In Vivo Confocal Imaging of the Conjunctiva as a Predictive Tool for the Glaucoma Filtration Surgery Outcome

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In Vivo Distribution of Corneal Epithelial Dendritic Cells in Patients With Glaucoma

The purpose of this study was to evaluate dendritic cell (DC) distribution, morphology, and DC density in the entire cornea of medically controlled glaucoma patients (MCGP), using in vivo confocal microscopy (IVCM).Fifty MCGP were enrolled, 15 patients with dry eye, and 15 healthy subjects served as controls. Patients were asked to complete the Ocular Surface Disease Index (OSDI) questionnaire and then underwent tear film break-up time (BUT), corneal staining, and Schirmer test (ST) I and then IVCM. In vivo confocal microscopy evaluated the limbal and central DC density, the DCs morphology and distribution. Relationships among DC density, OSDI score, and corneal staining were analyzed.Medically controlled glaucoma patients were divided into 2 groups; group 1 (29 eyes) was tested with one drug; group 2 (21 eyes) was tested with ≥2 drugs. Dendritic cells were significantly higher at limbus than at central cornea in both groups. Limbal DCs were found in the 86.7%, 89.7%, 90.4%, and 93.3% of eyes in controls, groups 1 and 2, and DED; central corneal DCs were found in the 26.6%, 75.9%, 80.9%, and 86.6% of eyes in controls, groups 1 and 2, and DED. Dendritic cell density was higher in glaucoma groups and DED than in controls (P < 0.001). Group 2 and DED presented DC density significantly higher compared with group 1 (P < 0.05). In group 1 DC density was higher in patients taking preserved drugs than in those taking preservative-free drugs (P < 0.05). Dendritic cell density was higher in DED than in group 2 (P < 0.05). Dendritic cell density significantly correlated with corneal staining and OSDI (P < 0.001).Dendritic cells increase in the entire cornea of MCGP, with a higher density at limbus. These modifications may take part in the induction of the glaucoma-related ocular surface disease

In vivo goblet cell density as a potential indicator of glaucoma filtration surgery outcome

Purpose: We analyzed the preoperative conjunctival goblet cell density (GCD), MUC5AC, and HLA-DR in glaucomatous patients undergoing trabeculectomy, using laser scanning confocal microscopy (LSCM) and impression cytology (IC). Methods: We enrolled 57 patients undergoing trabeculectomy. At baseline LSCM and IC were performed at the site planned for surgery; LSCM was repeated after 12 months at the bleb site. The main outcomes were: GCD, mean microcyst density (MMD) and area (MMA) at LSCM, MUC5AC, and HLA-DR positivity at IC, and IOP. The relationships between baseline GCD, and 12-month IOP, MMD, and MMA were analyzed. Results: Trabeculectomy was successful in 39 patients (complete success in 27, Group 1; qualified in 12, Group 2), and unsuccessful in 18 (Group 3). At baseline IOP (mm Hg) was 27.2 ± 3.12, 27.5 ± 2.23, and 27.7 ± 1.90 in Groups 1 to 3, respectively; GCD and MUC5AC positivity were higher in Group 1 compared to Groups 2 and 3 (P < 0.05); HLA-DR, MMD, and MMA were not significantly different among the groups. At 12 months, IOP reduced by 45.3%, 35.4%, and 12.8% in Groups 1 to 3, respectively. Goblet cell density did not change in Group 1, whereas it was reduced in Groups 2 and 3 (P < 0.05), with values lower in Group 3. Mean microcyst density and MMA increased in Groups 1 and 2 (P < 0.05), with values higher in Group 1 (P < 0.05). Baseline GCD positively correlated with 12-month IOP reduction (P < 0.001, r = 0.641), MMD (P < 0.05, r = 0.454), and MMA (P < 0.001, r = 0.541). Conclusions: Goblet cells positively affect the filtration ability after trabeculectomy; therefore, preoperative GCD could be considered as a potential in vivo biomarker of surgical success

Topical preservative-free ophthalmic treatments: an unmet clinical need

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations. Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects. Expert opinion: Because of the lack of an adequate number of randomized clinical trials, there are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening

Immunology and Microbiology In Vivo Confocal Microscopy of Conjunctiva-Associated Lymphoid Tissue in Healthy Humans

Citation: Agnifili L, Mastropasqua R, Fasanella V, et al. In vivo confocal microscopy of conjunctiva-associated lymphoid tissue in healthy humans. Invest Ophthalmol Vis Sci. 2014;55:5254-5262. DOI:10.1167/ iovs.14-14365 PURPOSE. To investigate modifications with aging of the presence, distribution and morphologic features of conjunctiva-associated lymphoid tissue (CALT) in healthy human subjects using laser scanning in vivo confocal microscopy (IVCM). METHODS. A total of 108 (age range, 17-75 years) subjects were enrolled. In vivo confocal microscopy of the tarsal and bulbar conjunctiva, and impression cytology (IC) with CD3 (intra-epithelial T-lymphocytes) and CD20 (intra-epithelial B-lymphocytes) antibody immunofluorescence staining were performed. The main outcomes were subepithelial lymphocyte density (LyD), follicular density (FD), and follicular area (FA). The secondary outcomes were follicular reflectivity (FR), and lymphocyte density (FLyD), and CD3 and CD20 positivity. RESULTS. Conjunctiva-associated lymphoid tissue was observed in all subjects (97% only superior and 3% in both superior and inferior tarsum). Lymphocyte density ranged from 7. (26,440 [26,280]). All three parameters showed a highly significant inverse cubic relationship with age (P &lt; 0.001); that is, in the first and last parameters a steep decline up to 35 years and above 65 years of age, with a plateau phase between these ages, whereas FA had a gradually decreasing rate of loss over the studied age range. CD3 and CD20 IC were consistent with these results. CONCLUSIONS. In vivo confocal microscopy was effective in revealing CALT and modifications these structures undergo with aging. Aging correlated with an involution of all parameters defining lymphoid structures. These modifications may account for the decrease of mucosal immune response and increase of ocular surface diseases in the elderly

Molecular biomarkers in primary open-angle glaucoma: From noninvasive to invasive

Glaucoma, the first cause of irreversible blindness worldwide, is a neurodegenerative disease characterized by the progressive loss of retinal ganglion cells. There are different subtypes of glaucoma, all expression of a common optic neuropathy; primary open-angle glaucoma (POAG) is the most diffuse subtype in western countries. To date, unfortunately, several questions still remain unsolved in the glaucoma management, such as the availability of powerful methods for screening high-risk populations, early diagnosis, timely detection of damage progression, and prediction of response to therapy. Over the last years, biomarkers have gained immense scientific and clinical interest to solve these issues, with countless molecules that have been candidate as potential biomarkers. In the present review, we summarize the current knowledge about the most robust molecular biomarkers proposed in POAG, distinguishing noninvasive from minimally invasive, and invasive biomarkers, according to the procedure adopted to collect fluid samples

Corneoscleral limbus in glaucoma patients: in vivo confocal microscopy and immunocytological study

PURPOSE: To investigate morphologic changes of the corneoscleral limbus in glaucoma patients using laser scanning confocal microscopy (LSCM) and impression cytology (IC).METHODS: Eighty patients with glaucoma and 20 with dry eye were enrolled; 20 healthy subjects served as controls. Patients underwent the Ocular Surface Disease Index (OSDI) questionnaire, tear film break-up time, corneal staining, Schirmer test I, and LSCM of the limbus. Laser scanning confocal microscopy evaluated the limbal transition epithelium (LTE) regularity, dendritic cell (DC) density, and palisades of Vogt (POV). Impression cytology was performed and samples stained with HLA-DR and IL6.RESULTS: Glaucomatous patients were divided into three groups: Group 1 (40 eyes): one drug; Group 2 (20): two drugs; and Group 3 (20): three or more drugs. Limbal transition epithelium regularity was worse, and DC density higher in Groups 2, 3, and dry eyes compared with Group 1 and controls (P < 0.01). Preserved drugs worsened LTE regularity and induced higher DC density compared with preservative-free (PF) drugs (P = 0.041; P = 0.004). Despite typical POV architecture was preserved, signs of inflammation were found in glaucoma groups. HLA-DR and IL-6 positivity were higher in Groups 2, 3, and dry eye compared with controls (P < 0.001), and in preserved versus PF drugs (P < 0.05; P < 0.001). Dendritic cell density and LTE regularity correlated with HLA-DR, IL-6, and OSDI score in glaucoma groups and dry eyes (P < 0.001).CONCLUSIONS: Laser scanning confocal microscopy and IC documented antiglaucoma therapy induced morphologic alterations of limbus, which may play a role in the glaucoma-related ocular surface disease. Further studies are required to determine if limbal changes affect stem cell viability

Topical Steroids and Glaucoma Filtration Surgery Outcomes: An In Vivo Confocal Study of the Conjunctiva

(1) Background: The purpose of this study is to investigate the effects of topical steroids on conjunctiva in patients undergoing filtration surgery (FS) for glaucoma by using confocal microscopy (CM); (2) Methods: One hundred and four glaucomatous patients were randomized to fluorometholone or lubricants four weeks before FS. CM was performed before treatments and pre-operatively. Dendritic and goblet cell densities (DCD, GCD), stromal meshwork reflectivity (SMR), vascular tortuosity (VT), and intra-ocular pressure (IOP) were the main outcomes. By evaluating treatments and outcomes (12-month success/failure) as categorical variables, patients were grouped into Group 1, 2, 3, or 4 (success/failure with fluorometholone, or lubricants); (3) Results: Twelve-month IOP was reduced in Groups 1 and 3 (p p p p p = 0.004). There were no significant differences between the fluorometholone and lubricant groups for success percentages. The number of bleb management procedures and IOP lowering medications were lower in Group 1 compared to Groups 2–4 (p < 0.05); (4) Conclusions: Topical steroids mitigate conjunctival inflammation and lower the stromal density in patients undergoing FS. These modifications lead to less intensive post-operative management