Dacryoadenitis differential amplifier
The tear production and drainage system is vital for health of the outer eye. Tear glands within the orbit lacrimal and in some species Harder gland as well as the superficial tear gland of the nictitating membrane third eyelid produce the collective preocular or precorneal tear film. This film consists of three layers: outer lipid from the Meibomian glands , middle aqueous layer from lacrimal and third eyelid glands , and deep layer mucus from the goblet cells within the conjunctiva. The tear drainage system consists of two lacrimal puncta except in the rabbit and pig, which have only one punctum , two canaliculi, the lacrimal sac within the bony lacrimal fossa , and the long and often tortuous lacrimal duct to empty tears within the forward nasal cavity.
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Asteroid Hyalosis
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A baseline BL evaluation included 36 AS patients and 39 healthy controls. DED is a frequent and under-diagnosed ocular disease in AS patients.
Ankylosing spondylitis AS is a chronic inflammatory rheumatic disease associated with HLA-B27, axial involvement, and the presence of extra-articular manifestations such as involvement of the eyes, skin, and gastrointestinal tract 1.
Anterior uveitis is the classical ocular manifestation in AS. There are few and inconsistent reports regarding the simultaneous occurrence of AS and DED, even though the eye dry eye tests performed in these studies were incomplete 5 , 6 , 7. The clinical expression and pathophysiology of DED have recently changed 8 , 9.
DED is a multifactorial disease of the ocular surface OS characterized by a loss of homeostasis of the tear film accompanied by symptoms of ocular discomfort, visual disturbance, and tear film instability with potential harm to the ocular surface and visual function There is instability, hyperosmolarity of the tear film, neurosensory abnormalities, and inflammation of the OS, leading to damage of the surface epithelial cells, with the release of proinflammatory cytokines, chemokines, and matrix metalloproteinases in the tear film and the OS tissue 10 , Inflammation and apoptosis of OS cells might play a role in the development of DED, promoting loss of goblet cells and a decrease of mucin secretion The conjunctival impression cytology from DED patients comprised these alterations Recently, the use of biologic agents has been investigated for the treatment of inflammatory eye diseases 15 , aiming at a more accurate target and with the potential for preventing disease progression 15 , The objective of this study was to evaluate the frequency and severity of DED in AS patients using a complete systematic evaluation of the OS, including the cytological grade.
This prospective, observational study included 36 consecutive patients over 18 years of age with AS defined by the New York criteria 23 and 39 healthy volunteer controls matched for age and gender. Both groups were undiagnosed for DED. Clinical and laboratory features were obtained from the ongoing electronic database. The exclusion criteria were the use of medications that might induce DED, topical anti-inflammatory drugs, active ocular diseases, previous ocular surgical procedures, and the use of contact lenses.
From the initial 36 patients, 14 consecutive AS patients, refractory to conventional treatment with non-steroidal anti-inflammatory drugs NSAIDs , and to disease-modifying anti-rheumatic drugs DMARD and who were eligible to receive TNFi therapy, were enrolled for the longitudinal analysis. Those patients who presented mild or moderate KCS were oriented to use lubricant eye-drop four times per day but not on the day of evaluation.
All the clinical procedures followed the tenets of the Declaration of Helsinki. At the baseline BL visit, a biomicroscopy examination performed under the slit lamp assessed the OS.
A feature of eyelids, cornea, conjunctiva, and tear film was evaluated and recorded. Initially, the instillation of fluorescein drop evaluated the graduation of the corneal staining pattern, followed by lissamine green conjunctival staining This survey evaluated dry eye symptoms, their impact on daily life activities, and environmental triggers. The score 0— discriminated among normal 0—12 , mild 13—22 to moderate 23—32 , and severe above 33 DED From the measurements described above, the DED severity grading scheme, according to the Behrens et al.
The symptoms and the value of the clinical signs resulted in a disease severity grading score. The status of severity ranged from 1 to 4 A masked observer assigned the severity grade system. All the ocular clinical measurements were performed within the same time of day from PM to PM at the same conditions of temperature and relative air humidity. Impression cytology IC collected samples of tissue from the temporal bulbar conjunctiva.
The specimens were fixed in absolute ethyl alcohol and stained with periodic acid-Schiff PAS -hematoxylin stain. Grade 0 was considered normal, and grades 1, 2 and 3, altered. Ten fields of each specimen were analyzed, and the most prevalent classification was the final grade 13 , The evaluation of all the samples succeeded under a microscope at the same magnification x and in a masked assessment Inflammation was evaluated using the erythrocyte sedimentation rate ESR by the modified Westergren method and the C-reactive protein CRP by nephelometry.
The Local Research Ethics Committee approved the study, and all the subjects signed informed consent. The median age of the AS patients was comparable to that of the healthy controls The mean disease duration was Nine Symptoms of the dry eye measured by the OSDI score was similar in patients and controls [6.
The median of lissamine green staining score was lower in the AS patients than in the controls [0 0—3 vs. Meibomian gland dysfunction MGD was present in 18 A higher IC score [1 0—1 vs. The IC was altered in 20 There was a significant improvement in all the disease and inflammatory parameters in the 14 patients receiving TNF-i therapy from BL vs.
To our knowledge, this study is the first to demonstrate a high frequency of underdiagnosed mild to moderate DED in AS patients. The noteworthy contribution of this study is the use of systematic and validated dry eye clinical criteria. These assessments were reported to be useful in a systematic review and a recent multinational European Consensus Group recommendation 31 , We excluded factors strongly associated with DED, such as the use of antihistamines, tricyclic antidepressants, antihypertensive agents, and benzodiazepines Advanced age is a known cause of DED; consequently, only patients under 65 years old were included Additionally, equal and homogeneous gender distribution in patients and controls was relevant because hormone changes unbalance tear production and tear quality Therefore, after excluding these factors, AS may play a role in the development of DED, and the ocular surface and lacrimal gland may be target organs in the autoimmune process in AS.
We observed herein that the majority of AS patients, despite the lack of clinical complaints and objective tests for the dry eye without a usual pattern for DED, showed mild to moderate DED severity. This classification comprises both aqueous deficient and evaporative components. The severity classification does not have a continuous linear relationship for mild to moderate DED.
The range of values, when combined after following the severity grading system, results in different scores seen between cases and controls.
Thus, in mild to moderate dry eye levels, a discreet variance of results expresses in different stages of severity. Once there is no gold standard for dry eye test to correlate with severity, this system allows early diagnosis, and the accuracy of severity classification, especially in mild cases of DED The discordance between signs and symptoms of DED could be related to the mild DED level with compensatory mechanisms 34 , and the presence of MGD, which is more commonly asymptomatic So, a thorough evaluation of AS patients is necessary regardless of symptoms once the appreciation of symptoms alone will result in missing a significant percentage of DED patients Gunes et al.
Ortak et al. Consequently, they suggested careful attention in surgical interventions such as photorefractive keratectomy and laser in situ keratomileuses in AS patients Despite the dysfunctional dry eye tests found in these studies, the authors did not determine the DED severity level. The significant elevation of the inflammatory disease parameters ESR and CPR in AS patients compared to the control group supports the role of inflammation in this process.
Increased expression of adhesion molecules and inflammatory cytokines of the OS epithelium and the tear fluid was demonstrated in DED, reinforcing the importance of inflammation in the pathogenesis of this condition The conjunctival IC analyzes epithelial cells that are related to the conjunctival inflammatory and apoptotic pathways, goblet cells producing mucin MUC5AC, and playing defense and regulatory role on the homeostasis of the OS Besides, this scoring system is well-validated The lack of goblet cells is associated with inflammatory disorders of the ocular surface and has a vital role in the mechanism of DED Thus, the conjunctival IC can be used as an additional parameter for dry eye as well as analyze inflammation on the ocular surface.
The score of altered IC is usually compatible with the severity of clinical disease The severe dry eye might require systemic immunomodulatory therapy to inhibit the expression of pro-inflammatory cytokines The increase in the aqueous tear production observed in the AS patients indicated that TNFi therapy might interfere with the OS metabolism and restore lacrimal gland acinar cells affected by proinflammatory cytokines 19 , Trousdale et al.
Li et al. They concluded that topical application of the drug could improve tear production and ocular surface irregularity, decrease inflammatory cytokines, and cells on the ocular surface and increase conjunctival goblet cell density Although the improvement in systemic inflammatory markers, disease activity, and IC scores observed in AS patients treated with TNFi, there was not a reduction in the vital staining score.
This outcome is not different from a previous study that correlated vital dye staining scores and conjunctival squamous metaplasia measured by impression cytology In conclusion, the prevalent underdiagnosed DED observed in the AS patients enrolled in this study and the long-term improvement of tear production and goblet cell density in those receiving TNFi therapy suggest that the OS can be an additional target of the systemic inflammation in this disease.
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Braun, J. Ankylosing spondylitis [Review]. Martin, T.
Anterior uveitis: current concepts of pathogenesis and interactions with the spondyloarthropathies [Review]. Curr Opin Rheumatol. PubMed Article Google Scholar. Linder, R. Prevalence of the spondyloarthritides in patients with uveitis. J Rheumatol. Monnet, D. Ophthalmic findings and frequency of extraocular manifestations in patients with HLA-B27 uveitis: a study of cases. Tosun, M. Rheumatol Int. Clin Rheumatol. Marsovsky, L.
Dacryocystitis
Metrics details. We retrospectively evaluated SS, SSc, and SS-SSc overlap patients admitted to our outpatient rheumatology clinic between January and December who underwent a minor salivary gland biopsy. Patient demographics and some clinical features were obtained from hospital records. The biopsy specimens were also examined for the presence and degree of fibrosis.
Chalazion and Hordeolum (Stye)
Thank you for visiting nature. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. A baseline BL evaluation included 36 AS patients and 39 healthy controls. DED is a frequent and under-diagnosed ocular disease in AS patients. Ankylosing spondylitis AS is a chronic inflammatory rheumatic disease associated with HLA-B27, axial involvement, and the presence of extra-articular manifestations such as involvement of the eyes, skin, and gastrointestinal tract 1. Anterior uveitis is the classical ocular manifestation in AS. There are few and inconsistent reports regarding the simultaneous occurrence of AS and DED, even though the eye dry eye tests performed in these studies were incomplete 5 , 6 , 7. The clinical expression and pathophysiology of DED have recently changed 8 , 9.
Preseptal Cellulitis
Thank you for visiting nature. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. This prospective cohort study aims to investigate the incidence, related factors and prognosis of IgG4-related disease IgG4-RD with malignancies in the Chinese cohort.
Nasolacrimal and Lacrimal Apparatus
DeCS - February 22, version. Alphabetic Index of Descriptors. D-Ala 2 ,MePhe 4 ,Met 0 -ol-enkephalin. D-Alanine Transaminase. D-Amino-Acid Oxidase.
SUNY Downstate Health Sciences University
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Additional Research Publications (January – December 2018)
Chalazia and hordeola styes are sudden-onset localized swellings of the eyelid. A chalazion is caused by noninfectious meibomian gland occlusion, whereas a hordeolum usually is caused by infection. Both conditions initially cause eyelid hyperemia and edema, swelling, and pain. With time, a chalazion becomes a small nontender nodule in the eyelid center, whereas a hordeolum remains painful and localizes to an eyelid margin.
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Dacryocystitis is infection of the tear lacrimal sac usually due to a blockage in the tear nasolacrimal duct. The tear sac is a small chamber into which tears drain. The usual cause of dacryocystitis is a blockage of the nasolacrimal duct, which leads from the tear sac into the nose. Often the dacryocystitis infection is mild. Sometimes, the infection is severe and can cause fever. Sometimes a collection of pus abscess may form, which can rupture through the skin, creating a passage for drainage. In acute dacryocystitis, the area around the tear sac is painful, red, and swollen.
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