New surgical treatment for superior limbic keratoconjunctivitis and its association with conjunctivochalasis

PURPOSE: To introduce a new surgical procedure for treating superior limbic keratoconjunctivitis (SLK) and to suggest the association of SLK with conjunctivochalasis. DESIGN: Interventional case series. METHODS: Six eyes of five patients with long-standing severe ocular irritation unresponsive to treatment with topical steroid and artificial tears were operated on using our new procedure. This technique consists of four steps as follows: (1) Rose bengal (RB) staining is used to localize the abnormal conjunctival area; (2) an arc-like conjunctival incision is placed from the 2 to the 10 o'clock position adjacent and distal to the RB-stained area; (3) the conjunctiva is resected to form a crescent using the arc-like incision as the base; the size of the resection is determined by conjunctival redundancy after removal of the subconjunctival connective tissue; and (4) the crescent conjunctival opening is closed with interrupted sutures. In two eyes, the new surgical procedure was performed together with surgery for inferior bulbar conjunctivochalasis. RESULTS: In all operated eyes, RB staining had disappeared by the end of the second postoperative week; recovery from symptoms and loss of inflammation were recorded by 1 month after treatment. In the case with the longest follow-up (14 months), there was cytologic evidence of goblet cell recovery at 3 months after the operation. In another, there was normalization of the nucleo/cytoplasmic ratio of conjunctival cells without the appearance of goblet cells. CONCLUSIONS: Our treatment very effectively resolved symptoms associated with SLK, even in eyes unresponsive to conventional therapy with eye drops. Considering that we did not address the diseased part of the conjunctiva but rather the adjacent conjunctival redundancy, we propose that superior bulbar conjunctivochalasis is involved in the pathogenesis of SLK.     

New surgical approach for superior conjunctivochalasis

PURPOSE: To show poor adhesion between the conjunctiva and the sclera in eyes with superior conjunctivochalasis (CCh) and to introduce a new surgical approach by reinforcing adhesion between the conjunctiva and the sclera for correcting this deficiency. METHODS: After conjunctival peritomy and removal of the loose Tenon remnants, "Tenon reinforcement" for conjunctival adhesion to the underlying sclera was achieved by transplantation of cryopreserved amniotic membrane with fibrin glue (group A, 9 eyes of 6 patients) or 10-0 nylon sutures (group B, 8 eyes of 6 patients) in 17 eyes of 12 patients with refractory superior CCh. RESULTS: The mean age of patients was 68.2 +/- 9.8 years (range, 54-80 years). Superior CCh was associated with a superior limbic keratoconjunctivitis (SLK)-like clinical feature before surgery and found to exhibit dissolved Tenon capsule during surgery in all patients. During a mean follow-up of 3.7 +/- 1.9 months after surgery, all eyes achieved smooth conjunctival surface without any sign of CCh. Complete resolution of symptoms was seen in 9 eyes (52.9%) and significant resolution in 8 eyes (47.1%). There was no significant difference between groups A and B in improvement of symptoms and signs. No complications related to surgery were noted during follow-up. CONCLUSIONS: We propose that loose and dissolved Tenon tissue is correlated with the development of superior CCh, which may result in an SLK-like appearance by blink-related microtrauma. Reinforcement of conjunctival adhesion onto the sclera by amniotic membrane with either fibrin glue or sutures is effective in alleviating symptoms and signs in eyes with superior CCh.     

2型糖尿病患者不同翼状胬肉手术方式的疗效比较及其对泪膜的影响

目的:比较2型糖尿病患者三种不同翼状胬肉手术方式的疗效及其对泪膜的影响.方法:回顾分析我院2013-03/2016-03期间收治的手术治疗的翼状胬肉合并2型糖尿病患者102例102眼.其中行翼状胬肉单纯切除术34例34眼(单纯切除组);胬肉切除联合自体结膜瓣移植术34例34眼(球结膜瓣组);胬肉切除联合角膜缘干细胞移植术34例34眼(干细胞组).观察三组患者术后伤口修复时间、并发症、裸眼视力、复发率以及手术前、手术后6、12 mo三组患者泪膜破裂时间(BUT)、基础泪液分泌试验(SⅠt).结果:术后三组患者视力均较术前明显提高(P=0.039、0.013、0.024),且三组间比较无统计学差异(P=0.317).术后单纯切除组伤口修复时间为5.67±1.45d,明显大于球结膜瓣组(4.18±0.76d)与干细胞组(4.09±0.79d),差异有统计学意义(P<0.001);而结膜瓣组与干细胞组比较无统计学差异(P=0.937).术后单纯切除组有4例复发,复发率为11.8%,明显高于其它两组(P=0.037),球结膜瓣组有1例复发,复发率为2.9%,而干细胞组未见明显复发患者.术后SⅠt和BUT均明显增加(P<0.05),尤其是结膜瓣组和干细胞组增加比较显著(P<0.001).而球结膜瓣组和干细胞组间无统计学差异(P=0.845、0.894).结论:翼状胬肉切除联合结膜瓣移植和角膜缘干细胞移植对于治疗血糖和泪膜功能正常的2型糖尿病患者具有相似的疗效及术后泪膜功能,且优于单纯翼状胬肉切除术.     

球结膜遮盖联合角膜病灶切除治疗阿米巴性角膜炎的临床分析

目的:探讨球结膜遮盖术在阿米巴性角膜炎手术治疗中的有效性。方法:回顾性研究我院阿米巴性角膜炎患者8例8眼的临床表现和治疗方法。结果:行角膜溃疡切除+球结膜遮盖术8眼,术后7眼角膜感染控制,1眼感染复发而行穿透性角膜移植术。结论:局部角膜溃疡切除+球结膜遮盖术能有效控制感染,缩短患者病程,为行光学性角膜移植提供条件。     

Conjunctival resection treatment and ultrastructural histopathology of superior limbic keratoconjunctivitis

Four patients with symptomatic superior limbic keratoconjunctivitis underwent resection of the superior bulbar conjunctiva. One of these patients also underwent a tarsal conjunctival resection in the other eye. Three of the patients had previously been treated by various regimens without resolution; the fourth had had no prior treatment. All four patients had immediate and continued relief of the ocular symptoms after the superior bulbar conjunctiva was excised. The patient who underwent tarsal conjunctival resection experienced only short-term relief. We studied the conjunctival tissue by light and transmission electron microscopy. Both techniques revealed abnormalities related to the bulbar conjunctival surface with keratinization of the epithelium, acanthosis, degeneration of the nuclei, and intracellular accumulation of glycogen. Inflammatory cells were minimally present. The tarsal conjunctiva appeared essentially normal.     

The fine structure of nuclear changes in superior limbic keratoconjunctivitis

Superior limbic keratoconjunctivitis (SLK) is a condition of unknown etiology. Histological signs include acanthosis, dyskeratosis, keratinization, and ballon degeneration of the bulbar conjunctival epithelium. Ultrastructural examination of biopsy material from five eyes of patients with SLK shows numerous nuclear changes in the conjunctival epithelial cells. These include abnormal distribution and aggregation of nuclear chromatin, the presence of filaments within the nucleus, and dense accumulations of cytoplasmic filaments which surround the nucleus, resulting in "strangulation" and the formation of multilobed nuclei or multinucleated cells. These changes do not appear to have been described previously in any cell type.     

角膜缘干细胞移植术治疗双侧翼状胬肉的疗效

目的：观察自体角膜缘干细胞移植术(LCAT)治疗双侧翼状胬肉的临床效果。

方法：前瞻性病例研究。收集2014-01/2015-07在解放军第四七四医院诊断为双侧翼状胬肉患者46例54眼,其中双眼双侧胬肉8例16眼,一眼双侧胬肉一眼鼻侧胬肉11例11眼(仅纳入双侧胬肉眼作为研究对象),单眼双侧胬肉27例27眼,均采用鼻侧翼状胬肉切除联合同眼上方LCAT,而颞侧翼状胬肉切除联合对侧眼下方LCAT。术后1、7d,1mo,1a复查,复查时完成视力、裂隙灯等检查,观察术后并发症及翼状胬肉复发情况。

结果：完成1a随访患者共44例52眼,失访2例2眼。术后1a复发3例3眼(6%),鼻侧翼状胬肉复发2眼,颞侧翼状胬肉复发1眼。未见其它术后并发症。

结论：鼻侧翼状胬肉切除联合同眼上方LCAT,同时颞侧翼状胬肉切除联合对侧眼下方LCAT治疗双侧翼状胬肉安全有效,复发率低。     

单纯胬肉切除、角膜缘干细胞移植与带蒂结膜瓣移植治疗翼状胬肉疗效比较

目的比较单纯胬肉切除、角膜缘干细胞移植及带蒂结膜瓣移植术治疗翼状胬肉的疗效，探讨降低术后复发率的方法。方法667例（718眼）翼状胬肉，采用上述三种术式治疗，术后随访5～20个月观察胬肉复发情况。结果单纯胬肉切除术组62例（62眼），6眼胬肉复发，复发率为9．68％。联合角膜缘干细胞移植术组430例（462眼），3眼复发，复发率0．65％。联合带蒂结膜瓣移植术组175例（194眼），2眼复发，复发率1．03％。单纯切除组与其他两组复发率之间差异具有统计学意义（P〈0．01）。联合角膜缘干细胞移植组与联合带蒂结膜瓣移植组之间差异不具有统计学意义（P〉0．05）。结论胬肉切除联合角膜缘干细胞移植术治疗翼状胬肉其复发率与联合带蒂结膜瓣移植术相比无明显优势。两者术后复发率均明显低于单纯胬肉切除术。     

Treatment of superior limbic keratoconjunctivitis by thermocauterization of the superior bulbar conjunctiva

Superior limbic keratoconjunctivitis (SLK) is a chronic and recurrent inflammatory disease of the superior tarsal, bulbar and limbal conjunctiva that often responds to topical treatment with silver nitrate. As an alternative treatment in 11 patients (13 eyes), we applied thermal cautery to the inflamed superior bulbar conjunctiva following subconjunctival injection of 2% xylocaine. The overall positive response rate to thermocautery was 73% (8 patients). Of the positive responders, 63% (5 patients) had been considered silver nitrate treatment failures. Keratitis sicca was additionally noted in 55% of the patients studied. Impression cytology of involved superior bulbar conjunctiva was nearly devoid of goblet cells during the acute stage of the disorder. Following successful cauterization, goblet cells returned. Thus, thermocauterization of the superior bulbar conjunctiva appears to be a safe and effective mode of therapy for SLK.     

绷带式角膜接触镜在翼状胬肉切除合并结膜移植术的应用

目的:探讨绷带式角膜接触镜应用于翼状胬肉切除合并结膜移植术的临床效果。方法:回顾性分析2012-06/2013-06行翼状胬肉切除合并结膜移植术101例114眼的临床资料,按术后处理方式分为A、B、C三组,A组30例38眼,配戴绷带式角膜接触镜,B组33例38眼,绷带加压包扎,C组38例38眼,遮盖普通眼垫,术后第1,3,5d观察。结果:选取114眼术后随诊均未发生角膜溃疡、肉芽肿、复发等并发症。三组间比较在各种眼部刺激症状程度方面A组比其他两组轻;术后角膜上皮修复时间上比较A、B组短于C组。结论:绷带式角膜接触镜能明显减轻翼状胬肉切除合并结膜移植术后患者各种眼部刺激症状,促进缺损区角膜上皮修复,与传统处理方式比较能明显提高患者术后的舒适度,易于推广,风险小,具有广泛的临床实用价值。     

两种术式治疗翼状胬肉的疗效观察

目的:分析两种不同的手术方式治疗翼状胬肉的临床效果。方法:第1组33例35眼,有2例2眼为复发病例,采用翼状胬肉切除联合游离球结膜瓣移植术。第2组32例35眼,有2例2眼为复发病例,采用翼状胬肉切除联合游离球结膜瓣移植加丝裂霉素棉片术。结果:术后1a内随访,第1组复发1例(1眼),复发率3.03%(2.85%)。第2组复发1例(1眼),复发率3.12%(2.85%),有1例发生球结膜瓣愈合不良,于术后20d拆除结膜瓣缝线。无巩膜溶解等严重并发症。结论:翼状胬肉切除联合游离球结膜瓣移植术与翼状胬肉切除联合游离球结膜瓣移植加丝裂霉素棉片术,复发率均较低,两组间没有差异。     

长期联合应用噻吗洛尔对结膜组织炎性反应的影响

目的:通过观察长期应用抗青光眼滴眼剂作用后结膜炎症反应的发生和炎性标记物ICAM-1在眼部的表达,探讨长期应用抗青光眼滴眼剂对结膜反应的影响。方法:从我科收住的原发性开角型青光眼患者90例,分为三组:应用5g/L噻吗洛尔与2g/L阿法根(联合用药组)30例;应用5g/L噻吗洛尔(单一用药组)30例;未用药组30例;单纯白内障患者作为空白对照组30例。按抗青光眼药物治疗时间及白内障患病时间分为三个时相(0～6mo,7～12mo,13～18mo)组,各个时相组10例,进行结膜上皮组织形态学观察及检测结膜上皮组织中ICAM-1炎性标记物的表达。结果:单一用药组在用药13～18mo时其球结膜组织学改变明显,表现为上皮形态不规则,表面不平或有上皮分离或增生,球结膜下纤维结缔组织排列不规则,小血管增多,巨噬细胞、淋巴细胞、成纤维细胞数增多。联合用药组在用药13～18mo时球结膜有明显的组织学改变,上皮有不同程度的增生或鳞状化生,上皮厚薄不均,表面不光滑,有上皮脱落,球结膜下组织中小血管增多,巨噬细胞、淋巴细胞、成纤维细胞数目明显增多、杯状细胞减少。单一用药组与联合用药组在13～18mo结膜组上皮组织中含ICAM-1抗原的阳性细胞数与其他组差别有统计学意义(P<0.01)。结论:长期联合应用抗青光眼药物可致结膜组织的炎性反应,结膜上皮组织中的炎性标记物ICAM-1表达明显增加。     

Expression of involucrin by ocular surface epithelia of patients with benign and malignant disorders

PURPOSE: Keratinization of the ocular surface epithelium is associated with various disorders impairing vision. We immunohistochemically determined whether the ocular surface epithelia express involucrin, and whether its expression pattern may differ in benign vs. malignant disorders. Expression of cytokeratins was also examined to provide further information relative to the epithelial differentiation. METHODS: We evaluated 17 specimens; 6 specimens of the normal ocular surface epithelia, 3 specimens from cases of conjunctival intraepithelial neoplasia (CIN), 6 of conjunctival squamous cell carcinoma (SCC) and 2 of conjunctivae from cases of superior limbic keratoconjunctivitis (SLK). RESULTS: Corneal epithelium exhibited intracellular immunoreactivity for involucrin. Four of the 6 specimens of bulbar conjunctival epithelium showed involucrin immunoreactivity in the perimembranous region, whereas the fornical conjunctiva was negative. Cornified envelope in SLK specimens was positive for involucrin. The CIN showed its immunoreactivity in the perimembranous region in all levels of the hyperproliferative epithelium without keratinization, i.e., similar to the bulbar conjunctiva. The neoplastic cells of well-differentiated SCC showed involucrin in the perimembranous region, and those of moderately- to poorly-differentiated SCC have involucrin in their cytoplasm. The expression pattern of cytokeratins was unrelated to grade of malignancy in ocular SCC. CONCLUSION: The epithelia of normal subjects and of CIN expresses involucrin without keratinization. In contrary, the keratinized SLK epithelium markedly expresses involucrin in the cornified envelope. The subcellular immunolocalization of involucrin in the ocular SCC may help in evaluating the differentiation, i.e., malignancy, of neoplastic cells.     

带角膜缘的自体结膜瓣移植术治疗翼状胬肉合并结膜囊肿

目的:观察带角膜缘的自体结膜瓣移植术治疗翼状胬肉合并结膜囊肿患者的疗效.方法:收集华中科技大学同济医学院附属同济医院眼科于2013-08/2015-08住院接受手术的翼状胬肉患者126例188眼,其中翼状胬肉合并区域结膜囊肿者11例11眼作为观察组,余为对照组,所有患者均行裂隙灯显微镜检查、眼前节照相、眼前节OCT检查,并采用翼状胬肉颈部宽度×遮盖角膜的长度计算翼状胬肉的大小,采取翼状胬肉切除联合带角膜缘的自体结膜瓣移植的手术方式,切除物均行病理切片HE染色观察,术后随访4~28mo.结果:观察组术后病检结果均证实为翼状胬肉合并结膜囊肿,囊壁完整,内附单层上皮细胞.观察组翼状胬肉大小平均为6.9±1.7mm2,对照组大小平均为6.3±1.8mm2,两组间比较无统计学差异(P>0.05).观察组术后角膜上皮愈合时间平均为2.1±0.9d,对照组术后角膜上皮愈合时间平均为1.9±0.8d,两组间比较无统计学差异(P>0.05).随访期内观察组术后未见翼状胬肉复发,对照组术后2例2眼复发.结论:带角膜缘的自体结膜瓣移植治疗翼状胬肉合并结膜囊肿是一种安全有效的治疗方法,结膜囊肿术后对翼状胬肉的复发率无显著影响.     

翼状胬肉切除联合角膜缘干细胞移植及术后药物治疗临床观察

目的:观察翼状胬肉切除联合角膜缘干细胞移植及术后药物治疗翼状胬肉的临床疗效。方法:共行翼状胬肉切除联合角膜缘干细胞移植术治疗的翼状胬肉患者760例980眼。选取亚复发期的162例162眼进行观察,随机分为A,B两组,A组滴1g/L丝裂霉素C+诺氟沙星滴眼液1～3mo;B组交替滴地塞米松滴眼液、双氯芬酸钠滴眼液1～3mo。结果:A组痊愈67眼(81.7%),亚复发12眼(14.6%),复发3眼(3.7%)。B组痊愈35眼(43.8%),亚复发29眼(36.3%),复发16眼(20.0%)。A组复发率明显低于B组(P<0.01)。结论:翼状胬肉切除联合自体角膜缘干细胞移植术,无排斥反应、安全有效、术后复发率低,术后给予滴眼液后续治疗尤为重要,更能有效地抑制和降低翼状胬肉术后的复发率,能明显提高治疗效果。     

翼状胬肉切除联合不同移植术式后干眼症的临床观察

目的：探讨翼状胬肉切除联合移植的不同手术方法术后干眼症的情况。
　　方法：选取翼状胬肉患者78例81眼,随机分成3组, A组：行翼状胬肉切除联合大块自体球结膜瓣移植术;B组：行翼状胬肉切除联合小块自体球结膜瓣移植术;C组：行翼状胬肉切除术联合小块带自体角膜缘干细胞结膜瓣移植术。观察三组患者术后角膜上皮修复时间,术前和术后1,3mo检查泪膜破裂时间(BUT)以及眼表疾病指数(ocular surface disease index,OSDI)问卷调查,来评价翼状胬肉及胬肉切除术后引起干眼症的情况。
　　结果：BUT：术后15d,A组较B,C组明显缩短(P<0.05),术后1mo,A组与B,C组间无明显差异(P>0.05),但术后1mo时并发干眼症阳性率均较B,C组高(P<0.05);B,C 组间术后并发干眼症阳性率比较无显著差异( P>0.05),但C组有阳性率低的趋势。上皮修复时间A组较B,C组长(P<0.05);B,C组间无显著差异(P>0.05),但C组有时间更短的趋势。
　　结论：胬肉切除联合小块自体角膜缘干细胞移植术术后角膜上皮修复更快,引起干眼症的几率最小,术式最佳。     

Immunological aspects of superior limbic keratoconjunctivitis.

Three patients with superior limbic keratoconjunctivitis (SLK) were treated by conjunctival resection. The results of immunological studies and histological examination of the excised tissue were unremarkable; none of seven criteria of antibody dependence were met. We found no specific immune defects in three patients with superior limbic keratoconjunctivitis.     

Supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis

PURPOSE: To evaluate the efficacy of supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis (SLK). METHODS: Forty eyes of 20 patients were diagnosed with SLK. All eyes with long-standing severe ocular irritation unresponsive to topical steroid and artificial tears were treated with supratarsal triamcinolone injection in addition to ongoing treatment of dry eye. Objective tarsal conjunctiva inflammation, bulbar conjunctiva, cornea staining, and subjective symptom gradings were performed before and after 2 weeks of therapy. All patients underwent laboratory evaluations of underlying systemic abnormalities. RESULTS: All 40 eyes responded well to treatment and had long-term (average, 7.8 months) improvement of irritation and dry sensation and improvement of inflammation and staining of conjunctiva and cornea. Fourteen patients (70%) had associated autoimmune diseases. There were no irreversible complications related to this therapy. CONCLUSIONS: Supratarsal triamcinolone injection effectively and rapidly resolved symptoms and signs associated with SLK. It is helpful as primary or adjunctive therapy for SLK.     

翼状胬肉撕除联合球结膜移植及丝裂霉素C的临床效果观察

目的观察翼状胬肉撕除联合球结膜移植及丝裂霉素C治疗翼状胬肉的效果。方法将69例（69眼）患者随机分为三组,A组行单纯翼状胬肉撕除术;B组为翼状胬肉撕除联合应用丝裂霉素C;C组为翼状胬肉撕除联合应用丝裂霉素C及球结膜移植术。术后观察角膜创面、移植片情况、术后并发症及胬肉复发情况。结果 A组23眼有6只眼复发（26.09%）;B组23眼有3只眼复发（13.04%）;C组23眼有1只眼复发（4.35%）复发率。C组与A组、B组比较,差异均具有统计学意义（P〈0.05）。角膜创面愈合三组差异无统计学意义（P〉0.05）。结论翼状胬肉撕除联合球结膜移植及丝裂霉素C是一种安全有效的治疗翼状胬肉的方法,且复发率低。     

Diagnostic tests for dry eye disease in normals and dry eye patients with and without Sj?gren's syndrome.

In order to compare the diagnostic tests for dry eye disease and the results of conjunctival impression cytology, we examined three groups of eyes: 146 eyes of normal controls, 108 eyes of keratoconjunctivitis sicca (KCS) patients without Sj?gren's syndrome (SS) and 102 eyes of patients with SS. The clinical tests (break-up time, Schirmer test, Rose Bengal staining) and conjunctival impression cytology specimens from the superior part of the bulbar conjunctiva were evaluated from all the eyes. Our results showed that the patients with KCS without SS have abnormal lacrimal tests (p < 0.001) without changes in impression cytology [nucleo/cytoplasmic ratio (N/C), p > 0.1]. The patients with KCS and SS have also abnormal lacrimal tests (p < 0.01), and their epithelial cells presented squamous metaplasia (N/C, p < 0.001). The goblet cell number remained unchanged in the three groups (p > 0.1).