Topical tacrolimus for high-risk corneal transplantation: a randomized, clinical trial.

BACKGROUND: The prevalence of rejection is 10-30% in penetrating keratoplasty (PKP) case, and the rate is higher in cases of high-risk patients. Although using topical corticosteroids is a standard method for management the rejection of post-PKP patients, it may not be sufficiently potent in high-risk patients. Topical administration of tacrolimus (TAC) may be effective in suppression rejection after corneal transplantation. This study aimed to investigate the efficacy and safety of topical TAC in high-risk PKP patients in Japan. METHODS: This study was a single centre, single-blinded, randomized controlled trial. Patients with a history of PKP, graft rejection, atopic dermatitis, or deep corneal neovascularisation who underwent PKP were enrolled. They were randomly assigned to receive 0.1% TAC ophthalmic suspension or artificial tear (AT) up to week 52 after surgery. All participants received 0.1% betamethasone up to week 13 after surgery then they received 0.1% fluorometholone up to week 52. The incidence of immunological rejection during the observation period was the main outcome measure in this study. RESULTS: Thirty patients were enrolled in this study, and 12 eyes in the TAC group and 13 eyes in the AT group completed the study, respectively. Five out of 30 patients discontinued participation after providing informed consent. No serious adverse effects were developed in patients who received 0.1% TAC ophthalmic suspension. No rejection episodes occurred in the TAC group, while one eye in the AT group had rejection. Graft clarity, best spectacle-corrected visual acuity, intraocular pressure, and corneal endothelial cell density were not significantly different between the TAC and AT groups. CONCLUSION: Our results demonstrated that good tolerability of 0.1% TAC ophthalmic suspension. However, we failed to demonstrate its efficacy in preventing immunological rejection in high-risk patients undergoing PKP. TRIAL REGISTRATION: This study was first registered in the University Hospital Medical Information Network (UMIN000029669, Date of registration: November 1, 2017). With the enforcement of the Clinical Trial Act in Japan, the study re-registered in the Japan Registry of Clinical Trials (jRCTs031180342, Date of registration: March 18, 2019).

Clinical Trial of Autologous Cultivated Limbal Epithelial Cell Sheet Transplantation for Patients with Limbal Stem Cell Deficiency.

PURPOSE: To confirm the efficacy and safety of Good Manufacturing Practice (GMP)-compliant autologous cultivated limbal epithelial cell sheets in government-controlled clinical trials that adhered to Good Clinical Practice stipulations for patients with unilateral limbal stem cell deficiency (LSCD). DESIGN: A prospective, multicenter, open-label, uncontrolled, single-arm clinical trial. PARTICIPANTS: Ten consecutive eyes of 10 patients with unilateral LSCD were followed for 2 years after surgery. Preoperative LSCD stage was IIB in 4 eyes and III in 6 eyes. METHODS: A limbal tissue biopsy was obtained from the healthy eye, after which limbal stem cells were dissociated and cultivated on temperature-responsive culture surfaces. All cell sheets were fabricated in a GMP-grade facility under established standard operating procedures. Cell sheets were evaluated using defined shipment criteria before transplantation, and only those that met the criteria were used. The cell sheet was transplanted onto each of the patients' diseased eye after removing the conjunctival scar tissue that covered the corneal surface. The severity of LSCD was determined according to a staging method agreed on by global consensus, with eyes evaluated as being in stages IA-C representing successful corneal epithelial reconstruction. Diagnosis and staging of LSCD were determined by the trial's Eligibility Judgment Committee and Effect Assessment Committee using slit-lamp photographs including fluorescein staining. Both committees comprised 2 or 3 third-party cornea specialists, who were provided with information anonymously and randomly. MAIN OUTCOME MEASURE: Corneal epithelial reconstruction rate was the primary end point. RESULTS: Corneal epithelial reconstruction was successful in 6 of 10 eyes (60%) 1 year postoperatively and was significantly higher than the 15% clinically significant efficacy rate achieved by allogeneic limbal transplantation. The reconstruction rate was 70% of eyes 2 years postoperatively. Additionally, improvements in visual acuity were noted in 50% and 60% of eyes at 1 and 2 years, respectively. No clinically significant transplantation-related adverse events were observed. CONCLUSIONS: The efficacy and safety of cultivated limbal epithelial cell sheet transplantation were thus confirmed, and the cell sheet, named "Nepic," is now approved as a cellular and tissue-based product in Japan. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Japanese guidelines for allergic conjunctival diseases 2020.

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease 2019. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the abovementioned drugs.

Decreased Visual Acuity by an Irregular Corneal Posterior Surface After Repeat Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To investigate the impact of higher-order aberrations (HOAs) on visual acuity after repeat Descemet stripping automated endothelial keratoplasty (DSAEK) in the same eyes. METHODS: This retrospective comparative case series includes 23 patients who underwent DSAEK twice in the same eyes (46 DSAEK in total). We evaluated the HOAs of the anterior and posterior corneal surfaces, and total cornea using the Fourier analysis data from anterior segment optical coherence tomography. Eyes were divided into one of the following groups, based on the improvement and decline in the best-corrected visual acuity (BCVA) after repeat DSAEK; group A: 12 eyes with an improvement ≥ 2 lines, group B: 12 eyes with a decline ≤ 2 lines, and group C: 11 eyes with no change or change within 1 line. RESULTS: The HOAs of the posterior surface in group B were significantly greater than those of group A (P=0.028), whereas there were no significant differences in the anterior surface and total corneal HOAs between groups A and B (P=0.12 and 0.08). There were no significant differences in the anterior and posterior surface as well as total cornea HOAs between initial DSAEK and repeat DSAEK in group C (P=0.87, 0.65, and 0.42). The postoperative BCVA had a significant correlation with the HOAs of the anterior and posterior surfaces as well as the total cornea (R=0.40, 0.46, and 0.53; P=0.01, 0.002, and 0.001). CONCLUSIONS: Posterior corneal HOAs can have a negative influence on the visual acuity after endothelial keratoplasty.

Association of Epithelial Atypia With Recurrence After Surgical Excision in Conjunctival Papilloma.

PURPOSE: To investigate the association between recurrence of conjunctival papillomas and presence of atypical epithelial changes in patients undergoing surgical excision for conjunctival papilloma. METHODS: We retrospectively reviewed 1,195 ophthalmic pathology specimens from 2004 to 2014 at Ichikawa General Hospital. Pathologic specimens of 5 patients with a final diagnosis of "conjunctival papilloma" were stained with hematoxylin-eosin, Ki 67, p53, human papillomavirus (HPV) 16 and 18 antibodies. RESULTS: Of 1,195 patients, 5 patients (4 men, 1 woman; age range: 27∼57 years, mean age: 38.4 years) had a diagnosis of conjunctival papilloma, which constituted to 0.42% of the pathologic diagnosis made for the ophthalmology specimens. All specimens displayed multiple fronds of thickened conjunctival epithelium that enclosed cores of vascularized connective tissues. Three patients with recurrence after surgical excision demonstrated moderate to severe epithelial atypia, who also showed higher staining with Ki67 and p53 compared with patients with no recurrence. HPV16 and 18 antibodies staining did not appear to relate to recurrences. CONCLUSIONS: Conjunctival papillomas with higher positive staining for Ki67 and p53 seem to have a higher risk of recurrence even after complete surgical excision and necessitate careful follow-up.

Japanese guidelines for allergic conjunctival diseases 2017.

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease (Second Edition) revised in 2010. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the abovementioned drugs.

[Factors Affecting Outcomes of Repeated Penetrating Keratoplasty].

PURPOSE: To investigate prognosis for repeated penetrating keratoplasty (PKP) and factors that affect the outcome. METHODS: We retrospectively investigated graft survival rates, 1-year postoperative best-corrected visual acuity and irreversible rejection rates in 108 eyes of 106 patients that had repeated PKP. Factors that might affect the outcome were, age, number of previous PKP, original diseases, history of glaucoma and rejection and the use of postoperative immunosuppressant were also studied. RESULTS: Individual-factor analysis showed that history of rejection and postoperative immunosuppressant significantly increased the risk of postoperative rejection. Multi-factor analysis showed that graft survival rate was significantly lower among cases that had systemic immunosuppressants (steroids and cyclosporine). One year postoperative best-corrected visual acuity was significantly worse in cases that had history of glaucoma. In cases with history of rejection, systemic administration of postoperative immunosuppressants was significantly associated with postoperative irreversible rejection. CONCLUSION: History of rejection and glaucoma tend to have poor outcome, and the outcome might not improve by postoperative immunosuppressants.

The effects of 3% diquafosol sodium application on the tear functions and ocular surface of the Cu,Zn-superoxide dismutase-1 (Sod1)-knockout mice.

PURPOSE: To investigate the role of a water and mucin secretagogue (3% diquafosol sodium eye drops) on the tear function and conjunctival ocular surface changes in Sod1(-/-) in comparison to the wild-type (WT) mice. METHODS: Fourteen eyes of 7 Sod1(-/-) male mice with C57BL/background and 14 eyes of 7 C57BL6 strain wild-type male mice were examined at 40 weeks in this study. All mice had application of 3% diquafosol ophthalmic solution six times a day for 2 weeks. Tear film stability and corneal epithelial damage was evaluated by fluorescein and Rose Bengal stainings. Anterior segment photography was performed before and after eye drop instillations. Aqueous tear quantity was measured with phenol red-impregnated cotton threads without anesthesia. Animals were sacrificed at 42 weeks after diquafosol treatment and the whole globe specimens were subjected to periodic acid Schiff staining. Goblet cell density was quantified by J Image software. Quantitative real-time PCR for conjunctival muc 5AC messenger RNA expression was also performed. RESULTS: Sod1(-/-) mice had significantly higher fluorescein staining scores compared to the WT mice before eye drop instillation. The mean tear film breakup time, Rose Bengal staining scores, and muc5 messenger RNA expression improved significantly with diquafosol treatment in both the WT and the knockout mice. The mean fluorescein staining score and aqueous tear quantity significantly improved in the Sod1(-/-) mice with treatment. A notable and consistent increase in goblet cells and decrease in inflammatory cell infiltrates could be confirmed in all specimens after 2 weeks of diquafosol eye drop application. CONCLUSIONS: Three percent diquafosol ophthalmic solution appears to be effective in the treatment of ocular surface disease in this age-related dry eye disease mouse model.

Efficacy and safety of topical azithromycin therapy in patients with blepharitis and meibomian gland dysfunction.

PURPOSE: To assess the effects of 1% azithromycin ophthalmic solution (AZM) in patients with bacterial blepharitis accompanied by meibomian gland dysfunction (MGD). STUDY DESIGN: A multicenter, single arm, prospective interventional study. METHODS: AZM was administered to the affected eyes twice daily for the first 2 days and once daily for the subsequent 12 days. Lid margin hyperaemia/redness, collarette at the root of the eyelashes, conjunctival hyperaemia, foreign body sensation, and epiphora were assessed on Days 1, 14, and 28. The Dry Eye-related Quality of Life Score (DEQS) and objectives related to MGD, including lid vascularity, lid margin irregularity, foaming, lid plugging, keratoconjunctival disorders, Marx line, meibum grade, and tear breakup time, were also assessed. Bacterial culture of the conjunctival sac and meibum was performed on Days 1 and 14. RESULTS: Twenty-four eyes of 24 patients (10 men/14 women, mean age 72.3 ± 13.2) were included. On Days 14 and 28, the total score, lid vascularity, lid plugging, and meibum grade showed significant improvement (p < 0.05). On Day 1, 71 strains were isolated from 22 of the 24 eyes (91.7%). Cutibacterium acnes, Corynebacterium spp., and Staphylococci were detected at high frequencies. The overall disappearance rates of the bacteria in the conjunctival sac and meibum at the end of treatment were 65.7% and 58.3%, respectively. No serious ocular or systemic adverse events were observed. CONCLUSION: Fourteen-day treatment with AZM was effective in patients with blepharitis accompanied by MGD, and the efficacy of AZM persisted for a period after the treatment.

Effects of diesel exhaust particles on primary cultured healthy human conjunctival epithelium.

BACKGROUND: Air pollution from road traffic is a serious public health problem. Epidemiologic studies have demonstrated adverse health effects associated with environmental pollution. Diesel exhaust is a major contributor to ambient particulate matter air pollution. We studied the effects of exposure to diesel exhaust particles on allergic conjunctivitis using cultured conjunctival epithelial cells obtained from healthy people. OBJECTIVE: To identify the factors involved in the human conjunctival epithelial response to diesel exhaust in vitro. METHODS: Healthy individuals underwent conjunctival biopsy, and the samples were incubated on conjunctival epithelial sheets. We investigated the effects of exposure to diesel exhaust using GeneChip arrays. The adhesion molecules and cytokines showing increased expression on GeneChip arrays were verified by real-time reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay. RESULTS: The GeneChip array showed increased expression of adhesion molecules, cytokines, chemokines, and growth factors after exposure to diesel exhaust. Real-time reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay confirmed that the expression of intercellular adhesion molecule 1 and interleukin 6, in particular, were significantly upregulated. CONCLUSION: Our experimental data confirm that exposure to diesel exhaust particles increases inflammatory factor expression in human conjunctiva and thereby contributes to allergic conjunctival responses.

Peripheral optical quality and myopia progression in children.

BACKGROUND: To investigate the peripheral optical quality and its relationship with axial elongation, myopic progression in Japanese children. METHODS: Twenty-nine Japanese children, ages 10 to 12 years old, with baseline refraction from +0.75 D to -5.5 D, were included and followed for 9 months. The central and peripheral point spread functions (PSFs; 0°, 10°, 20°, 30° nasally) were obtained at 0.25 D steps around ±2.5 D of best-focus PSF (BF-PSF) using double-pass PSF system. Modulation transfer function (MTF) area of the BF-PSF was calculated from BF-PSF to represent the peripheral optical quality. Relative peripheral defocus (RPD), the refraction of anterior/posterior focal lines, MTF area, and their correlations with myopia progression were analyzed. RESULTS: The average refractive change in 9 months was -0.5 ± 0.8 D. The change in axial length was significantly positively correlated with the amount of myopic progression (P = 0.0058) and RPD (P = 0.0007, 0.0036 and 0.0040, at 10°, 20°, 30° respectively) at the initial visit, but did not correlate with the peripheral MTF area. Myopic progression of more than 0.5 D with axial elongation was observed in seven children (MP group). The RPDs at 20° and 30° in the MP group were significantly more hyperopic than in the non-MP group (P = 0.002 and 0.007), whereas there was no significant difference in axial length, and central and peripheral MTF area between the MP and non-MP groups. MP group had more hyperopic focal lines compared with non-MP group at 20° and 30°. CONCLUSION: These results suggest that the progression of axial myopia in children is associated with hyperopic RPD and refraction of focal lines, not with peripheral optical quality.

Efficacy and safety of long-term corticosteroid eye drops after penetrating keratoplasty: a prospective, randomized, clinical trial.

PURPOSE: Endothelial rejection remains a major cause of graft failure after penetrating keratoplasty (PKP). Topical corticosteroids are the gold standard for preventing rejection; however, protocols for corticosteroid treatment have been diverse. The aim of the present study was to examine the efficacy and safety of long-term use of corticosteroid eye drops after PKP in a randomized, clinical trial. DESIGN: Randomized, nonblinded, clinical trial. PARTICIPANTS: We enrolled 42 patients (21 males and 21 females) with a mean age of 65.3 years who underwent PKP and maintained graft clarity for >1 year with topical steroid eye drops. INTERVENTION: Patients were randomly assigned to 1 of 2 groups: Administration of 0.1% fluorometholone 3 times a day (steroid group) or discontinuation of steroid eye drops (no steroid group). All patients were followed for 12 months. MAIN OUTCOME MEASURES: Proportion of eyes without endothelial rejection and the proportion of eyes with clear grafts and the incidence of local or systemic side effects. RESULTS: Of the initial 42 patients, 4 in the steroid group and 6 in the no steroid group did not complete the trial. Of the patients who completed the trial, 1 patient in the steroid group and 6 in the no steroid group developed endothelial rejection at an average of 5.2±4.5 (mean ± standard deviation) months after study enrollment. The difference in the incidence of rejection between groups was found to be significant by both chi-square (P = 0.027) and Kaplan-Meier analyses (log-rank test, P = 0.032). No difference was observed between the 2 groups in visual acuity, intraocular pressure, epithelial damage, tear-film break-up time, cataract progression, infection, or incidence of systemic side effects. CONCLUSIONS: Prolonged use of 0.1% fluorometholone was beneficial for the prevention of rejection after PKP. Because no adverse consequences were noted, we recommend continuing use of the low-dose corticosteroids, even in non-high-risk cases.

Surgical outcome of Descemet's stripping automated endothelial keratoplasty for bullous keratopathy secondary to argon laser iridotomy.

BACKGROUND: To report the 6-month clinical outcome of Descemet's stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy (BK) secondary to argon laser iridotomy (ALI), and compare the results with those of DSAEK for pseudophakic bullous keratopathy (PBK) or Fuchs' endothelial dystrophy (FED). METHODS: A total of 103 patients (54 with ALI, 28 with PBK, 21 with FED) undergoing DSAEK were retrospectively analyzed. Simultaneous cataract surgery was performed in 37 patients with ALI and 13 with FED. Preoperative ocular conditions, best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction (SE), induced astigmatism, keratometric value, endothelial cell density (ECD), and complications were determined over 6 months postoperatively. RESULTS: Mean axial length in the ALI group (21.8 ± 0.8 mm) was significantly shorter than that in the FED (P = 0.02) or PBK groups (P = 0.003). Severe corneal stromal edema (n = 6), advanced cataract (n = 10), posterior synechia (n = 3), poor mydriasis (n = 5), and Zinn zonule weakness (n = 1) were found only in the ALI group. A significant improvement was observed in postoperative BSCVA in all groups. No significant difference was observed in BSCVA, SE, induced astigmatism, keratometric value, ECD, or complications among the three groups. CONCLUSIONS: Descemet's stripping automated endothelial keratoplasty for BK secondary to ALI showed rapid postoperative visual improvement, with similar efficacy and safety to that observed in DSAEK for PBK or FED.

[Evaluation of the efficacy of subjective symptoms, objective findings, and of a total tear IgE detection kit in diagnosis of allergic conjunctival diseases].

PURPOSE: To evaluate the efficacy of subjective symptoms, objective findings, and of a total tear IgE test kit in the diagnosis of allergic conjunctival diseases (ACD). SUBJECTS AND METHODS: The subjects were 223 patients with ACD, diagnosed according to the clinical practice guidelines for allergic conjunctival diseases in 28 medical facilities in Japan. The ACD patients were divided into the following five groups: 84 patients with seasonal allergic conjunctivitis (SAC), 52 patients with perennial allergic conjunctivitis (PAC), 41 patients with atopic keratoconjunctivitis (AKC), 38 patients with vernal keratoconjunctivitis (VKC) and 8 patients with giant papillary conjunctivitis (GPC). All cases were examined for clinical ACD, subjective symptoms, objective findings by the clinical score and by a total tear IgE test. An eosinophil examination by conjunctival smear was also performed in 87 ACD patients. RESULTS: The most prevalent subjective symptoms were itching (81.6%) and hyperemia (77.6%). The clinical scores of the objective findings in the patients with SAC, PAC, AKC, VKC and GPC were 16.3 +/- 3.8 (mean +/- SD) points, 16.2 +/- 2.8, 19.8 +/- 6.5, 23.1 +/- 5.3, and 21.4 +/- 3.9, respectively. In the total tear IgE test 72.2% of the ACD patients were positive; i.e., the ratios were 61.9% in SAC, 65.4% in PAC, 80.5% in AKC, 94.7% in VKC, and 75.0% in GPC. In the examination of eosinophils in the 87 ACD patients, 42.5% (37 eyes) were positive, i.e., the ratio was 20.0% in SAC, 36.8% in PAC, 53.3% in AKC, 75.0% in VKC and 33.3% in GPC. The rate of agreement between the total tear IgE test and the examination of eosinophils was kappa = 0.28 (Cohen kappa coefficient). CONCLUSION: Because of the high positive ratio in patients quasi-definitively diagnosed with ACD, we conclude that the total tear IgE test is useful as an auxiliary method for diagnosing ACD.

[A quality of life questionnaire for Japanese allergic conjunctival disease].

PURPOSE: To establish a specific quality of life (QOL) questionnaire for Japanese allergic conjunctival disease (ACD) (Japanese allergic conjunctival disease QOL questionnaire: JACQLQ). SUBJECTS AND METHODS: A multicenter study was conducted in 521 patients with ACD and 127 healthy volunteers (total 648 cases). The JACQLQ ver. 0 was developed by modifying the Japanese rhino-conjunctivitis QOL questionnaire (JRQLQ). The participants were asked to complete the questionnaire, and objective scores were determined by an ophthalmologist using a slit lamp. To confirm validity, item and factor analyses were conducted and correlation coefficients were calculated. RESULTS: The items were grouped into four subscales (Daily activity, Psychological well-being, Eye symptoms, Nasal symptoms) after factor analysis. The JACQLQ had good item-internal consistency (Cronbach's alpha: 0.846-0.934). QOL scores were correlated with eye itching, eye irritation and tearing. Objective scores were correlated with eye redness, eye itching and eye irritation. Face scores were correlated with eye itching, eye irritation and eye redness. CONCLUSION: The JACQLQ is a useful tool for assessing disease specific QOL in ACD.

Eosinophil cationic protein as a marker for assessing the efficacy of tacrolimus ophthalmic solution in the treatment of atopic keratoconjunctivitis.

PURPOSE: To examine the clinical efficacy and anti-inflammatory effects of tacrolimus eye drops; we studied the changes in clinical ocular findings and measured tear eosinophil cationic protein (ECP) levels of atopic keratoconjunctivitis (AKC) patients before and after the treatment. METHODS: Nine eyes of 9 patients (8 males, 1 female; mean age: 16.9 ± 11.4 years; range: 6-44 years) diagnosed with moderate or severe AKC disease were enrolled in this prospective study and treated with tacrolimus. All patients received 0.1% tacrolimus eye drops 2 times a day for 1 month. Tear samples were taken before and after treatment and ECP concentrations were obtained. Corneal fluorescein staining and conjunctival injection, edema, and papillary formation were graded on the recruitment day and one month later. Analysis of pre- and post-treatment findings was done using the Wilcoxon signed test. The ECP concentrations were correlated with the clinical signs using Spearman correlation tests. RESULTS: Post-treatment tear ECP levels were significantly reduced compared to the pre-treatment level. Clinical corneal scores also improved significantly after one month treatment with tacrolimus eye-drops. The mean conjunctival injection and conjunctival edema scores were significantly (p<0.05) decreased after the drug therapy. Strong positive linear correlations between ECP values and clinical signs were observed. Patients did not present side effects during the treatment with tacrolimus. CONCLUSIONS: In this pilot study, tacrolimus eye drops were found to reduce signs of AKC. ECP proved to correlate well with clinical signs of AKC.

Long-term outcome of cultivated oral mucosal epithelial sheet transplantation in treatment of total limbal stem cell deficiency.

PURPOSE: To evaluate the long-term outcome of cultivated oral mucosal epithelial transplantation (COMET) in treatment of eyes with total limbal stem cell deficiency. DESIGN: Noncomparative, retrospective, interventional case series. PARTICIPANTS: Forty eyes in 36 patients with total limbal stem cell deficiency (Stevens-Johnson syndrome in 12 eyes, chemical or thermal burns in 11 eyes, ocular cicatricial pemphigoid [OCP] in 9 eyes, pseudo-OCP in 7 eyes, and gelatinous drop-like dystrophy in 1 eye) were treated at the Department of Ophthalmology, Tokyo Dental College, Chiba, Japan. INTERVENTION: Cultivated autologous oral mucosal epithelial sheets were transplanted onto the ocular surface in eyes with total limbal stem cell deficiency. MAIN OUTCOME MEASURES: Reconstruction of a stable ocular surface with a clear appearance and no epithelial defects, reduction in fibrovascular tissue invasion of corneal surface, a functional fornix, change in visual acuity, and postoperative complications. RESULTS: The mean follow-up period was 25.5 months (range, 6-54.9 months). Kaplan-Meier analysis of a corneal surface stability revealed an early decline in transplanted oral mucosal epithelial stability over the first 6 months, remaining comparatively stable thereafter (1 year, 64.8%; 2 years, 59.0%; and 3 years, 53.1%). Postoperative persistent epithelial failure developed within the first 3 months in 9 eyes. Early epithelial failure was associated closely with preoperative corneal defects. Gradual fibrovascular tissue invasion of the corneal surface was observed in 8 eyes and was marked in cases of OCP. Survival of a functional fornix decreased progressively until approximately 6 months. Postoperative visual acuity seemed to be related to the presence of corneal opacity. Complications included stromal melting or perforation in 8 eyes, infectious keratitis in 2 eyes, glaucoma in 8 eyes, and recurrence of herpetic keratitis in 1 eye. Corneal melting or perforation and infectious keratitis were associated closely with persistent epithelial defects after COMET. CONCLUSIONS: The transplantation of cultivated oral mucosal epithelial sheets offers a viable and safe alternative in the reconstruction of a stable ocular surface. Epithelialization of the corneal surface is very important not only in obtaining a satisfactory long-term outcome, but also in achieving a lower incidence of complications. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Japanese guideline for allergic conjunctival diseases.

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease (Second Edition) revised in 2010. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the above mentioned drugs.

Subepithelial corneal fibrosis partially due to epithelial-mesenchymal transition of ocular surface epithelium.

PURPOSE: To determine whether epithelial-mesenchymal transition is involved in the development of corneal subepithelial fibrosis (pannus). METHODS: Frozen samples of pannus tissue removed from human corneas with a diagnosis of total limbal stem cell deficiency were characterized by immunostaining for both epithelial and mesenchymal markers. We selected transformation-related protein 63 (p63) and pancytokeratin as epithelial markers and vimentin and α-smooth muscle actin (α-SMA) as mesenchymal markers. Immunostaining for ß-catenin and E-cadherin was performed to determine wingless-Int (Wnt)-pathway activation. RT-PCR analysis was also performed on epithelial tissue obtained from pannus samples after dispase digestion. RESULTS: Immunohistochemistry revealed strong nuclear expression of p63 and weak intercellular expression of E-cadherin in epithelial basal cells of pannus tissue. Furthermore, translocation of ß-catenin from intercellular junctions to the nucleus and cytoplasm was also observed. Double-positive cells for both p63 and α-SMA were observed in the subepithelial stroma of pannus tissue, which was supported by RT-PCR and cytospin analysis. CONCLUSIONS: Epithelial-mesenchymal transition may be partially involved in the development of subepithelial corneal fibrosis due to total limbal stem cell deficiency.

Evaluation of lipid oxidative stress status and inflammation in atopic ocular surface disease.

BACKGROUND: Although the oxidative stress status in atopic skin disease has been reported to be elevated, there are still no studies related to the status of oxidative stress in atopic ocular surface disease. The purpose of this study was to evaluate the ocular surface lipid oxidative stress status and inflammation in atopic keratoconjunctivitis (AKC) patients and normal subjects. METHODS: Twenty eight eyes of 14 patients (9 males, 5 females) with AKC and 18 eyes of 9 age and sex matched (4 males and 5 females) normal healthy controls were examined in this prospective study. The severity of atopic dermatitis (AD) was scored by the SCORing Atopic Dermatitis (SCORAD) index. All subjects underwent Schirmer test, tear film break up time (BUT), fluorescein/Rose Bengal stainings, tear collection, and brush cytology from the upper palpebral conjunctiva. The brush cytology samples were stained with Diff-Quik for differentiation of inflammatory cells and immunohistochemistry (IHC) staining with HEL (hexanoyl-lysine) and 4-HNE (4-hydroxy-2-nonenal) to study lipid oxidation. HEL and cytokine (interleukin-4 (IL-4), interleukin-5 (IL-5), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ)) levels were measured by enzyme-linked immunosorbent assay (ELISA) from tear samples of AKC patients and control subjects. Toluidine Blue and IHC staining with HEL, 4-HNE and cluster of differentiation 45 (CD45) were performed on papillary samples of AKC patients. This study was conducted in compliance with the "Declaration of Helsinki." RESULTS: The tear stability and vital staining scores were significantly worse in eyes of AKC patients (p<0.05) compared to the controls. Inflammatory cells and positively stained conjunctival epithelial cells for HEL and 4-HNE showed a significant elevation in brush cytology samples of AKC patients. Significantly higher levels of HEL and cytokines were detected in tears of AKC patients compared to controls. Papillary specimens also revealed many CD45 inflammatory cells as well as many cells positively stained with HEL and 4-HNE in IHC. A strong significant linear positive correlation between conjunctival inflammation and epithelial lipid oxidative stress status was observed. Conjunctival lipid oxidative stress also correlated strongly with tear HEL levels and epithelial damage scores. CONCLUSIONS: The ocular surface disease in AKC was characterized by marked tear instability, ocular surface epithelial damage, increase in inflammatory infiltrates and presence of increased lipid oxidation.