiper epitheliopathy and dry eye]

OBJECTIVE

To investigate the prevalence of lid-wiper epitheliopathy (LWE) and risk factors in dry eye patients.

METHODS

One hundred forty-one patients (141 eyes) were recruited in Peking University First Hospital from September 2006 to March 2007. These patients were divided into three groups based on the dry eye symptoms and the results of break up time, Schirmer I test and corneal fluorescein staining. Group A: 60 patients (60 eyes) with no dry eye symptoms and normal results of BUT, Schirmer I test and corneal fluorescein staining. Group B: 51 patients (51 eyes) with dry eye symptoms and normal results of BUT, Schirmer I test and corneal fluorescein staining. Group C: 30 patients (30 eyes) with dry eye. The patients in group A and group B were further divided into two subgroups based on wearing contact lens. Subgroup A1:30 patients (30 eyes) with no contact lens wearers; Subgroup A2:30 patients (30 eyes) with contact lens wearers. Subgroup B1:21 patients (21 eyes) with no contact lens wearers; Subgroup B2: 30 patients (30 eyes) with contact lens wearers. Lid-wiper staining was graded in all patients following the instillation of fluorescein and lissamine green dyes. Impression cytology (IC) was made up in the patients in group C and the patients with LWE in group B.

RESULTS

The prevalence of LWE was 18.3% (11 patients), 86.3% (44 patients) and 100.0% (30 patients) in group A, B, C respectively. The prevalence of LWE was 13.3% (4 patients), 23.3% (7 patients), 81.0% (17 patients) and 90.0% (27 cases) in subgroup A, A2, B1, and B2. There was a significant statistical difference in the prevalence of LWE among groups A, B and C (X2 = 78.256, P < 0.01). There were no statistical difference in the prevalence of LWE between subgroup A2 and subgroup A1 (X2 = 1.002, P = 0.253), subgroup B2 and subgroup B1 (X2 = 0.854, P = 0.301). In group B, IC was graded as mark zero in 74.0% of patients with LWE, as mark one in 26.0% of patients with LWE. In group C, IC was graded as mark one in 40.0% of patients, as mark two in 50.0% of patients, and as mark three in 10.0% of patients. There was a significant statistical difference in grade of IC between group B and C (M-W = 36.0, P < 0.01). The result of the corneal fluorescein staining was positive in 18.8% of patients with LWE. The result of lissamine green staining was positive in 14. 1% of patients with LWE. However, the result of both fluorescein and lissamine green staining was 67. 1% in patients with LWE.

CONCLUSIONS

The prevalence of LWE is higher in patients with dry eye symptoms and normal results of BUT, Schirmer I test and corneal fluorescein staining. LWE may be an early manifestation of the dry eye.

Sjögren's syndrome disease damage index and disease activity index: Scoring systems for the assessment of disease damage and disease activity in Sjögren's syndrome, derived from an analysis of a cohort of Italian patients

OBJECTIVE

To develop valid instruments for the assessment of disease-related damage and disease activity in Sjögren's syndrome (SS).

METHODS

Data on 206 patients with primary SS were collected in 12 Italian centers. Each patient was scored by 1 investigator, on the basis of a global assessment of the degree of disease damage and disease activity. Patients judged to have active disease at the time of enrollment underwent a second evaluation after 3 months. Univariate and multivariate analyses were performed to select the clinical and serologic variables that were the best predictors of damage and of disease activity, and these variables were used to construct the Sjögren's Syndrome Disease Damage Index (SSDDI) and the Sjögren's Syndrome Disease Activity Index (SSDAI). The weight of each variable in the index was determined by the beta coefficients in multivariate regression models. Scores obtained using the SSDDI and the SSDAI were compared with scores initially given by the investigators. Finally, a receiver operating characteristic (ROC) curve was used to determine the cutoff value in the SSDAI with the highest level of accuracy in identifying patients with a significant level of disease activity.

RESULTS

A multivariate model with 9 variables was the best predictor of investigator scores of damage. The scores obtained using the SSDDI were closely correlated with investigator ratings (R = 0.760, P < 0.0001). A model composed of 11 variables was the best predictor of investigator scores of disease activity. The scores obtained using the SSDAI were strongly correlated with the investigator ratings both at the time of enrollment and 3 months after enrollment (R = 0.872, P < 0.0001, and R = 0.817, P < 0.0001, respectively). The differences between scores given by investigators at study enrollment and after 3 months, a measure of variation of disease activity over time, were also closely correlated with the differences calculated using the SSDAI (R = 0.683, P < 0.0001). The ROC curve analysis showed that patients with the highest level of disease activity could be identified on the basis of an SSDAI score of >or=5.

CONCLUSION

Our findings indicate that the SSDDI is an adequate instrument to objectively measure damage in patients with SS, and that the SSDAI is a valid tool to measure disease activity when used either as a single-state index or as a transition index.

[Current status and recommendation of ocular surface disease in China]

Basic research on ocular surface disease is currently focused on the location, marker and culture of corneal limbal stem cells, the biological character and function of amniotic membrane; the culture carriers for stem cells and goblet cells are also addressed. But many of the investigations are lack of scientific originality in the international community. A lot of efforts have been put in clinical research, especially in ocular surface reconstruction, which has been widely applied and has yielded satisfactory surgical results. However, a set of integrated surgical rules is essential to make scientific criteria for the extent of ocular surface impairment and treatment efficacy. Moreover, indications for use of amniotic membrane are in random expansion in some degree, and there is no regulation for obtaining amniotic materials. In addition, diagnosis and treatment of dry eye symptom remains in the status of austerity. Suggestions are made regarding the existing problems.

Tear film and ocular surface abnormalities after eyelid tattooing

A 45-year-old woman who underwent eyelid tattooing 20 years earlier presented with decreased left vision and eye discomfort. Her ocular history revealed an uneventful LASIK procedure 4 years previously with epithelial problems of the flap followed by S. aureus keratitis. Resultant corneal opacity necessitated a deep lamellar keratoplasty performed 9 months prior to admission followed by frequent epithelial problems. At the time of admission, her left eye had a corneal epithelial defect and both lower eyelid margins revealed subepidermal pigmentation and keratinization. Her initial examination revealed tear instability with increased ocular surface staining scores and advanced tear film lipid layer abnormality in both eyes. Meibography showed bilateral total meibomian gland dropout. Treatment with autologous serum eye drops resulted in full epithelialization. Meibomian gland disease-specific therapy did not result in any change in breakup time, vital staining scores, tear film lipid layer interferometry grades, or glandular dropout state.

Late Onset Diffuse Lamellar Keratitis Associated With an Epithelial Defect in Six Eyes

PURPOSE

To report six cases of late onset diffuse lamellar keratitis associated with epithelial defects 2 to 12 months following uncomplicated laser in situ keratomileusis (LASIK).

METHODS

Retrospective case series.

RESULTS

The interface inflammation and epithelial defects were treated aggressively with topical corticosteroids and topical antibiotics with complete resolution over 1 to 2 weeks. There were no complications or loss of best spectacle-corrected visual acuity. These cases illustrate new understanding in the etiology of diffuse lamellar keratitis following lamellar surgery.

CONCLUSION

Late onset diffuse lamellar keratitis in association with epithelial defects may occur following LASIK. Treatment with topical antibiotics and topical corticosteroids may result in uncomplicated, complete resolution.

Dysgeusia, gustatory sweating, and crocodile tears syndrome induced by a cerebellopontine angle meningioma

Facial nerve involvement in cerebellopontine angle tumors, both during their development and after excision, may be expressed in irreversible dysfunction of the parasympathetic pathways. The exact location of the lesion along the efferent nerve fibers can be established through evaluation of the functional level of those organs supplied by the cholinergic motor secretory components. This report deals with a female patient in whom peripheral facial palsy developed shortly after removal of a right cerebellopontine angle meningioma. She had slight facial asymmetry and deafness in the right ear and complained of prandial flush and sweating of the right malar area. Occult ipsilateral hyposalivation and hypolacrimation were diagnosed. In patients with seventh and ninth cranial nerve pathoses, evaluation of the end organs that are supplied by their associated autonomous nerve fibers is mandatory to prevent late ocular and oral sequelae.

Impression cytology: a practical index of vitamin A status

Impression cytology was performed on 148 Indonesian preschool children of whom half had mild xerophthalmia and half were age-matched control subjects. Subjects were divided into subgroups that reflected the degree of confidence in their true vitamin A status as determined by serum vitamin A levels, clinical examination, and response to therapy. Impression cytology was considered normal if goblet cells were present and abnormal if they were absent. Thirteen of 14 (93%) children with vitamin A-responsive Bitot's spots and night blindness with base-line serum vitamin A less than 20 micrograms/dL (0.70 mumol/L) (group 1, definite deficiency) had abnormal cytology. In contrast, 17 of 18 (94%) children with normal ocular exam and serum vitamin A greater than 25 micrograms/dL (0.87 mumol/L) (group 7, least likely deficient) had normal cytology. Importantly, 12 of 26 (46%) clinically normal children with serum vitamin A levels less than 20 micrograms/dL (0.70 mumol/L) had abnormal impression cytology.

Prognosis in Bell's palsy based on symptoms, signs and laboratory data

A prognostic study was performed in 197 consecutive cases of Bell's palsy. The patients were investigated soon after onset, after one week, after one month and then every second month until total recovery or one year had elapsed. Case histories, clinical findings, and laboratory data were noted. Facial EMG, pure tone audiometry, stapedius reflex test and electrogustometry were performed. The healing time, quality of final healing and amount of sequelae were noted. All data were fed to a computer and correlations were calculated. The final degree of healing was well correlated to the initial EMG, the stapedial reflex test and the electrogustometry but also to the clinical evaluation of the degree of motility at the first visit. A combination of EMG, electrogustometry, stapedial reflex test and evaluation of lacrimation showed a high rate of prognostic value.

[Trophic corneal diseases. Their pathogenesis and corneal nutrition (author's transl)]

Experimental research has not provided any proof that "trophic" corneal diseases are caused by nutritional deficiencies. It seems that cases in which the course is chronic, but characterized by an absence of exacerbations of great pain and failure of medical therapy, are said to be trophic. Some of these diseases are dry eye conditions. Sensory disturbances lead to corneal complications by lowering the blinking frequency, but not seem to interfere with nutrition of the tissue. Otherwise keratoplasty would be impossible, since the innervation of the graft is often impaired for months or even years.

[Xerophthalmia]

Xerophthalmia results from an insufficient supply of vitamin A to the eye. Primary signs of xerophthalmia are conjunctival xerosis, Bitôt's spots with conjunctival xerosis, corneal xerosis, corneal ulceration with xerosis, keratomalacia. Secondary signs of xerophthalmia are night blindness, xerophthalmia fundus and corneal scars. According to the WHO 20 000--100 000 children in developing countries are struck annually with blindness due to xerophthalmia. With regard to the treatment immediate therapy with 100 000 I.U. vitamin A intramuscularly and 200 000 I.U. orally on the following day are advised in all cases of active disease. The doses should be reduced by half for children less than one year old. Prior to discharge from the clinic and additional dose of 200 000 I.U. vitamin A (children under the age of one year 100 000 I.U.) orally should be administered.