Angiogenin for the Diagnosis and Grading of Dry Eye Syndrome

PURPOSE: To investigate the properties of angiogenin (ANG) as a potential tool for the diagnosis and grading of dry eye syndrome (DES) by analyzing tear protein profiles. METHODS: Tear samples were collected with capillary tubes from 52 DES patients and 29 normal individuals as controls. Tear protein profiles were analyzed with an immunodot blot assay as a screening test. To confirm that the tear ANG levels were in inverse proportion to the disease severity grade, the ANG and lactoferrin (LF) tear contents of normal controls and DES patients were compared in an enzyme-linked immunosorbent assay. RESULTS: In the immunodot blot assay, the ANG area was lower in patients with grades 3 and 4 DES than in normal controls. The areas of basic fibroblast growth factor, transforming growth factor β2, and interleukin 10 were significantly greater than those of normal controls only in grade 4 DES patients, but these proteins were not linearly correlated with dry eye severity. Upon enzyme-linked immunosorbent assay analysis, the mean concentrations of ANG and LF decreased significantly as dry eye severity increased, except between grades 1 and 2. In addition, the ratios of ANG and LF to total tear proteins were correlated significantly with DES severity. CONCLUSIONS: ANG level was significantly lower in DES patients than in normal controls, and was significantly correlated with the worsening severity of DES, except between grades 1 and 2, as was LF. Therefore, ANG may be a useful measure of DES severity through proteomic analysis.

Deep Anterior Lamellar Keratoplasty Using Irradiated Acellular Cornea with Amniotic Membrane Transplantation for Intractable Ocular Surface Diseases

PURPOSE: To report the clinical outcomes of deep anterior lamellar keratoplasty (DALK) when sterile gamma-irradiated acellular corneal tissues (VisionGraft) are used in combination with amniotic membrane transplantation (AMT) for intractable ocular surface diseases. METHODS: The medical records of fifteen patients who had DALK with AMT were retrospectively reviewed. Indications for surgery included ocular burn, bacterial keratitis, herpes simplex virus keratitis, corneal opacity with Stevens-Johnson syndrome, Mooren's ulcer, idiopathic myxoid degeneration of corneal stroma, and recurrent band keratopathy. DALK was performed using partial-thickness acellular corneal tissue and a temporary amniotic membrane patch was added at the end of the operation. RESULTS: All cases that underwent DALK with AMT became epithelialized within 2 postoperative weeks. Twelve patients showed favorable outcomes without graft rejection, corneal opacification, or neovascularization. The other three grafts developed corneal opacification and neovascularization, and required additional penetrating keratoplasty (PK). Unlike the results of previous PKs, there were no graft rejections and the graft clarity was well-maintained in these three cases for at least 8 months after PK. CONCLUSIONS: DALK using sterile acellular corneal tissues in combination with AMT may be a good therapeutic strategy for treating intractable ocular surface diseases because of lowered immune rejection, fibroblast activation, and facilitation of epithelialization. Furthermore, DALK can help stabilize the ocular surface, prolong graft survival, and may allow better outcomes when combined with subsequent PK.

Treatment of an 8-mm Myxoma Using Acellular Corneal Tissue

A myxoma is a benign tumor found in the heart and in various soft tissues; however, a corneal myxoma is rare. A mucinous mass of unknown etiology was observed on the left cornea of a 32-year-old male patient. We performed deep anterior lamellar keratoplasty using acellular corneal tissue and concurrent amniotic membrane transplantation. Hematoxylin and eosin staining revealed vacuolation of the parenchyma and myxoid change in the corneal tissue that occurred in the anterior half of the corneal parenchyma. We identified a myxoid stroma by Alcian blue staining and observed collagen fibers with denatured stroma by Masson trichrome staining. The patient's visual acuity improved from light perception to 20 / 200, and the intraocular pressure remained within the normal range for one year after surgery. The transplanted cornea survived successfully with well-maintained transparency, and recurrence was not observed one year after surgery.

Treatment of an 8-mm Myxoma Using Acellular Corneal Tissue

A myxoma is a benign tumor found in the heart and in various soft tissues; however, a corneal myxoma is rare. A mucinous mass of unknown etiology was observed on the left cornea of a 32-year-old male patient. We performed deep anterior lamellar keratoplasty using acellular corneal tissue and concurrent amniotic membrane transplantation. Hematoxylin and eosin staining revealed vacuolation of the parenchyma and myxoid change in the corneal tissue that occurred in the anterior half of the corneal parenchyma. We identified a myxoid stroma by Alcian blue staining and observed collagen fibers with denatured stroma by Masson trichrome staining. The patient's visual acuity improved from light perception to 20 / 200, and the intraocular pressure remained within the normal range for one year after surgery. The transplanted cornea survived successfully with well-maintained transparency, and recurrence was not observed one year after surgery.

Two Cases of Superior Limbic Keratoconjunctivitis Treated with Bevacizumab and Triamcinolone Injection

PURPOSE: To report two cases of intractable superior limbic keratoconjunctivitis (SLK) treated with bevacizumab and triamcinolone injection. CASE SUMMARY: A 69-year-old female visited our clinic with pain in the left eye for 3 days and was diagnosed with SLK in her left eye. After 3 months of using steroid eye drops, artificial tears, and oral steroid intermittently, there was no improvement in symptoms and signs, thus this case was considered intractable with the conventional therapy. A mixture of bevacizumab (0.15 cc) and triamcinolone (0.05 cc) was injected into the sub-tenon's capsule of the left eye. After 1 week, all symptoms and signs disappeared, and there was no recurrence for 6 months. A 55-year-old female was transferred to our clinic due to SLK that did not respond to artificial tears, steroid eye drops, punctal occlusion, and botox injection for 3 months. A mixture of bevacizumab (0.15 cc) and triamcinolone (0.05 cc) was injected into the sub-tenon's capsule of the left eye. After 2 weeks, all symptoms and signs were improved, and there was no recurrence for 4 months. CONCLUSIONS: The presented 2 SLK cases are meaningful, because neovascularization disappeared and controlled inflammation was obtained following sub-tenon injection with both bevacizumab and triamcinolone.

Clinical Usefulness of the Phenol Red Thread Test as Diagnostic Tool in Dry Eye Patient

PURPOSE: To evaluate the clinical usefulness of the phenol red thread test as a diagnostic tool of dry eye by comparing the phenol red thread test, Schirmer's test and tear break-up time. METHODS: The present study included 30 dry eye patients belonging to dry eye workshop grade 1 or 2 and 25 normal subjects. Phenol red thread test, Schirmer's test, and tear break-up time were performed on each subject's right eye. The sensitivity, specificity and repeatability of each test were compared, and the correlations between the 3 tests were also analyzed. RESULTS: Tear break-up time was superior to the other tests in terms of sensitivity and repeatability. The phenol red thread test was better than Schirmer's test in terms of specificity and repeatability. In all 55 patients including dry eye patients and normal subjects, the phenol red thread test showed a greater correlation with tear break-up time than did Schirmer's test. In addition, in 25 dry eye patients, the correlation between the phenol red thread test and Schirmer's test increased significantly. CONCLUSIONS: The phenol red thread test is less irritating and requires a shorter testing time than Schirmer's test. Additionally, the phenol red thread test is superior to Schirmer's test in terms of specificity, repeatability, and relation to tear break-up time. In addition, the correlation between the phenol red thread test and Schirmer's test significantly increases in dry eye patients. Therefore, the phenol red thread test is a good substitute option for Schirmer's test in diagnosing dry eye.

Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis

The purpose of this study was to evaluate the relation between ocular discomfort and ocular Demodex infestation, and therapeutic effects of tea tree oil (TTO) in Demodex blepharitis patients. Three hundred and thirty-five patients with ocular discomfort were evaluated for ocular Demodex infestation and subjective symptoms with ocular surface discomfort index (OSDI) score. Among them, Demodex-infested patients were randomized to receive either eyelid scrubbing with TTO (TTO group,106 patients) or without TTO (Control group, 54 patients) for 1 month. Demodex were found in 84% of patients with ocular discomfort. The number of Demodex was significantly correlated with age (P = 0.04) and OSDI score (P = 0.024). After eyelid scrub treatment, Demodex count was reduced from 4.0 +/- 2.5 to 3.2 +/- 2.3 in the TTO group (P = 0.004) and from 4.3 +/- 2.7 to 4.2 +/- 2.5 in the control group (P = 0.27). Also, OSDI score was reduced from 34.5 +/- 10.7 to 24.1 +/- 11.9 in the TTO group (P = 0.001) and from 35.3 +/- 11.6 to 27.5 +/- 12.8 in the control group (P = 0.04). In conclusion, Demodex number showed a significant positive correlation with age and subjective ocular discomfort. The tea tree oil eyelid scrub treatment is effective for eliminating ocular Demodex and improving subjective ocular symptoms.

Two Clinical Manifestations of Anterior Segment Associated with Systemic Lupus Erythematosus

PURPOSE: To report the clinical course and results of two cases of anterior segment manifestations associated with systemic lupus erythematosus (SLE). CASE SUMMARY: The first case was a 63-year-old female patient who was diagnosed with corneal ulcer and symblepharon on her left eye and dry eye in both eyes. Although the patient was treated with topical antibiotics, autologous serum and artificial tears, amniotic membrane transplantation and symblepharon removal were subsequently required. At 1 month after medical and surgical treatment, the corneal ulcer improved, but a descemetocele was formed because of persistent corneal thinning. The second case was a 24-year-old female patient diagnosed with filamentary keratitis and recurrent corneal erosion in both eyes and uveitis in her left eye. After treatment with therapeutic contact lenses, topical antibiotics and steroids, her symptoms were slightly improved. After 6 months of treatment, filamentary keratitis and corneal erosion recurred to being intractable. The patient received systemic evaluation and was diagnosed with SLE. After a combined therapy of oral and topical treatments, filamentary keratitis and recurrent corneal erosion improved significantly. CONCLUSIONS: Clinical manifestations of anterior segment associated with SLE rarely respond to topical treatment and are apt to recur easily; therefore, systemic treatment should be applied for better prognosis. Thus, the therapeutic strategy in intractable ocular diseases should be designed with consideration of accompanying systemic diseases.