Decreased Tear Production Research Articles

Comparison of Toxicological Profiles of Benzalkonium Chloride and Polyquaternium-1: An Experimental Study

The aim of this study was to compare, in vivo on a rat model, two different preservatives- benzalkonium chloride (BAC) and polyquaternium-1 (PQ-1)-using new experimental approaches. Thirty (30) eyes of 15 male Lewis rats were used in this study. Rats were randomly divided into five groups instilled twice a day for 11 days with eye drops containing different concentrations of preservatives, 0.1% BAC, 0.5% BAC, 0.1% PQ-1, 0.5% PQ-1, and balanced salt solution (BSS) as a control. The ocular surface toxicity of these two preservatives was investigated using new in vivo experimental approaches. Slit-lamp examination, the fluorescein test, the red phenol test, impression cytology, and in vivo corneal confocal microscopy were used to evaluate the rat ocular surface after preservative instillation. Histology sections and immunohistochemistry were also examined to confirm these results. Compared to PQ-1, BAC consistently and dramatically altered the corneoconjunctival surface as evaluated by slit-lamp examination, the fluorescein test, impression cytology, in vivo confocal microscopy, and histology. The 0.5% BAC solution also significantly decreased tear production compared to the control. Although 0.5% PQ-1 significantly decreased goblet cell density in comparison to the control, and some abnormalities were observed with in vivo confocal microscopy, no statistically significant differences were observed between these two groups using the tear production test, slit-lamp and fluorescein evaluation, or histology. Using an acute rat model of ocular toxicity by comparing preservatives at high concentrations, we demonstrated in vivo that high doses of PQ-1 were much less toxic than BAC. In vivo confocal microscopy and impression cytology are new promising experimental approaches to studying the rat corneoconjunctival surface, particularly in the field of ocular surface toxicity.

Use of Nerve Growth Factor to Treat Congenital Neurotrophic Corneal Ulceration

This study was designed to assess the efficacy of nerve growth factor in the treatment of neurotrophic corneal ulceration in a child with bilateral congenital corneal anesthesia secondary to trigeminal insufficiency. A 5-month-old child presented to the casualty department with a 2-week history of red eyes and right corneal ulceration. Slit-lamp examination showed a central defect in the right corneal epithelium with underlying stromal opacification, only mild conjunctival inflammation with slight decreased tear production, and otherwise apparently normal eyes. Initially this was investigated as an infected ulcer and treated for several weeks as herpetic ulceration with no beneficial effect. Further clinical examination demonstrated bilateral decreased corneal sensation along with decreased facial sensation in keeping with congenital trigeminal nerve insufficiency. Investigation with magnetic resonance imaging showed no obvious abnormality. Conservative treatment with lubricants resulted in progressive right corneal stromal loss, and no healing occurred in the left corneal ulcer. Bilateral large lateral tarsorrhaphies were performed. Despite this, the left corneal ulcer demonstrated no improvement and increasing stromal opacification was noted. Topical nerve growth factor (NGF) was then used to treat the left cornea and resulted in epithelial healing within 1 week. Treatment was continued for a further 10 days after epithelial healing. Despite conventional treatment on 3 separate occasions, further epithelial breakdown occurred. Topical NGF treatment resulted in a rapid improvement and healing of the epithelial defect.'At present, the patient is receiving a 6-month continuous treatment plan of NGF. Persistent epithelial defects (PED) secondary to neurotrophic ulceration have responded to topical NGF on 3 separate occasions during a 2-year period. The corneal epithelium now remains intact, and the cornea has no vascularization; however, mild anterior stromal opacification has gradually increased despite prolonged NGF treatment. NGF seems to represent a safe and efficacious treatment option to restore the integrity of corneal epithelium in which there is congenital corneal anesthesia because of trigeminal insufficiency. However, this treatment alone is insufficient to prevent progressive anterior stromal opacification.

Botulinum Toxin B-Induced Mouse Model of Keratoconjunctivitis Sicca

To develop a mouse model of human chronic dry eye (keratoconjunctivitis sicca [KCS]). Under direct visualization with an operating microscope, CBA/J mice received a transconjunctival injection of saline or 1.25, 5, or 20 milliunits (mU) of botulinum toxin B (BTX-B) into the lacrimal gland. The mice were either left unstressed or were subjected to an air blower for 5 h/d, 5 d/wk in fixed temperature and humidity conditions. Tear production and corneal fluorescein staining were evaluated in all groups before injection and at several time points after. Tear production was measured with phenol red-impregnated cotton threads. Corneal fluorescein staining was photographed under cobalt blue light with a digital camera fitted with a macro lens. BTX-B-injected mice displayed significantly decreased tear production until the 4-week time point. Throughout all time points, the addition of environmental blower stress did not appear to alter tear production significantly. Linear regression models, used to evaluate the effects of various doses of BTX-B on tear production, showed that doses higher than 1.25 mU did not provide significantly different outcomes. After 3 days, saline-injected mice showed no corneal staining, whereas BTX-B-injected mice displayed various amounts of staining. At the early time point (day 3), there did not appear to be an additional effect of the blower on corneal fluorescein staining. However, at 1, 2, and 4 weeks, the blower stress appeared to increase the amount of corneal fluorescein staining at each BTX-B dose, although not significantly. Furthermore, at 8 to 10 weeks, in the BTX B-injected groups, corneas had persistent staining, even though tear production had already returned to normal levels. Histopathologic analyses revealed no inflammatory cell infiltration of the stroma or acini of the lacrimal glands and conjunctivae of both saline-injected and BTX-B-injected animals. Intralacrimal gland injection of BTX-B resulted in persistent corneal fluorescein staining within 3 days, and a significant decrease in aqueous tear production that persisted for 1 month. Intralacrimal gland injection of BTX-B suppressed lacrimation, thereby establishing a dry eye state. This animal model could be a useful tool for investigating the pathogenesis of the chronic condition KCS in humans.

The effects of different hormone replacement therapy regimens on tear function, intraocular pressure and lens opacity

Objective. Estrogen may have adverse effects on the ocular surface, intraocular pressure (IOP), lens opacity and tear function. The aim of the present study was to elucidate the effects of different hormone replacement therapy (HRT) protocols on tear function, IOP and lens opacity.Design and setting. This was a prospective, uncontrolled study carried out at the Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Faculty of Medicine, Uludağ University, Turkey.Patients and interventions. Thirty postmenopausal patients who had spontaneous or surgical menopause for at least 1 year and were not taking any medications were assigned to one of three groups. Group 1 comprised 19 patients (n = 38 observations) given conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5 mg (Premelle 2.5®) daily; Group 2 contained six patients (n = 12 observations) given tibolone 2.5 mg (Livial®) daily; and Group 3 comprised five patients (n = 10 observations) treated with estradiol patch, 3.9 mg/12 cm2 (Climara®). Tear function, evaluated with Schirmer's test, IOP and lens opacity were determined before treatment and at 6 and 12 months of treatment.Results. Mean Schirmer's test score in each group and all eyes (n = 60) did not change significantly after 6 months of treatment but decreased significantly at 12 months. The percentage decrease in tear function was greatest in the estrogen-only group (Group 3). Mean IOP did not change significantly in Groups 1 and 2; however, in Group 3, IOP showed a statistically significant decrease from 14.63 ± 0.84 mmHg before treatment to 12.60 ± 0.68 mmHg (mean ± standard error) at the end of treatment. Lens opacity in women of all groups did not change during treatment.Conclusions. HRT decreased tear production, the decrease being greater in the estrogen- only group. Woman who are taking or considering HRT should be informed of the potential increased risk of dry eye syndrome with this therapy. In addition, estrogen-only treatment decreased IOP while estrogen plus progesterone and tibolone had no effect. HRT did not affect lens opacity after 12 months of treatment.

Recent advances in the management of ocular complications of sjögren’s syndrome

Sjögren's syndrome (SS) is an autoimmune disorder, the principal ocular manifestation of which is decreased tear production leading to chronic irritation and damage to the corneal and conjunctival epithelium. The most important advance in the treatment of ocular manifestations of SS is the introduction of topical anti-inflammatory agents such as cyclosporine A, which increases tear production and decreases symptoms without any significant side effect. Stimulators of tear secretion, both topical, such as diquafosol, and systemic, such as pilocarpine and cevimeline, are also effective, although they have been associated with frequent side effects. Topical use of autologous serum is another new and effective form of treatment, but problems in the preparations prevent their widespread use. Additionally, nonpharmacologic treatments, such as insertion of punctal plugs, are beneficial in the dry eye of SS, whereas several other modalities, such as anti-CD4 monoclonal antibody eye drops and gene transfer, are still in experimental phases.

Autonomic Disorders and the Eye

Autonomic Disorders and the Eye

Effects of Topical Antiglaucoma Medications on the Ocular Surface

The side effects of topical antiglaucoma medications and their preservatives range from ocular discomfort to sight-threatening alterations of the ocular surface. Conjunctival hyperemia, decreased tear production and function, and superficial punctate keratitis are among the most common signs seen on routine clinical examination. Squamous cell metaplasia and changes in cell morphology have been demonstrated by impression cytology studies and evaluation of biopsy specimens, and inflammatory effects are documented by the presence of inflammatory markers. The adverse effects of topical antiglaucoma eyedrops interfere with the treatment of glaucoma on two levels: first, the discomfort produced by the eye drops discourages patient compliance; and, second, long-term treatment with eyedrops is associated with a higher failure of filtration surgery. The detailed mechanism of inflammatory response and/or direct toxicity of eye drops has yet to be determined, but it may vary with the different classes of eye drops, different preservatives, and durations of treatments. Upcoming multicenter trials for new antiglaucoma eye drops should specifically evaluate ocular surface effects.

Impression Cytology and Ocular Characteristics in Ocular Rosacea

To examine clinical findings and histologic changes on the conjunctival surface in ocular rosacea. Thirty-five patients with ocular rosacea and 30 normal subjects underwent dermatologic and ocular examinations. Tear film break-up time, Schirmer tests with and without topical anesthesia, and conjunctival impression cytology were done. Patients were divided into the following groups according to quantity of ocular signs: mild (Group 1), moderate (Group 2), and severe (Group 3). Impression cytology was performed on both upper-bulbar and intrapalpebral inferonasal-bulbar conjunctiva. Patients had significant cell alteration on the conjunctival surface compared with normal eyes. The most frequent ocular signs and symptoms were feelings of dryness and blepharitis. Average tear break-up times for patients with ocular rosacea were 8.2 seconds in Group 1, 5.69 seconds in Group 2, and 5 seconds in Group 3 (17.2 seconds in normal subjects). Schirmer test results with anesthesia were 11.5 mm, 7.6 mm, and 5.0 mm, and without anesthesia were 14.8 mm, 13.6 mm, and 7.0 mm, in Groups 1, 2, and 3, respectively. These results were 18.7 mm with anesthesia and 24.7 mm without anesthesia in normal controls. Schirmer tests and tear film break-up time were significantly lower in patients with ocular rosacea than in normal controls (p < 0.05). Impression cytology showed that both upper bulbar and inferonasal interpalpebral bulbar ocular surface had significant cell alterations compared with those obtained from normal subjects. Patients with ocular rosacea not only had decreased tear production but also tear instability. Ocular surface epithelium had significant degeneration in patients compared with normal subjects.

Tear production after unilateral removal of the main lacrimal gland in squirrel monkeys.

To study the effects of lacrimal gland removal on basal and reflex tear production and on the ocular surface in the squirrel monkey. Unilateral main lacrimal gland removal in 6 squirrel monkeys was followed by Schirmer testing, slit-lamp examination with fluorescein, and collection of basal and reflex (stimulated) tears for analysis of tear protein spectra between 0 and 20 kd, as well as histological evaluation. Schirmer test results showed an 80% decrease in basal tears and a 90% decrease in reflex tears during week 1, and a 32.2% and 33.3% decrease, respectively, at week 20 after surgery, compared with the contralateral control side. However, no gross abnormalities or fluorescein staining were seen in 5 of the 6 monkeys, and the conjunctival surfaces remained normal. The main and accessory lacrimal glands appeared to secrete similar types of proteins. No histological changes were seen in corneal, conjunctival, or eyelid tissues 20 weeks after surgery. Tears from accessory lacrimal glands were sufficient to maintain a stable tear layer on the cornea, suggesting that so-called basal tear flow is made up of fluid from both main and accessory lacrimal glands and that decreased tear production by the main lacrimal gland is not a causative factor in keratoconjunctivitis sicca. This study shows that total removal of the main lacrimal gland does not in itself lead to keratoconjunctivitis sicca. However, the nature of neural control of the accessory glands is not yet clear.

Effects of intramuscular sedative and opioid combinations on tear production in dogs.

The effect of commonly used sedation protocols on tear production rate was evaluated in dogs. Schirmer I tear tests were examined before and after intramuscular injection of acepromazine and oxymorphone (ACE + OXY; n = 7), diazepam and butorphanol (DIA + BUT; n = 8), and xylazine and butorphanol (XYL + BUT; n = 8). Two Schirmer I tear tests were also performed 15-25 min apart in dogs which received no sedative drugs (control; n = 4). Tear production rate decreased to 15 +/- 2, 17 +/- 1, and 6 +/- 1 mm min-1, respectively, while control animals averaged 21 +/- 2 mm min-1 at the same time point. Because XYL + BUT profoundly decreased tear production rate, we evaluated the two drugs separately. While BUT mildly decreased tear production when given alone to dogs (18 +/- 1 mm min-1; n = 5), xylazine had no effect on tear production. Thus it appears that the two agents act synergistically to decrease tear production rate in dogs. Moreover, sterile ocular lubricant or tear replacement should be used during XYL + BUT sedation.

Nasolacrimal Stimulation of Aqueous Tear Production

Aqueous tear production decreases after anesthetizing the ocular surface. Loss of the nasolacrimal reflex is a risk factor for neurotrophic keratopathy and keratoconjunctivitis sicca. The purpose of this study was to evaluate the effect of nasal mucosal anesthesia on aqueous tear production. Eleven healthy human volunteers with a normal ocular surface and Schirmer I tear-test scores > 10 mm participated in this study. Schirmer I values were obtained daily for 3 days to establish a normal baseline. On a separate day, the right nasal mucosa was anesthetized with aerosolized 10% lidocaine (Xylocaine). After a 10-min period to allow the anesthetic to take effect and reflex tearing to subside, the Schirmer I test was repeated. A saline nasal spray was used as a control. Baseline Schirmer I values for both eyes had a mean of 22.98 +/- 1.05 mm (SEM). There was no difference in Schirmer scores between the two eyes after nasal anesthesia (p > 0.6); however, when these were compared with the baseline Schirmer I values, a significant decrease in tear production was noted (p < 0.001). The mean Schirmer I value after nasal anesthesia was 15.18 +/- 1.38 mm (SEM), a 34% decrease from baseline. The difference between the baseline and the normal saline control values was not significant (p = 0.160). There was a significant difference in Schirmer test scores between the saline control and nasal anesthesia groups (p < 0.02). In addition to sensory neural stimulation from the ocular surface, sensory stimulation of the nasal mucosa also promotes aqueous tear production. These results may help explain the decreased tear production observed in patients who have nasal mucosal damage, disease, or denervation.

Observações clínicas e laboratoriais em cães com cinomose nervosa

Em 81 cães com sinais clínicos, lesões histológicas e corpúsculos de inclusão no sistema nervoso central característicos de cinomose nervosa foi constatada ocorrência freqüente de: alteração das reações posturais (87,65%), diminuição da secreção lacrimal (83,95%), presença de mioclonias (75,30%), paresias (69,12%), conjuntivite (56,79%), corioretinite/ hiperqueratose naso-digital (51,85%), linfopenia (51,85%), anemia (48,05%), principalmente microcítica hipocrômica, e discretas alterações liquóricas caracterizadas por aumento de proteínas totais (77,33%) e pleocitose linfocítica (50,72%). A presença de corpúsculos de Lenz em tecidos extraneurais oscilou entre 30 e 45 %, com maior freqüência em linfonodos. Enquanto outras anormalidades clínicas, neurológicas e laboratoriais não tiveram freqüência expressiva para dar apoio ao diagnóstico, o incorreto programa de vacinação foi uma constante.

Dry eye: Pharmacological approaches, effects and progress: Gilbard JP; CLAO J 1996; 22: 141–145

The effects of available pharmaceuticals on the tear film and ocular surface in dry eye are reviewed and the progress that has been made in dry eye treatment is discussed.Pharmaceuticals are examined with regard to their effect on physical and morphological events or milestones in the natural history of dry eye disease.Dry eye disease evolves cumulatively over time through a sequence of four events: 1) decreased tear production or increased tear film evaporation (increased tear osmolarity); 2) decreased conjunctival goblet-cell density; 3) increased corneal epithelial desquamation; and, finally, 4) destabilization of the cornea-tear interface. In the 1970s, demulcents were introduced to decrease tear film instability. More recently, preservative-free solutions have been shown to decrease corneal desquamation. The newest pharmaceutical available today is known as TheraTears (ATF); in pre-clinical studies it restores conjunctival goblet cells. On the horizon are medications such as 3-isobutyl-1-methylxanthine (IBMX), which directly stimulate tear production.As our understanding of the pathogenesis and natural history of dry eye disease has improved, pharmaceuticals have been designed to act at earlier and more crucial points in the disease process. We are now entering a new era in dry eye treatment with the introduction of the first agent that can reverse the basic events of dry eye surface disease.

Tear hyperosmolarity in renal dialysis patients asymptomatic for dry eye.

Renal dialysis patients have hyperosmolar bodily fluids due to high urea levels, and accordingly their tears should be hyperosmolar. Tear hyperosmolarity is a sensitive and specific test for dry eye. The purpose of this study was to determine whether renal dialysis patients have hyperosmolar tears and dry eye. Ten renal dialysis patients completed the McMonnies and Ho dry eye questionnaire and underwent tear osmolarity testing before dialysis. Serum osmolarity was calculated from serum sodium, potassium, and blood urea nitrogen levels. Half of the subjects also participated in tear osmolarity testing after dialysis and underwent an eye examination that included rose bengal and fluorescein staining, Schirmer's testing, and tear break-up time testing. All of the subjects had both hyperosmolar serum and tears, and tear osmolarities were positive for dry eye in all subjects. However, none of the subjects tested positively for dry eye with the questionnaire. The subjects had some physical findings consistent with dry eye, and Schirmer's testing showed decreased tear production. Renal dialysis patients are a population that have hyperosmolar tears yet remain asymptomatic for dry eye. Urea has been used for years as a dermatologic treatment for dry skin. The high levels of urea in the tears of dialysis patients may protect them from developing dry eye. Tear hyperosmolarity due specifically to ionized solutes such as sodium and potassium is probably more pathogenic in causing dry eye than is hyperosmolarity in general. Nevertheless, tear osmolarity testing should not be used as a dry eye monitor in renal failure patients.

Dysautonomia in dogs: a retrospective study.

Dysautonomia was diagnosed in 11 young (median age, 14-months), predominantly medium- to large-breed dogs from 1988 to 1995. Clinical signs caused by autonomic dysfunction of the urinary, alimentary, and ocular systems were most common. Dysuria, mydriasis, absence of pupillary light reflexes, decreased tear production, dry mucous membranes, weight loss, and decreased anal tone were present in over 75% of affected dogs. Ocular pharmacological testing with a dilute (0.1%) solution of pilocarpine was used to demonstrate iris sphincter receptor function in all dogs. A low-dose (0.0375 mg/kg s.c.) bethanechol test and pharmacological testing with phenylephrine and epinephrine also demonstrated cholinergic and adrenergic receptor function in 4 dogs. All dogs died or were euthanized as a results of autonomic dysfunction. Neuronal depletion, with associated gliosis and minimal inflammation were noted histologically in the autonomic ganglia of each dog. The pelvic, ciliary, celiac, cranial cervical, and cranial and caudal mesenteric ganglia were affected in all dogs. The cause of autonomic failure in these dogs was not determined.

Sicca Syndrome in Patients Infected with the Human Inununodeficiency Virus

To investigate an association of the severity of the human immunodeficiency virus (HIV) disease with decreased tear production in a controlled setting. Seventy-two patients (144 eyes) and 30 age- and sex-matched control subjects (60 eyes) were studied prospectively. Tear production was measured using the Schirmer I test (measured in millimeters after 5 minutes). Patients were classified into three clinical groups: asymptomatic HIV infection, lymphadenopathy syndrome (LAS) or acquired immune deficiency syndrome (AIDS)-related complex (ARC), and AIDS. Additionally, patients were classified according to the CD4+ lymphocyte count. Tear production (mean +/- standard deviation) did not differ (P = 0.32) among eyes of patients with asymptomatic HIV infection (17.1 +/- 10.8; n = 14), LAS or ARC (18.3 +/- 10.3; n = 70), and AIDS (20.7 +/- 10.3; n = 60). In addition, mean tear production was not decreased significantly when comparing each clinical group with the control subjects (17.8 +/- 4.4). However, the relative frequency of eyes with significantly decreased tear production (< 9 mm) was 23.6% in all 144 eyes. In addition, the relative frequency of significantly decreased tear production did not differ (P = 0.52) between eyes of patients with asymptomatic HIV infection (35.7%), LAS or ARC (21.4%), and AIDS (24.1%). In addition, the relative frequency of significantly decreased tear production did not differ (P = 0.30) between eyes of patients with a CD4+ count of more than 400 cells/microliters (23.1%; n = 26), 400 to 200 cells/microliters (31.3%; n = 48), 200 to 50 cells/microliters (14.3%; n = 42), and less than 50 cells/microliters (21.4%; n = 28). The authors data show that decreased tear production occurs in approximately 20% to 25% of patients with HIV infection. This increased frequency of decreased tear production is not associated with the CD4+ count, or related to the severity of HIV disease, respectively. The possibility of an autoimmune-like pathogenesis of abnormalities of tear production in patients with HIV infection should be studied intensively.

Sjögren Syndrome in an Adolescent with IgA Deficiency

A 16-year-old girl presented with bilateral parotitis, and further investigation revealed that the patient had serologic evidence of an undifferentiated connective tissue disease. Biopsy revealed a lymphocytic infiltrate of salivary glands, and a positive Schirmer's test indicated decreased tear production. A diagnosis of Sjogren syndrome was made. Further evaluation revealed that the patient had selective IgA deficiency. Patients with selective IgA deficiency are known to be at an increased risk for autoimmune diseases. While Sjogren syndrome is rare in childhood and adolescence, the presence of selective IgA deficiency is thought to produce clinical conditions that may favor the access of infectious agents and macromolecules to the host. These substances in turn may activate the immune system, ultimately leading to autoimmune disease.

Acute and long-term effects of radiation therapy to the eye in children

The goal of radiation therapy in pediatric cancer is to destroy cancer cells and preserve functional surrounding normal cells. Although all radiation for pediatric cancers does not result in complications of the eye, acute and long-term radiation effects can occur after treatment. Acute radiation effects to the eye include erythema, epilation, conjunctivitis, dermatitis, keratitis, corneal ulceration, iritis, and retinal edema. Long-term radiation effects include tissue necrosis, decreased tear production, telangiectasia, scleral melting, cataract, corneal neovascularization, radiation retinopathy, retarded bone growth (of bones within the irradiated field), and radiation-induced cancers. Nursing interventions and implications will be presented in conjunction with medical management for each of these acute and long-term effects.

Success of the Fasanella-Servat Operation Independent of Müller's Smooth Muscle Excision

In an attempt to elucidate the mechanism whereby the Fasanella-Servat operation corrects ptosis, the authors examined the histopathologic features of 40 consecutive surgical specimens from 37 patients. Because all specimens contained tarsus, this tissue was graded into two groups according to vertical height: (1) minimal (30%) and (2) moderate (70%). Müller's smooth muscle was graded into four groups: (1) absent to negligible (42.5%); (2) minimal (45%); (3) moderate (10%); and (4) large (2.5%). Levator aponeurosis was absent, and conjunctiva was present, in all resections. Accessory lacrimal gland tissue was present in 42.5% of cases and did not cause decreased tear production. Although 87.5% of cases had absent to minimal smooth muscle resections, these patients had equally successful results in comparison to patients with moderate to large amounts of smooth muscle resections. Based on these data, the authors have concluded that the effectiveness of the Fasanella-Servat operation does not depend on a Müllerectomy, but instead is probably due to a combination of other factors: (1) a vertical posterior lamellar shortening; (2) secondary contractile cicatrization of the wound; and (3) plication or advancement of the Müller's smooth muscle-levator aponeurosis complex on the tarsus.

Conjunctival Resection for Superior Limbic Keratoconjunctivitis

Abstract: Ten patients with superior limbic keratoconjunctivitis were examined. Eight patients were female and 9 had bilateral disease. Five of the 10 patients had a history of thyroid disease. Two of the patients had filaments and four had a significantly decreased tear production. A conjunctival resection was carried out in all of the patients. Postoperatively, eight of these patients were either asymptornatic or much improved. Two patients with decreased tear production showed no improvement. Preoperatively, a normal Schirmer's test is helpful in predicting the success of conjunctival resection.