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[Current treatments of xerophthalmia in Sjögren's syndrome].

PURPOSE: To describe the large variety of treatments currently used in Sjögren's syndrome for one of its major manifestations, keratoconjunctivitis sicca or xerophthalmia. CURRENT KNOWLEDGE AND KEY POINTS: Sjögren's syndrome causes a diffuse immunoinflammatory disturbance of main lacrimal glands and the whole ocular surface. Dry eye syndrome is responsible for chronic and deep impairment of quality of life. Many different tear substitutes have been widely developed that are poorly efficient for relieving patients from their complaints. Tear substitutes of various viscosity from standard artificial tears to synthetic gels may be used. Hyaluronic acid is currently the most promising tear substitute, but all eye drops and gels are only efficient in mild to moderate dry eyes and keratoconjunctivitis sicca mostly resists to lubricants. Moreover, the latter may increase patients' complaints when they are associated to preservatives, antiseptic drugs that have widely demonstrated their toxic or irritating potential. Preservatives are, therefore, to be avoided whenever possible in keratoconjunctivitis sicca, by using monodose disposable packaging or specific bottle filtering or eliminating the preservative. Stimulation of lacrimal and salivary secretions with systemic pilocarpine, or obturation of lacrimal puncta in order to limit the drainage of tears in lachrymal ducts may be useful in most severe forms of Sjögren's syndrome. However, the development of topical cyclosporine and other immunomodulating agents is the most relevant progress in the treatment of keratoconjunctivitis sicca in Sjögren's syndrome. PERSPECTIVES: The future for treating Sjögren's syndrome is most likely to pass through the use of new drugs capable of treating the disease or at least its mechanisms, and not only to try to relieve symptoms with poorly efficient tear substitutes.

Administration, Topical↗

Treatment of corneal xerophthalmia with topical retinoic acid.

Retinoic acid 0.1% in arachis oil was applied to one eye and arachis oil alone to the other eye, of each of 19 patients with equivalent degrees of corneal xerophthalmia in the fellow eyes. Even with concomitant systemic vitamin A therapy, topical retinoic acid was associated with more rapid healing of corneal lesions in a substantial proportion of cases. Application of retinoic acid three times a day produced no significant side effects; application five times a day, however, resulted in moderate to severe conjunctival injection and increased corneal vascularization and scarring.

Administration, Topical↗

Xerophthalmia, protein-calorie malnutrition, and infections in children.

All children with evidence of xerophthalmia who were admitted to an inpatient facility for treatment of severe protein-calorie malnutrition and its complications were compared to other inpatients with severe PCM but free from signs or symptoms of vitamin A deficiency. Xerophthalmic inpatients were older and had more severe hypoproteinemia than inpatients without eye signs, and were more undernourished by anthropometric criteria than a comparison group matched for age, sex, and type of PCM. Children with more severe eye lesions were more retarded in growth than those with minimal ocular signs. All inpatients had high rates of bacterial infections, regardless of their vitamin status. However, xerophthalmic children had a highly significant increase in the rate of positive urine cultures. Mortality rates were similar in all study groups.

Bacterial Infections↗

History of nightblindness: a simple tool for xerophthalmia screening.

Among 5925 preschool-age children examined in a house to house rural field study, X1B (Bitot's spot with xerosis) and/or an history of nightblindness (XN) was presented in 325. Mean serum vitamin A levels among those with isolated XN (13.9 microgram/dl), isolated X1B (13.4 micrograms/dl), and coexistent XN/X1B (12.1 microgram/dl) were similar, and significantly below that of normal age/sex/neighborhood matched controls (17.6, 17.1, and 18.3 microgram/dl, respectively). The mean serum vitamin A level of the matched controls was significantly below that of normal, randomly sampled children from the study population as a whole (20.6 microgarm/dl). As independent screening criteria, disregarding the presence of absence of other signs, twice as many children had a history of XN as had X1B (84 and 41% of all clinically abnormal children, respectively). Of randomly sampled children 55% but only 15% of cases of XN had serum vitamin A levels above 20 microgram/dl. Of children with a history of nightblindness 97% had impaired scotopic vision on objective testing, but the mean serum vitamin A levels among test positives and negatives were identical. These results suggest a properly eleicited history of nightblindness can be almost as specific and far more sensitive an index of vitamin A deficiency and early xerophthalmia than the prescence of Bitot's spots (X1B), and that vitamin A deficiency is a clustered, neighborhood phenomenon rather than an isolated, sporadic occurrence.

Child↗

"Practical suggestions on facial plastic surgery--how I do it". Parotid duct transfer in xerophthalmia.

Xerophthalmia, or dry eye, is an old human affliction. Among the many causes are trachoma, surgical or traumatic destruction of the lacrimal gland, and paralysis of the greater superficial petrosal nerve after Bell's palsy or from the presence or removal of an intracranial posterior fossa tumor. The technique of parotid duct transfer is a well established effective means to rehabilitate the dry eye. A method of parotid duct transfer is described.

Eyelids↗

The efficacy of retinoic acid ointment for treatment of xerophthalmia and corneal epithelial wounds.

In previous studies of topical application of retinoic acid to the eye, retinoic acid in an oil vehicle has been used. An all-trans-retinoic acid (Tretinoin, USP) formulation in a petrolatum-based ophthalmic ointment vehicle has now been developed which is chemically stable for at least one year. The ointment is effective at retinoic acid concentrations of 0.01-0.1% in reversing corneal keratinization in vitamin A-deficient, xerophthalmic rabbits. At 0.1% it also stimulates the healing rate of corneal epithelial wounds in rabbits and monkeys. Retinoic acid ointment may prove to be valuable clinically in the treatment of xerophthalmia, corneal epithelial erosions, and related ocular surface abnormalities.

Animals↗

Treatment of corneal xerophthalmia in rabbits with micromolar doses of topical retinoic acid.

Several reports have appeared on the efficacy of topically applied 0.01% or 0.1% all-trans retinoic acid (0.04-0.4 millimolar) for treatment of xerophthalmia, conjunctival squamous metaplasia, and corneal epithelial erosions in humans and animals. An observation common to many of these studies is the occurrence of an adverse reaction to retinoic acid in the form of lid margin hyperemia and blepharoconjunctivitis. Since retinoic acid is biologically active at micromolar to nanomolar concentrations, it may be possible to reduce side effects while maintaining therapeutic effectiveness by reducing the retinoic acid concentration in ophthalmic formulations. In the present study, topical 0.005% retinoic acid in petrolatum ointment reversed corneal keratinization in xerophthalmic, vitamin A-deficient rabbits in 3-4 days while 0.0005% (2 micromolar) retinoic acid ointment was effective in 4-6 days. Further clinical trials of topical retinoic acid for treatment of ocular surface disease should be conducted using micromolar concentrations of retinoic acid which are expected to maintain a therapeutic effect while reducing adverse reactions.

Administration, Topical↗

[Treatment of xerophthalmia by transplantation of autologous vascularized submandibular gland].

OBJECTIVE: To investigate the feasibility of treatment of xerophthalmia by transplantation of autologous vascularized submandibular gland (SMG). METHODS: The SMGs of 19 patients with severe keratoconjunctivitis were transferred to their temporal region by microsurgery. The arteries and veins of the SMGs were anastomosed to the super-temporal arteries and veins, the SMG ducts were implanted into the conjunctival fornix of the eye. The saliva secreted by the SMG was used as the substitute of tear. RESULTS: The transplantation succeeded in 14 patients and failed in 4. Follow up lastred for 3 months to 2 years. The symptom of corneal xerosis disappeared, the symptoms of photophobia and anemophobia were alleviated, and artificial tear substitutes were not used any more. Epiphora appeared in 4 cases and disappeared after partial resection of the transplanted gland. Atresia of orifice occurred in one case and was cured by reconstruction of the duct. CONCLUSION: Transplantation of autologous vascularized SMG is effective in treating severe keratoconjunctivitis sicca.

Adolescent↗

Detection of early xerophthalmia by impression cytology and rose Bengal staining--a comparative study.

Twenty two cases were studied for early detection of Xerophthalmia by impression cytology and Rose Bengal staining. Patients were below 6 years of age and admitted in the paediatric ward of Dhaka Medical College Hospital. Assessment were done by conjunctival impression cytology and staining with 1% Rose Bengal dye. Estimation of serum retinol level was done by HPLC to correlate conjunctival findings with biochemical status. The mean age of the subjects were 3.15 +/- 1.75. Rose Bengal staining was positive in 40% cases and impression cytology was in 60% cases. The mean serum retinol level of the diseased children were 10.5 +/- 3. ug/dl. The sensitivity of Rose Bengal staining was 53.3% and that of impression cytology was 80% in detecting vitamin A deficiency when compared with serum retinol level. The specificity of Rose Bengal staining was 40% and that of impression cytology was 100%. Sensitivity of impression cytology was 100% in patient with retinol level 10 ug/dl.

Child, Preschool↗

[Effect of integral syndrome differentiation acupuncture on the tear film stability in the patient of xerophthalmia].

OBJECTIVE: To probe into a treatment method for increasing clinical therapeutic effect on xerophthalmia. METHODS: Forty-five cases were randomly divided into acupuncture group 1, acupuncture group 2 and control group. The acupuncture group 1 were treated with acupuncture based on syndrome types, and the acupuncture group 2 with acupuncture at local acupoints, and the control group with dripping of artificial tears. Local symptoms of eyes, S1T, BUT and FL were observed before and after treatment. RESULTS: S1T and BUT increased after treatment in the two groups (P < 0.01, P < 0.05), but did not significantly change in the control group (P > 0.05). There were significant differences in change of FL as the control group compared with the acupuncture group 1 and 2. The total effective rate was 86.7%, 66.7% and 33.3% in the acupuncture group 1, 2 and the control group, respectively. CONCLUSION: The integral syndrome differentiation acupuncture can improve secretion of tear, increase stability of tear film, improve local symptoms of eyes with a therapeutic effect better than acupuncture at local acupoints and artificial tears.

Acupuncture Points↗

Modified classification of xerophthalmia.

"There are many classifications of xerophthalmia in existence. In the present study all these classification have been exhaustively reviewed. Many objections to previous classifications have been raised following experiences with these classifications for over six years. Based on these objections a self explanatory, easy to remember and modified classification has been proposed, which will be of use in wider areas."

Humans↗

[Xerophthalmia caused by self-induced deficiency].

The case is described of a 36 years old woman with bilateral xerophthalmia secondary to his diet. She presented a perforation of the left cornea which required an emergency penetrating keratoplasty. The treatment is described.

Adult↗

Advanced xerophthalmia as a presenting sign in cystic fibrosis.

Xerophthalmia is a common complication of vitamin A deficiency in communities where malnutrition is found. We report on a 16-month-old infant with severe photophobia and failure to thrive. On examination, her major presenting sign was corneal xerosis, with corneal and conjunctival keratinization, and corneal stromal edema with opacification. Based on these findings, vitamin A deficiency secondary to fat malabsorption was suspected, and a workup confirmed the diagnosis of cystic fibrosis. With parenteral vitamin A supplementation, she had complete resolution of her ocular signs and symptoms. This case illustrates the value of a complete ophthalmic examination in the diagnosis of fat malabsorption syndromes.

Conjunctival Diseases↗

Food consumption of children with and without xerophthalmia in rural Tanzania.

Food intake of 26 children (4-9 years old) of whom nine had xerophthalmic eye lesions (Bitot's spots), was recorded over a period of four days. The principal staple foods were maize and sweet potatoes, while sorghum and cassava were also used as staple foods. The intake of energy was rather low partly due to the bulkiness of the diet. Protein intake was above the recommended intake but mainly derived from vegetable sources. The intake of retinol, beta-carotene, folic acid and iron was low in all children especially those with xerophthalmia. Dried green leafy vegetables contributed about 20% of the total beta-carotene intake during the period that the survey was carried out.

Child↗

[Epidemiological aspects of xerophthalmia in Chad].

An epidemiologic survey by random cluster sampling was carried out in Chad. Its purpose was to evaluate the importance of xerophthalmia. 3.002 children under 10 years of age were surveyed for two different periods: in 1984 after the drought striking the Sahelian zone and in 1985 after a normal crop. Computerization of the results according to nutritional circumstances and geographical distribution demonstrated that avitaminosis is a true Public Health problem, whatever climatic zones, food products and nutritional conditions are. However situation worsens during a drought and calls for an emergency distribution of vitamin A to the most-in-need populations.

Chad↗

[Xerophthalmia. Identification of populations at intermediate risk].

In developing countries, vitamin A deficiency (VAD) is a major contributor to child blindness and is associated with increased mortality. We assessed the vitamin A status of a Sahelien population and evaluated the correlation between the various criteria used to score xerophthalmia. The survey was carried out between June 1992 (the end of the dry season) using a representative sample of 906 children between the ages of 3 and 7 years in the district of Douentza. The population sample was selected by a two stage cluster sampling method (villages and then households). Vitamin A status was evaluated using clinical, histological and nutritional criteria. Clinical examination included testing for night blindness (XN), Bitot's spots (X1B) and corneal scars (XS). The Impression Cytology with Transfer (ICT) test described by Amedee-Manesme was used for histological analysis. Cases of follicular trachoma were recorded because of the possible influence of active trachoma on the findings of the ICT test. Nutritional status was determined by measuring the height for weight ratio according to the National Center for Health Statistics criteria. The prevalence of XN was 2.7% (1.6-3.7), significantly higher than the WHO threshold for a public health problem. The prevalence of X1B was 0.5% (0.1-1.2), and no corneal scars were detected. 31.7% of the children were suffering from malnutrition, but malnutrition did not correlate with any of the ophthalmological indicators of a public health problem. Among the 842 readable ICT tests, 265 were abnormal (31.4% of the total, 28.2-34.5). This incidence of abnormal results was unexpectedly low, in the light of the clinical results, and well below the threshold value of 50% suggested by Carlier.(ABSTRACT TRUNCATED AT 250 WORDS)

Africa, Northern↗

Vitamin A-responsive panocular xerophthalmia in a healthy adult.

An unusual case of classical xerophthalmia occurred in an otherwise healthy, well-nourished, 25-year-old woman. She had marked conjunctival and corneal xerosis, including early stromal edema, evolving pigmentary alterations of the retinal pigment epithelium, and notable constriction of her visual fields, which paralleled the distribution of the retinal lesions. Abnormalities of the conjunctiva, cornea, and visual fields disappeared within two weeks of oral vitamin A therapy, and 1 1/2 months later, many of the retinal lesions cleared as well. This case supports the primacy of isolated vitamin A deficiency in the etiology of corneal xerosis and "fundus xerophthalmicus"; demonstrates that stromal edema is an important early component of corneal involvement; and localizes the funduscopic abnormalities to the retinal pigment epithelium.

Adult↗