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Distribution of mucins at the ocular surface.

Mucins are vital for maintenance of a healthy, wet ocular surface. Once only thought to be secreted by goblet cells, mucins are now also known to be of the membrane-associated type. Stratified ocular surface epithelia express at their apical-tear fluid surface a repertoire of membrane-associated mucins including MUC1, MUC4, MUC16. These mucins are concentrated on the tips of the microplicae, forming a dense glycocalyx at the epithelial tear film interface. A major mucin of the secretory class is the goblet-cell-derived gel-forming mucin MUC5AC. A small soluble mucin, MUC7, is expressed by the lacrimal gland acini. Our hypothesis of the role/distribution of the secreted and membrane-associated mucins at the ocular surface is that the secreted mucins are soluble in the tear fluid, and are moved about and shunted to the nasolacrimal duct and by the eyelids during blinking. Thus, in the tears, the secreted mucins act as clean-up/debris removing multimeric networks that at the same time, through their hydrophilic nature, hold fluids in place and harbor defense molecules secreted by the lacrimal gland. Membrane-associated mucins, on the other hand, form a dense barrier in the glycocalyx at the epithelial tear film interface. This barrier prevents pathogen penetrance and is a lubricating surface that allows lid epithelia to glide over the corneal epithelia without adherence. The secreted mucins move easily over the glycocalyx mucins because both have anionic character that creates repulsive forces between them. Little is known regarding regulation of expression and glycosylation of mucins by ocular surface epithelia. Since ocular surface drying diseases alter both goblet cell and mucin production, and production and glycosylation of membrane-associated mucins, studies of mucin gene regulation and glycosylation may yield treatment modalities for these diseases.

Conjunctiva↗

Pulmonary complications from ophthalmic preparations.

Topical beta-adrenergic blocking agents are commonly used to treat glaucoma. Exacerbations of asthma and bronchospasm caused by topical beta-adrenergic ophthalmic preparations are well known. We describe a 67-year-old woman who had aspiration pneumonitis characterized by a nodular infiltrate in the right middle lobe of the lung and nocturnal coughing after beginning topical application of an ointment (Lacri-Lube) for treatment of xerophthalmia. Bronchial washing demonstrated lipid-laden pulmonary alveolar macrophages. After the use of Lacri-Lube was discontinued, her cough and the chest roentgenographic abnormality totally disappeared. We postulate that the topical ophthalmic preparation, which contains mineral oil and petrolatum, drained into the nasopharynx, trachea, and bronchial tree through the nasolacrimal duct and caused lipoid pneumonitis from aspiration of the oil contents. To our knowledge, this is the first report of pulmonary complications caused by Lacri-Lube. We briefly review the pulmonary complications, including pulmonary edema, apnea from paralysis of respiratory muscles, bronchospasm from non-beta-adrenergic blocking drugs, and electrolyte abnormalities, attributable to topically and systemically administered ophthalmic medications.

Administration, Topical↗

Disorders of the lacrimal system apparatus.

Epiphora, or excess tearing, is a common problem in infants. The most frequent etiology of this disorder is a nasolacrimal duct obstruction. There are other conditions, however, some of which can be serious, which can cause tearing. Infections of the eyelids and conjunctiva, an undiscovered foreign body, and congenital glaucoma are among the conditions that must be ruled out when any child presents with excessive tearing.

Child↗

Australasian orbital and adnexal Wegener's granulomatosis.

OBJECTIVE: To report a retrospective case series of 29 Australian and New Zealand patients with orbital and adnexal Wegener's granulomatosis (WG). DESIGN: Retrospective case series. PARTICIPANTS: Twenty-nine cases of orbital and adnexal WG were identified. METHODS: A number of oculoplastic surgeons and other clinicians in Australia and New Zealand was asked about their experience with orbital and adnexal WG. Clinical data regarding these cases were conveyed by means of a questionnaire. Cases of ophthalmic WG without features of orbital or adnexal disease were excluded. MAIN OUTCOME MEASURES: Data obtained from the questionnaire includes age, gender, limited or generalized disease, antineutrophil cytoplasmic antibody (ANCA) status, symptoms and signs: nasolacrimal obstruction, sinusitis, fistula/orbital bone erosion, orbital mass/proptosis, extraocular muscle/diplopia, visual acuity reduction caused by optic nerve compression, orbital pain, lid edema/erythema, biopsy status, and treatment status. RESULTS: Twenty-nine patients with orbital and adnexal WG were identified and described. Symptoms included awareness of an orbital mass, epiphora, orbital pain and diplopia. Signs included an orbital mass or proptosis (69%), nasolacrimal duct obstruction (52%), limited ocular rotations (52%), lid erythema and edema (31%), bony destruction (21%), and reduced visual acuity (17%). Two patients had a persistent nasolacrimocanthal fistula. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA) were present in 52% of patients, and in 9 of 10 patients with generalized disease. However, c-ANCA was positive in only 32% (6 of 19) of patients with limited WG. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) was positive in 10% of cases. CONCLUSIONS: To diagnose and treat ophthalmic WG effectively, the clinician must be aware of its protean orbital and adnexal manifestations. WG may occur with or without systemic involvement, and c-ANCA was negative in approximately half our cases. Our cases also demonstrated two orbital fistulae, an observation previously believed to be rare.

Adolescent↗

Delayed-onset bleb-associated endophthalmitis: clinical features and visual acuity outcomes.

OBJECTIVE: To investigate clinical factors, causative organisms, treatments, and visual acuity and intraocular pressure outcomes associated with delayed-onset, bleb-associated endophthalmitis. DESIGN: Retrospective, noncomparative, consecutive case series. PARTICIPANTS: All patients treated for bleb-associated endophthalmitis at Bascom Palmer Eye Institute between January 1, 1996, and July 1, 2001. All patients had prior glaucoma filtering surgery. Patients with inadvertent functioning blebs after cataract extraction were excluded. MAIN OUTCOME MEASURES: Visual acuity outcomes and intraocular pressure control after endophthalmitis. RESULTS: An antifibrotic agent was used in 40 (82%) of the 49 eyes identified, including mitomycin-C in 33 (67%) and 5-fluorouracil (5-FU) in 7 (14%). The mean interval between the initial filtering surgery and endophthalmitis diagnosis was 5.0 years (range, 0.7-12.2 years). The mean follow-up time after treatment for endophthalmitis was 6.9 months (range, 1-60 months). As recorded in the medical record, potential risk factors and clinical features among the study population included history of bleb leak in 13 (27%) eyes, bleb manipulations in 15 (31%) (needling in 3 [6%], compression sutures in 2 [4%], laser suture lysis in 6 [12%], bleb revision in 5 [10%], and autologous blood injection in 2 [4%]), bleb defects in 6 (12%), inferior bleb location 6 (12%), and nasolacrimal duct obstruction in 1 (2%). The most common causative organisms were Streptococcus species in 15 eyes (31%) and Staphylococcus species in 11 eyes (22%). Final visual acuities in the vitrectomy group (n = 22) versus the initial tap group (n = 26) were as follows: > or = 20/40 (5% versus 15%), 20/50 to 20/400 (32% versus 54%), and < 5/200 (64% versus 31%). Eleven (22%) patients eventually underwent enucleation or evisceration secondary to pain and/or poor vision (light perception to no light perception). In 4 (11%) of the 38 eyes not enucleated, intraocular pressures were poorly controlled at last follow-up (>21 mmHg) after treatment of endophthalmitis. CONCLUSIONS: Streptococcus species and Staphylococcus species were the most common causative organisms in the current series of patients with delayed-onset bleb-associated endophthalmitis. Despite successful treatment of the infection, visual outcomes are generally poor.

Adult↗

Canalicular stenosis secondary to weekly versus every-3-weeks docetaxel in patients with metastatic breast cancer.

PURPOSE: To compare the frequency of canalicular stenosis as a side effect of weekly versus every-3-weeks docetaxel in patients with metastatic breast cancer. DESIGN: Retrospective nonrandomized comparative trial. PATIENTS AND METHODS: Eighteen patients enrolled in a phase II study of weekly docetaxel plus trastuzumab and 18 patients enrolled in a phase II study of every-3-weeks docetaxel plus doxorubicin were evaluated. Each patient underwent a comprehensive ophthalmologic examination, probing and irrigation of the nasolacrimal duct, and, in some instances, a nuclear lacrimal scan. MAIN OUTCOME MEASURES: If epiphora (excessive tearing) was reported by the patient, its time of onset was documented. In patients with epiphora, presence or absence of canalicular stenosis was evaluated on the basis of the findings on probing and irrigation. The duration of treatment with docetaxel, the dose frequency, and the cumulative dose of docetaxel were recorded in each case. RESULTS: Fourteen patients (77%) receiving weekly docetaxel plus trastuzumab had epiphora. Nine of these patients had significant anatomic narrowing of the canaliculi. Bicanalicular silicone intubation or dacryocystorhinostomy was recommended in all nine patients. Eight patients underwent surgery and experienced complete or near complete resolution of epiphora. Although two patients (11%) receiving every-3-weeks docetaxel plus doxorubicin reported transient symptoms of epiphora, neither patient was found to have narrowing of the canaliculi, and the epiphora was not severe enough to justify surgical intervention. The mean duration of docetaxel therapy for the patients in this study was 19 weeks. The mean cumulative dose of docetaxel was higher in patients with canalicular stenosis than in patients without this side effect. CONCLUSIONS: Canalicular stenosis was more common in patients receiving weekly docetaxel than in those receiving every-3-weeks docetaxel for metastatic breast cancer. Bicanalicular silicone intubation early in the course of weekly docetaxel therapy should be considered, because this intervention can prevent complete closure of the canaliculi. Once complete or near complete stenosis of the canaliculi occurs, placement of a permanent Pyrex glass tube may become necessary to overcome the blockage of tear outflow.

Adult↗

Functional and anatomic results after two types of endoscopic endonasal dacryocystorhinostomy: surgical and holmium laser.

PURPOSE: To determine subjective and objective outcomes after two types of endoscopic endonasal dacryocystorhinostomy (DCR) and to evaluate the use of the functional endoscopic dye test (FEDT). DESIGN: Prospective, nonrandomized trial. PARTICIPANTS: Sixty-nine consecutive adult patients with primary acquired nasolacrimal duct obstruction. METHODS: Patients underwent primary endonasal surgical or laser (Holmium:yttrium-aluminum-garnet [YAG]) DCR with temporary silicone intubation. MAIN OBJECTIVE MEASURES: Data were collected 6 months after surgery (at least 3 months after removal of tubes). Subjective results were based on the patients' symptoms of epiphora. Objective results consisted of (1) lacrimal system irrigation, (2) FEDT-this test is positive when dye placed in the conjunctival fornix is observed to enter the nasal space via the DCR rhinostomy, and (3) rhinostomy appearance. RESULTS: Thirty-six patients had endosurgical and 33 had endolaser (Holmium:YAG) DCR. Symptomatic success was 83% after endosurgical and 71% after endolaser DCR. Lacrimal irrigation was a good test after surgery for identifying patients with successful or unsuccessful outcome (sensitivity, 98%; specificity, 87%). The FEDT had a few false negatives and small number of false positives (sensitivity, 83%; specificity, 91%). CONCLUSIONS: Endoscopic endonasal DCR performed surgically had better results than those achieved with Holmium:YAG laser alone (but did not reach statistical significance). The FEDT is useful in assessing rhinostomy patency and understanding the effects of surgery but was not as good as lacrimal irrigation in predicting symptomatic success.

Adolescent↗

Tarsal-conjunctival disease associated with Wegener's granulomatosis.

OBJECTIVE: To describe the clinical characteristics of tarsal-conjunctival disease in a cohort of patients with Wegener's granulomatosis (WG). DESIGN: Retrospective, case-controlled study. PARTICIPANTS: The medical records of 82 consecutive WG patients who underwent an eye examination between January 1996 and June 2002 at the National Institutes of Health were reviewed. METHODS: Details of the ophthalmic examination, results of medical therapy, and histopathologic analysis results were recorded. Tarsal-conjunctival disease was defined by (1). conjunctival hyperemia and granuloma formation, areas of necrosis, or active fibrovascular changes in the tarsus or conjunctiva, or (2). evidence of inactive fibrovascular scar. The association of tarsal-conjunctival disease with major organ system involvement was assessed using Bayesian methods. MAIN OUTCOME MEASURES: The occurrence and clinical characteristics of tarsal-conjunctival disease in a cohort of patients with WG and associations with major organ system involvement. RESULTS: Tarsal-conjunctival disease occurred in 13 of 82 patients (16%) with WG examined over a 6.5-year period. The palpebral surface of the upper lid was involved most commonly, showing conjunctival hyperemia in seven patients, granulomatous lesions in three patients, tarsal-conjunctival necrosis in four patients, active fibrovascular proliferation in six patients, and inactive fibrous scar tissue in seven patients. Histopathologic analysis of eyelid biopsy specimens showed granulomatous inflammation, focal necrosis, and areas of occlusive vasculitis in the tarsus and conjunctiva. In reviewing the patterns of organ involvement in patients with and without tarsal-conjunctival disease, the association of subglottic stenosis and nasolacrimal duct obstruction with tarsal-conjunctival disease showed a high probability of clinical significance. CONCLUSIONS: Tarsal-conjunctival disease, a previously uncommon finding in patients with WG, was characterized by inflammation of the palpebral conjunctiva and tarsus followed by a fibrovascular proliferation and scar formation. Because of the important association of tarsal-conjunctival disease with subglottic stenosis, which can progress and lead to laryngeal obstruction and respiratory failure, patients with tarsal-conjunctival disease should be referred to an otolaryngologist for evaluation.

Adult↗

Lacrimal system complications in trachoma.

A clinical study of the lacrimal complications of trachoma was conducted in the eastern province of Saudi Arabia. Of the 579 Saudi Arabian patients examined, 446 (77%) showed clinical evidence of trachoma, 62 of whom had severe inactive trachoma. In this last group the following lacrimal complications were observed: dry eye syndrome, punctal phimosis, punctal occlusion, canalicular occlusion, nasolacrimal-duct obstruction, dacryocystitis, dacryocystocele, and dacryocutaneous fistula. Histopathologic examination of seven lacrimal-sac biopsies showed the same cicatrizing changes seen in 14 conjunctival biopsies.

Aged↗

Ocular complications of Wegener's granulomatosis.

140 patients with biopsy-proven Wegener's granulomatosis were examined during a 16-year period at the Mayo Clinic. Forty patients had diverse and explosive ophthalmic involvement, including conjunctivitis, episcleritis, scleritis, corneal ulceration, uveitis, retinal vasculitis, optic neuropathy, orbital mass, orbital cellulitis, and obstruction of the nasolacrimal duct. The multiple ophthalmic and systemic complications in these 40 patients and the importance of establishing the pathologic diagnosis are discussed. Treatment with corticosteroids and immunosuppressive agents has dramatically improved the prognosis, although substantial mortality (four patients died of Wegener's granulomatosis) and ocular morbidity (three eyes were enucleated) are still associated with this disease.

Adolescent↗

Fibrous dysplasia of the orbit in childhood. Clinical features and management.

In 16 children with orbitocranial fibrous dysplasia confirmed histopathologically, facial asymmetry, orbital dystopia, and unilateral proptosis were the main presenting problems. Five children had radiological evidence of narrowing of the optic canal but only two developed optic atrophy and visual loss. One patient had persistent epiphora due to involvement of the bony nasolacrimal duct. Sixteen patients were treated by excision of the dysplastic bone and 15 had immediate craniofacial reconstruction. A good cosmetic and functional result was achieved in the majority of cases although transient vertical diplopia and minor degrees of ptosis occurred postoperatively in about a third. Fibrous dysplasia of the orbit is progressive in childhood and is best managed by radical surgery and reconstruction in a specialized craniofacial unit.

Adolescent↗

Epidemic keratoconjunctivitis and lacrimal excretory system obstruction.

Epiphora is a common symptom associated with the acute phase of epidemic keratoconjunctivitis (EKC). Reflex lacrimal secretion occurs secondary to conjunctival or corneal inflammation. Acquired obstruction of the lacrimal excretory system may account for persistence of tearing after resolution of the acute inflammatory phase of the viral infection. Three cases of lacrimal excretory system obstruction after EKC are reported. Multifocal obstruction of the canaliculi and nasolacrimal duct is characteristic. Dacryocystorhinostomy (DCR) was required to relieve obstruction in all cases. Probing and corticosteroid irrigation may avoid the need for silicone intubation or conjunctivodacryocystorhinostomy in the management of canalicular obstruction. Persistent epiphora after EKC should raise clinical suspicion of acquired dacryostenosis. Early recognition may allow for optimal management.

Adult↗

Efficacy of the primary dye test.

A primary dye test was performed on the right lacrimal system of 25 normal subjects by three physicians of differing levels of experience in performing the test. The frequency of positive primary dye tests for each of the three examiners was higher than previously reported. The most experienced examiner had the highest percentage (100%) of positive primary dye tests, and the least experienced examiner had the lowest percentage (80%) of positive tests. However, variation between the most experienced examiner and the other two was due, at least in part, to a difference in fluorescein instillation. Therefore, the effect of experience could not be ascertained. The most experienced examiner used four moistened fluorescein strips medially and each used a 10-minute interval after dye instillation before looking for evidence of dye passage through the nasolacrimal duct. Twenty-one (84%) of the subjects had a positive primary dye test on initial blowing of the nose. This indicates that even inexperienced examiners can expect to detect a high percentage of functioning lacrimal drainage system with the method of the experienced examiner.

Adult↗

Atypical presentation of fungal dacryocystitis. A report of two cases.

BACKGROUND: Candida albicans has only rarely been implicated in nasolacrimal duct obstruction. Its association with dacryoliths is well known, but it is unclear whether it is an etiologic factor or is present as a result of the obstruction. FINDINGS: The authors report 2 cases of fungal dacryocystitis that were not associated with dacryolith formation and where Candida species appear to be the primary etiologic agent. CONCLUSION: The possibility of a fungal infection should be considered in the evaluation of "routine" chronic dacryocystitis, particularly in the presence of corneal ulceration or postoperative endophthalmitis, as prompt initiation of appropriate therapy may be crucial.

Aged↗

Periocular atypical mycobacterial infections.

OBJECTIVE: To examine the clinical characteristics and management of periocular infections caused by atypical mycobacteria. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Six patients were identified with periocular atypical mycobacterial infections: four with Mycobacterium chelonae and two with Mycobacterium fortuitum. INTERVENTION: The treatment of these infections included removal of the foreign bodies with debridement of the lesions. Specimens were sent for histopathologic examination, routine cultures, and fresh tissue for culture after homogenization. MAIN OUTCOME MEASURES: A retrospective review of culture-proven atypical mycobacterial infections involving the periocular tissues was performed. Charts were reviewed for age, gender, infectious organism, medical history, surgical history, presenting symptoms, clinical features, and treatment. RESULTS: Four associations with infection were identified in these patients: immunosuppression, nasolacrimal duct obstruction, the presence of a foreign body, and a history of recent surgery. All six of the patients had at least one of these associations and five of the patients had at least two. Clinical characteristics that may distinguish atypical mycobacterial infections from acute bacterial infections include subacute presentation, firm nodular lesions, mild erythema, mild tenderness, and minimal purulent discharge. All patients had resolution of their infections after debridement and several weeks of systemic antibiotic therapy guided by susceptibility testing. CONCLUSIONS: Periocular atypical mycobacterial infections are uncommon. The clinical history and examination can raise the suspicion of this infection by revealing the clinical characteristics of these infections. Treatment includes removal of foreign bodies, debridement, and long-term systemic antibiotic therapy.

Adult↗

Supernumerary nostril: a rare congenital deformity.

Duplication anomalies of the nose include polyhinia (double nose) and supernumerary nostril (assessory nostril). These are rare congenital nasal deformities resulting from aberrant embryological development. Differential diagnoses include glioma, encephalocele, nasal dermoid, nasolacrimal duct duplication, mid facial cleft and proboscis lateralis (K. Nakamura, T. Onizuka. Plast. Reconstr. Surg. 80 (3) (1987) 436-441). Our review of the English language literature revealed eight reported cases of duplication anomalies of the nose. Four of these were cases of polyrhinia (double nose). Of the cases remaining, one patient had a supernumerary nostril in association with a cleft lip, leaving only three reported cases of an isolated supernumerary nostril. We present a newborn infant with an isolated right supernumerary nostril. MRI, CT and photographic documentation are provided. Pertinent embryology, anatomy and a thorough review of the literature are included.

Humans↗

[Nasal fossae hemangiopericytoma revealed by acute dacryocystitis].

We report a 42-year-old woman with a hemangiopericytoma tumor located in nasal fossae, revealed by acute dacryocystitis. Clinical rhinoscopic examination and orbitofacial tomodensitometry showed tumefaction of the lacrimal sac and nasolacrimal duct. We removed the tumor by endonasal surgery. The anatomopathology examination confirmed the diagnosis of hemangiopericytoma. The internal canthus area and the maxillary sinus roof were treated with complementary irradiation.

Acute Disease↗

Canine and feline primary ocular bacterial infections.

Bacterial infections are frequently associated with diseases of the eyelids, cornea, and conjunctiva. Animals sustaining KCS commonly have bacterial infections of the external eye owing to a lack of antimicrobial properties present in the normal tearfilm. Infection can occur in the nasolacrimal duct or lacrimal sac, which is referred to as dacryocystitis. Severe corneal ulcers are frequently infected with bacteria, especially Pseudomonas sp. Three new topical ophthalmic antibiotics have recently become commercially available: ciprofloxacin, norfloxacin, and ofloxacin.

Animals↗