IgG4-related Disease Presenting as Isolated Cicatrising Conjunctivitis.

A 46-year-old male presented with a 12-month history of trichiasis and was found to have significant, progressive cicatrization of the tarsal conjunctiva causing entropion of the upper and lower eyelids. A biopsy confirmed the diagnosis of IgG4-related cicatrizing conjunctivitis in the absence of any other organ involvement, a previously unreported manifestation of this immune-mediated disease.

PAX6 molecular analysis and genotype-phenotype correlations in families with aniridia from Australasia and Southeast Asia.

Purpose: Aniridia is a congenital disorder caused by variants in the PAX6 gene. In this study, we assessed the involvement of PAX6 in patients with aniridia from Australasia and Southeast Asia. Methods: Twenty-nine individuals with aniridia from 18 families originating from Australia, New Caledonia, Cambodia, Sri Lanka, and Bhutan were included. The PAX6 gene was investigated for sequence variants and analyzed for deletions with multiplex ligation-dependent probe amplification. Results: We identified 11 sequence variants and six chromosomal deletions, including one in mosaic. Four deleterious sequence variants were novel: p.(Pro81HisfsTer12), p.(Gln274Ter), p.(Ile29Thr), and p.(Met1?). Ocular complications were associated with a progressive loss of visual function as shown by a visual acuity ≤ 1.00 logMAR reported in 65% of eyes. The prevalence of keratopathy was statistically significantly higher in the Australasian cohort (78.6%) compared with the Southeast Asian cohort (9.1%, p=0.002). Variants resulting in protein truncating codons displayed limited genotype-phenotype correlations compared with other variants. Conclusions: PAX6 variants and deletions were identified in 94% of patients with aniridia from Australasia and Southeast Asia. This study is the first report of aniridia and variations in PAX6 in individuals from Cambodia, Sri Lanka, Bhutan, and New Caledonia, and the largest cohort from Australia.

DNA methylation at the 9p21 glaucoma susceptibility locus is associated with normal-tension glaucoma.

PURPOSE: Recent genome-wide association studies reported strong association of genetic variation at the CDKN2B/CDKN2B-AS1 locus on 9p21 with normal-tension glaucoma (NTG) in multiple populations. The mechanism by which this locus causes disease remains to be elucidated. We investigated the association of DNA methylation of CpG islands at this locus with NTG. METHODS: We conducted a retrospective case-control study of 178 NTG cases and 202 unaffected controls from Australia. CDKN2B and CDKN2B-AS1 promoter methylation was measured quantitatively using the MassCleave assay, and assessed for association with the disease, and the genotype of the associated risk variants using IBM SPSS statistics 22.0 CpG sites at which methylation status was associated with NTG were validated using pyrosequencing. RESULTS: We identified one CpG site (F1:13-14) in the CDKN2B promoter which showed significant association with NTG (p = 0.001). The association was highly significant in female cases (p = 0.006) but not in male cases (p = 0.054). The association was validated using an independent method confirming the likely association of DNA methylation with NTG in females (p = 0.015), but not in males (p = 0.497). In addition, methylation at CpG sites in CDKN2B was also associated with genotype at rs1063192, which is known to confer risk for NTG. CONCLUSION: This study reveals an association of methylation status in the CDKN2B promoter with NTG, particularly in females. This suggests that the observed genetic association with the disease at this locus could be in part due to epigenetic mechanisms, and is likely to be independent of the association of nonsynonymous coding variation within the gene.

A comparison of endothelial and penetrating keratoplasty outcomes following failed penetrating keratoplasty: a registry study.

PURPOSE: To compare graft survival and visual outcomes for endothelial keratoplasty (EK) after a first penetrating keratoplasty (PK), with outcomes of repeat PK after a first PK. METHODS: 400 eyes with a second graft (65 EKs, 335 PKs) performed after failure of a primary PK were identified through the Australian Corneal Graft Registry, a national prospectively followed cohort. Grafts were performed after January 2008 (follow-up of the second graft extending to 6.75 years maximum). Kaplan-Meier graft survival plots were constructed and Cox proportional hazards regression was used to identify independent risk factors for graft failure. Best-corrected Snellen visual acuity (BCVA) at last follow-up was compared with pregraft acuity. RESULTS: Poor Kaplan-Meier graft survival was observed for PK-EK compared with PK-PK (log-rank=29.66, p<0.001). Variables retained in multivariate analysis as significantly influencing survival of the second graft included graft type (PK-EK or PK-PK, p<0.001), length of survival of the previous PK (global p=0.011), graft era (global p=0.018), occurrence of rejection in the second graft (p=0.005) and a history of raised intraocular pressure at any time (p=0.048), but not indication for the first graft. BCVA improved in the majority of surviving grafts and attainment of 6/12 vision was similar for both PK-EK and PK-PK groups. CONCLUSIONS: Our registry findings suggest that repeat PK may deliver a better outcome in terms of graft survival than EK after a failed PK that was performed initially for keratoconus or pseudophakic bullous keratopathy. For surviving grafts, visual outcomes appeared equivalent across groups.

Severe intraocular pressure response to periocular or intravitreal steroid treatment in Australia and New Zealand: data from the Australian and New Zealand Ophthalmic Surveillance Unit.

BACKGROUND: Increase in intraocular pressure is a recognized complication of corticosteroid treatment via intravitreal or periocular injections for treatment of a range of conditions including macular oedema and retinal neovascularization. DESIGN: This surveillance study was designed to determine the incidence and nature of severe intraocular pressure elevation as a complication of intravitreal or periocular corticosteroid injections in Australia and New Zealand. PARTICIPANTS: Seventeen cases meeting the defined criteria of severe intraocular pressure elevation, above 35 mmHg, following an intravitreal or periocular corticosteroid injection were included in the study. METHODS: Over an 18-month period, ophthalmologists were invited to report cases to the Australian and New Zealand Ophthalmic Surveillance Unit. After reporting, further demographic and clinical information was sought via a follow-up questionnaire. MAIN OUTCOME MEASURES: Intraocular pressure elevation above 35 mmHg. RESULTS: Follow-up questionnaires were received for 20 cases of 34 initially reported to the unit. Seventeen met the defined criteria. Triamcinolone acetonide was used in all 17 cases, with 16 delivered as a 4-mg intravitreal injection. There was an absence of identified underlying risk factors in the majority of cases with personal history of glaucoma in 2 of 17 cases. No cases reported a positive family history of glaucoma. Trabeculectomy was performed in 8 of 17 patients (47%) for intraocular pressure management. CONCLUSIONS: Severe intraocular pressure elevation following intravitreal or periocular corticosteroid injection can occur in the absence of risk factors such as personal and family history of glaucoma. The severe intraocular pressure elevation may ultimately require trabeculectomy.

Comparative outcomes of penetrating and component endothelial cell corneal allografts in outbred sheep.

Lamellar (component cell) corneal transplantation is replacing penetrating keratoplasty for some corneal disorders in humans, but the relative risks of immunological graft rejection for the two procedures remain uncertain. A model of component endothelial cell keratoplasty (endokeratoplasty) was developed in outbred sheep. Clinical and histological graft outcomes after endokeratoplasty were then compared with contemporaneous penetrating corneal allografts. No topical or systemic immunosuppression was administered to any recipient sheep. Endothelial cell allografts (n = 10) took significantly longer to achieve perfect transparency following surgery than did penetrating corneal grafts (n = 7) (day 10 vs. day 4; p = 0.003; two-tailed Mann-Whitney U test). The median day to rejection of penetrating grafts was postoperative day 18; for endothelial cell grafts, it was day 48 (p = 0.04; two-tailed Mann-Whitney U test). The clinical courses of the two procedures were therefore quite different. Penetrating grafts gained clarity quickly but exhibited rapid graft neovascularization. Clinical rejection was preceded by inflammation in the anterior segment. Endothelial cell grafts exhibited a fluctuating, more indolent course of opacification, although all did eventually fail. Histological analysis confirmed immunological rejection in all failed grafts, but with different patterns of leukocytic infiltration in endokeratoplasties compared with penetrating keratoplasties. Inflammatory cells in endothelial cell grafts were generally fewer in number and were more often found in the posterior stroma. We conclude that, in the absence of immunosuppression, all endothelial cell allografts do undergo immunological rejection, albeit at a slower rate than penetrating grafts.

Replication and meta-analysis of candidate loci identified variation at RAB3GAP1 associated with keratoconus.

PURPOSE: Keratoconus is a common complex corneal ectasia that can lead to severe visual impairment. Although a genetic component is well recognized, the genetic risk factors for keratoconus are yet to be fully elucidated. A recent genome-wide association study (GWAS) by Li et al. identified 15 potentially associated single nucleotide polymorphisms (SNPs). Here, we aimed to replicate these associations, and conduct a meta-analysis of the current and previous studies. METHODS: We genotyped the 15 reported associated SNPs in 524 Australian Caucasian cases with keratoconus and 2761 controls. Association analysis was conducted in PLINK. A meta-analysis of this study with the adjusted P values of the previously published GWAS was conducted using the method of Fisher to combine P values. RESULTS: Our Australian cohort showed association (P < 0.003) at SNPs near RAB3GAP1, KCND3, IMMPL2, and in a gene desert on chromosome 13q33.3, providing evidence of replication of the published results. The meta-analysis showed SNP rs4954218 near RAB3GAP1 gene was associated significantly with keratoconus, with P = 9.26 × 10(-9) passing the genome-wide significance level. CONCLUSIONS: Although the mechanism of disease association is yet to be determined, SNP rs4954218 is associated consistently with keratoconus and likely tags a functional variant that contributes to disease susceptibility.

Australian and New Zealand Registry of Advanced Glaucoma: methodology and recruitment.

BACKGROUND: Glaucoma is a sight-threatening disease affecting 3% of the population over the age of 50. Glaucoma is treatable, and severe vision loss can usually be prevented if diagnosis is made at an early stage. Genetic factors play a major role in the pathogenesis of the condition, and therefore, genetic testing to identify asymptomatic at-risk individuals is a promising strategy to reduce the prevalence of glaucoma blindness. Furthermore, unravelling genetic risk factors for glaucoma would also allow a better understanding of the pathogenesis of the condition and the development of new treatments. DESIGN: The Australian and New Zealand Registry of Advanced Glaucoma is a prospective study that aims to develop a large cohort of glaucoma cases with severe visual field loss to identify novel genetic risk factors for glaucoma blindness. METHODS: Clinical information and blood are collected from participants after referral by eye practitioners. Samples are collected across Australia and New Zealand using postage kits. PARTICIPANTS: Our registry has recruited just over 2000 participants with advanced glaucoma, as well as secondary and developmental glaucomas. RESULTS: A positive family history of glaucoma is present in more than half of the advanced glaucoma cases and the age at diagnosis is significantly younger for participants with affected relatives, which reinforces the involvement of genetic factors in glaucoma. CONCLUSIONS: With the collection of glaucoma cases recruited so far, our registry aims to identify novel glaucoma genetic risk factors to establish risk profiling of the population and protocols for genetic testing.

Pythium insidiosum keratitis in an Australian child.

A 3-year-old girl from the Northern Territory developed suppurative keratitis after swimming in pools. A mycelial organism suspected to be Pythium insidiosum was cultured. Treatment with polyhexamethylene biguanide and voriconazole for 5 days was unsuccessful, and a corneal graft was performed. The infection was cleared and when last seen 14 months after surgery the patient had a stable graft and useful vision. The identification of the organism was confirmed by rRNA gene sequencing. P. insidiosum is an oomycete, an organism more closely related to kelp than to fungi. Masses of hyphae were seen in sections and, for the first time, the ultrastructure of P. insidiosum in human tissue is described. The staining characteristics of cultured hyphae were assessed; lactofuchsin and acridine orange were found to be the most useful methods. Although the diagnosis of P. insidiosum keratitis is not difficult, and the organism is susceptible in vitro to a number of antimicrobial agents, early corneal transplantation remains the treatment of choice.

Erosive mucosal lichen planus and secondary epiphora responding to systemic cyclosporin A treatment.

Erosive mucosal lichen planus (LP) is a well-established variant of LP characterized by the formation of ulcerative lesions predominantly involving the oral and genital mucosae. Less commonly, this condition may involve oesophageal and/or ocular mucosal surfaces, and case reports within the ophthalmology literature have recently confirmed the potential for this condition to affect the nasolacrimal ducts. We report the case of a woman with severe cicatrizing mucosal LP and ocular symptoms secondary to presumed nasolacrimal duct involvement. We also report the potential for this newly appreciated manifestation of LP to respond to systemic cyclosporin A.

Heritability of central corneal thickness in nuclear families.

PURPOSE: Many ocular parameters show strong heritable tendencies. The significance of central corneal thickness (CCT) in the context of glaucoma has been the subject of much debate recently, but its heritability has not been extensively explored. This study was designed to investigate the parent-child heritability of CCT among groups who have CCT considered to be at the extreme ends of the normal range. METHODS: Index cases were recruited through a tertiary referral center if their CCT was greater than 578 microm (thick) or less than 510 microm (thin), representing +/-1 SD from a previously published meta-analysis mean of 544 microm (34 microm SD). Subsequently, CCT was measured in all available family members of the index cases. Family units were then analyzed to establish the degree of heritability of CCT from parent to child. RESULTS: Thirty-three index cases were included in the analysis (10 >1 SD and 23 <1 SD from the meta-analysis CCT mean). The mean CCT of the children of index cases with a CCT more than 1 SD from the mean (n = 15) and less than 1 SD from the mean (n = 40) was 568 microm (32 microm SD) and 521 microm (22 microm SD), respectively (t = 6.14; P < 0.0001). The parent-child heritability estimate for CCT was h(2) = 0.68 (95% CI, 0.64-0.73). CONCLUSIONS: These results indicate that CCT shows strong parent-child heritability, with offspring likely to demonstrate CCT similar to the parental index case.

Effect of immunosuppression on outcome measures in a model of rat limbal transplantation.

PURPOSE: To examine the effect of immunosuppression with intramuscularly injected cyclosporine and topical corticosteroid on limbal allograft survival in a new model in the inbred rat. METHODS: Orthotopic limbal tissue harvested from male Fischer 344 (isografts) or male Wistar-Firth donors (allografts) was sutured into superior and inferior lamellar excision sites in female recipient Fischer 344 rats. Grafts were examined clinically for at least 55 days. Superficial epithelial cells were sampled weekly, and the DNA extracted and probed for the male-specific gene Sry by polymerase chain reaction. Recipients were killed at established intervals for immunohistochemistry. Graft-recipient animals were randomly assigned to receive either intramuscular cyclosporine plus topical prednisolone phosphate or vehicle for 4 weeks from the time of transplantation. RESULTS: Isografts survived for a median of more than 55 days. Allografts underwent clinical rejection at a median of 6 to 7 days after grafting. Acutely rejecting allografts showed a dense mononuclear infiltrate consisting of activated CD4(+) and CD8(+) T cells with some macrophages. Genomic Sry was usually detectable in cells sampled from the ocular surface for more than 55 days in isografts, but not beyond 7 days in allografts. Immunosuppression prolonged allograft survival significantly, as assessed clinically, but did not prolong donor cell survival on the ocular surface, as assessed by detection of genomic Sry. CONCLUSIONS: A robust model of limbal transplantation was developed in the rat. Isografts survived for the long term, whereas allografts underwent rapid rejection. Although clinical allograft survival was prolonged to a modest extent by immunosuppression, donor cell survival on the ocular surface was not improved.