The application of in vivo confocal scanning laser microscopy in the diagnosis and evaluation of treatment responses in Mooren's ulcer.

PURPOSE: To evaluate the extent of corneal inflammation and the response to treatment in patients with Mooren's ulcer, by in vivo confocal microscopy (IVCM). METHODS: Twenty-two eyes of 15 patients with Mooren's ulcer were enrolled in this prospective study. All subjects underwent routine ophthalmic examinations, IVCM, and conjunctival histopathologic examination of specimens in patients undergoing conjunctival excision. Eyes with active ulcer were treated with topical corticosteroids and additional therapy, depending on the signs and symptoms. Eyes in remission continued to receive the previous treatment protocols. The relation between the severity of ulcer and inflammation status as assessed by IVCM was also studied. The endpoints were inflammatory cell density (ICD), counted by IVCM, and the extent of the limbal arc involved with ulcers. RESULTS: Ten eyes had active corneal ulcers, and 12 eyes had been in remission for the past year. The mean ICD of eyes with active ulcers before treatment was 2092.7 ± 1538.6 cells/mm(2) (range, 835.3-7832.7; 95% CI, 3232.5-952.9). Nine of the eyes improved at 8 weeks, with a decrease in ICD to 249.1 ± 109.0 cells/mm(2) (range, 100.3-595.3; 95% CI, 329.8-168.3). One eye had corneal perforation, and ICD immediately before perforation was 1677.6 ± 247.6 cells/mm(2). The mean ICD of 12 eyes in remission was 357.5 ± 266.8 cells/mm(2) (range, 12.7-1127.0; 95% CI, 555.2-159.8). The correlation of the ICD and the extent of limbal involvement with ulcers was strong (R(2) = 0.8119). CONCLUSIONS: ICD evaluated by IVCM is a useful and promising parameter for evaluation of the degree of inflammation in eyes with Mooren's ulcer and for assessment of response to treatment.

The sparkle of the eye: the impact of ocular surface wetness on corneal light reflection.

PURPOSE: To measure the sparkle of the human eye evaluated by the intensity of corneal light reflection in normal subjects and dry eye patients to investigate whether ocular surface wetness has an impact on the sparkle of the eye. DESIGN: Prospective case-control study. METHODS: We examined a consecutive series of eight dry eye patients with Sjögren syndrome (SS, 15 eyes), as well as eight normal subjects (16 eyes). The specular corneal surface light reflection was quantitatively measured with an ophthalmic slit-lamp microscope and image capturing system under fixed conditions of light source, incident angle, and detector sensitivity. The intensity of images from subjects' corneal light reflection was quantified with image analysis software along with the measurement of grade of self-reported brilliancy of the eye, corneal fluorescein staining score, tear film break-up time, and Schirmer test value. The intensity of corneal light reflection was also compared before and after dry eye treatment. RESULTS: The mean intensity of corneal light reflection was significantly lower in dry eye patients (125.0 ± 40.1) than normal subjects (167.6 ± 36.6, P=.004). Grade of self-reported brilliancy of the eye, corneal fluorescein staining scores, tear film break-up time, and Schirmer test values showed good correlation to the intensity of corneal light reflection. After punctal plug treatment, the intensity of corneal light reflection significantly increased from 125.0 ± 40.1 to 167.2 ± 45.0 (P<.0001). CONCLUSIONS: The intensity of corneal light reflection representing the sparkle of the eye was significantly more intense in normal subjects compared to dry eye patients, and was increased after punctal plug treatment. The intensity of corneal light reflection appeared to correlate well with tear film stability, volume, and ocular surface desiccation. We showed that tears contributed not only to ocular surface wetness but also to the extent of the light reflection from the eye.

In vivo evaluation of ocular demodicosis using laser scanning confocal microscopy.

PURPOSE: To investigate the applicability of in vivo laser scanning confocal microscopy in the diagnosis and follow-up of ocular demodicosis infestation in a prospective controlled study. METHODS: Fifteen right eyes of 15 patients with blepharitis associated with cylindrical dandruff (10 males, 5 females; mean age: 62.9 ± 9 years) and eight right eyes of eight age- and sex-matched control subjects underwent HRTII/RCM, evaluation of ocular symptom scores, tear function tests including vital stainings, Schirmer test, and tear clearance test, and evaluation of mite numbers in the eyelids. RESULTS: In vivo confocal microscopy effectively disclosed the mites in the terminal bulbs of the eyelashes, which were not observed after treatment. Eyelids with demodicosis infestation showed marked inflammatory infiltrates around the meibomian glands and conjunctiva, which cleared with tea tree oil treatment. CONCLUSIONS: Laser scanning confocal microscopy seems to be an efficient noninvasive tool in the diagnosis and follow-up of ocular demodicosis infestation.

In vivo evaluation of superior limbic keratoconjunctivitis using laser scanning confocal microscopy and conjunctival impression cytology.

PURPOSE: To investigate the cytologic findings of superior bulbar conjunctiva in superior limbic keratoconjunctivitis (SLK) using laser scanning confocal microscopy and impression cytology in a prospective controlled study. METHODS: Twenty-one eyes of 11 SLK patients (9 women, 2 men; mean age, 49.3 +/- 17.9 years) and 18 eyes of 9 control subjects (6 women, 3 men; mean age, 46.4 +/- 8.7 years) underwent tear function tests including vital stainings, Schirmer test, tear clearance test, digital confocal laser scanning microscopy, and conjunctival impression cytology. After confocal microscopy and impression cytology images were obtained, the mean individual epithelial cell area (MIECA), nucleocytoplasmic (N/C) ratio, and inflammatory cell density were analyzed. The correlation between confocal microscopy and impression cytology parameters was investigated. RESULTS: The MIECA of SLK patients and control subjects in confocal microscopy was 786.54 +/- 463.88 microm(2) and 311.50 +/- 78.30 microm(2), respectively. The mean N/C ratio was 0.356 +/- 0.090 and 0.490 +/- 0.038, respectively. The MIECA and N/C ratio in impression cytology showed significant correlation with the corresponding confocal microscopy parameters (MIECA, P = 0.0028; N/C, P = 0.0051). The inflammatory cell density in confocal microscopy significantly correlated with superior bulbar conjunctival Rose-Bengal scores (P = 0.0264). CONCLUSIONS: Laser scanning confocal microscopy seems to be an efficient noninvasive tool in the evaluation of phenotypic alterations of the conjunctival epithelium in SLK and may serve as an alternative for impression cytology. N/C ratio and inflammatory cell density appear to be two new promising parameters of in vivo confocal microscopy in the assessment of ocular surface disease in SLK.

Passive cigarette smoke exposure and soft contact lens wear.

PURPOSE: To prospectively investigate the effects of passive cigarette smoke exposure on the ocular surface and tear film in soft contact lens (SCL) wearers. METHODS: Twelve right eyes of 12 SCL wearers without any ocular or systemic diseases and 10 right eyes of 10 subjects who never wore CLs were examined before and 2 h after 5 min of passive cigarette smoke exposure in a controlled smoke chamber. Tear evaporation rate measurement, tear film break-up time (TBUT) examination, ocular surface fluorescein, rose bengal stainings, and Schirmer I test were performed at each visit. RESULTS: The mean tear evaporation rates, TBUTs, and vital staining scores were significantly worse in CL wearers compared with healthy control subjects. TBUTs showed significant worsening after passive smoke exposure in both groups. The mean tear evaporation rate and vital staining scores showed a significant increase with brief passive smoke exposure in subjects not wearing CLs but not in CL wearers. CONCLUSION: Even brief passive exposure to cigarette smoke is associated with adverse effects on the ocular surface as evidenced by an increase in tear instability and damage to the ocular surface epithelia in SCL wearers and non-CL wearers.

Conjunctival in vivo confocal scanning laser microscopy in patients with Sjögren syndrome.

PURPOSE: To demonstrate the conjunctival alterations in patients with Sjögren's (SSDE) and non-Sjögren's syndrome dry eye (NSSDE) using a new generation confocal microscope (HRTII/ RCM; Heidelberg Engineering, Heidelberg, Germany), in a prospective controlled study. METHODS: Twenty-eight right eyes of 28 patients with SSDE (28 women; mean age, 58.2 +/- 14.3 years), 7 right eyes of patients with NSSDE (7 women; mean age, 66.1 +/- 14.4 years), and 14 right eyes of 14 age- and sex-matched control subjects were studied. All subjects underwent the Schirmer test, tear film breakup time (BUT), vital staining, and confocal microscopy of the temporal bulbar conjunctiva. The density of conjunctival epithelial cells, epithelial microcysts, and conjunctival and corneal inflammatory infiltrates were also assessed. RESULTS: The tear quantity, stability, and vital staining scores were significantly worse in patients with SSDE or NSSDE than in control subjects (P < 0.001 and P < 0.05, respectively). Eyes of the patients with SSDE or NSSDE had a significantly higher density of conjunctival and corneal inflammatory infiltrates than did the control eyes (P < 0.001). Conjunctival inflammatory cell densities showed a negative correlation with tear stability and tear quantity and a positive correlation with the vital staining scores. Conjunctival epithelial cell densities were significantly lower in SSDE and NSSDE compared with control subjects (P < 0.05). The density of epithelial cysts was significantly higher in SS than in healthy control eyes (P < 0.001). CONCLUSIONS: Confocal scanning laser microscopy was an efficient and a noninvasive tool for the quantitative assessment of the conjunctival inflammation and epithelial cell densities as well as evaluation of conjunctival morphologic alterations, such as microcysts in patients with SSDE and NSSDE dry eye disease.

The evaluation of the treatment response in obstructive meibomian gland disease by in vivo laser confocal microscopy.

PURPOSE: To evaluate the status of periglandular inflammation, ocular surface and tear function alterations in patients with obstructive meibomian gland disease (OMGD) by in vivo confocal microscopy before and after anti-inflammatory treatment, and to compare the results with patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops without anti-inflammatory agents. METHODS: Thirty-two eyes of 16 OMGD patients receiving anti-inflammatory treatment (treatment group) and 22 eyes of 11 OMGD patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops (control group) were recruited in this prospective study. All subjects underwent slit-lamp examinations, tear film break-up time (BUT) measurements, fluorescein and Rose-Bengal stainings, Schirmer test capital I, Ukrainian without anesthesia, transillumination of the lids (meibography), and in vivo laser confocal microscopy of the lids (HRTII-RCM). RESULTS: The mean BUT, fluorescein staining scores, and inflammatory cell densities observed by in vivo confocal microscopy improved significantly in the group receiving anti-inflammatory treatment (p < 0.05), whereas no significant alterations of these parameters were observed in the group not receiving anti-inflammatory agents (p > 0.05). CONCLUSIONS: In vivo confocal microscopy was able to effectively demonstrate the treatment responses in patients with OMGD. Inflammatory cell density calculation seems to be a promising new parameter of in vivo confocal microscopy in the evaluation of treatment responses.

The application of in vivo laser confocal microscopy to the diagnosis and evaluation of meibomian gland dysfunction.

PURPOSE: To evaluate the morphological changes of the meibomian glands (MG) in patients with meibomian gland dysfunction (MGD) compared to normal subjects by in vivo confocal microscopy and to investigate the relation of these changes to the clinical ocular surface findings and tear functions. METHODS: Twenty MGD patients and 15 normal subjects were recruited into this prospective study. Patients and controls underwent slit lamp examinations, tear film break-up time (BUT) measurements, fluorescein and Rose-Bengal stainings, Schirmer test I without anesthesia, tear evaporation rate assessment (TEROS), tear film lipid layer interferometry (DR-1), transillumination of the lids (meibography), MG expressibility test, and in vivo laser confocal microscopy of the lids (HRTII-RCM). RESULTS: The BUT, DR-1 tear film lipid layer interferometry grades, fluorescein and Rose-Bengal staining scores, MG drop out grade in meibography, and MG expressibility grades were significantly worse in MGD patients compared to normal controls (p<0.05). The severity of both MG dropout and MG expressibility related significantly with the BUT, DR-1 grades, and TEROS (p<0.05). The mean density of acinar units of MGs as measured by HRTII-RCM was significantly lower in MGD patients (47.6+/-26.6/mm(2)) than in control subjects (101.3+/-33.8/mm(2); p<0.05). The mean acinar unit diameter as determined by HRTII-RCM was significantly larger in MGD patients (98.2+/-53.3 mum) than in controls (41.6+/-11.9 mum; p<0.05). Both the density and diameter of MG acinar units related significantly with the severity of MG dropout and MG expression grades (p<0.05). CONCLUSIONS: In vivo confocal microscopy can effectively demonstrate the morphological changes of the MG in patients with MGD. Glandular acinar density and acinar unit diameter seemed to be promising new parameters of in vivo confocal microscopy, which is significantly related to the clinical ocular surface and tear function findings of MGD.

Reduced choroidal blood flow can induce visual field defect in open angle glaucoma patients without intraocular pressure elevation following encircling scleral buckling.

PURPOSE: To determine the cause of the progressive glaucomatous visual field defects in three patients after an encircling scleral buckle for a rhegmatogenous retinal detachment (RRD). METHODS: Scanning laser Doppler flowmetry and visual field tests were performed on three cases with unilateral progressive visual field defect after an encircling scleral buckling for a RRD. Similar measurements were made after the buckle was removed. RESULTS: After implanting the scleral buckle, the intraocular pressure was normal and chamber angle was open. The blood flow in the neuroretinal rim of the optic disk was lower than that in the healthy fellow eye. After removing the buckle, the blood flow improved to normal levels and a further worsening of the visual field was not detected. CONCLUSIONS: These results suggest that an encircling scleral buckle may impair choroidal circulation and lead to visual field defects similar to eyes with normal tension glaucoma.

Microcirculation in eyes after rhegmatogenous retinal detachment surgery.

PURPOSE: To investigate the tissue blood flow in the neuroretinal rim of the optic disk and macula after rhegmatogenous retinal detachment (RRD) surgery. METHODS: Tissue blood flow in the neuroretinal rim of the optic disk and macula was measured with the Heidelberg retina flowmeter in 53 eyes of 53 patients who had undergone successful surgery for unilateral RRD. Patients were divided into three groups; those who had the RRD treated by conventional encircling scleral buckling (group E), by local buckling (group L), and by primary vitrectomy (group V). Blood flow measurements were made more than 6 months after surgery in a 10 degrees x 2.5 degrees area of the superior and inferior margins of the neuroretinal disk rim and of the superior and inferior macula area. The mean blood flow (MBF) and the ratio of the MBF in the affected eye to the healthy fellow eye (a/f ratio) were compared among the three groups. The influence of several clinical factors on the MBF was also investigated. RESULTS: The MBF rate and mean a/f ratios of the MBF of the three groups were not significantly different. Multiple regression analysis revealed that the averaged MBF both at superior and inferior disk rims was significantly correlated with only the gas tamponade procedure. CONCLUSIONS: The ocular microcirculation is normal 6 months after scleral buckling or vitrectomy for RRD. However, the use of gas tamponade might have a subclinical adverse effect on the circulation in the neuroretinal disk rim.

The application of in vivo confocal scanning laser microscopy in the management of Acanthamoeba keratitis.

PURPOSE: To evaluate the role of in vivo laser scanning confocal microscopy (Heidelberg Retina Tomograph II, Rostock Cornea Module, HRTII-RCM) in the management of Acanthamoeba keratitis (AK). METHODS: Four eyes of four patients with AK seen at Keio University Hospital at the Department of Ophthalmology were studied in this single-center, prospective, interventional case series. All patients were routinely examined by slit-lamp microscopy including corneal fluorescein staining. Best corrected visual acuity (BCVA) was also measured before and after the treatment for AK. Both the scraped corneal epithelium and soft contact lens (SCL) storage solution in each patient's SCL case were cultured. Patient corneas were examined regularly using the HRTII-RCM before treatment and after commencement of medications including azoles, echinocandins, and chlorhexidine. RESULTS: All patients had various degrees of conjunctival injection, corneal edema, stromal opacity with radial keratoneuritis with slit-lamp examination. Cultures for AK were positive in three out of four cases by corneal scraping. Contact lens storage solutions were also positive in three of four cases. HRTII-RCM examination could detect Acanthamoeba cysts or trophozoites in all eyes before corneal scraping. No organisms were detectable in any of the cases in any of the corneal layers four to six weeks after treatment. The BCVA improved with treatment in three of four eyes. CONCLUSIONS: HRTII-RCM could effectively demonstrate cysts and trophozoites and the nature of the inflammatory process in AK. In vivo laser scanning confocal microscopy employing HRTII-RCM could provide an end-point for treatment, saving the patient from additional invasive diagnostic procedures and unneeded exposure to long term topical or systemic medications.

Decreased blood flow at neuroretinal rim of optic nerve head corresponds with visual field deficit in eyes with normal tension glaucoma.

PURPOSE: To determine the relationship between the blood flow parameters of the optic disc rim and the glaucomatous visual field changes. DESIGN: Observational cross-sectional study. METHODS: Tissue blood flow in the neuroretinal rim within the optic disc was determined with the Heidelberg retina flowmeter(HRF) in 54 eyes of 54 patients with normal tension glaucoma (NTG). Patients were selected whose visual field defects were confined to either the superior or inferior hemifield. Blood flow measurements were made in a 10 degrees x 2.5 degrees area of the superior and inferior neuroretinal rim within the optic disc. The mean blood flow (MBF) was calculated by the automatic full-field perfusion image analyzer program, and the ratio of the MBF in the superior to the inferior rim areas (the S/I ratio) was calculated from the same HRF image in order to minimize the variation of measurement condition. RESULTS: Inferior rim blood flow is less than superior rim blood flow in patients with superior hemifield defect, and superior rim blood flow is reduced compared to inferior in patients with inferior hemifield defect. The mean S/I ratios of the MBF in the patients with superior hemifield defect (1.46, n=37) was significantly higher than that in the patients with inferior hemifield defect (0.79, n=17; P<0.0001, Mann-Whitney U-test). CONCLUSIONS: The blood flow in the neuroretinal rim was found to correspond to the regional visual field defect in eyes with NTG. Reductions in flow were associated with reductions in function.

Macular nerve fibers temporal to fovea may have a greater potential to recover function in patients with Leber's hereditary optic neuropathy.

PURPOSE: It is known that even after visual loss, younger patients with Leber's hereditary optic neuropathy (LHON) can recover vision. The purpose of this study was to determine the mean age at onset for LHON patients with and without visual recovery who carried the 11778 mutation, and to determine the pattern of central vision recovery. METHODS: Thirty-five LHON patients with the 11778 mutation of mitochondrial DNA who had visited the Keio University Hospital between 1980 and 1999 and were followed for 2 to 20 years, were the subjects of this retrospective study. The patients who had recovered vision were tested by Goldmann perimetry, Humphrey perimetry, and landmark-driven fundus microperimetry with a scanning laser ophthalmoscope (SLO). The fixation status was assessed by SLO microperimetry. RESULTS: Nine of the 35 patients (14 of 70 eyes) demonstrated a recovery of visual acuity to better than 0.3 in at least one eye. The mean age of disease onset was 15.9 +/- 4.6 years in patients with visual recovery and 25.5 +/- 8.9 years in patients without visual recovery. This difference in the mean age at onset was significant (P =.0001; Welch t-test). These 9 patients (14 eyes) showed fenestrated central scotomas in testing by Humphrey 10-2 threshold and SLO microperimetry. The nasal side of the central visual fields had a higher sensitivity than the temporal side in 7 of the 9 patients in Humphrey 10-2 threshold testing. Areas insensitive to 0 dB were detected on the nasal side of the central retina in these patients by SLO microperimetry, and fixation stability was related to the degree of clinical visual acuity. CONCLUSION: The LHON patients with the 11778 mutation and a younger age of onset were more likely to show visual recovery. The findings made by perimetry suggest that the nerve fiber bundles in the nasal field (retina temporal to the fovea) may have a greater potential to recover function in LHON patients.