[Chronic inflammatory and dystrophic diseases of the eye anterior segment and their association with genetic polymorphisms in workers of metallurgic industry].

The ophthalmologic investigation of workers of the two metallurgical enterprises has shown that 1045 persons (55%) from 1911 observed workers suffer chronic diseases of a forward piece of eyes. Chronic inflammatory diseases (blepharitis, conjunctivitis and blepharoconjunctivitis) are found at 28,9% of them, and dystrophic diseases (pinguecula/pterygium)--at 25,8%. Among metallurgists (1801 persons) ophthalmopathy was found in 2, 2 times more often than at persons in control group (110 observed engineers and managers). Two polymorphisms of cytochrome P450 1A1 (CYP1A1) and P-450 2E1 (CYP2E1) genes were defined in 91 workers, by the method of allele-specific polymerase chain reaction. It is revealed that CYP1A1 Ile462Val polymorphism associates with pinguecula/pterygium, raising risk of their development almost in 3 times, unlike CYP 2E1 -1293G/C polymorphism. Development of chronic inflammatory diseases is not connected with tested polymorphisms.

P38-Mediated Cellular Senescence in Conjunctivochalasis Fibroblasts.

Purpose: Conjunctivochalasis (CCH) is a common ocular disease and has received extensive attention recently. However, its exact pathogenesis remains largely unknown. Owing to the high morbidity of CCH in older people, this study aimed to investigate whether cellular senescence contributes to CCH progression and the underlying mechanism. Methods: Loose conjunctival tissues from CCH patients (n = 13) and normal conjunctival tissues from age-matched persons (n = 12) were obtained and the fibroblasts were separately induced and obtained. Cellular senescence, and the expression of senescence-associated genes (p53 and p21) and p38 in CCH conjunctival tissues and normal controls, were determined by senescence-associated ß-galactosidase (SA-ß-Gal) staining and quantitative (q)RT-PCR, respectively. To explore the effects of p38 on cellular senescence in CCH fibroblasts, small interfering RNA (siRNA) targeting p38 (siP38) and p38-specific inhibitor SB203580 was performed in CCH fibroblasts. Then, cellular senescence, cell viability, reactive oxygen species (ROS) production, and gene expression were detected according to the corresponding methods. Results: CCH conjunctival tissues had significantly more senescent cells, evidenced by more SA-ß-Gal-positive cells, and higher expression of senescence-associated genes (p53 and p21) and p38. CCH fibroblasts transfected with siP38 or treated with SB203580 had obviously reduced numbers of senescent cells, decreased ROS production, and increased cell viability, as well as reduced expression of senescence-associated genes. Meanwhile, blocking p38 signaling decreased the expression of p53 and p21. Conclusions: Therefore, these findings indicate that cellular senescence might be a causative factor for CCH. P38 signaling might play an important role in the progress of cellular senescence in CCH fibroblasts via manipulation of p53/p21 signaling.

Conjunctival deposits as the first sign of systemic sarcoidosis in a pediatric patient.

PURPOSE: Sarcoidosis is an inflammatory disease of unknown cause, characterized by noncaseating granulomas. In this study, the authors present a sarcoidosis patient without systemic signs diagnosed by histopathologic analysis of conjunctival deposits. METHODS: A 10-year-old girl had bilateral, focal, multilobular, multiple pale yellow deposits in bulbar conjunctiva for a year. In the patient's biomicroscopic examination, numerous 0.50- to 2-mm diameter pale yellow deposits were determined in both bulbar conjunctivas. The patient had no other systemic or ocular complaints. A conjunctival biopsy was performed. RESULTS: The biopsy specimens showed noncaseating granulomas with prominent asteroid bodies. Serum angiotensin-converting enzyme levels were increased in the patient. Conjunctival deposits were the first manifestation of sarcoidosis in the patient and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. CONCLUSIONS: To the authors' knowledge, this is the second study that reports a sarcoidosis patient with non-systemic involvement diagnosed after histopathologic analysis of conjunctival deposits.

Overexpression of MMP-1 and MMP-3 by cultured conjunctivochalasis fibroblasts.

PURPOSE: To determine whether conjunctivochalasis, denoting redundant, loose, nonedematous inferior bulbar conjunctiva, is associated with increased expression and activity of matrix metalloproteinases (MMPS) over their tissue inhibitors (TIMPs). METHODS: Expression of transcripts and proteins of MMPs, TIMPs, and urokinase plasminogen activator (uPA) by cultured normal human conjunctival and conjunctivochalasis fibroblasts was determined by Northern hybridization, enzyme-linked immunosorbent assay (ELISA), and Western blot analysis, respectively. Gelatin and casein zymography and quantitative collagenase activity assay were performed in the serum-free conditioned media. RESULTS: Compared with normal conjunctival fibroblasts from six subjects, conjunctivochalasis fibroblasts from eight patients showed markedly increased transcript expression of MMP-1 (5- to 32-fold) and MMP-3 (4 to 30-fold), whereas that of MMP-2, TIMP-1, TIMP-2, and uPA was similar between the two groups. Protein levels were increased in the serum-free conditioned media of conjunctivochalasis fibroblasts for MMP-1 (3.5- to 7.6-fold) and MMP-3 (2.3- to 13-fold), determined by ELISA and Western blot analysis. There was increased caseinolytic activity of MMP-3 and collagenolytic activity of MMP-1 (2.2-fold) by conjunctivochalasis fibroblasts, whereas no difference was noted between these two types of fibroblasts in the protein and gelatinolytic activity of MMP-2 or expression of TIMP-1 and TIMP-2 proteins, although that of TIMP-1 transcript was slightly higher in some conjunctivochalasis fibroblasts. No expression of MMP-9 was detected. CONCLUSIONS: Overexpression of MMP-1 and MMP-3 mRNA by conjunctivochalasis fibroblasts is correlated with their increased protein levels and proteolytic activities. Collectively, these data help explain how conjunctivochalasis manifests excessive degradation of the conjunctival matrix and Tenon's capsule.

Regulation of collagenase, stromelysin, and gelatinase B in human conjunctival and conjunctivochalasis fibroblasts by interleukin-1beta and tumor necrosis factor-alpha.

PURPOSE: Overexpression and increased activities of matrix metalloproteinases (MMPs) have recently been reported in cultured conjunctival fibroblasts from patients with conjunctivochalasis. The role of inflammatory cytokines in modulating expression of MMPs, their tissue inhibitors (TIMPs), and urokinase plasminogen activator (uPA) as potential contributors to the pathogenesis of conjunctivochalasis was investigated. METHODS: Interleukin-1beta (IL-1beta) or tumor necrosis factor-alpha (TNF-alpha) was added at 10 ng/ml to a serum-free medium. Expression of transcripts and proteins of MMPs, TIMPs, and uPA by cultured normal human conjunctival and conjunctivochalasis fibroblasts was determined by Northern hybridization, enzyme-linked immunosorbent assay (ELISA) and Western blot analysis, respectively. Gelatin and casein zymographies were performed in serum-free conditioned media with and without the respective enzyme inhibitors. RESULTS: Without challenging the cells, conjunctivochalasis fibroblasts showed mRNA and protein overexpression of MMP-1 and MMP-3 compared with normal conjunctival fibroblasts, which showed minor or no expression of these enzymes. IL-1beta markedly and TNF-alpha to lesser extent increased mRNA and protein expression of MMP-1 and MMP-3 in conjunctivochalasis fibroblasts from 2 subjects when compared with normal conjunctival fibroblasts from 2 subjects and with their nonstimulated counterparts. In conjunctivochalasis fibroblasts and normal conjunctival fibroblasts, TNF-alpha, but not IL-1beta, induced a gelatinolytic activity of MMP-9, which was further confirmed by Western blot analysis and ELISA. Expression of MMP-2, TIMP-1, and TIMP-2 mRNA and protein was not influenced by IL-1beta or TNF-alpha, and no difference was found in the gelatinolytic activity of MMP-2 between both cell types. CONCLUSIONS: Inflammatory cytokines such as IL-1beta and TNF-alpha, which can potentially be derived from the ocular surface and tears, may be responsible for increased expression of MMPs in cultured conjunctivochalasis fibroblasts. Ocular inflammation might be one important denominator in the pathogenesis of conjunctivochalasis.

Plasminogen activator activity and plasminogen independent amidolytic activity in tear fluid from healthy persons and patients with anterior segment inflammation.

Plasminogen activator activity and plasminogen independent amidolytic activity were measured in human tears by a spectrophotometric method using human plasminogen and chromogenic peptide substrate S-2251. This assay is sensitive predominantly to urokinase-like plasminogen activator. Tears were collected with glass capillaries. The activator activity in normal tears was found to be low, 0.06 +/- 0.04 (SD) IU/ml. Elevated levels were measured in the tears of patients with various types of conjunctival and corneal disorders. The affected epithelial cells of the cornea and conjunctiva were suggested to be responsible for the elevated activity. Plasminogen independent amidolytic activity was usually very low except in cases of increased permeability of the conjunctival blood vessels. The procedure is recommended as a useful tool for the study of the pathological changes in the epithelial cells of the cornea and conjunctiva.

Immunoassay of tear lysozyme in conjunctival diseases.

The tear lysozyme content in 111 normal subjects and in 159 patients with various conjunctival diseases was determined by a single radial immunodiffusion technique. Tear lysozyme level in normal people was 1.33/mg/ml. (SI conversion: mg/ml = g/l.) The mean tear lysozyme levels in patients with chronic irritative conjunctivitis (0.97 mg/ml) and nutritional deficiency with epithelial xerosis (0.76 mg/ml) were significantly lower than in the normal controls. The mean tear lysozyme levels in tears from patients with vernal conjuctivitis (1.20 mg/ml), phlyctenular conjunctivitis (1.10 mg/ml), and acute bacterial conjunctivitis (1.48 mg/ml) were not significantly different from those in the normal controls. Superimposition of acute bacterial conjunctivitis on trachoma did not alter the low tear lysozyme level that existed before in these patients.

Gelatinase expression in ocular surface disorders.

PURPOSE: To determine the expression of gelatinase A [matrix metalloproteinase (MMP)-2] and gelatinase B (MMP-9) in ocular surface disorders, we carried out examinations of the eyes of patients with such disorders. METHODS: The cases consisted of a normal group comprising three eyes as the control and a patient group comprising six eyes of patients with ocular surface disorders. These groups underwent the following examinations. (1) Gelatin zymography: Tear samples taken by using the Schirmer I test were eluted and analyzed by gelatin zymography. (2) Immunohistochemical study: By using the alkaline phosphate-anti-alkaline phosphatase or avidin-biotin complex method, corneal or conjunctival tissue was examined for the presence of MMP-2, MMP-9, and membrane type 1 (MT1)-MMP, which activates MMP-2. (3) Reverse transcription-polymerase chain reaction (RT-PCR): Total RNA was eluted from the specimens, and the expression patterns of MMP-2, MMP-9, and MT1-MMP mRNA were analyzed. RESULTS: (1) Gelatin zymography: Only the proforms of MMP-2 and MMP-9 were detected in the normal group. Both active MMP-2 and active MMP-9 were detected in all studied cases in the patient group. (2) Immunohistochemical study: In the normal group, only MMP-2-positive cells were present in conjunctival epithelium. In the patient group, cells positive for MMP-2, MMP-9 and MT1-MMP were present in the epithelium of the conjunctiva or cornea except in one thermal burn case. (3) RT-PCR: In the normal group, only MMP-2 expression was observed. MMP-2, MMP-9, and MT1-MMP mRNA expression was observed in three cases in the patient group. CONCLUSIONS: MMP-2, MMP-9, and MT1-MMP, which activates MMP-2, were expressed in the patients with various ocular surface disorders. In ocular surface disorders, therefore, the expression of gelatinases is upgraded.

Tear MMP-9 levels as a marker of ocular surface inflammation in conjunctivochalasis.

PURPOSE: To evaluate the efficacy of surgical treatment for conjunctivochalasis by monitoring matrix metalloproteinase (MMP)-9 levels in the tears of patients with conjunctivochalasis before and after surgery and their correlation with clinical signs and symptoms. METHODS: Twelve eyes of patients with symptomatic conjunctivochalasis were included in this study as well as five eyes of healthy volunteers. Ocular surface inflammation was measured in terms of the concentration of pro-MMP-9 in tears, by enzyme-linked immunosorbent assay and zymography. Tear analysis was performed before and 1 month after surgery. The surgical technique consisted of the excision of redundant tissue and the use of organic glue for wound closure. RESULTS: The concentration of pro-MMP-9 was significantly higher in the conjunctivochalasis eyes than in the healthy controls (223.4 ± 74.53 ng/mL vs. 20.32 ± 5.21 ng/mL; P < 0.001). Tear pro-MMP-9 levels decreased significantly after conjunctival resection in patients with conjunctivochalasis without dry eye compared with patients with conjunctivochalasis and dry eye associated. Zymographic analysis indicated that MMP-9 is present in its active form only in conjunctivochalasis tears. After a follow-up of 4.9 ± 1.3 weeks, all operated eyes were found to have recovered a smooth and stable conjunctival surface, epithelial defects had improved, and epiphora had been resolved in 89% of cases. CONCLUSIONS: Our results indicate that inflammation is likely to play a relevant role in the pathogenesis of conjunctivochalasis. Appropriate surgery decreases inflammatory activity, leading to symptom improvement, and tear analysis may facilitate the treatment of the ocular surface.

PTX3 controls activation of matrix metalloproteinase 1 and apoptosis in conjunctivochalasis fibroblasts.

PURPOSE: Conjunctivochalasis (CCh) is an age-related inflammatory ocular surface disease manifesting redundant, loose conjunctiva folds. The pathogenic role of Pentraxin 3 (PTX3) in controlling upregulation of matrix metalloproteinase 1 (MMP-1) and MMP-3 in CCh remains undefined. METHODS: Cytolocation of PTX3 and apoptosis were compared by immunostaining and terminal deoxyribonucleotidyl transferase-mediated FITC-linked dUTP nick-end DNA labeling (TUNEL) assay between normal and CCh specimens containing the conjunctiva and the Tenon. Second to third cultures of normal and CCh fibroblasts were treated with or without Aprotinin, Batimastat, or N-isobutyl-N-(4-methoxyphenylsulfonyl)-glycylhydroxamic acid (NNGH), followed by transfection with or without PTX3 siRNA, and TNF-α or IL-1ß. Cell lysates and culture media were collected to assess apoptosis measured by the Cell Death Detection ELISA and expression of PTX3, MMP-1, and MMP-3 transcripts and proteins by quantitative RT-PCR and Western blot, respectively. RESULTS: PTX3 immunostaining was negative in normal specimens, but strongly positive in the subconjunctival stroma of CCh specimens. More apoptotic cells were found in CCh samples than in normal specimens. Expression of PTX3 transcripts and protein was not constitutive in resting normal fibroblasts but was in resting CCh fibroblasts and was upregulated by IL-1ß in both cell lysates and culture media of both fibroblasts. PTX3 siRNA further upregulated MMP-1 and MMP-3 transcripts in resting normal fibroblasts, but synergistically with IL-1ß upregulated the expression of MMP-1 and MMP-3 transcripts only in CCh fibroblasts, with activation of MMP-1 more so than MMP-3. PTX3 siRNA knockdown also promoted cell death characterized by apoptosis and necrosis, and such cell death could be rescued by inhibitors against serine proteinase, MMP1, or MMP3. CONCLUSIONS: Perturbation of PTX3 expression might partake in apoptosis and pathogenesis of CCh by upregulating expression of MMP-1 and MMP-3, and activation of MMP-1 and MMP-3.

TSG-6 controls transcription and activation of matrix metalloproteinase 1 in conjunctivochalasis.

PURPOSE: To investigate the role of anti-inflammatory TSG-6 in controlling MMP-1 and MMP-3, which have been shown to be upregulated in conjunctivochalasis (CCh). METHODS: Immunostaining of TSG-6 was compared between normal and CCh conjunctiva and Tenon's capsule. Second cultures of normal and CCh fibroblasts were transfected with or without TSG-6 siRNA and then with or without the addition of TNF-α or IL-1ß. Cell lysates and culture media were collected to assess apoptosis with the use of ELISA and the expression of TSG-6, MMP-1, and MMP-3 transcripts and proteins with the use of qRT-PCR and Western blot analysis, respectively. RESULTS: TSG-6 expression was constitutive in the in vivo normal conjunctival epithelium. Significantly more TSG-6-positive cells than normal specimens were noted in CCh subconjunctival tissue and Tenon's capsule. TSG-6 was constitutively expressed intracellularly by both resting normal and CCh fibroblasts but was secreted extracellularly only by resting CCh fibroblasts. Intracellular and extracellular TSG-6 proteins were markedly upregulated by TNF-α or IL-1ß in normal and CCh fibroblasts. Active MMP-1 was found in CCh fibroblasts intracellularly and extracellularly, whereas only proMMP-1 was found intracellularly in normal fibroblasts. Knockdown by TSG-6 siRNA upregulated more MMP-1 than MMP-3 transcripts in normal and CCh fibroblasts. TSG-6 siRNA led to extracellular MMP-1 expression by normal fibroblasts such as CCh fibroblasts. This activation of MMP-1 was further enhanced by IL-1ß. Cell apoptosis was higher in CCh fibroblasts and further aggravated by TSG-6 siRNA knockdown. CONCLUSIONS: TSG-6 exerts an anti-inflammatory function by counteracting the transcription of MMP-1 and MMP-3 and the activation of MMP-1. Dysfunction of TSG-6 might play a role in the pathogenesis of CCh.

Advancing the treatment of conjunctival scarring: a novel ex vivo model.

OBJECTIVES: To develop and validate a novel ex vivo model of conjunctival contraction. METHODS: Ex vivo segments of conjunctiva were maintained in culture for 4 weeks in permeable support plates. Digital images were obtained twice a week to monitor contraction using tissue area changes and weekly weight measurements. Investigated were the effects of known contraction stimulators (fetal bovine serum and transforming growth factor ß(2)) and of the matrix metalloproteinase inhibitor GM6001. Microscopic contraction, tissue organization, and cell viability (using the cell vital dye carboxyfluorescein diacetate) were monitored by confocal reflection and 2-photon microscopy, revealing detailed real-time kinetics of tissue remodeling. RESULTS: Fetal bovine serum and transforming growth factor ß(2) induced significant tissue contraction in conjunctiva segments, with no changes in cell viability. This correlated with dramatic and specific degradation of the collagen component in the tissue. Contraction and collagen degradation were reduced in the presence of GM6001. CONCLUSIONS: Ex vivo segments of conjunctiva can be used as an integral model system to provide a higher level of understanding about the efficacy of antiscarring therapies and can help bridge the current gap between in vitro and in vivo models. CLINICAL RELEVANCE: Scarring leads to the failure of several ocular surgical procedures. This novel ex vivo model recapitulates tissue contraction (with kinetics close to that of in vivo scarring) and allows for a more physiological analysis of conjunctival scarring, which could better evaluate potential therapeutic targets.

The protective effect of alpha-lipoic acid against oxidative damage in rabbit conjunctiva and cornea exposed to ultraviolet radiation.

PURPOSE: The purpose of this study was to determine the protective effect of alpha-lipoic acid against oxidative damage in rabbit conjunctiva and cornea exposed to ultraviolet radiation. METHODS: 20 rabbits weighing 2,500- 3,000 g were used, and we divided them into 4 groups with 5 randomly selected rabbits. The rabbits were exposed to 2 J/cm(2)/h of ultraviolet A radiation (UVA) in the range of 320-405 nm for 12 h per day within 90 days. The control group did not undergo any procedure, the UVA group was only exposed to UVA radiation. The PUVA group was treated with 8-methoxypsoralen and UVA. The alpha-lipoic acid group was administered 8-methoxypsoralen + UVA + alpha-lipoic acid. At the end of 90 days, the rabbits were killed by decapitation, and the eyes were enucleated. Both eyes of each rabbit were used for biochemical evaluation. Conjunctival and corneal free malondialdehyde (MDA), glutathione peroxidase (GSH-PX) and superoxide dismutase (SOD) levels were compared among the groups. RESULTS: Conjunctival free MDA levels were lower in the alpha-lipoic acid group compared with the UVA and PUVA groups (p < 0.05, p < 0.001, respectively). Both conjunctival SOD levels (p < 0.05, p < 0.01, respectively) and conjunctival GSH-PX levels (p < 0.01, p < 0.001, respectively) were higher in the alpha-lipoic acid group compared with other groups. Corneal free MDA levels were lower in the alpha-lipoic acid group compared with the UVA and PUVA groups (p < 0.01, p < 0.001, respectively). Both corneal SOD levels (p < 0.01, p < 0.01, respectively) and corneal GSH-PX levels (p < 0.01, p < 0.01, respectively) were higher in the alpha-lipoic acid group compared with the other groups. CONCLUSION: alpha-Lipoic acid which is considered as potent antioxidant protects the eye from the damaging effect of ultraviolet exposure.

Determination of plasminogen activator activities in normal and pathological human tears. The significance of tear plasminogen activators in the inflammatory and traumatic lesions of the cornea and the conjunctiva.

Plasminogen activator activity in normal human tears was found to be 0.03 +/- 0.02 IU/ml with casein plate, and 0.06 +/- 0.04 IU/ml with a spectrophotometric method. Elevated levels of plasminogen activator activity (range 0.11-2.05 IU/ml) were detected in the tear fluid of patients suffering from various corneal and conjunctival diseases including corneal ulcers, superficial keratitis, persistent epithelial defects, recurrent erosions, bullous keratopathy, contact lens associated erosions, alkali burns of the cornea, Mooren's ulcer, conjunctival pemphigoid, acute keratoconus, and corneal melanoma. Plasminogen activator activity, determined in the absence of fibrin in tear samples collected by capillary tubes at low flow rates, is considered to be the result of the presence of urokinase-type plasminogen activator (uPA) deriving from the epithelial cells of the cornea and the conjunctiva. It is suggested that an increase in the level of uPA in tears plays an important role not only in ulceration (the formation and repair of epithelial and stromal defects), but also in the development and healing of a number of other inflammatory processes, infections, immunological processes, chemical burns, contact lens associated lesions; in the invasion of microorganisms and leukocytes, in edema formation, in neovascularization, and in the invasive growth of tumors in the cornea and the conjunctiva.

Chronic ulcerative conjunctivitis in a patient with alpha-1-antitrypsin deficiency.

A 62-year-old woman had chronic bilateral conjunctival ulceration of the palpebral and bulbar conjunctivae. Conjunctival scrapings for viral, chlamydial, and bacteriologic studies were unrevealing. A conjunctival biopsy specimen was taken and submitted for histopathologic and immunofluorescent studies. Hematoxylin-eosin-stained tissue sections showed lymphocytes, plasma cells, and eosinosphils. Laboratory findings showed serum alpha-1-antitrypsin deficiency. alpha-1-Antitrypsin has a molecular weight of approximately 60,000 and inhibits a number of proteolytic enzymes including cellular trypsin, elastase, collagenase, and proteases. The deficiency of alpha-1-antitrypsin may have caused such enzymes to perpetuate the tissue damage, thus eventuating in chronic ulcerative conjunctivitis. The association of deficient alpha-1-antitrypsin with chronic ulcerative conjunctivitis could thus have been coincidental or a contributing factor to the conjunctival disease.

Angiotensin-converting enzyme in sarcoid and chalazion granulomas of the conjunctiva.

Angiotensin-converting enzyme (ACE) was studied immunohistochemically in conjunctival biopsies from 6 patients with systemic sarcoidosis, 4 patients with posterior non-sarcoid uveitis and in specimens from 4 patients with chalazion of the eyelid. Specimens with sarcoid granulomas showed intense ACE-positive immunoreactivity in epitheloid cells of the granuloma, whereas chalazion granulomas did not contain ACE-immunoreactivity. There was no difference in staining patterns between specimens without granulomas. Thus immunohistochemical staining for ACE may be of help in differentiating conjunctival granulomatous tissue of a chalazion from sarcoid granuloma.

Epithelial hyperproliferation and transglutaminase 1 gene expression in Stevens-Johnson syndrome conjunctiva.

In Stevens-Johnson syndrome, pathological keratinization of the ordinarily nonkeratinized corneal and conjunctival mucosal epithelia results in severe visual loss. We examined conjunctiva covering cornea in five eyes in the chronic cicatricial phase of Stevens-Johnson syndrome. Normal conjunctiva from five age-matched individuals was studied also. The number of epithelial cells in Stevens-Johnson syndrome conjunctiva that were immunoreactive with a monoclonal antibody, Ki-67, to a nuclear antigen found only in proliferating cells was greater than normal (93.8+/-19.8 cells above 100 basal cells versus 12.8+/-0.5 cells above 100 basal cells; P = 0.009). In addition, although clinical inflammation was mild, massive lymphocytic infiltration was seen in the substantia propria of conjunctiva covering cornea. In situ hybridization documented transglutaminase 1 (keratinocyte transglutaminase) mRNA in suprabasal cells of the abnormally thickened conjunctival epithelium in all Stevens-Johnson syndrome patients. In contrast, no message was detected in normal conjunctival or corneal epithelia. Transglutaminase 1 is expressed during the terminal differentiation of keratinocytes where it helps synthesize cornified cell envelopes. We speculate that in Stevens-Johnson syndrome, epithelial hyperproliferation, and transglutaminase 1 gene expression lead to the pathological keratinization of ocular surface mucosal epithelia.