Association of Dry Eye with Laryngopharyngeal Reflux in Clinical Practice.

BACKGROUND: Dry eye disease (DED) is a common disorder, accounting for up to 35% of the general population. Therefore, we hypothesized that laryngopharyngeal reflux (LPR), inducing refluxate rising into airways, may involve the ocular surface and may either induce or worsen DED. AIM: To investigate the prevalence and relevance of suspected LPR in DED patients and subjects with refractive problems (RP) without DED, they were defined as non-dry eye group (NEG) in clinical practice. METHODS: This retrospective study included consecutive patients evaluated because of dry eye-like symptoms at eight tertiary ophthalmological clinics. Parameters included reflux symptom index (RSI), ocular surface disease index (OSDI), symptom assessment in dry eye (SANDE) for frequency and severity, Schirmer test, tear break-up time (BUT), and Oxford grading. RESULTS: The study included 245 subjects (72.5% females; mean age 56.3 years), 152 DED patients, and 93 sex- and age-matched NEG subjects. Pathological RSI (score>13) was detected in 80 subjects (32.6%); 68 (85%) with DED and 12 (15%) CG (OR = 8; p < .0001). In NEG, pathological RSI was associated with higher SANDE (Frequency and Severity), OSDI, and Schirmer scores (OR = 16.36; 14.51; 12.54; and 7.22, respectively. In DED patients, pathological RSI was associated with higher OSDI values (OR = 8.75). CONCLUSION: Patients with DED are at eight times higher risk for having pathological RSI than NEG patients. Moreover, pathological RSI was associated with more severe ocular symptoms both in DED and non-DED patients. The role of LPR in definite DED patients remains to be clarified, but this condition deserves to be investigated in managing patients with DED symptoms.

Clinical staining of the ocular surface: mechanisms and interpretations.

In this article we review the mechanism of ocular surface staining. Water-soluble dyes are excluded from the normal epithelium by tight junctions, the plasma membranes and the surface glycocalyx. Shed cells can take up dye. A proportion of normal corneas show sparse, scattered time-dependent, punctate fluorescein uptake, which, we hypothesise, is due to a graded loss of the glycocalyx barrier, permitting transcellular entry into pre-shed cells. In pathological staining, there is little evidence of 'micropooling' at sites of shedding and the term 'punctate erosion' may be a misnomer. It is more likely that the initial event involves transcellular dye entry and, in addition, diffusion across defective tight junctions. Different dye-staining characteristics probably reflect differences in molecular size and other physical properties of each dye, coupled with differences in visibility under the conditions of illumination used. This is most relevant to the rapid epithelial spread of fluorescein from sites of punctate staining, compared to the apparent confinement of dyes to staining cells with dyes such as lissamine green and rose bengal. We assume that fluorescein, with its lower molecular weight, spreads initially by a paracellular route and then by transcellular diffusion. Solution-Induced Corneal Staining (SICS), related to the use of certain contact lens care solutions, may have a different basis, involving the non-pathological uptake of cationic preservatives, such as biguanides, into epithelial membranes and secondary binding of the fluorescein anion. It is transient and may not imply corneal toxicity. Understanding the mechanism of staining is relevant to the standardisation of grading, to monitoring disease and to the conduct of clinical trials.

In vivo confocal microscopic evaluation of keratic precipitates and endothelial morphology in Fuchs' uveitis syndrome.

PURPOSE: To evaluate the endothelial cell layer in patients with Fuchs' uveitis syndrome (FUS) with respect to the type and distribution of keratic precipitates (KP), endothelial cell morphology, and endothelial cell density (ECD), using in vivoconfocal microscopy (IVCM). METHODS: Forty eyes of 40 patients (mean age of 32.2 ± 12.5 years) with the clinical diagnosis of FUS were evaluated with IVCM (Confoscan 3.0, Vigonza, Italy). KP were classified as type I (small, round), type II (stippled), type III (dendritiform), and type IV (globular). When >1 KP type was present, differentiation between the predominant and less frequent KP was made as 'primary' and 'secondary'. ECD was measured and compared with age-matched 60 control subjects. Endothelial blebs were classified as small (3-10 µm) or large (>10 µm). RESULTS: In 36 (90.0%) cases with FUS, more than one KP type was observed with IVCM. Type III (dendritiform) KP was the most frequently observed primary KP type (85.0%), followed by type II (stippled) KP (15.0%). Secondary KP included type II (58.3%), type IV (globular) (27.8%), and type III (13.9%). The mean endothelial cell density of eyes with FUS (2588 ± 396 cells/mm(2)) was significantly lower than that of control subjects (2930 ± 364 cells/mm(2)) (t-test; P<0.001). Eyes with FUS had lower proportion of hexagonal cells and higher percentage of polymegethism compared with the uninvolved contralateral eyes. Endothelial blebs (21 small, 16 large blebs) were observed in 37 (92.5%) eyes. CONCLUSIONS: FUS is characterized by dendritiform KP and is associated with decreased ECD and altered endothelial cell morphology.

Association of polymorphisms in APOE, p53, and p21 with primary open-angle glaucoma in Turkish patients.

PURPOSE: To investigate the association between Apolipoprotein E (APOE), tumor suppressor protein p53 (p53), and cyclin-dependent kinase inhibitor 1A (p21) genes and primary open-angle glaucoma (POAG) in a cohort of Turkish subjects. METHODS: Seventy-five POAG patients (49 women, 26 men) and 119 healthy subjects (67 women, 52 men) were genotyped with polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Allele and genotype frequencies between healthy subjects and glaucoma patients were compared by the chi(2) test, and intraocular pressure (IOP), cup/disc ratio (C/D) and visual field indices (MD and PSD) were compared among different APOE, p53, and p21 genotypes in POAG group. A p value <0.05 was considered as statistically significant. RESULTS: The mean ages were 63.8+/-9.5 and 61.8+/-10.2 years in POAG and control groups, respectively (p=0.18). There were no significant differences in the distribution of APOE, p53, and p21 genotypes between the healthy subjects and POAG patients (p=0.38, p=0.12, and p=0.2, respectively). There were no significant differences in maximum IOP, MD, and PSD values among different groups of p53 and p21 genotypes (p>0.05). POAG subjects with the epsilon2epsilon3 genotype had a worse PSD value (median=2.2) than those with the epsilon3epsilon4 genotype (median=1.77; p=0.01) and POAG subjects with the epsilon3epsilon3 genotype had worse MD and PSD values (median= -7.4 and 3.4, respectively) than those with the epsilon3epsilon4 genotype (median= -4.1 and 1.77, respectively; p=0.034 and 0.028, respectively). CONCLUSIONS: Our study found no link between polymorphisms in APOE, p53, and p21 genes and POAG in Turkish patients, although a larger sample is required to elucidate the role of these polymorphisms in the pathogenesis and course of glaucoma.

Mean intraocular pressure and progression based on corneal thickness in patients with ocular hypertension.

PURPOSE: To determine the incidence of glaucomatous progression at mean intraocular pressure (IOP) levels in patients with ocular hypertension (OHT). METHODS: A retrospective, multicentre, cohort analysis of 230 OHT patients with 5 years of follow-up evaluated for risk factors associated with progressive optic disc and visual field loss to determine the incidence of glaucomatous progression. RESULTS: Forty percent of patients with IOPs > or = 24 mmHg, 18% of patients with IOPs of 21-23 mmHg, 11% of patients with IOPs with 18-20 mmHg, and 3% of patients with IOPs of < or = 17 mmHg progressed to glaucoma. The mean IOP was 19.8+/-2.4 mmHg in the stable group and 21.7+/-2.6 mmHg in the progressed group (P=0.0004). The highest average peak IOP was 23.4+/-4.0 mmHg in the stable group and 25.2+/-3.1 mmHg in the progressed group (P=0.006). Based on the pachymetry values for central corneal thickness, patients with thinner corneas more often progressed to glaucoma (P<0.0001). A multivariant regression analysis to determine risk factors for progression was positive primarily for higher peak IOPs, older age, male gender, argon laser trabeculoplasty, visual acuity > or = 20/50, and no topical medical therapy or beta-blocker therapy prior to the study. CONCLUSIONS: IOP reduction within the normal range over 5 years of follow-up reduces the chance of progression to primary open-angle glaucoma in OHT patients.

Keratic precipitate morphology in uveitic syndromes including Behçet's disease as evaluated with in vivo confocal microscopy.

PURPOSE: To identify the morphologic appearance of keratic precipitates (KPs) with in vivo confocal microscopy (IVCM) in uveitic syndromes. METHODS: A total of 75 eyes of 72 patients with a mean age of 38.6+/-15.1 years who had active intraocular inflammation and whose corneas had KP on slit-lamp examination were included in this study. IVCM (Confoscan 3.0, Vigonza, Italy) was used to image the part of the corneal endothelium in which KP were most densely deposited. KP were classified into five groups: type I (small, round), type II (stippled), type III (dendritiform), type IV (large, smooth-rounded), and type V (globular). When more than one type of KP was observed with IVCM, a distinction between the predominant and the less frequent KP was made as 'primary' and 'secondary' KP. RESULTS: In 50 (66.7%) eyes more than one type of KP was imaged. The size of the KP ranged between 5 and 150 microm. The most frequently observed primary KP type in Behçet's disease was type I (100%), in ankylosing spondylitis type II (57.1%), in Fuchs' uveitis syndrome type III (85.7%), in granulomatous uveitis type V (42.9%), in infectious uveitis type III (66.7%), and in juvenile idiopathic arthritis associated uveitis type I (66.7%). The KP types showed a statistically significant difference between different uveitic syndromes (Fisher's exact test, P<0.001). CONCLUSIONS: Certain KP types appear to be characteristic of various uveitic syndromes. IVCM may have a potential role in the diagnostic work-up of uveitic patients.

Serum allergen specific immunoglobulin E levels in patients with allergic conjunctivitis.

PURPOSE: To evaluate serum allergen specific immunoglobulin E (IgE) levels in patients with various types of allergic conjunctivitis. METHODS: Twenty-five patients with seasonal allergic conjunctivitis (SAC), 17 patients with perennial allergic conjunctivitis (PAC), and 10 patients with vernal conjunctivitis (VC) were included in the study. Specific IgE levels to Dermatophagoides pteronyssinus (Dp), Dermatophagoides farinae (Df), mixed grass pollens, and animal epithelia were measured using Pharmacia CAP system (Pharmacia Diagnostic AB, Uppsala, Sweden). RESULTS: The percentage of subjects with specific IgE against Dp and Df was statistically higher in VC (30%) compared to PAC (5.9%) and SAC (0%) (p=0.03). Specific IgE against mixed grass pollens was found in 30% of VC and 40% of SAC, whereas 10% of VC and 8% of SAC patients were found to be hypersensitive to animal epithelia. CONCLUSIONS: Allergic reaction against house dust mites and pollens was common in VC, whereas specific IgE against grass pollens was remarkable in SAC. IgE levels specific to various antigens might be measured by UNICAP system, which is a rapid and practical technology.