Ikuko Toda

Surgical Reconstruction of the Ocular Surface in Advanced Ocular Cicatricial Pemphigoid and Stevens-Johnson Syndrome

PURPOSE Ocular cicatricial pemphigoid and Stevens-Johnson syndrome often cause ocular damage and blindness not amenable to surgical correction. We present a new surgical technique for reconstructing affected eyes. METHODS Fourteen eyes of 11 patients with cicatricial keratoconjunctivitis (seven patients with cicatricial pemphigoid and four with Stevens-Johnson syndrome; average age +/- S.D., 55.5 +/- 25.4 years) were treated with a combination of allograft limbal transplantation, amniotic membrane transplantation, and tarsorrhaphy, followed every 15 minutes by artificial tears derived from the patients blood serum. Eight eyes required concomitant penetrating or lamellar keratoplasty because of corneal opacity. RESULTS With a mean follow-up of 143 days (range, 10 to 608 days), we achieved successful ocular surface reconstruction in 12 eyes, with minimal recurrence of symblepharon. Failure occurred in two eyes (one each in 9- and 10-year-old boys) that developed corneal infiltration and vascularization. CONCLUSIONS A combination of allograft limbal transplantation, amniotic membrane transplantation, and tarsorrhaphy, followed by the use of serum-derived tears, can reconstruct the ocular surface in most cases. Although in this study the follow-up period was short and relatively few patients were studied, this approach appears to offer an alternative to keratoprosthesis for treating severe cicatricial keratoconjunctivitis with dry eye.

Reconstruction of the corneal epithelium by limbal allograft transplantation for severe ocular surface disorders

Purpose: Although penetrating keratoplasty is an established surgical procedure, it often is ineffective for severe ocular surface diseases such as alkali burns or limbal deficiency. The authors have performed limbal allograft transplantation for the reconstruction of the corneal epithelium. Methods: A total of nine patients (3 with chemical injury, 3 with limbal deficiency with unknown etiology, 2 with moderate ocular pemphigoid [OCP], and 1 with traumatic limbal deficiency) were treated by limbal allograft transplantation. Penetrating keratoplasties were performed in all patients with the exception of one with OCP. Patients received cyclosporine both systemically (10 mg/kg) and topically (0.05%) as well as high-dose intravenous dexamethasone (8 mg). Results: The corneal epithelium was reconstructed in all patients, although two showed partial increased fluorescein permeability and two others required a second surgery. The other five epithelia remained clear at mean follow-up of 12.3 months, with two episodes of graft rejection which were controlled successfully by medication. Conclusions: Limbal allograft transplantation with intensive immunosuppression by cyclosporine and high-dose steroids appears to be a promising surgical intervention for the reconstruction of corneas affected by severe ocular surface disease.

Dry eye after laser in situ keratomileusis.

PURPOSE To determine whether patients undergoing laser in situ keratomileusis have postoperative dry eye. METHODS In this retrospective, interventional case series, 124 eyes of 64 consecutive patients who underwent laser in situ keratomileusis were examined for a dry eye symptom, Schirmer test with anesthesia, tear clearance rate, tear break-up time, vital staining for ocular surface, corneal sensitivity, and blink rate. All values were compared before and after surgery (1 month, 3 months, 6 months, and 1 year) and values of P <.05 were considered statistically significant. RESULTS Subjective score for dryness was increased after laser in situ keratomileusis. Tear function index (Schirmer value/tear clearance rate) and break-up time were decreased until 1 month (tear function index) and 3 months (break-up time) after laser in situ keratomileusis but recovered to preoperative levels thereafter. Fluorescein and rose bengal scores were unchanged at all follow-up points except for improvement of the rose bengal score at 6 months. Corneal sensitivity was decreased at 1 month and 3 months, and returned to the preoperative level at 6 months after laser in situ keratomileusis. Blink rate was decreased at 3 months, 6 months, and 1 year after laser in situ keratomileusis. CONCLUSIONS Patients undergoing laser in situ keratomileusis develop dry eye with compromised tear function for at least 1 month after surgery. Use of artificial tears in the early postoperative period may help to prevent unwanted symptoms and ocular surface damage.

Ocular fatigue is the major symptom of dry eye

ABSTRACT A total of 524 consecutive new patients (195 male, 329 female, 434±208 yo) were evaluated for the presence of ocular fatigue and/or dry eye Dry eye was diagnosed based on our criteria, which included symptoms, vital staining, break‐up time (BUT) measurement, and the Schirmer test Among all the patients, 212% (111/524) reported symptoms of ocular fatigue and 153% (80/524) were diagnosed as having dry eye with symptoms Of the 111 patients who complained of ocular fatigue, 514% (57/111) had dry eye, which was significantly higher than the 153% for the entire group (p<0001) Additionally, 713% (57/80) of dry eye patients with symptoms complained of ocular fatigue, which was also significantly higher than the 212% among all patients (p<0001) Dry eye patients had a greater number of complaints (43±21 per patient) compared to controls (19±13 per patient) (p<0001) These findings suggest that there is a strong relation between ocular fatigue and dry eye

Sodium hyaluronate eyedrops in the treatment of dry eyes.

BACKGROUND--Several studies in the past have attempted to demonstrate the efficacy of sodium hyaluronate in the treatment of dry eyes. However, results have been conflicting and a definite conclusion has not yet been reached. This study recruited a larger group of patients and has incorporated for the first time both fluorescein and rose bengal staining in the evaluation of the epithelium. METHODS--Eighteen albino rabbit corneas were used in a basic animal study to demonstrate the efficacy of sodium hyaluronate by comparing the effects on the rate of epithelial healing. The optimal concentration to be used in the clinical trial was determined from the results of the basic study. In the clinical study 104 patients with dry eye syndrome were enrolled in a double masked controlled clinical trial. Patients received sodium hyaluronate drops in one eye and control medication in the other eye for 4 weeks. Grading of subjective symptoms and clinical examinations were performed at 2 and 4 weeks. RESULTS--In the animal study sodium hyaluronate at concentrations of 0.1% and 0.5% significantly accelerated the recovery time of iodine vapour induced corneal erosions (p < 0.01). In the clinical study no statistical significance was observed in the improvement of subjective symptoms or rose bengal staining, while fluorescein scores significantly improved in eyes receiving sodium hyaluronate (p = 0.0001) at 4 weeks. CONCLUSION--Sodium hyaluronate drops applied in six daily doses could not be demonstrated to offer advantages over conventional tear supplies in the improvement of subjective symptoms, but may play a role in maintaining a healthy corneal epithelium.

Androgens and Dry Eye in Sjögren's Syndromea

ABSTRACT: Sjögrens syndrome is an extremely complex and currently incurable autoimmune disorder, which occurs primarily in females, and is associated with lacrimal gland inflammation, meibomian gland dysfunction, and severe dry eye. We hypothesize that androgen deficiency, which reportedly occurs in primary and secondary Sjögrens syndrome (e.g., systemic lupus erythematosus, rheumatoid arthritis), is a critical etiologic factor in the pathogenesis of dry eye syndromes. We further hypothesize that androgen treatment to the ocular surface will promote both lacrimal and meibomian gland function and alleviate both “aqueous‐deficient” and “evaporative” dry eye. Our results demonstrate that androgens regulate both lacrimal and meibomian gland function, and suggest that topical androgen administration may serve as a safe and effective therapy for the treatment of dry eye in Sjögrens syndrome.

Influence of Gender, Sex Steroid Hormones, and the Hypothalamic-Pituitary Axis on the Structure and Function of the Lacrimal Gland

Throughout the twentieth century it has become increasingly apparent that males and females are different, and not just in terms of physical characteristics. Scientists have discovered that fundamental, gender-related differences exist in almost every cell, tissue and organ of the body, including those associated with respiration, digestion, metabolism, circulation, renal function, and neural and endocrine activity. Indeed, during a recent five year period, at least 8,159 scientific reports were published that addressed the basic and/or clinical influence of gender on health and disease (Table 1).

Corneal temperature in patients with dry eye evaluated by infrared radiation thermometry.

AIMS: The corneal temperature change following each blink was investigated in patients with dry eye using an infrared radiation thermometer. METHODS: Twenty patients with dry eye and 20 normal controls were enrolled in this study. Subjects kept their eyes open for 10 seconds without blinking and corneal temperature was measured every second with a recently improved infrared radiation thermometer. RESULTS: In the 20 patients with dry eye, corneal temperature change after keeping the eye open for 10 seconds was 0.21 (SD 0.06) degree C while it was 0.61 (0.28) degree C in the 20 normal patients (p = 0.0001). In an exponential equation, the inclination of the slope of a patient with dry eye was smaller than the normal. The correlation coefficient was r = 0.79 (0.16) in patients with dry eye and r = 0.90 (0.07) in normal patients. The mean K value of patients with dry eye was 0.20 (0.13)/second and that of normal subjects was 0.31 (0.19)/second (p = 0.03). CONCLUSION: Findings demonstrate the usefulness of this thermometer for measuring corneal temperature in the evaluation of dry eye. Decrease in corneal temperature with each blink in patients with dry eye was smaller than in normal subjects.

Three Different Types of Dry Eye Syndrome

We analyzed patients with dry eye syndrome with regard to autoimmune conditions. A total of 116 patients with dry eye syndrome were divided into three groups: simple dry eye (SDE), i.e., dry eye with no circulating autoantibodies; autoimmune positive dry eye (ADE), dry eye with circulating autoantibodies; and Sjogrens syndrome (SS), dry eye associated with Sjogrens syndrome. Schirmer test showed values of 3.0 ± 2.2 mm in SDE, 3.1 ± 2.0 mm in ADE, and 2.4 ± 2.3 mm in SS reflecting the inadequacy of this test in differentiating among the groups. However, Schirmer test with nasal stimulation showed values of 19.1 ± 12.4 mm in SDE and 16.4 ± 10.9 mm in ADE, which were significantly higher than the 7.0 ± 6.6 mm found in SS (p < 0.01). Moreover, ocular surface alterations evaluated by vital staining and brush cytology were significantly milder in SDE and ADE than in SS. SDE and ADE have less ocular surface abnormalities with good reflex tearing, whereas SS has less reflex tearing and more squamous metaplasia.

Epithelial ingrowth after laser in situ keratomileusis: Clinical features and possible mechanisms

PURPOSE To analyze the incidence, clinical course, and possible mechanisms of epithelial ingrowth after laser in situ keratomileusis (LASIK). DESIGN Interventional case series. METHODS Retrospective evaluation of 4,867 eyes of 2,502 patients who had LASIK. The type of microkeratome (LSK-One or MK-2000), corneal flap thickness, and clinical course were analyzed. We also compared the cutting characteristics of both microkeratomes in pig cadaver eyes by scanning electron microscopy. RESULTS The frequency of epithelial ingrowth was significantly greater in the MK-2000 (34 of 1,680 eyes; 2.0%) than the LSK-One group (30 of 3,187 eyes; 0.94%; P =.001). In 24 eyes (37.5%), blood, cell infiltration, ointment under the corneal flaps, or epithelial defect were detected at the area of epithelial ingrowth postoperatively. The incidence of epithelial ingrowth was correlated with the incidence of epithelial defect during surgery (P <.001) and with incidence of diffuse lamellar keratitis after surgery (P =.003). Flap thickness was thinner in eyes with epithelial ingrowth (126.0 +/- 29.1 microm) compared with flap thickness in eyes without epithelial ingrowth (133.8 +/- 27.3 microm; P <.001). Scanning electron microscopy showed clear differences in the appearance of flap edges created by the two types of microkeratomes. Epithelial ingrowth disappeared or remained unchanged in 54 eyes (90%) and progressed in six cases (10%). CONCLUSIONS Poor adhesion caused by excessive hydration due to epithelial defect as well as by foreign bodies between the flap stromal bed and thickness and morphologic characters of the corneal flap, depending on the type of microkeratomes, are related factors for development of epithelial ingrowth.