Immunopathology of cicatricial pemphigoid affecting the conjunctiva

Conjunctival biopsy specimens from 13 patients with cicatricial pemphigoid and from 13 age-matched healthy individuals undergoing cataract surgery were analyzed by light microscopy and immunohistochemical techniques, including a panel of monoclonal antibodies used to characterize inflammatory mononuclear cell phenotypes. Results of histologic examination of cicatricial pemphigoid specimens showed typical squamous metaplasia, vasculopathy, increased numbers of mast cells, and abundant plasma cells. All cicatricial pemphigoid specimens demonstrated immunoreactants at the epithelial basement membrane zone (BMZ). Epithelium of cicatricial pemphigoid conjunctiva showed significantly more T-helper cells (CD4+), dendritic cells (CD1+), and macrophages (CD14+), and a significantly higher helper/suppressor ratio than did controls. In the substantia propria, pemphigoid specimens showed dramatically increased inflammatory infiltrate with significantly more cells staining, in order of frequency, for T cells (CD3+, CD5+), T-helper cells (CD4+), T-suppressor cells (CD8+), macrophages (CD14+, Mac-1+), and dendritic cells (CD1+, HLA-DR+). Ten percent of these cells expressed interleukin-2 receptor protein (CD25+), indicating T-cell activation.     

Immunoelectron microscopic study of the conjunctiva in cicatricial pemphigoid

· Background: Immune deposits can be found on the conjunctival basement membrane zone of patients affected by cicatricial pemphigoid using immunofluorescence technique. The purpose of this study was to perform direct immunoelectron microscopy on the conjunctiva of patients with scarring conjunctivitis associated with cicatricial pemphigoid · Methods: Conjunctival and skin biopsies were performed in six patients who presented with presumed autoimmune cicatrizing conjunctivitis associated with cicatricial pemphigoid. Specimens were processed for direct immunofluorescence and direct immunoelectron microscopy. · Results: Direct immunofluorescence was positive in all skin samples and in three of six conjunctival samples. Direct immunoelectron microscopy showed immune deposits in the lamina lucida and the lamina densa of all skin and conjunctival samples. · Conclusions: Direct immunoelectron microscopy can be performed on the conjunctiva. It shows the precise localization of cicatricial pemphigoid target antigens within the conjunctival basement membrane zone. Received: 29 April 1997 Revised version received: 16 February 1998 Accepted: 9 March 1998     

Ultrastructural characteristics of conjunctiva in cicatricial pemphigoid

Conjunctival biopsy specimens were obtained from three patients with clinically active ocular cicatricial pemphigoid and from two of these patients after successful immunosuppressive therapy. Compared with specimens from normal subjects, the pretreatment specimens showed profound alteration in interepithelial adhesion as evidenced by a dramatic increase in desmosomes. Unusually prominent tonofilaments and tonofibrils were seen throughout the cytoplasm. The basal lamina showed areas of discontinuity, duplication, and focal thickening. The lamina propria was thickened and demonstrated an infiltration of inflammatory cells and disorganized collagen fibrils. Post-treatment specimens had a relative absence of desmosomes between the widely separated epithelial cells, less prominent tonofilaments and tonofibrils among epithelial cells, and, in one specimen, goblet cells. The enhanced network of desmosome-tonofilament complexes serves to tightly bind epithelial cells, perhaps providing a clue to the pathophysiology of conjunctival surface changes.     

Mast cells in conjunctiva affected by cicatricial pemphigoid

Ocular cicatricial pemphigoid (OCP) is characterized by progressive conjunctival subepithelial fibrosis often leading ultimately to corneal blindness. Mast cells have been shown to play a role in several fibrotic disorders, but the role of mast cells in OCP is unknown. The authors compared the mast cell population in conjunctival biopsy specimens from 14 OCP patients and from six controls by using specific histochemical stains for mast cell subsets. The total mast cell number and the ratio of connective tissue mast cells to mucosal mast cells (MMCs) were significantly higher in OCP than in normal conjunctiva (P less than 0.05). This report is the first analysis of mast cell subsets in human ocular tissue. The results suggest that connective tissue mast cells (CTMCs) may play an important role in OCP and that therapy directed toward mast cells and their mediators may be an appropriate avenue for further exploration.     

Light and electron microscopic studies of malignant melanoma of conjunctiva and palpebra

The authors experienced one case of malignant melanoma of the superior palpebral conjunctiva and the inferior palpebral skin, originating from benign acquired melanosis of the bulbar conjunctiva which developed in a 48-year-old man. Orbital exenteration including superior and inferior palpebrae was performed, and the removed tissue was examined by light and electron microscopy. In the temporal bulbar conjunctiva, melanocytes containing abundant fine melanin granules proliferated over almost the whole area of the epithelial layer. Cellular atypia and karyomitosis were not observed. The basement membrane remained intact with no proliferation of melanocytes in the substantia propria. However, in the perivascular area, in addition to the moderately prominent infiltration by lymphocytes and plasma cells, infiltration by melanophages was observed relatively frequently. Based on these findings, it was confirmed that the primary lesion of the bulbar conjunctiva was an acquired melanosis of Stage IB as classified by Zimmerman. The black nodular tumors of the superior palpebral conjunctiva and inferior palpebral skin consisted of melanoma cells showing markedly prominent cellular and nuclear atypia. The nuclei showed indentations in the membrane with electron-lucent karyoplasm, each having one nucleolus. The cytoplasm contained many round or elongated melanosomes in various developmental stages, with sizes of about 0.7 micron. Scattered among melanoma cells were a number of melanophages which had phagocytized many melanosomes at various stages of maturity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ocular cicatricial pemphigoid.

Cicatricial pemphigoid is an inflammatory disease of presumed autoimmune etiology. It most commonly affects the conjunctiva and oral mucosa and less commonly the skin. The ocular manifestations of the disease include bilateral conjunctival shrinkage, xerosis, and corneal opacification. The progression of cicatricial pemphigoid is variable and can be interrupted by periods of remission or by periods of rapid exacerbation. Ocular surgery and topical pharmaceuticals may contribute to the exacerbation of this disease. Current treatment consists of systemic immunosuppressants and systemic corticosteroids.     

Role of enhanced expression of m-CSF in conjunctiva affected by cicatricial pemphigoid

PURPOSE: Local proliferation of macrophages has been reported to augment the inflammatory response in various human and experimental diseases. Macrophage accumulation in the submucosa is also an important feature in the pathogenesis of ocular cicatricial pemphigoid (OCP). In the present study, the role of local proliferation of macrophages in conjunctiva affected by OCP and the relationship between local proliferation of macrophages and expression of macrophage-colony-stimulating factor (m-CSF) in such conjunctiva were examined. METHODS: Biopsy specimens from the conjunctiva of 10 untreated patients with active OCP and from 5 normal subjects were studied for the expression of m-CSF, macrophages, and proliferating cell nuclear antigen (PCNA), a cell cycle protein, by immunohistochemistry. Dual staining for CD68 (a cell surface marker for macrophages) and PCNA was also performed to identify proliferating macrophages. In addition, fibroblasts isolated from conjunctiva of normal individuals and from patients with OCP were studied for the expression of m-CSF by immunostaining and real-time PCR. To identify the factors that induce m-CSF in conjunctival fibroblasts, the fibroblasts were incubated with different concentrations of interleukin (IL)-1alpha and tumor necrosis factor (TNF)-alpha, and the levels of m-CSF mRNA were determined by real-time PCR and the amount of m-CSF produced was determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: Normal conjunctiva showed weak expression of m-CSF in the conjunctival epithelial cells and stroma. Conjunctival expression of m-CSF protein was significantly (P < 0.0001) increased in conjunctival biopsy specimens from patients with OCP. m-CSF was detected in the infiltrating macrophages, stromal cells (presumably fibroblasts), and conjunctival epithelial cells. Compared with normal control conjunctival tissue, a 1.2-fold increase in the expression of mRNA for m-CSF was detected by real-time PCR in the conjunctival tissue obtained from patients with OCP. Increased expression of m-CSF correlated significantly (P < 0.0004) with an increased stromal accumulation of macrophages in conjunctival biopsy specimens of patients with OCP. A number of these accumulated macrophages (CD68-positive) were found to be proliferating (PCNA-positive). In addition, fibroblasts isolated and cultured from conjunctiva of patients with OCP showed significantly increased (1.7-fold) expression of m-CSF compared with normal conjunctival fibroblasts. When conjunctival fibroblasts were treated with IL-1alpha or TNF-alpha, real-time PCR and ELISA detected an increased level of m-CSF. CONCLUSIONS: An increased expression of m-CSF was observed in conjunctiva from patients with active OCP. There was a positive correlation between expression of m-CSF and accumulation of macrophages in conjunctival biopsy sections obtained from patients with OCP. Increased expression of m-CSF, mainly by conjunctival fibroblasts and infiltrating inflammatory cells, may play an important role in the regulation of local proliferation of macrophages in OCP. In the conjunctiva of patients with OCP, this process could augment or enhance the local inflammatory response and tissue injury consequent to it.     

Detection of ocular mucus in normal human conjunctiva and conjunctiva from patients with cicatricial pemphigoid using lectin probes and histochemical techniques

Conjunctival biopsies from patients with cicatricial pemphigoid affecting the conjunctiva and patients undergoing cataract surgery (normal conjunctiva) were snap-frozen, cryostat sectioned and incubated with fluorescein-conjugated lectins; peanut agglutinin (PNA), Helix pomatia agglutinin (HPA), soybean agglutinin (SBA), wheat germ agglutinin (WGA) and succinylated wheat germ agglutinin (S-WGA). Controls consisted of preincubating the lectins with the appropriate blocking sugars before applying the lectins to the sections. PNA and HPA stained the mucus granules contained in the conjunctival goblet cells but did not stain mucus or glycocalyx at the ocular surface distal to the goblet cells. Native WGA and S-WGA had high affinities for conjunctival goblet cells and the apical epithelial cell layers. Native WGA stained mucus and glycocalyx at the ocular surface. This staining of the ocular surface by WGA was confirmed at the transmission electron microscopic level using WGA conjugated to ferritin. Cicatricial pemphigoid patients in this study had reduced numbers of goblet cells; however, those goblet cells which were observed in cicatricial pemphigoid conjunctiva stained positively with HPA, PNA, WGA, and SWGA as did goblet cells in normal conjunctiva.     

Conjunctival Rhinosporidiosis. Light and electron microscopic study

Two cases of conjunctival rhinosporidiosis were studied by light and electron microscopy. Two distinct phases of the tissue life cycle were present: trophic and endosporulating. Young trophocytes contained a single nucleus. As the trophocyte matured chromatin was dispersed throughout the cyst. During the next phase of the life cycle, sporangial cyst walls acquired a new inner layer that appeared to give rise to endospores. Histochemical and ultrastructural features of Rhinosporidium seeberi are consistent with it being a fungus. Complete surgical excision of the lesion is the only known method to eradicate the infection.     

Light microscopic and electron microscopic histopathology of an iris microhaemangioma.

A patient who had been observed to have an iris microhaemangioma (capillary haemangioma), confirmed on fluorescein iris angiography, came to cataract surgery. The lesion was excised at the time of surgery and submitted to light and electron microscopic study. It had the features of a hamartoma of the capillary haemangioma type, with its characteristics being specific for vessels seen in iris tissue.     

HLA antigens in ocular cicatricial pemphigoid.

HLA antigen frequencies were studied in 20 patients with ocular cicatricial pemphigoid and 245 normal persons. HLA-B12 demonstrated an increased frequency of 45% in patients with ocular cicatricial pemphigoid which was statistically significant when compared to a frequency of 19.6% in the general population (P less than 0.02). In patients with ocular cicatricial pemphigoid the prevalance of HLA-A3 was increased to 35% when compared to 22.9% in the general population, but this was not statistically significant. The frequency of finding either HLA-A3 or B12 in patients with ocular cicatricial pemphigoid was increased to 75% in comparison with 38.8% in the general population (P less than 0.005). The present study suggests that HLA-B12 and possibly HLA-A3 are genetic markers for ocular cicatricial pemphigoid.     

The normal surface of conjunctiva epithelium. A scanning electron microscopic study.

Scanning electron microscopy (SEM) of the cellular surface of the rabbit conjunctiva show the monotonous appearance of fine, finger-like cytoplasmic protrusions (microvilli) covering the polygonal cells. Many of these surface cells contained a variety of intracytoplasmic vesicles, unroofed vesicles, and full-thickness holes of different sizes. These surface changes were interpreted as occuring in a sequential pattern leading to cell destruction and exfoliation. Interspersed among these light and dark polygonal cells were goblet cells representing various stages in their maturation. Specialized filopodia were found between epithelial cells only in the area just proximal to the tarsi. Duct openings of many glands were shown to enter onto the conjunctival surface. The relation of these finding to the tear film is discussed.     

Ocular cicatricial pemphigoid and oesophageal carcinoma

A 65-year-old man developed ocular cicatricial pemphigoid. He was treated with topical and systemic immunosuppressive agents. Three months later, he was found to have metastatic oesophageal carcinoma. To our knowledge, the association of ocular cicatricial pemphigoid and oesphageal carcinoma has not previously been described.     

Drug-induced lipidoses of the cornea and conjunctiva

A variety of lysosomal disorders affect the human cornea and conjunctiva. These disorders may result from inborn abnormalities of a specific intralysosomal enzyme such as the deficit of ceramide trihexosidase in Fabry's disease. Alternately, lysosomal dysfunction may be the result of drug administration with subsequent drug-induced lipidosis. Chloroquine, amiodarone, amodiaquine, benoquin, tilorone, and gentamicin are lipidosis-inducing drugs with proven involvement of the human cornea and conjunctiva. Similarities between Fabry's disease and the drug-induced lipidoses include intraepithelial corneal deposits frequently arranged in a verticillate or vortex pattern, and the presence of abnormal inclusions of intralysosomal lipid in corneal and conjunctival tissue when examined by transmission electron microscopy. These striking parallels invite consideration of lysosomal dysfunction as a factor in the recognized or potential toxicity of drugs inducing lipidosis.Supported in part by Academic Investigator Award EY00156 from the National Eye Institute, NIH; a grant-in-aid from Fight For Sight, Inc., NYC; the Research to Prevent Blindness James S. Adams Award; Biomedical Research Support Grant RR05527 from the National Eye Institute, NIH; and the Massachusetts Lions Eye Research Fund, Inc. (Dr. Kenyon).     

Scanning electron microscopy of conjunctival surfaces in patients with ocular cicatricial pemphigoid

The conjunctival surfaces of ten patients with active, ocular cicatricial pemphigoid, three patients with drug-controlled ocular cicatricial pemphigoid, and six patients with normal conjunctivas were studied using scanning electron microscopy. A homogeneous granular sheet of amorphous mucin-like material was observed covering extensive areas of the conjunctiva in eight of ten patients with active ocular cicatricial pemphigoid. This sheet of amorphous material was absent on drug-controlled ocular cicatricial pemphigoid and normal conjunctival specimens. Our study demonstrates that patients with active ocular cicatricial pemphigoid possess ocular surface mucus that appears thicker and more continuous than normal ocular mucus when observed with scanning electron microscopy. This observation is in agreement with clinical observations of thick mucus strands in the inferior fornix of patients with active ocular cicatricial pemphigoid.     

Linear IgA dermatosis mimicking ocular cicatricial pemphigoid.

PURPOSE: To describe an unusual case of cicatrizing conjunctivitis. METHODS AND RESULTS: A 59 year old male presented in July 1997 with a complaint of intermittent redness and discharge of the right eye. Medical history was significant for a buccal mucosal lesion biopsy taken two years earlier that revealed subepidermal fibrosis. Conjunctival biopsy, performed to rule out ocular cicatricial pemphigoid, yielded a diagnosis of linear IgA dermatosis, an unusual diagnosis not often considered by ophthalmologists. CONCLUSIONS: The diagnosis of cicatrizing conjunctivitis is often overlooked. Its importance as it pertains to the life threatening disease of ocular cicatricial pemphigoid is clear.     

Progression of disease in ocular cicatricial pemphigoid.

BACKGROUND: Ocular cicatricial pemphigoid (OCP) is a sight threatening autoimmune disease that can lead to severe conjunctival cicatrisation and keratopathy. It has a variable course and little is known about the factors that determine disease progression. This study analysed the factors that have prognostic significance regarding disease outcome, progression, and keratopathy. METHODS: Sixty six patients with OCP were monitored prospectively at Moorfields Eye Hospital. The influence of ocular features, the systemic disease, and the management were analysed to identify factors that influence the outcomes and disease progression. RESULTS: The mean age at presentation was 67 years; 56% were men. The binocular visual acuities were 6/24 or worse in 25%. Extensive cicatrisation at presentation was common but correlated only weakly with the visual prognosis. Systemic manifestations included lesions of the mouth in 44%, pharynx in 30%, oesophagus in 27%, nose/sinus in 18%, and skin in 17%. There was no association between the ocular and systemic manifestations. Persistent corneal epithelial defects and limbitis occurred in 18% and 32%, respectively, and both were associated with a worse visual prognosis. Systemic immunosuppression was ultimately prescribed in 74%, mainly in patients with advanced stages of conjunctival cicatrisation. Of patients with more than 24 months follow up, progression of cicatrisation occurred in 35% of eyes (16/46) all but one of which were associated with episodes of conjunctival inflammation. CONCLUSIONS: Persistent epithelial defects, limbal inflammation, and ongoing conjunctival inflammation are important factors that lead to keratopathy and visual handicap. These require aggressive management, often with systemic immunosuppressive treatment. Close follow up is required in cases with extensive cicatrisation.     

Cryotherapy for trichiasis in ocular cicatricial pemphigoid.

Trichiasis is a common and potentially sight threatening complication of ocular cicatricial pemphigoid and is usually secondary to cicatricial entropion. This study aimed to assess the success and complications of eyelid cryotherapy for trichiasis in a group of patients with long term follow up. The case records of all patients with ocular cicatricial pemphigoid that attended the external disease clinic at Moorfields Eye Hospital from 1980 to 1992 were reviewed. Each eyelid was divided into three horizontal zones. Cryotherapy was delivered with an Amoilette cryoprobe for approximately 30 seconds. Failure of the cryotherapy was defined as a regrowth of the eyelashes within the treated zone that either required epilation for symptom control or caused keratopathy. Ninety two lid zones were treated, involving 25 lids of 12 patients. The cumulative chance of success decreased rapidly to 40% over the first year. Thereafter, the chance of success declined slowly to 34% at 4 years. Complications included lid notching (n = 2), tarsal atrophy (n = 1), altered lid contour (n = 1), and temporarily raised intraocular pressure (n = 1). All patients had quiescent disease at the time of the cryotherapy and no patients showed increased conjunctival disease activity after treatment. Six patients were taking systemic immunosuppression medication. When ocular cicatricial pemphigoid is quiescent, lid cryotherapy has an acceptable complication rate. The major reason for recurrence of the trichiasis was attributed to inadequate follicle freezing.