Sjögren's syndrome: a critical review of clinical management

Sjögren's syndrome (SS) is greatly under recognized in clinical practice, primarily for 2 reasons: its presentations are variable and often nonspecific and there are still no clear, uniform diagnostic criteria for this clinical entity. The prevalence, natural history, pathogenesis, and clinical taxonomy of SS are still not well understood. Potential criteria include both subjective symptoms and objective criteria such as measurements of salivary and tear flow, minor salivary gland biopsy, and an increasing variety of serological markers. Physicians often fail to appreciate the profound impact of SS on quality of life. Therefore, screening for SS should include questions exploring symptoms in terms of their effect on the patient's daily life. At present, there is no curative treatment for SS. For symptom relief, local treatments (such as artificial tears or oral topical sprays) are limited in their effects, whereas systemic treatment offers the advantage of addressing a wider range of symptoms. Controlled studies show that oral pilocarpine significantly improves sicca symptoms in the eyes, mouth, and other sites. Clinical experience to date suggests it is safe and well tolerated, with no serious adverse effects, tachyphylaxis, or drug to drug interactions of concern. The most frequent adverse effects are sweating, urinary frequency, diarrhea, and other parasympathomimetic effects, but these do not lead to substantial drug withdrawal rates. Patients should be forewarned that subjective improvement may lag behind improvement in objective measures. Because management often spans several specialties, coordination among them is essential. Dental, gynecological, and ophthalmological perspectives on diagnosis and management are discussed; the primary practitioner has the opportunity to play both a coordinating role and a direct role in early diagnosis and treatment.

Ultrasound biomicroscopic quantitative analysis of light-dark changes associated with pupillary block

PURPOSE

To quantitatively analyze the changes in anterior chamber angle and iris configuration induced by varying illumination in patients with narrow angles and pupillary block.

METHODS

Twenty-four eyes of 24 patients with pupillary block (mean age, 52.5 years) had ultrasound biomicroscopic images of the angle and iris structures obtained superiorly, nasally, inferiorly, and temporally. Images were performed in the light and the dark. We measured the angle opening distance, iris thickness, iris chord length, iris-lens touch, and iris curvature.

RESULTS

Changes in iris and angle configuration occurred within a few seconds of a change in lighting. The mean dark measurements were statistically significantly less than the mean light measurements for angle opening distance (96 +/- 18 vs 185 +/- 26 microm, P = .0001), iris chord length (2,505 +/- 61 vs 3,001 +/- 69 microm, P = .0001), and iris-lens touch (350 +/- 20 vs 693 +/- 35 microm, P = .0001). The mean dark measurements were statistically significantly greater than the mean light measurements for iris thickness at 500 microm from the scleral spur (367 +/- 10 vs 307 +/- 25 microm, P = .0001), and 1,500 microm from the scleral spur (404 +/- 14 vs 347 +/- 12 microm, P = .0001). Iris curvature in all four quadrants was statistically significantly greater in the dark than the light.

CONCLUSIONS

This study quantitatively confirms that angle narrowing in the dark in eyes with pupillary block is associated with iris shortening, increased iris thickness, and increased iris convexity. Iris-lens touch is relatively small in pupillary block and decreases with dilation. Angle narrowing with dilation is not related to increased iris-lens touch and occurs promptly without requiring time for aqueous pressure buildup behind the iris.

Infectious crystalline keratopathy

Infectious crystalline keratopathy was first described in 1983. affected corneal grafts generally show progressive scarring and often require penetrating keratoplasty. We present a patient in whom infectious crystalline keratopathy developed 3 months after surgery. The infection was successfully treated with antibiotic therapy.

Excimer laser-processed donor corneal lenticules for lamellar keratoplasty

We used the 193-nm argon-fluoride excimer laser to cut plano corneal lenticules from fresh corneal tissue for lamellar keratoplasty. The laser was used to cut away all corneal tissue outside a specially designed mold, which was developed to obtain a corneal lenticule of 10 mm in diameter and a constant thickness of 0.3 mm. The surface topography of the excimer laser-cut corneal lenticule was smoother and more regular on scanning electron microscopy than a hand-cut corneal lenticule, and the thickness was constant around the surface. No thermal or mechanical damage to the cornea was observed on light microscopy in the area adjacent to the cut.

Corneal hydrops in Terrien's marginal degeneration: an unusual complication

Spontaneous rupture of Descemet's membrane occurred in a 76-year-old woman with a 20-year history of Terrien's marginal degeneration. This resulted in corneal hydrops characterized by a clear cystic space filled with aqueous humour that formed between the epithelium and Descemet's membrane. This case represents an unusual complication of Terrien's marginal degeneration.