Unilateral vernal keratoconjunctivitis: a case report

PURPOSE: A rare case of unilateral vernal keratoconjunctivitis is presented. METHODS: A 5-year-old boy had itching, foreign body sensation, redness, and ptosis in his left eye. Impression cytology specimens were taken from both upper eyelid tarsal conjunctiva. RESULTS: On slit-lamp biomicroscopy, unilateral cobblestone papillae and a shield ulcer were found in the left eye. On impression cytology examination, there was a significant increase in inflammation, presence of a honeycomb pattern, plasma cells, and mucus strands in the upper tarsal conjunctiva of the specimens. CONCLUSIONS: Giant papillary conjunctivitis must be considered in differential diagnosis of unilateral vernal conjunctivitis. Impression cytology method may be combined with the clinical findings in vernal keratoconjunctivitis diagnosis.     

Conjunctival cytologic features in anophthalmic patients wearing an ocular prosthesis

PURPOSE: To evaluate the cytologic features of conjunctival epithelium in anophthalmic sockets with an ocular prosthesis, using an impression cytology technique and to determine the clinical factors associated with these changes. METHODS: In a prospective case-controlled study, 40 consecutive unilateral anophthalmic patients who wore an ocular prosthesis were recruited. A questionnaire on the care of the prosthesis included total wearing period, frequency of cleaning, frequency of polishing, cleaning solution, and eye drop use. The degree of inflammation of the anophthalmic conjunctival socket was evaluated. Impression cytology specimens were taken from the upper tarsal conjunctiva, the bulbar conjunctiva, and the lower tarsal conjunctiva of each socket, and from the contralateral eye (to serve as an internal matched control). The goblet cell density and the nucleus-to-cytoplasm ratio of the epithelial cells were measured. The relevance of these conjunctival cytologic features to the various factors of prosthesis care or conjunctival inflammation was analyzed. RESULTS: In the anophthalmic sockets, the conjunctiva showed squamous metaplasia at all 3 areas sampled. The goblet cell density was significantly decreased and the nucleus-to-cytoplasm ratio of the epithelial cells was significantly increased compared with the control eyes (p<0.05, on all 3 areas sampled, Wilcoxon signed rank test). These conjunctival cytologic changes were not significantly associated with total wearing time, frequency of polishing, cleaning solution, or eye drops use (p>0.05, Spearman's correlation test). CONCLUSIONS: Squamous metaplasia with decreased goblet cell density and increased nucleus-to-cytoplasm ratio occurred in anophthalmic conjunctival sockets but was not associated with particular aspects of prosthesis care.     

Biomicroscopy of Papillae Associated with Hard Contact Lens Wearing

We studied the macrostructural characteristics of papillary changes of the upper tarsal conjunctiva associated with the wearing of polymethyl methacrylate (PMMA) contact lenses. Fifty subjects with elevated conjunctival papillae >0.3 mm in diameter were studied. Macrostructural characteristics recorded were location, diameter, and number of papillae, presence or absence of staining at the apices of papillae, and degree of hyperemia of the upper tarsal conjunctiva. Patient information collected included age, duration of lens wear, average daily lens wearing time, presence or absence of itching or mucus, refractive status, and atopic history. The tarsal conjunctiva was divided into three zones of equal size. Papillae were present in various zones and combinations of zones; however, papillae were never confined exclusively to either (1) the zone adjacent to the tarsal folds or (2) the latter zone in combination with the zone adjacent to the eyelid margin without also occurring in the intervening zone. The diameter of the papillae ranged from >0.3 mm to 2.0 mm. The number of papillae per eyelid ranged from two to over 100. The apices of the papillae were frequently flattened and craterlike, and often stained with fluorescein.     

Biomicroscopy of papillae associated with wearing of soft contact lenses.

We studied the topographical, macrostructural, and fluorescein staining characteristics of papillary changes of the upper tarsal conjunctiva associated with the wearing of hydrophilic (soft) contact lenses. Fifty soft contact lens wearers with elevated conjunctival papillae greater than 0.3 mm in diameter were studied. Topographic characteristics recorded were distribution and number of papillae; macrostructural characteristics recorded were diameter and morphology of papillae. The information collected included age of patient, duration of lens wear, average daily time of wearing lens, presence or absence of itching or mucus, refractive status, and atopic history. Papillae were found in most cases in the conjunctival zone adjacent to the tarsal fold and were never found in the zone adjacent to the eyelid margin without also occurring in the intervening zone. The diameter of the papillae ranged from greater than 0.3 mm to 2.0 mm. The number of papillae per eyelid ranged from 4 to over 100. The apices of the papillae were frequently flattened, and these flattened surfaces frequently stained with fluorescein. The vascular supply of individual papillae was observed to radiate from a vessel occupying the central core of each papilla.     

The relation of conjunctival and corneal findings in severe ocular allergies

OBJECTIVE: Corneal lesions such as ulcers and erosions are major complications observed in patients with severe ocular allergic diseases. We aimed to look into the relationship between specific clinical conjunctival findings and the severity of corneal complications. METHODS: Thirty eyes of 6 patients with vernal keratoconjunctivitis (VKC) and 13 patients with atopic keratoconjunctivitis (AKC) were evaluated in this study. Slit-lamp photographs of upper tarsal conjunctiva and cornea were used to evaluate the clinical findings objectively. The corneal findings and clinical findings of upper tarsal conjunctiva such as conjunctival injection, edema, the height of papillae, and mucous discharge were evaluated and graded. Statistical correlations between conjunctival findings and the severity of corneal damage were analyzed. RESULTS: Conjunctival injection and edema significantly correlated with the severity of corneal complications. The height of the papillae and the amount of mucous discharge did not correlate with the severity of corneal complications. CONCLUSION: Direct signs of inflammation such as injection and edema correlated with corneal damage. The height of papillae did not show a significant correlation with the corneal findings. Our results suggest that inflammation of the conjunctiva rather than mechanical factors may play a greater role in the formation of corneal damage in severe ocular allergies.     

干眼症和前睑缘炎及季节性过敏性结膜炎中三种检测方法结果的比较

目的:比较三组临床患者和对照组患者的泪液功能测试,眼表染色以及结膜印象细胞学检测的结果。方法:这是一个单中心,前瞻性,双盲,随机对照试验。研究包括泪液分泌分数小于10mm和泪膜破裂时间(TBUT)小于10s的20例干眼症患者,有干燥和结痂睫毛的20例前睑缘炎患者,上眼睑睑板结膜乳头肥大的20例季节性过敏性结膜炎患者和20例对照组患者。比较泪液分泌的分数,泪膜破裂时间,眼表染色(牛津分级方案),杯状细胞密度(尼尔森分级方案评估所有患者的印象细胞学和化生分数)。结果:三组患者和对照组患者在泪液功能测试结果,眼表染色评分,杯状细胞密度和化生分数上有显著差异(P<0.001)。结论:结果证明这三种疾病的炎症反应造成严重眼表损害,并在局部产生炎症。这种损伤产生非常严重的影响,尤其是对结膜杯状细胞密度和化生。杯状细胞损伤程度与临床研究结果有关联。     

Unilateral eyelid lag and retraction as sequelae of trachoma

A 42-year-old woman had a large right palpebral fissure 13 mm high with 0.5 mm of scleral show both superiorly and inferiorly due to upper and lower eyelid retraction. The upper eyelid showed eyelid lag behind the globe only during the initial ocular movement. Superior tarsal height measured 7.5 mm with palpebral conjunctival cicatrization and Arlt's line. Severe cases of trachoma may lead to contracture of the conjunctiva and deeper tissues including Müller muscle and the tarsal plate, which supports the insertion of the levator aponeurosis. Shortening of the posterior lamella and fornix contracture would explain eyelid retraction and failure of the upper eyelid to smoothly follow the globe on downgaze.     

Remodeling in ocular allergic diseases

Vernal keratoconjunctivitis (VKC), a chronic and severe form of ocular allergic disease, is characterized by tissue remodeling such as the formation of giant papillae at the upper tarsal conjunctiva and the development of corneal plaques. Giant papillae develop as a result of infiltration of inflammatory cells, changes in the epithelial layer, increased deposition of extracellular matrix molecules, proliferation of conjunctival fibroblasts, and an increase in the number of blood vessels. Corneal plaques form subsequent to corneal epithelial defects, and their surface remains uncovered by the corneal epithelium; consequensly, corneal epithelial cells are not able to attach to or migrate over the plaques. These remodeling lesions not only affect tissue structure but also contribute to amplification of allergic inflammation in the conjunctiva and cornea. Recent evidence from in vitro studies indicates that activated fibroblasts play a central role in the induction and amplification of ocular allergic inflammation and the consequent development of giant papillae and corneal disorders in individuals with VKC. Tissue remodeling thus represents a potential therapeutic target for treatment of VKC.     

剥脱综合征患者结膜印迹细胞学的检查特征

目的:研究剥脱综合征对结膜细胞和泪液功能的影响.方法:研究共纳入剥脱综合征患者60例86眼作为试验组,年龄相仿正常人55例89眼作为对照组.所有115例175眼均接受Schirmer泪试验及泪膜破裂时间试验,并对上方和鼻下方睑裂区球结膜进行印迹细胞学检查.印迹细胞学检查结果根据Nelson方法分级.对TBUT,Schirmer泪试验及印迹细胞学结果进行相关性分析.结果:剥脱综合征患者的Schirmer试验、TBUT均较正常组显著降低,结膜细胞也有显著改变.剥脱综合征患者的印迹细胞学分级中位数为3级,而正常人组为0级.在试验组中发现45例样本出现了两种以上分级共存的现象,而对照组仅发现3例.此外,实验组中的45例样本结膜上皮细胞和杯状细胞分级出现明显差异,且均表现出杯状细胞的破坏甚于上皮细胞,而对照组未发现此种现象.结论:剥脱综合征患者的结膜细胞受到破坏,泪液分泌受到影响,极易造成眼表疾病的出现.     

Detection by impression cytologic analysis of conjunctival intraepithelial invasion from eyelid sebaceous cell carcinoma

OBJECTIVE: To demonstrate that conjunctival impression cytologic analysis can detect conjunctival intraepithelial invasion from sebaceous cell carcinoma of the eyelid. DESIGN: Observational case series with cytopathologic correlation. PARTICIPANTS: Four patients with unilateral blepharoconjunctivitis and biopsy-proven sebaceous cell carcinoma. METHODS: Impression cytologic analysis specimens were taken from the suspicious area of the bulbar conjunctiva of each patient. Staining of the specimens was performed with a modified Papanicolaou stain. MAIN OUTCOME MEASURE: Observation of the abnormal tumor cells in the collected specimens by bright field microscope. RESULTS: The technique of impression cytologic analysis allowed collection and identification of abnormal tumor cells with characteristic cytoplasmic vacuoles. CONCLUSIONS: Conjunctival impression cytologic analysis successfully detected the ocular surface sebaceous carcinoma cells from the eyelid. However, full-thickness biopsies are necessary to confirm the diagnosis. Judicious use of impression cytologic analysis may facilitate the detection and diagnosis of this invasive tumor.     

A survey of trachoma: the histopathology and the mechanism of progressive cicatrization of eyelid tissues

The aim of this study is to demonstrate the spectrum of conditions encompassed by the term 'trachomatous cicatrization of eyelid tissue', to discuss the mechanisms of scar tissue formation and to describe sequelae in this potentially blinding condition. Specimens of eyelid tissues were taken from 27 upper eyelids of 21 patients with entropion who underwent surgical procedures and 2 post-mortem upper eyelids with severe trachomatous entropion. Upper palpebral conjunctival swabs and biopsy specimens were taken from 5 patients with active trachoma and they were examined by fluorescence microscopy and routine histopathological methods. Conjunctival impression cytology samples were collected in all patients. In specimens taken from patients with active trachoma the inflammatory infiltrate was organized as lymphoid follicles in the underlying stroma and impression cytology showed cytoplasmic elementary bodies. In specimens taken from patients with scarring trachoma light microscopy studies showed subepithelial fibrous membrane formation, squamous metaplasia and loss of goblet cells, pseudogland formation in conjunctiva, degeneration of orbicularis oculi muscle fibres, subepithelial vascular dilatation, localized perivascular amyloidosis and subepithelial lymphocytic infiltration. Accessory lachrymal glands and the ducts of glands were compromised by subepithelial infiltration and scarring. The contraction of the subepithelial fibrous tissue formed by collagen fibres and anterior surface drying are the main factors contributing to the chronic cicatrization and entropion formation.     

Role of structural cells of the cornea and conjunctiva in the pathogenesis of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a severe type of allergic conjunctival disease characterized by the presence both of various corneal epithelial and stromal lesions as well as of conjunctival proliferative changes such as giant papillae of the upper tarsal conjunctiva and limbal lesions. These clinical findings as well as various pathophysiological characteristics of VKC are distinct from those of other types of ocular allergy and allergic diseases of other organs. The outer eye possesses specific allergological characteristics, one of which is communication between the cornea and conjunctiva through a thin layer of tear fluid. Fibroblasts of the cornea and the conjunctiva are activated by proinflammatory and T helper 2 (Th2) cell-derived cytokines. Corneal fibroblasts enhance ocular allergic reactions as a result of their activation-induced expression both of chemokines such as eotaxin and TARC as well as of adhesion molecules such as ICAM-1 and VCAM-1, all of which together promote the activation and infiltration of eosinophils and Th2 lymphocytes. In contrast, corneal epithelial cells suppress such reactions by physically separating corneal fibroblasts from bioactive substances in tear fluid. Exaggerated proliferation of and deposition of extracellular matrix by conjunctival fibroblasts likely exacerbate conjunctival inflammation. Restoration of an intact corneal epithelium and inhibition of the activities of corneal and conjunctival fibroblasts may provide a basis for the development of new treatments for severe ocular allergic diseases such as VKC.     

Conjunctival myeloid sarcoma in acute myeloblastic leukemia-M1

CLINICAL CASE: A 69-year-old man with a history of acute myeloblastic leukemia-M1 presented with bilateral conjunctival injection. Ophthalmological examination revealed lesions located at the upper tarsal conjunctiva of the right eye and lower tarsal conjunctiva of both eyes. Histological and immunohistochemical studies confirmed conjunctival myeloid sarcoma. The patient died due to multiorgan failure three months later. DISCUSSION: Extramedullary recurrence of leukemia can appear as an ocular manifestation that brings about a recurrence of the leukemia, leading to a poor prognosis.     

Palpebral cryptococcosis: case report

This paper is about a patient with acquired immunodeficiency syndrome empirically treated for miliary tuberculosis. During the clinical evolution the patient presented lesions compromising the right eyelid and tarsal conjunctiva. The initial diagnostic hypothesis was ocular tuberculosis with conjunctival and eyelid involvement. The biopsy of the conjunctival lesion identified an encapsulated yeast-like fungus: Criptococcus neoformans. After starting treatment with B anfotericin, the cutaneus lesions cleared.     

Quantitative evaluation of the early changes in ocular surface inflammation following MMC-aided papillary resection in severe allergic patients with corneal complications

BACKGROUND: Atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) are chronic inflammatory allergic diseases that are associated with some common conjunctival and corneal complications.1 The clinical corneal manifestations of both entities may include superficial punctate keratitis, macroerosions, corneal ulceration, plaque formation, corneal neovascularization, and lipid infiltration. PURPOSE: To quantitatively evaluate the early ocular surface inflammation before and after mitomycin C (MMC)-aided papillary resection in severe allergy patients with corneal complications. METHODS: Three eyes with VKC and 5 eyes with AKC were included in this study. All eyes had cobblestone-like papillae on the upper tarsal conjunctiva and corneal complications such as corneal ulcers, defect, or erosions that were refractory to conventional treatment of more than 2 weeks. Papillary resection with intraoperative 0.05% MMC application for 5 minutes on the palpebral conjunctiva was carried out in all eyes. Corneal and conjunctival findings were evaluated before and 1 week and 2 weeks after surgery. Brush cytology (BC) and evaluation of tear eosinophilic cationic protein (ECP) levels by radioimmunoassay techniques were performed as well pre- and postoperatively. RESULTS: Corneal and conjunctival complications resolved in all patients within 7 days after resection. Postoperative tear ECP levels decreased significantly with papillary resection (P< 0.05). Concomitant brush cytology showed a significant decrease in the number of eosinophils and neutrophils following papillary resection (P < 0.05). CONCLUSION: MMC-aided papillary resection provided a dramatic decrease in ocular surface inflammation as evidenced by decrease in the number of inflammatory cells as well as tear ECP levels with a rapid improvement of clinical corneal and conjunctival findings.     

A conservative blepharoplasty may be a means of alleviating dry eye symptoms

PURPOSE: Patients with dermatochalasis often complain of dry eye symptoms. In a prospective study, the influence of upper eyelid blepharoplasty on dry eye symptoms, tear film parameters and ocular surface morphology was evaluated. METHODS: Patients with upper eyelid dermatochalasis were studied before and 3 months after upper eyelid blepharoplasty. Changes in ocular symptoms and physical examinations such as tear film break-up time, Schirmer test without local anaesthesia, impression cytology of the bulbar conjunctiva and inflammatory reaction were recorded. RESULTS: Subjective dry eye symptoms were found in 11 patients (46%) preoperatively and in five patients (21%) postoperatively. Objective dry eye signs were present in eight patients (33%) before blepharoplasty and in nine patients (38%) 3 months postoperatively. Morphological findings did not change within the observation period. The inflammatory reaction shown by impression cytology decreased postoperatively. CONCLUSION: Blepharochalasis may be associated with dry eye. Blepharoplasty might be a means of alleviating dry eye symptoms. The reason for this subjective alleviation might be due to reduced inflammatory reaction, changes in blink mechanism or the fact that patients are more confident about their appearance.     

春季角结膜炎巨大乳头手术治疗的临床分析

目的探讨上睑乳头切除、冷冻联合羊膜移植治疗有巨大乳头的春季角结膜炎的临床效果。方法对8例（16只眼）以上睑结膜巨大乳头为特征的药物治疗无效的春季角结膜炎患者,采用上睑结膜巨大乳头切除,-70℃二氧化碳冷冻上睑结膜表面,并移植单层羊膜于上睑表面的方法予以治疗。术后随访3～22个月,观察患者症状、体征的改变及并发症等情况。结果术后1周内,盾性角膜溃疡、角膜上皮点片状着色全部愈合,且在随访期间未复发。14只眼治愈,眼刺激症状手术后1个月基本消失,巨大乳头无复发、未出现睑内翻、倒睫等并发症,但上睑结膜血管纹理欠清,有少许瘢痕。2只眼巨大乳头复发,但范围较术前缩小,眼刺激症状也较术前减轻;其中1只眼经药物治疗后好转;另1只眼再次手术,用5-氟尿嘧啶棉片浸润上睑后行羊膜移植,术后随访9个月未复发。结论切除加冷冻联合羊膜移植可能是治疗难治的有巨大乳头的春季角结膜炎的安全有效的方法,但是应严格选择手术适应证。     

Expression patterns of sialylated epitope recognized by KL-6 monoclonal antibody in ocular surface epithelium of normals and dry eye patients

PURPOSE: To determine the association of the KL-6 epitope (sugar moiety) with MUC1 and its distribution on the ocular surface of human non-dry and dry eyes. METHODS: The human ocular surface was examined immunohistochemically and immunoelectron microscopically using monoclonal antibody (mAb) KL-6, which recognize a carbohydrate epitope of MUC1. The expression patterns of KL-6 epitope in corneal and conjunctival cells were examined by impression cytology from 24 non-dry eye volunteers and 43 dry-eye patients. RESULTS: In the cornea, bulbar conjunctiva, and limbus epithelium, mAb KL-6 reacted to the apical cell membrane of superficial cells and the intercellular space of superficial and wing cells. No immune reactivity of mAb KL-6 was observed in the basal plasma membrane of basal epithelial cells. Results of impression cytology indicated that the corneal epithelium of 13 of 24 non-dry eyes was weakly stained by mAb KL-6, whereas 42 of 43 dry eyes showed a mosaic pattern. In non-dry eyes, 19 of 24 bulbar conjunctival epithelia expressed the KL-6 epitope in a honeycomb pattern. In mild (17/19) and moderate (17/17) dry eye conjunctiva, the KL-6 epitope showed a mosaic pattern. However, the expression of KL-6 epitope decreased in severe dry eyes, showing a mosaic pattern in three of seven patients and labeling a few cells weakly in four of seven patients. CONCLUSIONS: These findings suggest that there is an upregulation of the sialylated KL-6 epitope of MUC1 by apical corneal and conjunctival cells in mild and moderate dry eyes. This upregulation may in part alleviate the consequences caused by goblet cell mucin dysfunction in dry eyes. It is noteworthy that the KL-6 epitope is downregulated in the conjunctiva of severe dry eyes, a phenomenon that may be explained in part by the malfunction of conjunctival epithelial cells.     

Conjunctival impression cytology in patients with glaucoma using long-term topical medication.

Increasing evidence indicates that long-term use of topically administered medications can induce changes in the conjunctiva and ocular surface. We used the technique of conjunctival impression cytology to evaluate the conjunctival changes that develop with long-term use of topically administered antiglaucoma medications. Patients with glaucoma who were on a stable regimen of one, two, or three topically administered medications were recruited for study; glaucoma suspects who were not using topically administered medications served as controls. Eyes with clinical or historical evidence of external eye disease or conjunctival surgery were excluded. Impression cytology specimens, collected from the bulbar and palpebral conjunctiva, were coded and subsequently graded by a masked observer. We examined specimens from 72 eyes by using this technique. Aggregate scores for the bulbar conjunctiva were compiled, using a previously described grading system with a range of 0 (normal) to 3 (diffuse, severe metaplasia). The results show statistically significant degrees of conjunctival metaplasia associated with the number of glaucoma medications used. These results suggest that the long-term use of antiglaucoma medications induces changes in the conjunctival surface. These changes may be related to the medications themselves, the preservatives in the commercial preparations, or the duration of topical treatment. The clinical relevance of these changes remains unknown.     

Giant papillary conjunctivitis--a review.

First described in 1974 by an Australian ophthalmologist Dr. Spring, Giant Papillary Conjunctivitis (GPC) is one of the external ocular allergic conditions. It is most often associated with contact lens wear, but has also been described in patients with ocular prostheses and corneal sutures following surgery. Diagnosis is usually straightforward. Patients complain of decreasing lens tolerance, mucus production, often severe enough to cause blurred vision, and some itch. Inspection will reveal conjunctival hyperaemia and enlarged tarsal papillae. Management centres around patient education regarding careful lens hygiene but in severe cases may require a change to disposable lenses or a cessation of lens wear. In some cases, pharmacological agents may be required. The histopathology of GPC is very similar to Vernal Keratoconjunctivitis (VKC). It is caused by a complex immunological reaction and is not solely IgE-mediated. Trauma and foreign body reactions also play a role. The incidence of GPC has decreased with the advent of disposable lenses.