Conjunctival resection combined with tenon layer excision and the involvement of mast cells in superior limbic keratoconjunctivitis

PURPOSE: To evaluate the effectiveness of conjunctival resection combined with Tenon layer excision in treating superior limbic keratoconjunctivitis (SLK) and the involvement of mast cells in SLK. DESIGN: Retrospective, interventional case series. METHODS: Forty eyes of 30 SLK patients who were unresponsive to medical treatment received superior bulbar conjunctival resection, and another 20 patients who underwent cataract and retinal surgery served as a control group. The conjunctiva specimens from study and control patients were examined by hematoxylin and eosin staining and immunohistochemistry using antibodies against mast cell tryptase. RESULTS: In all operated eyes, the clinical symptoms and signs, including irritation and redness and superior bulbar conjunctival hyperemia and superior tarsal conjunctival papillary hypertrophy, subsided significantly three months after the operation. Only three eyes had recurrence from the margin of conjunctival resection, and this was relieved after reoperation. Keratinized conjunctival epithelium, loss of goblet cells, and increased mast cell numbers (P<.05) were found in the SLK group. CONCLUSIONS: Our cases demonstrate that superior bulbar conjunctival resection combined with Tenon layer excision is an effective treatment for SLK. The pathologic findings suggest that mast cells may play a role in the pathogenesis of SLK.     

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.     

A new surgical technique for management of conjunctivochalasis

PURPOSE: To present a new surgical technique for severe, symptomatic conjunctivochalasis and our hypothesis of the pathogenesis of this condition. METHODS: Six eyes of three patients with conjunctivochalasis (average age +/-SD, 70.0 +/- 9.6 years; range, 56-78 years) were treated with a conjunctival fixation to sclera with three 6-0 Vicryl (Johnson & Johnson, New Brunswick, New Jersey) stitches. RESULTS: With a mean follow-up period of 209.5 days (range, 181-219 days), we achieved successful treatment in all eyes, with no recurrence of conjunctival folds. CONCLUSION: We successfully treated conjunctivochalasis with conjunctival fixation to sclera, which strongly suggests that conjuctival folds are caused by the folding and the elevating of loosely adherent bulbar conjunctiva of the lower eyelid.     

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.     

部分结膜切除术治疗结膜松弛症性溢泪的疗效

目的：评价球结膜部分切除术治疗球结膜松弛症患者溢泪的安全性和有效性。方法：回顾性病例系列研究。对2015年6月到2017年12月在陆军军医大学附属西南医院眼科确诊为结膜松弛症并伴有溢泪症状,接受部分结膜切除手术治疗的患者31例（31眼）,完成随访的27例（27眼）进行统计分析。所有患者的结膜松弛症均为Ⅲ级或以上,接受球结膜部分切除术后,检查患者自觉症状及结膜脱垂体征变化。采用配对t检验比较术前及术后1、6、12个月泪膜破裂时间变化以及术前和术后6个月的下泪河高度变化。结果：术后患者的溢泪症状均消失。拆除结膜缝线后未见切口处的结膜裂开。至术后平均15个月的随访期间,裂隙灯显微镜检查未见结膜松弛症复发。术后随访各时间点泪膜破裂时间均显著提高（P<0.001）,术后12个月下泪河高度较术前提高（t=-14.642,P<0.001）。结论：切除松弛脱垂的球结膜,间断缝合球结膜切口,并固定于浅层巩膜上,可有效避免手术中结膜撕裂和术后结膜切口裂开等手术并发症,能够改善患者的溢泪,一定程度上稳定泪膜,且安全、有效。     

Effects of sequential artificial tear and cyclosporine emulsion therapy on conjunctival goblet cell density and transforming growth factor-beta2 production

PURPOSE: To evaluate the effects of sequential treatment with artificial tears and cyclosporine emulsion on conjunctival goblet cell density and production of transforming growth factor (TGF)-beta2 in patients with dry eye disease. METHODS: Patients with dry eye disease (N = 6) defined by an Ocular Surface Disease Index symptom score >or=25, Schirmer test 1 <10 mm, and corneal fluorescein and conjunctival lissamine green staining scores >or=3 were treated with artificial tears (Refresh Plus; Allergan, Irvine, CA) 4 times a day for 4 weeks, followed by 0.05% cyclosporine emulsion (Restasis; Allergan) twice a day for 12 weeks. Impression cytology was performed on the bulbar conjunctiva of both eyes at baseline, after artificial tear therapy, and after 6 and 12 weeks of cyclosporine therapy. Goblet cells were counted in 5 representative microscopic fields per membrane in those taken from the temporal and inferior bulbar conjunctiva of the worse eye, and membranes taken from the fellow eye were immunostained for TGF-beta2. RESULTS: There were no differences in mean goblet cell density between baseline and 4 weeks of artificial tears in the temporal and inferior bulbar specimens. After 6 weeks of cyclosporine emulsion, goblet cell density was significantly greater than baseline and artificial tears in the inferior bulbar conjunctiva (P < 0.01). After 12 weeks of cyclosporine emulsion, goblet cell density was significantly greater than baseline and artificial tears in both temporal and inferior bulbar sites (P < 0.01). The number of TGF-beta2-positive goblet cells was also noted to increase after 6 and 12 weeks of cyclosporine therapy (P < 0.001). CONCLUSIONS: Cyclosporine emulsion, but not artificial tears, increases goblet cell density and production of the immunoregulatory factor TGF-beta2 in the bulbar conjunctiva in patients with dry eye.     

Case-controlled clinical and histopathological study of conjunctivochalasis

BACKGROUND/AIMS: Conjunctivochalasis, a secondary cause of the watery eye, is frequently seen in the older age group as an elevation of the bulbar conjunctiva lying along the lateral or central lower lid margin. A prospective, interventional, case-controlled clinical and histopathological study was conducted. The relevant features of 18 patients (29 eyes) who had their conjunctivochalasis resected as part of the surgical management of their watery eye syndrome were examined. In the control group, tissue was obtained from an age matched series of 24 normal subjects undergoing routine cataract surgery. METHODS: 24 controls (24 specimens) and 18 patients (29 specimens) had conjunctival strip biopsies, taken from the usual lid margin level bulbar conjunctiva in line with the inferior limbus (controls), and the clinically apparent conjunctivochalasis (patients). These were submitted for histological study. RESULTS: 23 of 24 control sections demonstrated normal conjunctival variation. Four of 29 patient specimens demonstrated a chronic non-granulomatous conjunctivitis, while three eyes of the patient group (two patients) demonstrated features of elastosis. Of the four patients who had the inflammatory infiltrates, three had functional nasolacrimal duct obstructions (FNLDOs) and one had a primary acquired nasolacrimal duct obstruction (PANDO). Of the two patients who had elastosis, one had an FNLDO and the other had normal lacrimal drainage and was Jones 1 positive. CONCLUSION: Six of 18 patients--that is, seven of 29 specimens of conjunctivochalasis demonstrated signs of elastosis or of chronic non-granulomatous inflammation. Clinically, patients had a spectrum of aetiologies of their watery eye syndrome.     

手术治疗结膜松弛症临床疗效观察

目的:探讨结膜新月形切除术、结膜缝线固定术治疗结膜松弛症的疗效。方法:对27例48眼结膜松弛症患者随机分组,分别应用结膜新月形切除、结膜缝线固定术进行治疗,术后随访观察疗效。从术后患者自觉症状、裂隙灯显微镜观察结膜松弛改善情况及泪河和泪膜破裂时间(BUT)的变化进行观察分析。结果:术后1wk,结膜新月形切除术组有效率为92%,结膜缝线固定术组有效率为88%。术后1mo,结膜新月形切除术组有效率为92%,结膜缝线固定术组有效率为83%。结论:两种手术方法治疗结膜松弛症方法简单,疗效明确。     

Superficial conjunctiva cauterization to reduce moderate conjunctivochalasis

AIM: We report here a simple surgical approach to reduce moderate conjunctivochalasis. PATIENTS AND METHODS: A non-comparative prospective interventional case series study of fifteen consecutive patients with moderate conjunctivochalasis was carried out. On the inferior bulbar conjunctiva 10 to 20 superficial burns were performed with an electrical bipolar cauter to reduce moderate conjunctivochalasis. Before and around a mean time of six months after surgery digital photographs of the conjunctivochalasis were taken at the slit lamp. The maximal height of the conjunctivochalasis above the lower eyelid margin measured before surgery was compared with the height of the conjunctivochalasis measured after surgery around the same location (one eye per patient). RESULTS: In each patient, gentle and superficial cauterization induced contraction of the bulbar conjunctiva and reduction of the conjunctivochalasis. No complications were noted during or after the procedure. Mean (+/- SD) maximal conjunctivochalasis height above the lower eyelid margin was higher before (2.3 +/- 0.9 mm) than after surgery (0.8 +/- 0.6 mm). Preoperative values of conjunctivochalasis height were significantly (p < 0.001) different from the postoperative ones (Wilcoxon rank signed test). CONCLUSIONS: Gentle superficial cauterization of the inferior bulbar conjunctiva can induced significant reduction of a moderate conjunctivochalasis.     

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.     

Conjunctival cytologic features of primary Sj?gren's syndrome.

To determine whether there are specific cytologic features associated with primary Sj?gren's syndrome (SS), the authors evaluated impression cytology specimens from three conjunctival sites (temporal bulbar [TB], inferior bulbar [IB], and inferior tarsal [IT]) from 38 SS eyes, 34 eyes of aqueous tear-deficient patients without SS, 35 eyes of seborrheic blepharitis patients, and 17 eyes of normal controls in a masked fashion. The following features were observed more frequently in SS eyes than in the eyes of the other groups: squamous metaplasia of the TB and IB (P less than 0.05), extensive (greater than 75%) goblet cell loss of the TB (P less than 0.05), mucous aggregates of the bulbar conjunctiva (P less than 0.05), and inflammatory cells intercalated with epithelial cells on the IT conjunctiva (P less than 0.06). The conjunctival inflammatory cell infiltrate correlated with the presence of extensive squamous metaplasia (P less than 0.01) in SS specimens. The inflammatory cells on the IT conjunctival epithelium were found to consist predominantly of T-lymphocytes by immunofluorescent staining of cytologic specimens from six eyes. Based on these findings, the authors speculated that conjunctival squamous metaplasia, in addition to aqueous tear deficiency, may be due to primary involvement of the dysfunctional immune system of SS.     

结膜松弛症泪液黏蛋白及球结膜杯状细胞的研究

目的:评价结膜松弛症泪液功能及结膜杯状细胞的组织病理学及超微结构改变。方法:结膜松弛症与正常对照组各30例(60眼)进行泪膜破裂时间(tearbreakup time,BUT)SchirmerⅠ试验、泪液羊齿状试验(tear ferning test,TFT)检查。对10例松弛球结膜组织和10例对照组球结膜对应区组织,采用PAS,AB和HE染色,对照观察组织病理及超微结构改变。结果:结膜松弛症组BUT(7.72±2.90s)较对照组(14.40±3.68s)减少明显(P<0.05)。基础Schirmer试验中结膜松弛症组(13.20±4.07mm)较对照组(16.73±4.41mm)明显降低(P<0.05)。结膜松弛症组泪液中羊齿状结晶明显减少,与对照组间比较差异有显著意义(P<0.05)。结膜松弛症球结膜上皮中的杯状细胞密度为2.75±2.68/100个上皮细胞,对照组为4.64±3.25/100个上皮细胞,两组间差异无显著性(t=1.42,P=0.172)。随着结膜松弛症程度加重,球结膜杯状细胞密度降低。结膜松弛症球结膜杯状细胞组织形态和超微结构有异常。结论:结膜松弛症泪膜稳定性下降、泪液分泌减少,泪液中黏蛋白减少,结膜杯状细胞数量减少,超微结构有异常。     

Comparison of corneal and conjunctival rose bengal staining before and after punctal occlusion

PURPOSE: In severely tear-deficient dry eye patients whose puncta had been occluded, corneal and conjunctival rose bengal (RB) staining were graded and compared to before occlusion. SUBJECTS AND METHODS: Subjects were 17 eyes of 13 severely tear-deficient dry eye patients whose puncta had been successfully occluded (corneal fluorescein staining showed A 0 D 0 after occlusion). Corneal and conjunctival RB staining were graded 0, 1, 2 or 3, according to severity [B 1] at the cornea and at the temporal and nasal bulbar conjunctiva. The scores were then compared to those before punctal occlusion. To enable comparison of pre- and post-occlusion ocular surface concentrations of RB [B 2], post-occlusion concentration was adjusted by absorbing tears from the conjunctival sac with Schirmer's test paper until the lower meniscus height was equal to that before occlusion, as monitored by video-meniscometer. RB dye was then instilled into the patients conjunctival sac. RESULTS: RB staining score at the cornea decreased significantly; in contrast, no significant improvement was found at the nasal and temporal conjunctiva (p = 0.0025, p = 0.05, p = 0.7, respectively, Wilcoxon test). CONCLUSION: In accordance with the basic interpretation of RB staining, these results imply that RB positive staining [B 3] on the conjunctival surface is caused by a factor other than aqueous deficiency.     

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。     

结膜松弛症的临床及病理研究

目的探讨结膜松弛症的临床特征及组织病理学改变。方法收集结膜松弛症患者26例（39只眼）的相关临床资料,并进行回顾性分析;对患病组26例（39只眼）结膜松弛症患者松弛结膜组织和对照组15例（15只眼）单纯白内障患者球结膜组织进行病理组织学检查,对照观察两组样本组织病理改变。结果结膜松弛症患者多为中老年人,性别比较差异无显著性,均为双眼发病,均有溢泪与干眼症状,不同程度的多余球结膜堆积于下眼睑与眼球之间,泪膜破裂时间（BUT）〈3S,角膜荧光素染色阳性。组织病理学改变：对照组有14只眼为正常的结膜改变,患病组39只眼中有16只眼为慢性非肉芽肿性结膜炎,17只眼为弹性组织变性。结论结膜松弛症患者多为中老年人,主要表现为溢泪与干眼症状,选择合适的手术可以有效的改善患者的病情;其主要病理改变为弹性组织变性,慢性非肉芽肿性结膜炎及炎性细胞浸润等。     

结膜松弛症性溢泪的手术治疗

目的 :探讨结膜松弛性泪溢症手术治疗效果。方法 :设计 7种松弛结膜切除方法 ,对 31例 5 2眼结膜松弛性泪溢症患者手术切除松弛结膜。结果 :术后 4周 5 2眼中自觉溢泪改善达 76 92 % ;5 7 6 9%患眼室内观察溢泪得到改善 ;76 92 %患眼裂隙灯观察松弛结膜完全消除。结论 :手术切除松弛结膜对治疗结膜松弛性泪溢症有效     

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.     

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.     

In vivo confocal microscopy of the bulbar conjunctiva

Background:  The aim of this work is to develop a more complete qualitative and quantitative understanding of the in vivo histology of the human bulbar conjunctiva.
Methods:  Laser scanning confocal microscopy (LSCM) was used to observe and measure morphological characteristics of the bulbar conjunctiva of 11 healthy human volunteer subjects.
Results:  The superficial epithelial layer of the bulbar conjunctiva is seen as a mass of small cell nuclei. Cell borders are sometimes visible. The light grey borders of basal epithelial cells are clearly visible, but nuclei can not be seen. The conjunctival stroma is comprised of a dense meshwork of white fibres, through which traverse blood vessels containing cellular elements. Orifices at the epithelial surface may represent goblet cells that have opened and expelled their contents. Goblet cells are also observed in the deeper epithelial layers, as well as conjunctival microcysts and mature forms of Langerhans cells. The bulbar conjunctiva has a mean thickness of 32.9 ± 1.1 µm, and a superficial and basal epithelial cell density of 2212 ± 782 and 2368 ± 741 cells/mm², respectively. Overall goblet and mature Langerhans cell densities are 111 ± 58 and 23 ± 25 cells/mm², respectively.
Conclusions:  LSCM is a powerful technique for studying the human bulbar conjunctiva in vivo and quantifying key aspects of cell morphology. The observations presented here may serve as a useful marker against which changes in conjunctival morphology due to disease, surgery, drug therapy or contact lens wear can be assessed.     

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).