Adjacent Conjunctiva Research Articles

Effect of Needle Revision of Failed Filtering Blebs with Different Concentrations of Mitomycin C

Purpose: To investigate the efficacy and the risk factors for failure and complications of mitomycin C (MMC)-augmented needle revision (NR) of failed filtering blebs. Methods: Thirty eyes whose intraocular pressure (IOP) did not decrease after the cutting of scleral flap sutures were recruited. NR was performed with a 26-gauge needle under a slit-lamp. Immediately following NR, all eyes received a subconjunctival injection of 0.1 ml of 0.02 mg/ml (group A) or 0.1 mg/ml (group B) MMC at the adjacent conjunctiva. The mean follow-up period after the last needle revision was 13.2±4.2 months. Results: The mean IOP decreased from 25.7±10.6 mmHg before surgery to 13.7±2.5 mmHg at the last follow-up in group A and from 24.1±6.8 mmHg to 17.7±8.6 mmHg in group B (group A: p=0.001, group B: p=0.065). Subconjunctival hemorrhage, hyphema, and a shallow anterior chamber appeared in most cases. However, choridal detachment and avascular changes of the conjunctiva were observed in group B. Conclusions: IOP decreased in both groups A and B, but severe complications appeared only in group B. NR followed by a subconjunctival injection of 0.02 rather than 0.1 mg/ml is a safe and effective method. J Korean Ophthalmol Soc 49(6):951-957, 2008

Facial port-wine stains – clinical stratification and risks of neuro-ocular involvement

Port-wine stains are capillary malformations that commonly involve the skin of the head and neck region. They may affect the underlying subcutaneous tissue and bone, and extend on to adjacent mucous membrane and conjunctiva. Ipsilateral leptomeningeal and ocular choroidal involvement occurs in a small number of cases, with variable clinical manifestations. To analyse a series of consecutive patients with facial port-wine stains referred to our Vascular Anomalies Centre to (1) stratify their clinical manifestations, and (2) identify the risks of neurological and/or ocular involvement according to topographic pattern. Consecutive patients with facial port-wine stains were taken from our Vascular Anomalies Database 1996-2006. Port-wine stains were topographically analysed and mapped to the sensory distribution of division(s) of the trigeminal nerve, cervical plexus, and dorsal rami of the spinal nerves. 158 patients were identified. Many of these patients had extension of their facial port-wine stains or additional separate port-wine stains on their scalp, neck, trunk or limbs. Involvement of adjacent mucosa, conjunctiva, underlying soft tissue and bone was common. Fifteen patients had associated neurological and/or ocular complications. All had port-wine stains in V1 distribution. Additional involvement of V2 and/or V3, and bilaterality were common. Seven of the nine patients (78%) with port-wine stains affecting the entire V1 had neurological and/or ocular involvement. The risk of associated neurological and/or ocular disorder in a patient with partial or full V1 involvement was 26%, glaucoma and epilepsy being the most common manifestations. The clinical stratification of facial port-wine stains provides a guide to patient counselling and therapeutic interventions. Port-wine stains affecting the entire V1 distribution predict strongly for underlying neurological and/or ocular disorders that require on-going ophthalmological surveillance and/or neurological management. Although the classical Sturge-Weber syndrome encompasses a triad of clinical manifestations, incomplete forms are not uncommon. This neuro-oculo-cutaneous syndrome is believed to be a result of vascular malformations of associated structures derived from the neuroectoderm (facial skin, eye, and parieto-occipital region of the brain and leptomeninges) during the first trimester. However, the pathogenesis of port-wine stains and Sturge-Weber syndrome remains unclear.

Fornix Reconstruction with Conjunctival Inclusion Cyst Marsupialization in Stevens-Johnson Syndrome

A 17-year-old boy presented with multiple, progressively enlarging cystic masses located at the junction of the lower eyelids and anterior orbit, 1 year after recovery from Stevens-Johnson syndrome. Bilaterally, symblepharon obliterated the inferior fornix and restricted supraduction. All but 1 cyst (which was sent for microscopic evaluation) was marsupialized. Cut edges of the cysts were sutured to adjacent conjunctiva and the epithelial walls were used as fornix lining. Histologically, the wall of the excised cyst consisted of conjunctiva. One year after surgery, the inferior fornices remained substantially deepened with improved ocular motility. This case demonstrated that conjunctival inclusion cysts occurring in the aftermath of Stevens-Johnson syndrome can be effectively managed with marsupialization. The epithelial lining can then be used in fornix reconstruction.

Herpes Simplex Keratitis Misdiagnosed as Rheumatoid Arthritis-Related Peripheral Ulcerative Keratitis

To report 2 cases of herpes simplex keratitis misdiagnosed as rheumatoid arthritis (RA)-related peripheral ulcerative keratitis (PUK), where isolation of the herpes simplex virus (HSV) led to a complete modification in management. This is a case report. Two patients with RA presented with painful red right eyes. Ocular examination in both revealed an ulcer involving the peripheral cornea. The adjacent conjunctiva was infected, and the underlying sclera appeared inflamed. A diagnosis of corneal PUK secondary to RA was therefore made. The first patient had corneal scrapes taken for routine microbiological examination, which included polymerase chain reaction (PCR) for HSV. In the second patient, despite systemic immunosuppressive therapy, the ulcer progressed to involve deeper stroma and more central cornea. The conjunctiva adjacent to the ulcer was resected, and healthy conjunctival tissue was mobilized to cover the peripheral corneal ulcer. Resected conjunctival and corneal tissue was histopathologically assessed. In the first patient, PCR for HSV yielded a positive result. This prompted treatment with immediate systemic and topical acyclovir. The ulcer responded well to treatment. In the second patient, histopathological assessment and electron microscopy identified HSV. Treatment with topical trifluorothymidine and steroids was started, and a good recovery was made. Treatment of PUK is with systemic immunosuppressive therapy, and such therapies have serious side effects. PUK may have an occult cause in RA, and a search for a secondary agent may be beneficial. In particular, occult HSV infection must be ruled out before commencing immunosuppressive therapy.

Increased oxidative DNA damage, 8-hydroxydeoxy- guanosine, in human pterygium

Chronic exposure to ultraviolet (UV) light is a widely accepted aetiological factor in the development of pterygium. UV radiation may induce production of reactive oxygen species via photosensitized oxidation, thus causing oxidative damage. This study was conducted to test the hypothesis that oxidative damage to DNA is increased in pterygium. Immunohistochemical analysis employing a monoclonal antibody specific for 8-hydroxy-2'-deoxyguanosine (8-OHdG), a ubiquitous maker of oxidative stress, was performed in three patients with primary pterygium. The levels of 8-OHdG in DNA isolated from the other 29 pterygium specimens and their adjacent normal conjunctival tissues were determined using enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry of 8-OHdG showed a distinct pattern of more extensive and intense staining in the nuclei of pterygium tissue compared with that in their adjacent normal conjunctiva. ELISA also revealed that the average level of 8-OHdG in the pterygium tissues was 4.7-fold higher than that of the corresponding normal conjunctiva (P<0.001). The increased levels of 8-OHdG in the pterygium tissues indicate that oxidative stress could play a role in the development of pterygium. These findings provide new information to better understand the pathogenesis of pterygium and are useful in the prevention and treatment of this disease.

Lacrimal caruncle primary basal cell carcinoma: case report and review

Basal cell carcinoma (BCC) is a common malignant skin neoplasm. The surface of the caruncle contains sebaceous glands, hair follicles, and lacrimal and sweat gland elements. Consequently, the caruncle may spawn any neoplasm that occurs in the conjunctiva, skin, or lacrimal gland. We report a patient with a primary BCC located on the lacrimal caruncle. An 80-year-old man with a 5-month history of a gradually enlarging left caruncular neoplasm was seen. The lesion was nodular and irregularly brown-black colored, with no involvement of adjacent conjunctiva or skin. He had a history of sun exposure, but no personal or family history of other malignant neoplasms. The mass was excised completely. Histopathologic examination revealed a BCC originating in the basal layer of the conjunctival epithelium. No tumor recurrence has been noted after 7 years of follow-up. Primary BCC of the caruncle is unusual, and only four cases have been described in the PubMed. BCC should be considered in the differential diagnosis of caruncle and adjacent skin lesions.

Nonpreserved human amniotic membrane transplantation for conjunctival reconstruction after excision of extensive ocular surface neoplasia

To report our experience on the use of nonpreserved human amniotic membrane transplantation (AMT) in ocular surface reconstruction after excision of extensive ocular surface neoplasia (OSN). Prospective noncomparative interventional case series. In all, 10 eyes of 10 consecutive patients with extensive OSN involving various areas of limbus, conjunctiva, and cornea (conjunctival carcinoma in situ, four eyes; squamous cell carcinoma, three eyes; malignant melanoma, two eyes; conjunctival-orbital lymphangioma, one eye) were included in this prospective noncomparative interventional case series. After excision of the neoplasia with 3-4 mm tumour-free margins, double freeze-thaw cryotherapy was applied to the margins of the remaining conjunctiva, and nonpreserved human amniotic membrane graft was sutured to the adjacent conjunctiva using 8/0 vicryl sutures and cornea using 10/0 nylon sutures, with the epithelial side facing up to cover the bare sclera and cornea. Postoperatively, topical corticosteroids were used for 3 months. After tumour excision and AMT, a satisfactory result with a wet, stable conjunctiva, and rapid and complete healing was observed in all eyes. Over a mean follow-up of 10.0 months (range, 6-27 months), all but one eye remained free of tumour recurrence. In one eye with conjunctival melanoma, there was a small recurrence, which was treated with excision and cryotherapy. Treatment complications were partial stem cell deficiency in two eyes and symblepharon formation in one eye. Immune graft rejection was not encountered. Nonpreserved human AMT appears to be useful for reconstruction of ocular surface following excision of extensive OSN.

Immunosuppressives in peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is a crescent shaped, destructive, inflammatory lesion of perilimbal cornea. It is always associated with an epithelial defect and usually has a subepithelial infiltrate at its central edge [1]. Moreover most, but not all forms of PUK have associated inflammation of adjacent conjunctiva, episclera or sclera. PUK may be the presenting manifestation of a potentially lethal systemic autoimmune vasculitic disease or may even herald the onset of a potentially lethal systemic disease [2].

Die Bedeutung der frühzeitigen Aufklebung harter Kontaktlinsen in der Notfallbehandlung schwerer Alkaliverätzungen der Hornhaut (Fallbericht)

Severe alkali burns lead to massive limbal stem cell damage resulting in persistent epithelial defects, infiltration and stromal melting early in the disease process. A glued-on hard contact lens may serve as an "artificial epithelium" and protect the cornea from these complications. A 39-year-old male presented with severe lime burns in both eyes one week after injury. The right eye showed a totally denuded cornea and conjunctiva with circular paralimbic ischemia. In the left eye "only" two thirds of the cornea and adjacent conjunctiva and limbus were affected with less ischemia. Amniotic membrane transplantation was performed in both eyes but failed after four days already in the right eye. A hard contact lens was therefore glued on the right eye and allowed for visual acuity of 0.4 without correction in this primarily most heavily afflicted eye for 12 months duration. After removal of the contact lens, reepithelisation was quick, and function remained stable with addition of autologous serum eye drops. The primarily far less injured left eye, however, for which the amniotic membrane surgery was primarily judged to be adequate, could not be stabilised. The cornea perforated 4 weeks later necessitating a mini-keratoplasty plus a glued-on contact lens, and correctable vision never became better than 1/35. The clinical course confirms former observations that a glued-on hard contact lens is an effective treatment early after alkali burn and prevents the cornea from infiltration and melting. Moreover, two aspects merit consideration: first, with proper technique and timing of the gluing-on a patient may retain useful vision throughout the period of wearing the contact lens; second, for the long period during which the cornea was sealed by the contact lens, improper repopulation by conjunctival epithelium was inhibited, and proper corneal epithelium was given a chance for repopulation after recovery of the limbal area resulting in a stable surface and useful vision without additional keratoplasty measures.

Potency and duration of action of synthetic P2Y2 receptor agonists on Schirmer scores in rabbits.

P2Y2 receptors belong to the family of G-protein coupled receptors and are activated by nucleotides such as ATP and UTP.1,2 Activation of P2Y2 receptors (P2Y2-Rs) on various epithelial cell types enhances chloride, fluid and mucin secretion and thereby stimulates the body’s natural mucosal lubrication and clearance mechanisms.3,4 On the ocular surface, P2Y2-R mRNA is localized in various epithelial cells in the eyelid, cornea and conjunctiva. Previous work using conventional non-isotopic in situ hybridization techniques demonstrated localization of P2Y2-R mRNA in the palpebral conjunctiva of the eyelid, the epithelium of the lid margin and the meibomian gland; the corneal epithelium and adjacent bulbar conjunctiva, particularly the conjunctival goblet cells.5 KeywordsCase GroupOcular SurfaceBack SurfaceLesion DevelopmentSodium FluoresceinThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Comparative study of intraoperative mitomycin C and β irradiation in pterygium surgery

AIMSTo compare the rate of recurrence and complication after surgery for primary pterygium performed by one surgeon using either intraoperative mitomycin C or β irradiation.METHODSA retrospective study was performed of...

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Spontaneous regression of lentigo maligna melanoma (LMM) is well known to occur occasionally. We experienced a possible cass of LMM located from internal canthus to lower eyelid and a red-bean sized black-brown nodule at adjacent bulbar conjunctiva was also present. The apparent continuity was not found between two lesions. In addition, histological findings suggestive of spontaneous regression were not recognized. This discontinuity of two lesions is most possibly explained by spontaneous regression of LMM, although we did not prove clinical and histological continuity. The other possible explanations are that two lesions occurred separately, or that malignant melanoma of bulbar conjunctiva was due to intransit metastasis.

Cell kinetics of conjunctival and corneal epithelium during regeneration of different‐sized corneal epithelial defects

Rats with small (diam. 1.7 mm), medium sized (diam. 3.5 mm) or large (diam. 5.5 mm) corneal epithelial erosions in one eye were killed 1, 2 or 4 days after the injury. The proliferative response was evaluated by measuring the labelling index and the mitotic rate in the corneal epithelium and in the adjacent conjunctiva. The small erosions triggered a proliferative response in the cornea only with the maximum response occurring midperipherally. The medium sized erosions induced a higher and more extensive response in the cornea and also a slight increase of the labelling index in the limbal area. The large erosions induced an even more pronounced response in the peripheral cornea and an increase both of the labelling index and the mitotic rate well beyond the limbal part of the conjunctiva. It is concluded that the magnitude and the extent both of the conjunctival and the corneal regenerative response to a corneal abrasion is correlated to the size of the corneal defect. Temporary reduction in the conjunctival epithelial cell number shows that both cells in the limbal and the extralimbal conjunctiva migrate centripetally during healing of large corneal wounds. It is suggested that the stem cell theory should be modified. The limbal area is probably an area in which conjunctival epithelial cells or conjunctiva-derivated cells transform or differentiate to corneal epithelial cells.

Investigation of limbal touch sensitivity using a Cochet-Bonnet aesthesiometer.

Following the observation of complex sensory receptors concentrated within the palisade zone of the human conjunctiva, this study sought to measure limbal touch sensitivity using a Cochet-Bonnet aesthesiometer. Touch sensitivity was found to be significantly higher in the palisade zone compared with the adjacent conjunctiva. A comparison between temporal and inferior limbus showed a greater median sensitivity for the temporal zone. There was a significant reduction in touch sensitivity with age, but not with iris colour or contact lens wear. These data, showing a higher touch sensitivity for the palisade zone, provide indirect evidence for a role of complex nerve endings in mechanoreception.

Investigation of enzyme activities in severe burns of the anterior eye segment.

In severe burns of the anterior eye segment, including the cornea, limbus and adjacent conjunctiva, ischemia resulted from the necroses. While necrotic conjunctival and subconjunctival tissues may be removed to eliminate the toxic influence, the opaque cornea and ischemic sclera could not be removed. In the surrounding healthy tissues an inflammatory reaction developed, which brought about an infiltration of the damaged tissues by leukocytes and the release of lysosomal marker enzymes. N-Acetylglucosaminidase and cathepsin-D represent a number of other destructive enzymes involved with corneal and corneoscleral ulceration. Initially, their activities were low in the turbid, acellular cornea and increased 3 weeks after the burn. In the surrounding conjunctiva, these enzyme activities were normally higher than in the cornea and increased significantly after the burn. The elevated activities of N-acetylglucosaminidase and cathepsin-D in the conjunctiva and cornea were related clinically to corneal and corneoscleral ulceration.

The results of ischaemia in chemical injuries.

Severe burns of the anterior eye segment which include cornea, limbus and adjacent conjunctiva necrosis were accompanied by ischaemia. While necrotic conjunctival and subconjunctival tissue should be removed to eliminate its toxic influence, the opaque cornea and ischaemic sclera could not be removed. The ciliary body and the iris also suffer from ischaemic damage and under such conditions nutrient metabolites are deficient in the anterior segment of the eye. In the surrounding healthy tissues an inflammatory reaction begins after several days which induces an infiltration of the damaged tissues by leucocytes and an increase of N-acetylglucosaminidase and Cathepsin-D as demonstrated in model experiments and in patients. These destructive enzymes are apparently involved in the corneal and corneo-scleral ulceration and their activities may therefore be used to assess the severity of the ocular burn.

The Diagnosis and Treatment of Peripheral Ulcerative Keratitis

HE UNIQUE ANATOMIC and physiologT ical characteristics of the peripheral cornea explain its predilection to be involved in a variety of disorders.'.' Blood vessels and lymphatic channels from the adjacent conjunctiva and episclera enable diffusion into the cornea of some molecules, such as immunoglobulins and complement components. IgG and IgA are found in similar concentrations in the peripheral and central cornea; however, more IgM is found in the periphery, probably because its high molecular weight restricts diffusion into the central area.' Both classic and alternative pathway components of complement and its inhibitors have been demonstrated in normal human corneas; however, although most of the complement components have a ratio peripheral-to-central cornea of 1.2:1.0, C1 is denser in the periphery, with a ratio peripheral-to-central cornea of 5:l. The high molecular weight of C1, the recognition unit of the classic pathway, also may restrict its diffusion into the central a ~ e a . ~ ' ~ Normal human corneal epithelium contains small numbers of Langerhans' cells, with the greatest density at the limbus dropping to almost zero in the central cornea.6 The peripheral cornea also contains a reservoir of inflammatory cells, including neutrophils, eosinophils, lymphocytes, plasma cells, and mast cells.' The presence of IgM, C1, Langerhans' cells, and inflammatory cells makes the peripheral cornea more susceptible than the central cornea to ulceration in a wide variety of infectious and noninfectious local and systemic diseases, causing a specific entity named peripheral ulcerative keratitis (PUK) (Table 1). Whether it is the sequel of an infectious, trophic, traumatic, neurologic, dermatologic, anatomic, or autoimmune disease, PUK is always a local destructive process mediated by the final common pathway of collagenolytic and proteolytic enzyme release from inflammatory cells (Fig 1). PUK also may be the presenting manifestation of a potentially lethal systemic autoimmune vasculitic disease or may herald the onset of a potentially lethal systemic vasculitic process in a patient with an already known systemic disease. Early diagnosis and subsequent appropriate treatment may improve the ocular and systemic prognoses. We report our experience in the management of patients with noninfectious PUK emphasizing those historical, clinical, laboratory, and biopsy features that may be helpful in reaching a specific etiologic diagnosis. Recommendations for an approach to patients with noninfectious PUK are presented.

Treatment of Advanced Squamous Cell Carcinomas Involving the Equine Cornea

Corneal squamous cell carcinomas with surface areas of more than 2.0 cm were diagnosed in 26 eyes of 25 horses. The depth of the lesion into the corneal stroma and involvement of the ocular adnexa were important determinants for surgical treatment. Corneal tumors that extended into adjacent palpebral conjunctiva, eyelid, or orbit were not amenable to complete excision, while those that involved only cornea and bulbar conjunctiva were treated surgically by keratectomy and beta radiation. Initial treatment was keratectomy followed by beta radiation on 24 eyes and enucleation of two eyes. Twenty keratectomy patients remained tumor free after long-term follow-up. One was lost to follow-up and three recurred. The recurrences were retreated with subsequent cure (one horse), enucleation (one horse), or euthanasia (one horse).

KERATINIZING CORNEAL INTRAEPITHELIAL NEOPLASIA

Corneal intraepithelial neoplasia (CIN) is the term applied by some authors to the spectrum of disease ranging from mild dysplasia to carcinoma in situ. Such lesions usually are associated with dysplastic or neoplastic processes at the limbus or adjacent conjunctiva; isolated corneal dysplasia is rare. Clinically, CIN appears as a geographic, gray, translucent thickening of the epithelium with fimbriated or scalloped borders and lesions often contain scattered white dots. We report a case of intraepithelial neoplasia limited to the cornea that had the unusual clinical appearance of a white plaque, which prompted the misdiagnosis of a calcific scar. Histopathologic examination of the debrided tissue revealed intraepithelial neoplasia and marked hyperkeratosis as the cause of the opacification.

Fibrous Histiocytoma of the Corneoscleral Limbus and Conjunctiva

An 11-year-old boy and a 28-year-old woman each had a painless, slowly enlarging, elevated, yellow lesion of the inferior corneoscleral limbus and adjacent cornea and conjunctiva of the left eye. Histopathologic examination of both lesions disclosed involvement of the conjunctival substantia propria and the adjacent limbal and peripheral corneal stroma by a nonencapsulated, dense infiltrate composed of elongated fibrocytic cells, plump histiocytic cells occasionally with a vacuolated cytoplasm, some multinucleated giant cells, and scattered lymphocytes. The diagnosis in each case was fibrous histiocytoma. Both patients were otherwise in good health with no dermatologic, systemic, or other ocular abnormalities.