Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy.

OBJECTIVE: To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. METHODS: JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). RESULTS: Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. CONCLUSION: When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. / La technique de la césarienne : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Evaluation of obstetric management of women with macrosomic foetuses in two Level 3 maternity hospitals in France and identification of predictive factors for obstetric and neonatal complications.

OBJECTIVE: Foetal macrosomia is associated with high maternal and neonatal morbidity; however, obstetric management of suspected macrosomia has not been well defined. This study aimed to analyse obstetric management in a population of women who delivered macrosomic new-borns and assess maternal and neonatal outcomes and risk factors for complications in such cases. STUDY DESIGN: This two-centre retrospective study conducted in France over a 10-year period comprised 1724 women who had delivered macrosomic new-borns (defined as those whose weight was > 90th percentile according to the Association of Users of Computerised Records in Perinatology, Obstetrics, and Gynaecology curve) from 37SA. RESULTS: In this study, the caesarean section and instrumental extraction rates were 24.1% and 15.7%, respectively, and the postpartum haemorrhage rate was 7%. The rate of shoulder dystocia was 23.1% (including brachial plexus injuries, 0.4%; and clavicular fractures, 2.0%). Significant risk factors for caesarean section were maternal height < 160 cm, nulliparity, history of caesarean section, excessive uterine height, induction of labour and duration of labour > 10 h. The risk factors for shoulder dystocia were maternal height < 160 cm and instrumental extraction. CONCLUSION: The study findings may help determine predictive factors for an unfavourable outcome at the time of delivery of a macrosomic foetus, thus allowing clinical teams to better anticipate and manage potential complications.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Maternal Benefits and Risks of Planned Cesarean Delivery compared to Planned Vaginal Delivery]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Bénéfices et risques maternels de la césarienne programmée comparée à la tentative de voie basse.

OBJECTIVE: To evaluate maternal risks and benefits associated with planned mode of delivery in case of breech presentation at term. METHODS: MedLine and Cochrane Library databases search and review of the main foreign guidelines. RESULTS: To analyze maternal complications according to the planned mode of delivery for breech singleton at term, only one study of high quality is available, a randomized controlled trial- the Term Breech Trial, having found a similar maternal morbidity rate with planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 3 months postpartum a decreased risk of urinary incontinence and perineal pain, and an increased risk of abdominal pain in case of planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 2 years postpartum, a similar rate of maternal morbidity according to planned mode of delivery, in the absence of subsequent pregnancy (LE2). In studies with fetus in cephalic presentation, previous cesarean delivery exposes women in subsequent pregnancies at serious risk of uterine rupture, abnormalities of placental insertion and hysterectomy (LE2). CONCLUSION: For breech singleton at term, short and long term maternal complications appear similar in case of planned vaginal delivery compared to planned cesarean delivery without subsequent pregnancy. In subsequent pregnancies, women with previous cesarean section are at risk for serious complications (uterine rupture, abnormalities of placental insertion).

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVES: To determine the optimal management of singleton breech presentation. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C). CONCLUSION: In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

[Effectiveness of preventive cervical cerclage to prevent preterm birth in women with twin gestation with obstetrical history of late pregnancy loss or preterm birth]. / Efficacité du cerclage préventif indiqué sur des antécédents obstétricaux en cas de grossesse gémellaire.

OBJECTIVES: Evaluate the effectiveness of preventive cervical cerclage for twin pregnancy with obstetrical history. METHODS: Through this retrospective cohort study, subjects exposed between 2002 and 2017 were compared with unexposed ones. All patients who had twin pregnancy with at least one previous late pregnancy loss or prematurity before 34SA were included. Two groups were compared: "preventive cerclage" versus "no preventive cerclage". The outcome was the prematurity before 34 gestation weeks (GW) rate. RESULTS: Among 1972 twin pregnancies registered between 2002 and 2017, 69 (3.5%) patients with at least one previous late pregnancy loss or prematurity before 34 GW, were part of the study. There were 20 (29.0%) women in the group "preventive cerclage" and 49 (71.0%) women in the group "no preventive cerclage". Women in the "preventive cerclage" group had poorer obstetrical history. The rate of prematurity before 34GW was not significantly different between these both groups (45.0% versus 44.9%; P=0.99, crude OR: 1.00 (0.35-2.83), adjusted OR: 1.06 (0.33-3.44)). CONCLUSIONS: The prematurity rate before 34GW, in twin pregnancies with a previous late pregnancy loss or preterm birth, is not different with or without preventive cervical cerclage.

A case of non-treated Trichomonas vaginalis infection and severe preterm labor with positive obstetrical outcome.

Trichomonas vaginalis is a very common, sexually transmitted, infection that may sometimes be asymptomatic or cause vaginitis and urethritis. Recently, it has been associated with adverse obstetric outcomes such as preterm delivery, low birth weight and premature rupture of membranes. Trichomonas vaginalis can be vertically transmitted at birth. It has been found in pharynx and low respiratory tract of neonates with respiratory disease. It has also been involved in some cases of intellectual disability. The recommended treatment is a 2g metronidazole oral single dose, even for asymptomatic patients. This treatment is effective against Trichomonas and its use is safe during pregnancy. We report here a case of Trichomonas vaginalis infection diagnosed during pregnancy in a patient with severe preterm labor. The patient being allergic to nitroimidazole antibiotics, she did not receive any treatment. She finally gave birth at 34 weeks of gestation (WG) and 5 days, with no other adverse outcome than small prematurity.

Effectiveness of elective cervical cerclage according to obstetric history.

OBJECTIVE: To assess the effectiveness of elective history-indicated cervical cerclage according to obstetrical history. STUDY DESIGN: We analyzed pregnancy outcome of a retrospective cohort of women who have had history-indicated McDonald's cerclage. Principal outcome was gestational age (GA) at delivery. RESULT: Between January 2003 and December 2013, 205 women were included. We analyzed population in two risk groups: 1- Low-risk (≤2 prior preterm birth (PTB)/second trimester loss (STL), or prior success of cerclage), 2- High risk (≥3 prior PTB/STL, or prior failure of cerclage). In the high-risk group, there was a higher frequency of deliveries before 37 weeks (47.5% vs. 24.5%, P=0.001, OR=2.79, 95% CI [1.49-5.23]). Fifty percent of women (n=6/12) delivered before 37 weeks in case of three or more prior PTB/STL, and 51% (n=24/47) in case of prior failure of cervical cerclage. CONCLUSION: Elective cervical cerclage may be indicated for women with≤2 prior PTB/STL, or prior successful cerclage. For women with≥3 prior PTB/STL, trachelorraphy or cervico-isthmic cerclage could be possible alternatives to cervical cerclage.

[Maternal effects of prolonged expulsive efforts]. / Conséquences maternelles de la prolongation des efforts expulsifs.

OBJECTIVE: Some studies found an association between duration of expulsive efforts (DEE) and risk of postpartum haemorrhage (PPH). But none demonstrated an association between DEE and severe perineal lacerations. Our aim was to evaluate the impact of prolonged expulsive efforts (EE) beyond 45min on the risk of maternal complication, especially risk of severe perineal laceration. MATERIALS AND METHODS: We performed a retrospective study comparing 2 groups, 1: women with an instrumental vaginal delivery performed before 45min for non-fetal progression without FHR abnormalities (VBI for NP<45min) and 2: women with a DEE longer than 45min (DEE≥45min). We compared maternal issues (3rd and 4th degrees perineal lacerations and PPH), using uni- and multivariate analysis. RESULTS: We compared 85 women in group VBI for NP<45min with 124 women in group EE≥45min. In the group EE≥45min, 39% of women had an instrumental vaginal delivery versus 100% in the group VBI for NP<45min (P<0.001). The rate of severe perineal lacerations was significantly higher in the group VBI for NP<45min (8.2% versus 1.7%, P=0.027) and its risk remained significant after adjustment (adjusted OR=6.5 [1.1-40.1]). The rate of PPH was higher in the group EE≥45min (12.9% versus 3.5%, P=0.016), however this association was not significant after adjustment (adjusted OR=3.4 [0.9-12.4]). There was no difference about neonatal issues between the two studied groups. CONCLUSION: In comparison with a limitation of EE, to prolong EE beyond 45min allows a spontaneous vaginal delivery for more than half of women, if FHR is normal. Such strategy should also decrease the risk of severe perineal laceration.

In vivo detection of clinically non-apparent ocular surface inflammation in patients with meibomian gland dysfunction-associated refractory dry eye symptoms: a pilot study.

PURPOSE: The utility of in vivo confocal microscopy (IVCM) in the investigation of palpebral conjunctival and corneal inflammation in patients with meibomian gland dysfunction (MGD)-associated refractory dry eye symptoms following gland expression, despite objective clinical improvement. METHODS: A retrospective, observational pilot study was conducted evaluating five patients with MGD-associated refractory dry eye symptoms and three control groups: symptomatic untreated MGD patients (n=3), treatment-responsive MGD patients with improved symptoms (n=3) and asymptomatic healthy normals (n=11). Ocular surface disease index (OSDI) scores, tear break-up time (TBUT), the number of meibomian glands yielding liquid secretion (MGYLS), palpebral conjunctival epithelial and substantia propria immune cell (EIC, SIC), and corneal dendritic cell (DC) densities were measured. RESULTS: Despite clinical improvement (TBUT: 6.4±1.2 s to 10.1±2.1 s, P=0.03; MGYLS: 3.5±0.8 glands to 7.0±1.1 glands, P=0.13) and a normal clinical examination post treatment, MGD patients remained symptomatic. IVCM revealed increased immune cells in the palpebral conjunctiva (refractory MGD EIC=592.6±110.1 cells/mm2 untreated MGD EIC=522.6±104.7 cells/mm2, P=0.69; responsive MGD EIC=194.9±119.4 cells/mm2, P<0.01; normals EIC=123.7±19.2 cells/mm2, P< 0.001), but not the cornea (refractory MGD DC=60.9±28.3 cells/mm2; normals DC=25.9±6.3 cells/mm2; P=0.43). EIC did not correlate with TBUT (Rs=-0.26, P=0.33). OSDI scores correlated with both EIC (Rs=0.76, P<0.001) and TBUT (Rs=-0.69, P<0.01) but not SIC. Intraglandular immune cells were also seen. CONCLUSION: MGD-associated refractory symptoms and the symptom-sign disparity may be explained by clinically non-apparent, active inflammation of the palpebral conjunctiva as detected by IVCM. These patients may benefit from anti-inflammatory therapy.

Human ocular mucus. Scanning electron microscopic study.

Twenty biopsy specimens of the human conjunctival epithelial surface with its associated mucus from normal subjects and contact lens wearers with biomicroscopic evidence of excess mucus were studied by scanning electron microscopy. Mucus existed in strands, sheets, and granules; each morphologic type of mucus was observed in all samples. No qualitative difference in morphologic features of mucus was found between normal subjects and those with excess mucus. Mucous forms observed by scanning electron microscopy closely resembled structures previously shown by biomicroscopic and light microscopic techniques, providing evidence that careful scanning electron microscopic preparation of biopsy specimens containing mucus may not greatly alter in situ morphologic characteristics of mucus.

Surface deposits on worn hard contact lenses.

Giant papillary conjunctivitis (GPC) is associated with deposits on contact lenses. We used scanning electron microscopy to study the anterior surface of 30 hard contact lenses, both cleaned and not cleaned, worn by patients with GPC and with keratoconus and by asymptomatic subjects. Uncleaned lenses worn by asymptomatic subjects for one day had deposits on about 5% of the surface. In most cases, the deposits were removed completely by one cleaning. Uncleaned lenses worn by patients with GPC or keratoconus had deposits on about 90% of the surface. Most of these deposits were removed by one cleaning. However, residual deposits after cleaning were greater on lenses from patients with keratoconus than on those from patients with GPC. Lenses from asymptomatic subjects rarely had residual deposits after cleaning. We found that the types of deposits on worn soft and hard contact lenses are similar, that there are fewer deposits on hard lenses than on soft lenses, and that deposits on hard lenses, unlike those on soft lenses, generally can be removed by one cleaning.

Treatment of contact lenses with papain. Increase in wearing time in keratoconic patients with papillary conjunctivitis.

In 15 Keratoconic patients with papillary conjunctivitis associated with wearing rigid polymethylmethacrylate contact lenses, the cleaning of the lenses with enzymatic contact lens cleaner (papain) increased lens wearing time in nine and diminished the symptoms of mucus and itching in 12. In 13 control, lens-wearing keratoconic subjects with papillary conjunctivitis, three had a decrease, four had an increase, and six had no change in lens wearing time and one had a diminution of symptoms. Use of the enzymatic contact lens cleaner did not, however, influence the biomicroscopic appearance of the papillary conjunctivitis. The inclusion of the enzymatic contact lens cleaner in the cleaning regimen offered an adequate improvement in wearing time and tolerance for three of four patients that previously suffered a reduction in wearing time that compromised or precluded their vocational responsibilities.

Branching of microvilli in the human conjunctival epithelium.

Biopsy specimens were obtained from the upper tarsal and limbal conjunctivae of ten normal persons and from the upper tarsal conjunctivae of five asymptomatic contact lens wearers and five patients with giant papillary conjunctivitis (GPC) associated with contact lens wear. The microvillar surface of the conjunctival epithelium was studied by transmission and scanning electron microscopy. Branches often stemmed from the side of a straight tubular microvillus and formed an acute angle with the main process. Branches sprouted at various distances from the origin of the microvillus. The most common branching pattern was the bifurcated (bifid) form. Occasionally, both primary and secondary bifurcations were primary and secondary bifurcations were observed on the same microvillus. Some microvilli were branched in the normal conjunctivae, but the conjunctivae of asymptomatic contact lens wearers and patients with GPC had more branched microvilli and greater polymorphism, which correlated with the degree of alteration. This report demonstrates the presence of branched microvilli and describes the types seen in normal conjunctivae and compares the frequency with which branched microvilli are seen in altered conjunctival surfaces.

Mucus secretory vesicles in conjunctival epithelial cells of wearers of contact lenses.

Biopsy specimens from the upper tarsal conjunctivae of ten patients with clinically evident contact-lens-associated giant papillary conjunctivitis (GPC) and eight asymptomatic contact lens wearers without clinically evident conjunctival changes were compared by light and transmission electron microscopy to determine the contribution of nongoblet epithelial cells to increased mucus. A control group consisted of five subjects who had never worn contact lenses. The apical cytoplasm of superficial nongoblet epithelial cells in specimens from all groups showed single-membrane-limited vesicular inclusions that stained metachromatically with toluidine blue and were positive with PAS staining, which indicated muco-protein content. Some vesicles appeared to discharge their contents into the conjunctival sac. More vesicles were found in the GPC subjects and the asymptomatic contact lens wearers than in the normal subjects. These observations, coupled with the sign of increased or excessive mucus discharge in GPC subjects and in asymptomatic lens wearers, support the premise that the superficial layers of non-goblet conjunctival epithelial cells can contribute to an increase in mucus production.

Conjunctiva in asymptomatic contact lens wearers.

Biopsy specimens of the upper tarsal conjunctiva from 11 asymptomatic, biomicroscopically normal contact lens wearers (five hard and six soft) were studied by scanning electron microscopy. The conjunctiva in lens wearers showed areas of normal epithelial cell surfaces interspersed among areas of altered cells. The altered cell surfaces were characterized by centralized clumped microvilli and baring of that portion of plasma membrane around the cell periphery. The degree of centralization of microvilli varied widely, from a mild tendency to centralize accompanied by slight reduction in cell diameter, to an exteme centralization and dramatic diameter reduction. In some cells, the centralized microvillar structure had a unique mucuslike covering. Numerous altered cells were present in all 11 specimens from asymptomatic contact lens wearers. The number of these cells found by conjunctival biopsy of the hard contact lens wearers and the number in the soft contact lens wearers apparently did not differ. The upper tarsal conjunctiva in these asymptomatic contact lens wearers has an altered epithelial surface, different from that observed in normal subjects without contact lens-wearing experience and from subjects with contact lens-associated giant papillary conjunctivitis.

Prevalence of conjunctival changes in wearers of hard contact lenses.

The prevalence of elevated papillae more than 0.3 mm in diameter was 10.5% in the conjunctivae of 200 subjects who had successfully worn polymethylmethacrylate hard contact lenses for eight hours or more daily for more than five years. Only three of 500 (0.6%) control subjects who had never worn contact lenses had these papillary changes. The prevalence of papillary changes for those with the so-called normal symptoms of mucus, itching, or both associated with wearing of hard contact lenses was 53% (16 of 21 subjects). The prevalence of these symptoms was 76% among subjects with polymethylmethacrylate contact lenses who had papillary changes and 8% among subjects with polymethylmethacrylate contact lenses who did not have papillary changes. We conclude that changes in the upper tarsal conjunctiva are associated with the wearing of hard contact lenses, occur in a significant percentage of patients wearing hard contact lenses for prolonged periods, and include a spectrum of papillary changes.

Giant papillary conjunctivitis in contact lens wearers.

A syndrome that occurred in both hard and soft contact lens wearers was characterized by increased mucus, itching, decreased lens tolerance, and giant papillae in the upper tarsal conjunctiva. It developed in as few as three weeks with soft lens wearers but also occurred after months or even years of successful wear. The histology was characterized by basophils, eosinophils, and mast cells in the epithelium, and these cells as well as increased numbers of lymphocytes, plasma cells, and polymorphonuclear leukocytes in the stroma. The syndrome may be immunologic in origin with deposits on the lenses as the antigen, and the syndrome may be a major cause of difficulty in wearing contact lenses once they have been successfully fit.

Meibomian glands and contact lens wear.

A study of a syndrome characterised by deficient or inadequate Meibomian gland secretions, minimal or transient symptoms suggestive of ocular dryness, fluorescein staining of the cornea (often detected only after delayed observation or sequential instillation of stain), and contact lens intolerance is described. Clinical and cytological studies indicate that the syndrome is due to obstruction of the Meibomian gland orifices by desquamated epithelial cells that tend to aggregate in keratotic clusters, which results in alteration of the Meibomian glands' contribution to the precorneal tear film. Further complication may result from bacterial proliferation in the desquamated keratotic cells and the release of the bacteria and their toxic products into the precorneal tear film from these reservoirs in the excretory pathways of the Meibomian glands.

Biomicroscopy of papillae associated with wearing of soft contact lenses.

We studied the topographical, macrostructural, and fluorescein staining characteristics of papillary changes of the upper tarsal conjunctiva associated with the wearing of hydrophilic (soft) contact lenses. Fifty soft contact lens wearers with elevated conjunctival papillae greater than 0.3 mm in diameter were studied. Topographic characteristics recorded were distribution and number of papillae; macrostructural characteristics recorded were diameter and morphology of papillae. The information collected included age of patient, duration of lens wear, average daily time of wearing lens, presence or absence of itching or mucus, refractive status, and atopic history. Papillae were found in most cases in the conjunctival zone adjacent to the tarsal fold and were never found in the zone adjacent to the eyelid margin without also occurring in the intervening zone. The diameter of the papillae ranged from greater than 0.3 mm to 2.0 mm. The number of papillae per eyelid ranged from 4 to over 100. The apices of the papillae were frequently flattened, and these flattened surfaces frequently stained with fluorescein. The vascular supply of individual papillae was observed to radiate from a vessel occupying the central core of each papilla.