Juan Murube

Treatment of dry eye by blocking the lacrimalcanaliculi

Occlusion of the lacrimal canaliculi improves the objective signs and subjective symptoms of dry eye. In this review, methods of occlusion are classified as surgical, thermal and tamponade. Surgical methods include dacryocystectomy, canalicular ligature, canalicular offset, canalicular excision, transfer of the punctum to dry dock, punctal tarsorrhaphy and punctal patch. Thermal methods include cautery, diathermy and laser burn. Tamponade methods use absorbable inserts of hydroxypropyl cellulose, gelatin, collagen and catgut, and nonabsorbable inserts of silicone (punctum plugs, canalicular plugs), polyethylene, cyanoacrylate, and others. The characteristics of all these methods are analyzed.

Phacoemulsification in previously vitrectomized patients: an analysis of the surgical results in 100 eyes as well as the factors contributing to the cataract formation.

PURPOSE To evaluate the safety and effectiveness of phacoemulsification with clear corneal incision in previously vitrectomized patients as well as factors affecting the development time and type of cataract occurring after pars plana vitrectomy (PPV). METHODS The authors conducted a prospective study of 100 consecutive eyes of patients who developed a cataract after PPV. Three groups were established based on the underlying vitreoretinal pathology. The main outcome measurements were intraoperative and postoperative complications and changes in best-corrected visual acuity (BCVA). RESULTS The median interval between PPV and phacoemulsification was 11.5 months. Patients with proliferative diabetic retinopathy required phacoemulsification earlier (p=0.018). Posterior subcapsular cataracts developed more frequently in patients <50 years (73.7%, p=0.000) and affected those who underwent vitrectomy primarily for complicated retinal detachment (48.8%, p=0.046). Intraoperative complications included posterior capsular tears (4%), luxated nucleus into vitreous (2%), and zonular dialysis (5%). Postoperative complications were vitreous hemorrhage (6%), retinal redetachment (4%), pupillary synechiae (6%), ocular hypertension (4%), and Seidel phenomenon (3%). Posterior Nd:YAG laser capsulotomy was required in 44% of eyes. BCVA was improved in 85% of cases at the end of follow-up (median, 15.5 months). Twenty-one patients with one functioning eye (61.9%) demonstrated visual improvement compared with 79 patients with bilateral vision (91.1%; p=0.003). CONCLUSIONS The technique allows stable improvement in BCVA through long follow-ups. It is more risky than in nonvitrectomized eyes. The visual results after phacoemulsification in vitrectomized eyes seem to be limited by retinal comorbidity and surgical complications. (Eur J Ophthalmol 2006; 16: 52-9).

The Lacunar Sulci: A New Test to Measure the Shrinkage of Ocular Surface, and Its Relation with the Number of Goblet Cells

Mucosal shrinkage of the ocular surface is a frequent or occasional phenomenon of some diseases such as ocular cicatricial pemphigoid, erythema multiforme, Stevens-Johnson syndrome, atopic keratoconjunctivitis, sarcoidosis, scleroderma, epidermolysis bullosa, dermatitis herpetiformis, bullous pemphigoid, pemphigus vulgaris, linear IgA diseases, Sjogren’s syndromes and infectious conjunctivitis (adenovirus 8 and 19, diphtheria, beta-hemolytic streptococcus) as well as topical eyedrops (practolol, epinephrine, echotiophate iodide, iodo-desoxy-uridine, pilocarpine, timolol, dipivalyl epinephrine).1–14 To measure shrinkage of the ocular mucosae, the usual method is to examine the lower cul-de-sac by pulling the lower lid downward while the patient looks up.15–17 This method cannot measure incipient shrinkage of the conjunctiva and only allows belated measurements when the conjunctival folds are lacking, or strings and Symblepharon have already appeared.

Subcutaneous abdominal artificial tears pump-reservoir for severe dry eye

PURPOSE: To assay a totally implanted pump-reservoir unit placed under the subcutaneous tissue of the abdomen for providing artificial tears to the ocular surface in patients with severe dry eye. DESIGN: Prospective non-randomized comparative (self-controlled) trial. PARTICIPANTS: Six patients with severe dry eye, in whom intermittent moistening of the ocular surface with current collyria was clinically unsatisfactory. METHODS: The six patients were treated by implanting an artificial tear pump-reservoir unit under the subcutaneous tissues of the abdomen. The reservoir is operated by a gas pump, which pumps artificial tears to the eye from a 60-ml reservoir through a silicone tube leading subcutaneously from the reservoir, via the chest, neck and lateral part of the head, and entering the conjunctival sac over the lateral canthal ligament. The catheter is anchored to the aponeurosis of the temporal muscle at the lateral rim of the orbit with a butterfly sleeve. The terminal portion of the tube runs freely along the upper conjunctival fornix, and pours 1.5ml/day of the artificial tears into the ocular lacrimal basin with a constant flow rate. The reservoir must be refilled by percutaneous injection of artificial tears every 45 days. MAIN OUTCOME MEASURES: Schirmer test, corneal fluorescein staining, lacrimal film breakup time, lacrimal osmolarity, corneal impression cytology, best-corrected visual acuity, dryness sensation and blepharospasm before and after lacrimal reservoir implantation. RESULTS: The lacrimal subcutaneous abdominal reservoir was well tolerated with little discomfort. A delivery of 1.5ml/day was enough to maintain a comfortable wet eye. After an average follow-up of 15 months the signs and symptoms of dry eye were dramatically improved. Four of the patients had a severe blepharospasm, which disappeared some weeks after the implantation of the lacrimal abdominal reservoir. CONCLUSION: These are the first totally implanted lacrimal reservoirs in human beings. They have proved to be a good solution for severe dry eye. At present, this method is the only one that permits a maintained wet eye surface, and the performance of corneal, conjunctival, limbal and amniotic membrane transplants in total or almost total xerophthalmia. It may also be a good solution for some of the so-called essential blepharospasms, which are frequently triggered by an underlying dry eye.

Etymology of the Term “Tear”

©2005 Ethis Communications, Inc. The Ocular Surface ISSN: 1542-0124. Murube J. Etymology of the term “tear.” 2005;3(4): 177-181. I THE ORIGIN OF LANGUAGES n the evolution of mammals, hominids appeared 25 million years ago. The earliest Australopithecus dates back to about 5 million years ago, the Homo erectus to 2 million years ago, and Homo sapiens to 200,000 years ago. The communication skills (corporal movements, sounds) developed and improved slowly from lower to higher mammals. When studies of paleoanthropic remains revealed a buccalrespiratory tract able to vocalize,1, 2 anthropologists deduced that the capacity to produce rather rich and differentiated articulated sounds appeared in the genus Homo about 200,000 years ago. Brain development probably increased commensurately with the ability to communicate at higher levels. Initially, however, early humans combined very poor language-like sounds with other modes of communication (mainly gestures with the face and hands, etc.). The real Homo“loquens,” with a relatively rich conceptual vocabulary, seems to have emerged only 30,000 years ago. They developed an exponential complexity in their vocal intercommunication skills, which was the driving force in a process of mutual cause and effect that enhanced mental concepts and brain complexity. Language appeared in three basic stages: onomatopoeic, symbolic, and associative. Onomatopoeia was the phonetic simulation of environmental sounds to represent the object or the phenomenon that produced this noise (e.g., “grrr,” “sss”). Later, these phonetic noises evolved to mean other objects, phenomena, or abstractions that, in some way bore some relation with the onomatopoeic sound that the phenomenon represented (e.g., “growl,” “hiss”). Finally, in the associative step, several symbolic phonemes were joined to express more complex associations, resulting little by little in the immense vocabulary we have today. Despite its size, our vocabulary today still has limitations in describing the myriad concepts with which the human mind works.

Characteristics and Etiology of Conjunctivochalasis: Historical Perspective

©2005 Ethis Communications, Inc. The Ocular Surface ISSN: 1542-0124. Murube J. Characteristics and etiology of conjunctivochalasis: Historical perspective. 2005;3(1):7-12. onjunctivochalasis, derived from the Latin conjunctivus (joins) and the Greek chalasis (relaxation), refers to the redundance and laxity of the ocular conjunctiva. The condition is manifested by the easy displacement of conjunctiva from the episclera and the formation of pleated folds, especially visible just over the rim of the lower lid; these occupy the space of the inferior tear menicus (Figure 1).1-8 Some authors have reported laxity of the upper bulbar conjunctiva (usually without liplike pleats) associated with superior limbic keratoconjunctivitis (SLK),9-11 and it has recently been seen under the upper tear meniscus.12 Although conjunctivochalasis may be asymptomatic in mild cases, increasing knowledge of the physiology of the lacrimal system and tear film demonstrate the implications of this condition in ocular surface pathology. It has been related to mechanical, physical, and biochemical changes, including disruption of the lower tear meniscus, lacrimal flow stagnation, instability of the tear film, blepharitis, allergy, subconjunctival hemorrhage, and contact lens intolerance.

Triple clasificación de Madrid para el ojo seco

Desde el punto de vista del clinico, las enfermedades de Ojo Seco, incluidas en el sindrome de disfuncion de la pelicula lacrimal, tienen multiples causas etiologicas, distintas combinaciones de afectaciones anatomopatologicas y diversos grados de gravedad. El medico dacriologo debe conocer estos tres parametros, cuantificarlos, y establecer sobre ellos el tratamiento oportuno. Para ello, se ha elaborado la presente clasificacion clinica que en primer lugar incluye una clasificacion etiologica en causas etarias, hormonales, farmacologicas, inmunopaticas, hiponutricionales, disgeneticas, inflamatorias, traumaticas, neurodeprivativas y tantalicas, incluyendo cada uno de estos grupos numerosas variantes. En segundo lugar, una clasificacion histopatologica o ALMEN, acronimo de acuodeficiencia, lipodeficiencia, mucodeficiencia, epiteliopatia y afectacion de otras glandulas exocrinas no oculares. Y en tercer lugar, una clasificacion de gravedad en cinco escalones: subclinico (sintomas en situaciones de sobreexposicion), leve (sintomas habitualmente), moderada (sintomas y signos reversibles), grave (sintomas y signos irreversibles) e incapacitante (perdida irreversible de vision por dano corneal)

Triple Classification of Diagnosis of Dry Eyes

©2008 Ethis Communications, Inc. The Ocular Surface ISSN: 1542-0124. Murube J. Triple classification of diagnosis of dry eyes. 2008;6(2):61-69. syntagma is a unit formed by a group of words whose combination comprises a new meaning, not the original meaning, of a word. For instance, in dry wine, dry does not mean lacking moisture, but without sugar. Similarly, in dry eye, dry does not mean without humidity, but rather less-than-normal dampness, and eye does not mean the eye per se, but the ocular surface. Dry eye is a recent syntagma, which, for the last few decades, has been commonly used by doctors, patients, and the general population. Like many other terms, this syntagma has had fluctuating meanings; at present, it is applied to a clinical picture of ocular dryness symptoms (subjective manifestations of dryness perceived by the patient), signs (objective manifestations of ocular dryness), diseases (morbid condition with a specific origin, manifestation, and name that produces eye dryness), and syndromes (morbid conditions with characteristic associations of clinical manifestations that may be due to different causes). In this paper, dry eye refers to the syndrome consisting of “ disorders produced by the relative deficit between the quantity and quality of the tear secretion and the needs of the ocular surface.” Knowledge of dry eye has developed during three historical periods: The Hippocratic period (V century BC XIX century AD), during which only severe dry eye was identified. The Sjogrenic period (end of the XIX centurythe late XX century), when moderate dry eye was recognized. Now, in the XXI century period, mild dry eye has begun to be recognized. The transition between the three periods has not been abrupt, and there have been overlapping, transitional years. Dry eye syndromes are today considered the most frequent syndromes in ophthalmology, and some form of the syndromes will affect 100% of the population at some stage of their lives. The prevalence of dry eye syndromes varies according to sex, race, geography, socio-sanitary levels, age, and severity. Considering the last two variables (severity and age), severe dry eye affects about 0.002% of people under age 30; 0.01% of people between the ages of 30 and 60, and 0.1% over 60 years old. Medium dry eye affects 0.1% of people under 30, 1% between 30 and 60, and 10% over 60 years old. Mild dry eye affects about 1% of people under 30, 20% between 30 and 60, and 100% over 60 years old. Most people with mild dry eye are unaware that their symptoms belong to a dry eye syndrome. The increasing importance of dry eye has in recent years led to the establishment of several excellent classifications of the syndrome1-3 for different diagnostic, clinical, or treatment purposes. To manage dry eye, the clinician must determine the characteristics of the syndrome based on examination and the patient’s description in order to establish a diagnosis, prognosis and treatment. Therefore, many xerodacryologists from all over the world reached a consensus on the Triple Classification of Dry Eye.1 The three parameters for classification of dry eye in individual patients are: 1) etiology/pathogenesis, 2) type of affected glands and tissues, and 3) degree of severity. Identification of these parameters is essential to establish the type of dry eye syndrome and its specific characteristics. This knowledge allows the determination of the prognosis and the appropriate environmental, medical, physical, surgical, and psychological treatment of each patient with dry eye syndrome. The components of each parameter are shown in Table 1.

Analysis of corneal surface evolution after moderate alkaline burns by using impression cytology

Purpose: To compare corneal surface evolution after moderate alkaline burns by impression cytology in patients treated with medical therapy or with amniotic membrane transplantation (AMT). Methods: A prospective study of 24 eyes from 18 patients (13 men and 5 women) with moderate alkaline burns was performed. All patients were divided according to the clinical ocular severity and the therapy used. Twelve eyes were treated surgically with AMT and the other 12 eyes received only medical therapy. Corneal cytology was obtained immediately after the burns, and 1, 2, 5, and 9 months later. We differentiated between samples obtained from affected areas and areas not affected by the burns. Cellular size, nuclear size, and nuclear-cytoplasmic (N:C) ratio were examined in corneal epithelial cells, as was the presence of goblet cells in corneal epithelium. Results: Nuclear size, cellular size, and N:C ratio in non-burn-affected corneal areas had no significant alterations in comparison with normal eyes. In contrast, in burn-affected corneal areas, these parameters were significantly worse, and the presence of goblet cells in corneal epithelium was frequent 1 month after severe burns. Cellular size, nuclear size, N:C ratio, and corneal conjunctivalization improved during the study in all patients, but corneal reepithelialization occurred earlier in patients treated with AMT than in patients with only medical therapy. Conclusion: Morphologic and morphometric analysis of corneal cells by impression cytology after ocular burns permits the establishment of cellular reepithelialization patterns in relation with limbal deficiency level and with clinical ocular severity. AMT improves corneal reepithelialization earlier than medical therapy in moderate alkaline burns.

Different Concentrations of Amino Acids in Tears of Normal and Human Dry Eyes

Previously, there have been few publications on free amino acid analysis in human tears. These studies used dated techniques based on paper chromatography. Because of their poor determination and the need of a high volume sample for analysis, all of the assays were done on reflex tear and produced, at best, only semi-quantitative results. To date, the role of tear free amino acids in the economy of the cornea and conjunctiva has not been studied, and no specific diseases have been reported in which qualitative or quantitative derangement of the tear amino acid composition is implicated.