Incidence and severity of keratoconus in Asir province, Saudi Arabia.

AIM: To assess the incidence and associated signs and symptoms of patients with keratoconus in Asir Province, Saudi Arabia. METHODS: 125 new keratoconus patients (51 male, 74 female; mean age 18.5 (SD 3.8) years; range 8--28 years) were recruited from referrals to the department of ophthalmology, Asir Central Hospital, over a 1 year period. Age, visual acuity, and keratometry were recorded along with clinical signs and symptoms. RESULTS: The incidence of keratoconus in Asir Province is 20 cases per 100,000 population. Also, the disease severity is high, as indicated by an early mean age (17.7 (3.6) years) with advanced stage keratoconus. Visual acuity, with either spectacles or rigid contact lenses, was 6/12 or better in 98% of eyes measured. Just over half (56%) of patients had atopic ocular disease. 16% of patients had a positive family history of the disease and 16% had atopic dermatitis (eczema and/or vitiligo). CONCLUSION: The incidence and severity of keratoconus in Asir Province, Saudi Arabia, is high with an early onset and more rapid progress to the severe disease stage at a young age. This might reflect the influence of genetic and/or environmental factor(s) in the aetiology of keratoconus.

Characteristics of the human ocular surface epithelium.

An appreciation of the biological characteristics of the human ocular surface epithelium affords us a great insight into the physiology of the human ocular surface in health and disease. Here, we review five important aspects of the human ocular surface epithelium. First, we recognize the discovery of corneal epithelial stem cells, and note how the palisades of Vogt have been suggested as a clinical marker of their presence. Second, we introduce the concept of the gene expression profile of the ocular surface epithelium as arrived at using a new strategy for the systematic analysis of active genes. We also provide a summary of several genes abundantly or uniquely expressed in the human corneal epithelium, namely clusterin, keratin 3, keratin 12, aldehyde dehydrogenase 3 (ALDH3), troponin-I fast-twitch isoform, ssig-h3, cathepsin L2 (cathepsin V), uroplakin Ib, and Ca(2+)-activated chloride channel. Genes related to limbal and conjunctival epithelia are also described. Third, we touch upon the genetic abnormalities thought to be involved with epithelial dysfunction in Meesmann's dystrophy, gelatinous drop-like corneal dystrophy, and the ssig-h3-mutated corneal dystrophies. Fourth, we provide an update regarding the current state of knowledge of the role of cytokines, growth factors and apoptosis in relation to ocular surface homeostasis and tissue reconstruction; the main factors being epidermal growth factor (EGF), keratinocyte growth factor (KGF), hepatocyte growth factor (HGF), transforming growth factor-ss (TGF-ss), and some inflammatory cytokines. Fifth, corneal epithelial barrier function and dysfunction as measured by fluorophotometry is remarked upon, with an explanation of the FL-500 fluorophotometer and its ability to detect corneal epithelial dysfunction at a subclinical level. The research described in this review has undoubtedly generated a complete understanding of corneal epithelial pathophysiology-an understanding that, directly or indirectly, has helped advance the development of new therapeutic modalities for ocular surface reconstruction.

An x-ray diffraction investigation of corneal structure in lumican-deficient mice.

PURPOSE: The corneas of mice homozygous for a null mutation in lumican, a keratan sulfate-containing proteoglycan, are not as clear as normal. In the present study, mutant corneas were examined by synchrotron x-ray diffraction to see what structural changes might lie behind the loss of transparency. METHODS: X-ray diffraction patterns were obtained from the corneas of 6-month-old and 2-month-old lumican-null and wild-type mice. Measured in each cornea were the average collagen fibril diameter, average collagen fibril spacing, and the level of order in the collagen array. RESULTS: The x-ray reflection arising from regularly packed collagen was well-defined on all x-ray patterns from 6-month-old wild-type corneas. Patterns from 6-month-old lumican-deficient corneas, however, contained interfibrillar reflections that were measurably more diffuse, a fact that points to a widespread alteration in the way the collagen fibrils are configured. The same distinction between mutant and wild-type corneas was also noted at 2-months of age. Average collagen fibril spacing was marginally higher in corneas of 6-month-old lumican-null mice than in corneas of normal animals. Unlike x-ray patterns from wild-type corneas, patterns from lumican-deficient corneas of both ages registered no measurable subsidiary x-ray reflection, evidence of a wider than normal range of fibril diameters. CONCLUSIONS: The spatial arrangement of stromal collagen in the corneas of lumican-deficient mice is in disarray. There is also a considerable variation in the diameter of the hydrated collagen fibrils. These abnormalities, seen at 2 months as well as 6 months of age, probably contribute to the reduced transparency.

The detection of bacteria and bacterial biofilms in punctal plug holes.

PURPOSE: An investigation into bacterial biofilm formation on and in punctal plugs. METHODS: The study involved 21 patients with severe dry eye whose puncta were occluded by the use of punctal plugs. Of these, 15 had Sjögren's syndrome, 3 had non-Sjögren's syndrome, 2 had Stevens-Johnson syndrome, and 1 had graft-versus-host disease. From 17 of the 21 subjects, 18 samples of material were extracted from the holes of the punctal plugs (16 unilateral and 1 bilateral) and were subjected to enrichment culture. Nineteen punctal plugs were removed and processed for electron microscopy: 15 by scanning electron microscopy, and 4 by transmission electron microscopy. RESULTS: Positive cultures were found in 8 of 18 (44%) samples of the material extracted from the holes of punctal plugs. In six of these eight cases (75%) the cultured bacterial species was Staphylococcus epidermidis, whereas in the other two cases (25%) it was S. aureus. In 8 of the 15 punctal plugs examined by scanning electron microscopy and in the material extracted from 1 plug that was examined by transmission electron microscopy, there was clear evidence of bacterial colonization. CONCLUSION: Careful observation of patients with punctal plugs is important. If material accumulates in or on a punctal plug, it may contain bacteria and may form a bacterial biofilm. In these cases, replacement of the plug, clearing of the hole, or an alternative treatment should be considered.

The use of X-ray scattering techniques to determine corneal ultrastructure.

The manner in which X-rays are scattered or diffracted by the cornea provides us with valuable insights into the fine structure of the corneal stroma. This is because when X-rays pass through a cornea a diffraction pattern is formed due to scattering from regularly arranged collagen molecules and fibrils that comprise the bulk of the stromal matrix. Collagen provides the cornea with most of its strength, and its proper organisation is believed to be important for tissue transparency. Ever since 1978, when the first X-ray diffraction patterns were obtained from the cornea using radiation from a powerful synchrotron source, biophysicists have recorded and analysed a huge number of X-ray diffraction patterns from many different corneas. This article aims to explain the ideas that underpin our use of X-ray diffraction to investigate corneal ultrastructure, and show how the knowledge gained to date has far-reaching implications for tissue biomechanics, disease changes and transparency.

Conjunctival inflammation in the chronic phase of Stevens-Johnson syndrome.

AIMS: To understand the immunopathogenesis of the corneal conjunctivalisation in Stevens-Johnson syndrome. METHODS: Conjunctivalised corneas from five patients with Stevens-Johnson syndrome were studied immunohistochemically for several cell surface antigens and two cytokines. Chemical injury specimens were also studied. RESULTS: In all cases, immunohistochemistry revealed LFA-1, CD4, CD8, and CD68 on subepithelial infiltrating cells. Also, HLA-DR and ICAM-1 were found on the surfaces of epithelial cells, subepithelial infiltrating cells, subepithelial fibroblasts, and endothelial cells in blood vessels. IFN-gamma was found in basal epithelial cells; subepithelial cells and subepithelial extracellular matrix CD19 and IL4 were not detected. CONCLUSIONS: The infiltrating cell population in the Stevens-Johnson syndrome samples includes macrophages, CD4 positive T cells, and CD8 positive T cells. The cytokine expression pattern suggests CD4 positive T cells are Th1 cells. The infiltrating cell population is similar in Stevens-Johnson syndrome and chemical injury conjunctivalised corneas.

Cultivation of corneal epithelial cells on intact and denuded human amniotic membrane.

PURPOSE: Surgery to reconstruct the ocular surface is greatly facilitated by the use of amniotic membrane, either as a biologic drape or, more recently, as a substrate for the transplantation of cultivated corneal epithelial cells. This study was designed to compare the usefulness of intact and denuded human amniotic membranes as a substrate for corneal epithelial cell culture. METHODS: Small (3-mm-diameter) biopsy specimens of superficial cornea including epithelium were excised from the central and limbal regions in rabbits. They were cultured on human amniotic membrane with or without amniotic epithelial cells and examined by light, scanning electron, and transmission electron microscopy. RESULTS: Cellular outgrowth from the central explants (n = 10) after 14 days in culture measured 1.82 +/- 2.62 mm2 on intact amniotic membrane and 131.83 +/- 28.31 mm2 on denuded amniotic membrane. In contrast, outgrowths from the limbal explants (n = 10) at the same time measured 4.58 +/- 4.56 and 505.39 +/- 134.20 mm2 on intact and denuded amniotic membranes, respectively. The leading edges of the outgrowths on intact amniotic membrane were much less uniform than those on denuded amniotic membrane, and, in the former, corneal epithelial cells appeared to migrate over the top of amniotic epithelial cells. Limbal cells cultivated on denuded amniotic membrane formed a nicely stratified layer that adhered well to the underlying amniotic membrane. CONCLUSIONS: Denuded amniotic membrane appears to be an excellent substrate for the cultivation of corneal epithelial cells, with a view to transplantation.

Growth factor mRNA and protein in preserved human amniotic membrane.

PURPOSE: To investigate the expression of growth factor mRNA and the level of growth factor protein in preserved human amniotic membrane (AM). METHODS: RT-PCR was used to examine the expression of mRNA for eight growth factors (EGF, TGF-alpha, KGF, HGF, bFGF, TGF-beta1, -beta2, -beta3) and two growth factor receptors (KGFR and HGFR) in human AM preserved at -80 degrees C for one month. In addition, ELISAs were used to measure the protein concentrations of seven growth factors (EGF, TGF-alpha, KGF, HGF, bFGF, TGF-beta1, -beta2) in preserved human corneas and in AM both with and without amniotic epithelium. RESULTS: RT-PCR revealed that human AM expresses mRNA for EGF, TGF-alpha, KGF, HGF, bFGF, TGF-beta1, -beta2, -beta3, KGFR and HGFR, while ELISAs showed that it contains EGF, TGF-alpha, KGF, HGF, bFGF, TGF-beta1, -beta2. AM without amniotic epithelium also contains all seven growth factors examined, however, in this tissue the protein levels of EGF, KGF, HGF and bFGF were found to be significantly lower than in native AM. CONCLUSIONS: Preserved human AM expresses mRNAs for a number of growth factors and contains several growth factor proteins that might benefit epithelialization after AM transplantation. High levels of EGF, KGF, HGF and bFGF in AM with amniotic epithelium as compared to AM without amniotic epithelium suggest an epithelial origin for these growth factors. We feel that EGF, KGF and HGF in particular might play important roles in ocular surface wound healing after AM transplantation.

Ultrastructural localization of sulfated and unsulfated keratan sulfate in normal and macular corneal dystrophy type I.

Keratan sulfate (KS) proteoglycans are of importance for the maintenance of corneal transparency as evidenced in the condition macular corneal dystrophy type I (MCD I), a disorder involving the absence of KS sulfation, in which the cornea becomes opaque. In this transmission electron microscope study quantitative immuno- and histochemical methods have been used to examine a normal and MCD I cornea. The monoclonal antibody, 5-D-4, has been used to localize sulfated KS and the lectin Erythrina cristagalli agglutinin (ECA) to localize poly N -acetyllactosamine (unsulfated KS). In normal cornea high levels of sulfated KS were detected in the stroma, Bowman's layer, and Descemet's membrane and low levels in the keratocytes, epithelium and endothelium. Furthermore, in normal cornea, negligible levels of labeling were found for N -acetyllactosamine (unsulfated KS). In the MCD I cornea sulfated KS was not detected anywhere, but a specific distribution of N -acetyllactosamine (unsulfated KS) was evident: deposits found in the stroma, keratocytes, and endothelium labeled heavily as did the disrupted posterior region of Descemet's membrane. However, the actual cytoplasm of cells and the undisrupted regions of stroma revealed low levels of labeling. In conclusion, little or no unsulfated KS is present in normal cornea, but in MCD I cornea the abnormal unsulfated KS was localized in deposits and did not associate with the collagen fibrils of the corneal stroma. This study has also shown that ECA is an effective probe for unsulfated KS.

Amniotic membrane as a substrate for cultivating limbal corneal epithelial cells for autologous transplantation in rabbits.

PURPOSE: To examine the viability of using human amniotic membrane as substrate for culturing corneal epithelial cells and transplanting them onto severely injured rabbit eyes. METHODS: An ocular-surface injury was created in the right eye of eight rabbits by a lamellar keratectomy extending 5 mm outside the limbus. Next, from the limbal region of the uninjured left eyes of five of these animals, a small biopsy of corneal epithelial cells was taken and cultured on acellular human amniotic membrane. One month later, the invading conjunctiva that covered the corneal surface of all eight injured eyes was surgically removed. Five of the eyes then received grafts of amniotic membrane containing autologous cultured epithelial cells, whereas the other three received grafts of acellular amniotic membrane alone. RESULTS: A confluent primary culture of limbal corneal epithelial cells was established on acellular human amniotic membrane after 14 days. Cells were partially stratified and fairly well attached to the underlying amniotic membrane, although a fully formed basement membrane was not evident. The three rabbits that received amniotic membrane transplantation alone all had total epithelial defects on the graft in the early postoperative period. Eyes that were grafted with amniotic membrane that contained cultivated epithelial cells, however, were all successfully epithelialized up to 5 days after surgery. CONCLUSION: Autologous transplantation of cultivated corneal epithelium is feasible by using acellular amniotic membrane as a carrier.

Apolipoproteins J and E co-localise with amyloid in gelatinous drop-like and lattice type I corneal dystrophies.

AIMS: Apolipoprotein J (apoJ) and apolipoprotein E (apoE) are thought to contribute to amyloid formation in patients with Alzheimer's disease. The aim of this investigation was to discover whether or not these apolipoproteins associate with corneal amyloid in gelatinous drop-like corneal dystrophy (GDCD) and lattice corneal dystrophy type I (LCD-I). METHODS: Corneas from three eyes of three patients with GDCD and one eye of one patient with LCD-I were examined immunohistochemically using antibodies against apoJ and apoE. Two normal corneas were similarly examined. Tissue sections of brain from a patient with Alzheimer's disease were used as positive controls for the antibodies. For all negative controls, mouse IgG was used instead of the primary antibody. RESULTS: Intense apoJ and apoE immunoreactivities were found in congophilic amyloid deposits in GDCD and LCD-I. These deposits were located subepithelially in GDCD, and subepithelially and intrastromally in LCD-I. In GDCD, immunostaining of subepithelial amyloid with anti-apoJ was noticeably stronger than with anti-apoE. CONCLUSIONS: As in senile plaques in brain from a patient with Alzheimer's disease, apoJ and apoE co-localise with amyloid in corneas with GDCD and LCD-I.

Endothelial cell surface-associated keratan sulfate after excimer laser photoablation of the anterior rabbit cornea.

PURPOSE: The expression of keratan sulfate on the surfaces of corneal endothelial cells is altered when the cells are responding to injury. The purpose of this study was to investigate whether excimer laser surgery affected corneal endothelial cells and the levels of keratan sulfate associated with them. METHODS: We performed 14 bilateral, transepithelial phototherapeutic keratectomies in rabbits using a Nidek EC-5000 excimer laser. Ablations were 6 mm in diameter and 50 microm, 150 microm, or 240 microm deep. At various times following surgery the endothelium was immunolabeled for keratan sulfate and examined by scanning electron microscopy. Four untreated corneas were also examined. RESULTS: Three days after surgery, endothelial cells were not flat but were rounded or domed, a finding that was more pronounced after deeper ablations. No rounded cells, however, were seen at post-operative day 12. Keratan sulfate immunolabel was elevated on endothelial cells 3 days after surgery. By postoperative day 36, its expression was normal under the 50-microm ablations, but remained elevated under one of two 240-microm ablations. CONCLUSIONS: Corneal endothelial cells take on a rounded appearance in the early stages after excimer laser photoablations in rabbits, especially after deeper ablations. The apical surface of the endothelium also transiently expresses elevated levels of cell surface-associated keratan sulfate following surgery. These changes appear to be responses to some aspect of the surgery, and may have physiological implications.

Amyloid and Pro501 Thr-mutated (beta)ig-h3 gene product colocalize in lattice corneal dystrophy type IIIA.

PURPOSE: To assess the relative distribution in the cornea of amyloid and (beta)ig-h3 gene product in lattice corneal dystrophy type IIIA (LCD-IIIA). METHODS: Serial sections from the cornea of a patient with LCD-IIIA were subjected to either Congo red staining or immunohistochemistry employing an antibody to (beta)ig-h3. Also, genomic DNA was isolated from peripheral blood and used as a template for polymerase chain reaction to amplify all exons of (beta)ig-h3. RESULTS: Exon 11 of (beta)ig-h3 was mutated (Pro501Thr). Subepithelial and intrastromal congophilic deposits exhibited a birefringency characteristic of amyloid. These regions of the tissue were also highly immunoreactive with the antibody to the (beta)ig-h3 gene product. CONCLUSION: Amyloid and Pro501Thr-mutated (beta)ig-h3 protein accumulate and colocalize in LCD-IIIA.

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.

Gelatinous drop-like corneal dystrophy is not one of the beta ig-h3-mutated corneal amyloidoses.

PURPOSE: To discover if beta ig-h3 is mutated in gelatinous drop-like corneal dystrophy, as has been suggested. METHODS: Genomic DNA was isolated from unrelated individuals with lattice corneal dystrophy type I (n = 3), Avellino corneal dystrophy (n = 3), and gelatinous drop-like corneal dystrophy (n = 3) and used as a template for polymerase chain reaction to amplify all exons in beta ig-h3. The polymerase chain reaction product was then sequenced. RESULTS: Beta ig-h3 is mutated in lattice corneal dystrophy type I (Arg124Cys) and Avellino corneal dystrophy (Arg124His). In gelatinous drop-like corneal dystrophy, on the other hand, no mutation was detected in the entire coding region of beta ig-h3 (all 17 exons). CONCLUSION: Unlike the amyloidotic corneal dystrophies lattice type I and Avellino, gelatinous drop-like corneal dystrophy is not likely to be caused by a mutation in beta ig-h3.

Two distinct kerato-epithelin mutations in Reis-Bücklers corneal dystrophy.

PURPOSE: Two patients were diagnosed with Reis-Bücklers corneal dystrophy (RBCD), although the pattern and severity of corneal opacification differed. To see whether there was a genetic basis for these phenotypic variations, we analyzed beta ig-h3, the gene that codes for kerato-epithelin and that contains a mutation (Arg555Gln) that causes RBCD. METHODS: A 30-year-old man with honeycomb-shaped subepithelial opacities in his central cornea and a 25-year-old man with progressive subepithelial geographic opacities were both considered to have RBCD. We isolated genomic DNA from leukocytes of the two patients and their family members and screened for an Arg555Gln kerato-epithelin mutation. Then we analyzed all exons of the gene using the single-strand conformation polymorphism (SSCP) technique to search for any other kerato-epithelin mutations. RESULTS: The patient with honeycomb-shaped opacities had an Arg555Gln kerato-epithelin mutation that caused his RBCD, whereas the patient with geographic opacities did not; instead, he had a new kerato-epithelin mutation (Arg124Leu), which cosegregated with his family members. CONCLUSIONS: The variant of RBCD characterized by honeycomb-shaped opacities is caused by an Arg555Gln kerato-epithelin mutation. On the other hand, a new kerato-epithelin mutation, Arg124Leu, was found to cause the RBCD variant characterized by recurrent epithelial erosions and progressive geographic subepithelial opacification. Codon 124 is a hot spot for kerato-epithelin mutations, where the mutations responsible for three autosomal dominant corneal dystrophies--lattice type I (Arg124Cys), Avellino (Arg124His), and the variant of RBCD with geographic rather than honeycomb opacities (Arg124Leu)--are located.

An ultrastructural investigation into proteoglycan distribution in human corneas.

PURPOSE: We report an investigation into the distribution of proteoglycans (PGs) in normal, organ-cultured and dextran-treated human corneas. METHODS: Immunogold labeling was carried out at the electron microscope level to localize keratan sulphate (KS), chondroitin sulphate (CS), and heparan sulphate (HS) PGs. RESULTS: High levels of labeling for CS was found in the epithelium, endothelium, and keratocytes, with light labelling present in the basement membranes and the corneal stroma. Labeling for HS was present in the epithelium, endothelium, and keratocytes, with intense labeling present at the endothelium/Descemet's membrane interface and the epithelium/Bowman's layer interface. Large filaments were also observed in these regions in cuprolinic blue-stained specimens. Keratan sulphate was present at high levels in the stroma and the basement membranes with low levels present within the keratocytes, epithelium, and endothelium. The pattern of KS labeling along the collagen fibrils in the stroma sometimes showed evidence of periodicity. Organ-cultured corneas had extensive collagen-free "lakes," the interior of which immunolabeled positively for KS and showed staining with cuprolinic blue. The lakes were greatly reduced in the dextran-treated samples. CONCLUSION: This investigation determined the ultrastructural distribution of KS, CS, and HS PGs in human cornea and showed that organ culture is associated with a change in distribution of stromal PGs.