Microvascular autologous transplantation of partial submandibular gland for severe keratoconjunctivitis sicca.

OBJECTIVE: To evaluate the feasibility of microvascular autologous transplantation of partial submandibular gland (SMG) to prevent or reduce epiphora in severe keratoconjunctivitis sicca (KCS). METHODS: A total of 39 patients with KCS, covering 42 eyes, were randomised to undergo transplantation of partial or total SMG from January 2006 to December 2009. Clinical data of survival rate of transplanted SMG, ophthalmologic features of best-corrected visual acuity, Schirmer test results, break-up time (BUT) of tear film, fluorescence staining, incidence of postoperative epiphora and frequency of subsequent surgery were compared between two groups. RESULTS: Total SMG transplantation was performed in 22 eyes, and partial SMG transplantation was performed in the other 20 eyes. All transplanted SMGs survived. Microvascular crisis occurred in one case of partial SMG transplantation, but the gland survived after exploration to remove the venous thrombus. Obstruction of the ductal orifice in one case of partial SMG transplantation was resolved by reconstruction of the ductal orifice. Symptoms of dry eyes disappeared, and patients were able to discontinue use of artificial tears. Severe epiphora occurred in 6 eyes undergoing partial SMG transplantation and in 19 eyes undergoing total SMG transplantation (p<0.01). Surgical reduction was performed in 6 eyes undergoing partial SMG transplantation and 18 eyes undergoing total SMG transplantation (p<0.01). CONCLUSIONS: Microvascular transplantation of partial SMG is feasible and effective for severe KCS and does not decrease the survival rate of transplanted SMG. For ample SMGs with normal function, transplantation of partial SMG alleviates the symptoms of dry eye and significantly reduces the incidence of severe postoperative epiphora.

[Transplantation of autologous labial salivary glands for severe dry eye].

OBJECTIVE: Autologous labial salivary gland transplantation has been a promising alternative for the treatment of severe dry eye. In this article, we describe the results of the ocular surface changes after labial salivary gland transplantation and investigate the feasibility of this treatment. METHODS: The results of this technique in 8 patients (eyes) who suffered from severe dry eye were prospectively analyzed after surgery (follow-up of 6 months). The best-corrected visual acuity, Schirmer I test, degree of discomfort, usage of pharmaceutical tear substitutes, tear interferometry and slit lamp examination were investigated at different time before and after surgery. RESULTS: All grafts remained viable and the survival rate is 100%. All patients showed significant increase in the Schirmer's test and they expressed great improvement in their ocular discomfort. The use of artificial tear substitutes was reduced because of the increased ocular surface lubrication. CONCLUSION: Although the authors' long-term experience still is limited, we believe that the procedure is a promising alternative approach for severe dry eye.

Mutation analysis of PAX6 in a Chinese family and a patient with a presumed sporadic case of congenital aniridia.

AIMS: Mutations in the PAX6 are the major cause of congenital aniridia. The objective of this study was to analyze genetic mutations in PAX6 in Chinese patients with congenital aniridia. METHODS: Total genomic DNA was isolated from the peripheral blood of the aniridia patients, all healthy family members and 100 healthy volunteers. The 14 exons (including alternatively spliced exon 5a) of the PAX6 gene were amplified by polymerase chain reaction, and the products were sequenced to identify the mutation. RESULTS: Two mutations of PAX6 were detected in exon 11 in the congenital aniridia patients. One mutation was caused by the duplication of the 4 nucleic acids CTCC (c.1286insCTCC), which would lead to a frameshift. The other mutation was caused by a transition from C to T (c.1311C → T), which would generate a stop codon. Neither mutation was present in the healthy family members or 100 healthy volunteers. CONCLUSION: We examined the exon sequence of the PAX6 gene in a Chinese family and an unrelated individual with aniridia. The predicted outcome of both mutations is premature termination. The mutation found in the unrelated individual has not previously been reported and represents a new addition to the spectrum of mutations in PAX6.

A comparison of cyclosporine 0.05% ophthalmic emulsion versus vehicle in Chinese patients with moderate to severe dry eye disease: an eight-week, multicenter, randomized, double-blind, parallel-group trial.

PURPOSE: The goals of this study were to compare the efficacy and safety profile of topical cyclosporine 0.05% versus vehicle in Chinese patients with moderate to severe dry eye disease. METHODS: In this multicenter, randomized, double-blind, vehicle-controlled, parallel-group study, 233 dry eye patients were allocated to receive either cyclosporine 0.05% or vehicle twice daily for 8 weeks. Primary outcome was the difference between groups, in total score of 4 symptoms and 4 signs change from baseline at weeks 2, 4, and 8. Changes in symptoms (ocular dryness, foreign body sensation, photophobia and burning) and signs (conjunctival hyperemia, Schirmer test, tear Break-up time (BUT), and corneal punctate fluorescein staining) at weeks 2, 4, and 8 as well as frequency of administration of concomitant artificial tears, were considered as secondary outcomes. The safety profile was evaluated by examining adverse events, changes in visual acuity, and ocular tolerance. RESULTS: Greater improvements of the total score were seen in cyclosporine 0.05% group than in the vehicle group at all follow-up times (P < 0.01). Improvements in ocular dryness at week 8 (P = 0.040) and foreign body sensation during weeks 4 and 8 (P < 0.020) were significantly greater with cyclosporine. In addition, compared with the vehicle, cyclosporine significantly improved 2 objective dry eye disease signs: corneal staining at weeks 4 (P = 0.025) and 8 (P = 0.050) and the Schirmer test at week 4 (P = 0.035). However, no between-group difference approached statistical significance in photophobia, burning, BUT value, conjunctival hyperemia and frequency of administration of concomitant artificial tears at any follow-up times (P > 0.05).The cumulative frequency of adverse events did not significantly differ between the groups (P = 0.519), which were 11.21% and 8.55%, respectively. There were no patients who experienced reduced visual acuity. CONCLUSION: Cyclosporine 0.05% ophthalmic emulsion is an effective and safe treatment for Chinese patients with moderate to severe dry eye disease.

[Initial clinical observation of tissue-engineered epithelium transplantation for treating corneal conjunctivalization caused by burn].

OBJECTIVE: To study the therapeutic results of tissue-engineered epithelium transplantation for corneal conjunctivalization caused by chemical and thermal burns. METHODS: Clinical case series. From December 2007 to May 2008, in Beijing Tongren Eye Center and Beijing Tongren Hospital, six patients (6 eyes) with chemical or thermal burn injury were treated by auto-transplantation of limbus stem cells cultured on fibrin gel membrane and followed up 6 to 12 months for clinical evaluation. The clinical outcomes included visual acuity, corneal clarity and neovascularization. RESULTS: In 5 of 6 eyes, the postoperative visual acuity was slightly improved. During followed up period, the corneal new-forming vessels were lessen than before, but one eye showed neovascularization recurrent. The corneal clarity in 5 eyes was improved. 4 eyes were covered with transparent epithelium, 2 eyes showed light corneal opacity. CONCLUSION: The ocular surface condition of corneal conjunctivalization caused by corneal burn could be improved in short period by tissue-engineered epithelium transplantation.

[Systematic review of penetrating keratoplasty rejection treated by immunosuppressants].

OBJECTIVE: To investigate the validity and side-effect of immunosuppressants for preventing and treating of immune rejection after penetrating keratoplasty (PKP). METHODS: Randomized and non-randomized controlled trials of immunosuppressants after PKP were searched from Pubmed, EMbase.com, Cochrane library, CNKI and Wanfang database; methodological quality and meta-analysis were carried out according to Evidence-Based Medicine(EBM). RESULTS: Thirty-one studies in all were evaluated, of which twenty-three were about the prevention, and nine were about the treatment after PKP. The rate of immune rejection after normal PKP is 4.9%-28.9% when using corticosteroids to prevent immune rejection, especially for long-time use. According to meta-analysis: the effectiveness of local cyclosporine A and local FK-506 in preventing immune rejection after PKP is significant, and FK-506 is more effective than CsA topically; systemic CsA and MMF could effectively prevent immune rejection after high-risk PKP; as far as treating immune rejection, corticosteroid, whether topical or systemic, was effective; however additional topical CsA could not improve the treatment effect. CONCLUSION: The use of immunosuppressants such as corticosteroids and CsA whether topical or systemic can effectively prevent the occurrence of immune rejection after high-risk PKP.

[Corneal stromal layer changes of senile cataract patients with phacoemulsification in vivo].

OBJECTIVE: To observe and investigate corneal stromal layer's changes of healthy elderly with phacoemulsification operation. METHODS: The experimental design was prospective, one replicated measurement, one interventional method case series. Analysis of central corneal stromal layer's changes (including corneal thickness, keratocyte density of anterior and posterior corneal stromal layer and morphological changes) of 19 patients (22 eyes) just before operation and 1 week, 1 month, 3 months and 6 months after operation with CMTF and NCSM. The statistical test method of the three parameter groups was least significant difference. The significant sterling was P <0.05. RESULTS: (1) Corneal thickness: 1 week after operation, corneal thickness was significantly thicker than before operation as well as 1 month, 3 months and 6 months after operation (P < 0.05). Comparisons of the differences of other pairs of corneal thickness showed no significant differences (P> 0.05). (2) Keratocyte density: Keratocyte density in the posterior stromal before operation was (627 +/- 184)/mm2 and only the 1 month after operation group was significantly higher than before operation (P <0.05). Keratocyte density in the anterior stromal before operation was (859 +/- 137)/mm2. Comparisons of the differences of each pair of groups before and after operation showed no significant differences (P >0.05). (3) CMTF images displayed microfolds (4 eyes) in the middle and posterior stromal layers before operation. Different changes in stromal edema at an early stage after operation were observed within 3 months after operation, including different degrees of high-reflecting images and pathological microfolds (16 eyes). Keratocyte activation and fibroblast-like cells could also be found after operation. CONCLUSIONS: Phacoemulsification can injure the corneal stromal layers. CMTF test is a useful method to reveal corneal pathological changes in four-dimension space (three-dimension space + time).

[Management of blood vessels in the vascularized autogenous submandibular gland transfer for severe keratoconjunctivitis sicca].

OBJECTIVE: To summarize the management of blood vessels in the transfer of vascularized autogenous submandibular gland. METHODS: Sixty-eight cases of vascularized transfer of autogenous submandibular gland for severe keratoconjunctivitis sicca performed from August 1999 to April 2004 were reviewed. Data collected for each patient included general items, donor and recipient vessels, vessel crisis, salvage of the vessel thrombosis, and survival of transferred glands. RESULTS: Among the 68 cases, all the donor and recipient arteries were facial artery and superficial temporal artery respectively. For donor veins, 55 were facial veins, 1 was vein near the duct, and 12 were venae comitantes of facial artery. For recipient veins, 62 were superficial temporary veins and five were veins in the upper neck, one was deep temporary vein. Vessel thromboses occurred in 10 cases, 9 were venous and 1 were arterial. The salvage rate was 10.0%, with the overall survival rate of 86.8% of transferred gland. CONCLUSIONS: Variation in venous outflow is common in microvascular transfer of submandibular gland, and anastomosis between venae comitante of facial artery and superficial temporal vein is most dependable. Vessel anastomosis under microscope may reduce the vessel thrombosis rate after operation.

[Molecular genetic study on patients with lattice corneal dystrophy in China].

OBJECTIVE: To investigate the mutations of the BIGH3 gene in patients with lattice corneal dystrophy in China. METHODS: Molecular genetic analysis was performed on DNA extracted from peripheral leukocytes from eight patients with lattice corneal dystrophy and without systemic amyloidosis in Tongren Ophthalmic Center. Exons 4, 12, 14 of the BIGH3 gene were amplified by polymerase chain reaction and were sequenced directly. The cornea of these patients were examined with slit lamp biomicroscope and photographed. At the same time, 32 normal subjects were recruited in the molecular genetic analysis as the controls. RESULTS: Three LCDI patients had R124C mutation (one missense mutation at position 417 C-->G of exon 4) in the BIGH3 gene, all of them were heterozygous. The other five patients showed different H626R mutations at position 1924 from A to G of the BIGH3 gene in exon 14, all of them were heterozygous too. The clinical appearance in patients with H626R mutation was an intermediate type between LCDI and LCDIII or LCDIIIA. CONCLUSIONS: R124C mutation and H626R mutation are detected in Chinese patients with lattice corneal dystrophy. It seems that H626R mutation not only presents in British and French patients, but also can be found in Asia patients.

[Study on enhanced leukocyte antigen-related tyrosine phosphatase in keratoconus].

OBJECTIVE: To study the enhanced expression of leukocyte antigen-related tyrosine phosphatase (LAR) in human keratoconus cornea. METHODS: Corneal buttons of patients received keratoplasty in Eye Center of Beijing Tongren from December 2001 to March 2002 were collected. Total RNA was isolated from the buttons from keratoconus (15 eyes), normal cornea (7 eyes), bullous keratopathy (6 eyes), non-neovascular cornea scar (3 eyes) and corneal dystrophy (2 eyes). Polymerase chain reaction (RT-PCR) was performed in this group. The results were displayed by agarose gels electrophoresis. In another group of patients, the corneal buttons of patients received keratoplasty in Eye Center of Beijing Tongren from July 2002 to December 2002 were collected. Total protein was extracted from the buttons of keratoconus (6 eyes), normal cornea (3 eyes), bullous keratopathy (3 eyes), non-neovascular cornea scar (3 eyes) and corneal dystrophy (2 eyes). Western blot was performed in this group. The results were displayed by enhanced chemical illumination. Bands of LAR RNA and LAR protein from these two tests were analyzed quantitatively. RESULTS: In RT-PCR study using the same amount of total RNA, high signal of LAR RNA was detected in RNA from the keratoconus, whereas low or no signal was detected in normal cornea and other diseases. Sequence analysis of the product of amplified LAR fragment from keratoconus showed deletion of exon 13. In Western blot study using the same amount of total protein, high signal of LAR was detected in keratoconus by the LAR antibodies, while low or no signal was detected in normal cornea and other diseases. CONCLUSIONS: LAR mRNA and protein are enhanced in keratoconus, whereas there are low or no expression in normal cornea, bullous keratopathy, non-neovascular cornea scar and corneal dystrophy. Elevated LAR in keratoconus indicates that LAR plays an essential role in the occurrence of keratoconus. Deletion of exon 13 in keratoconus may play a potential role in the abnormal LAR function.

[Morphologic characteristics of cornea in Fuchs endothelial dystrophy observed by confocal microscopy].

OBJECTIVE: To analyze the image of corneas with Fuchs endothelial dystrophy using confocal microscopy in vivo. METHODS: Central corneas of 38 eyes (19 patients aged 33 approximately 76 years) were examined using scanning slit confocal microscopy in vivo after being diagnosed with Fuchs endothelial dystrophy. They were divided into two groups namely symptomatic (19 eyes) and asymptomatic (19 eyes). The control group comprised of 30 normal eyes. The images were analyzed visually for morphology of corneas and the densities of cells, as well as the diameter of the guttae and the corneal nerves were counted by NAVIS software. RESULTS: (1) In the symptomatic groups, confocal microscopy revealed guttae in 19 eyes. The diameter of the guttae ranged from 20 to 60 micro m. The density of endothelial cells was statistically significant compared with the control group (t = 18.74, P < 0.01). Descemet's membrane was thickened in 9 eyes. Dark bands 6.0 approximately 10.8 micro m in diameter were detected in 14 eyes. All eyes showed a diffuse increased light reflection in the stroma.17 eyes exhibited an abnormal Bowman's layer: multiple focal bright reflection. 10 eyes revealed normal corneal nerves. The differences between posterior and anterior keratocyte densities in the control and study groups were not statistically significantly different (t = 0.854, 1.173; P = 0.38, 0.24 respectively). (2) In the asymptomatic groups, less number of guttae could be seen in the endothelial layer. The diameter of the guttae was 15 approximately 40 micro m. The densities of endothelial cells were not significantly different compared with control group (t = 1.998, P = 0.053). Other layers of the cornea exhibited no other abnormal phenomenon. The densities of endothelial cells between symptomatic and asymptomatic groups were statistically significantly different (t = 8.352, P < 0.01). CONCLUSIONS: Morphologic characteristics of cornea are observed by confocal microscopy in Chinese patients with Fuchs endothelial dystrophy. Preliminary results demonstrate that there is no significant difference between Chinese and western patients. Confocal microscopy allows to diagnose Fuchs dystrophy and visualize endothelial cells within the swollen cornea. And it is especially useful for patients whose endothelial cells can not be seen with non-contact specular microscopy.

[Identification of BIGH3 gene mutations in the patients with two types of corneal dystrophies].

OBJECTIVE: To identify the mutations of BIGH3 gene in Chinese patients with corneal dystrophies. METHODS: Polymerase chain reaction in exon 4, exon 12 and direct DNA sequencing of BIGH3 gene were performed in fifteen patients with corneal dystrophies and ten normal individuals as controls. RESULTS: Mutations in BIGH3 gene were detected in all the patients with corneal dystrophies. BIGH3 gene mutations were not found in normal subjects. Twelve patients with Avellino corneal dystrophy had the missense mutation R124H in the BIGH3 gene. Three patients with granular corneal dystrophy had the missense mutation R555W in the BIGH3 gene. CONCLUSION: R124H and R555W mutations in BIGH3 gene were found in the patients with Avellino and granular corneal dystrophies. Avellino corneal dystrophy associated with the R124H mutation is the most common form in the corneal dystrophies resulting from BIGH3 gene mutations. Condons 124 and 555 are also the hot spots for the mutations in the BIGH3 gene in the Chinese patients with corneal dystrophies.

[Analysis of mutation of BIGH3 gene in Chinese patients with corneal dystrophies].

OBJECTIVE: To study whether Chinese patients with various corneal dystrophy carry mutations in BIGH3 gene. METHODS: Genomic DNA was extracted from Chinese patients with Avellino corneal dystrophy (ACD, 10 cases), Reis-Bücklers corneal dystrophy (CDRB, 2 cases), granular corneal dystrophy (GCD, 3 cases) and 5 control subjects. The exons 4 and 12 of BIGH3 gene were amplified by PCR and the product was sequenced directly. RESULTS: All 15 patients carried mutations in BIGH3 gene, R124H in 10 cases with ACD, R124L in 2 cases with CDRB and R555W in 3 cases with GCD. CONCLUSIONS: Corneal lesions in all 15 Chinese patients clinically diagnosed with corneal dystrophies are caused by mutations in BIGH3 gene. Dose-effect analysis shows that corneal lesions are more severe in homozygous patients than those in heterozygous cases and that clinical manifestation of patients with R124L mutation is more severe than that of patients with R124H mutation.

Microvascular submandibular gland transfer for severe keratoconjunctivitis sicca: operation key points, prevention and management of complications.

OBJECTIVE: To summarize operation key points, prevention and management of complications in vascularized autotransplantation of submandibular gland for treatment of severe keratoconjunctivitis sicca. METHODS: 23 patients with severe keratoconjunctivitis sicca were treated by this procedure. Postoperative (99m)Tc images, follow-up studies, and management of complications were performed. RESULTS: The transplantations were successful in 19 cases, whose symptoms of xerophthalmia disappeared. The patients could stop applying artificial tears. In 4 patients the transplanted glands did not survive. Epiphora occurred in 5 cases. They were successfully treated by reducing the size of the graft. Obstruction of the Wharton's duct took place in one case and was treated by reconstructing the duct. When the superficial temporal vein was too small, venous bridging was applied. To select a relevant vein for anastomosis, blood oozing from the three veins was carefully inspected prior cutting off the gland when the external maxillary artery was preserved and was infused with heparin after the gland had been freed. CONCLUSIONS: If every point has been properly managed, the successful rate of operation could be warranted.

[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.