Faculty Bibliography

Purpose: To analyze the surgical management and outcomes of patients with canalicular lacerations and to report the epidemiological data and clinical characteristics of this group of patients. Methods: A retrospective review of medical records of all patients with canalicular lacerations from 1992 to the present at a single institution. Results: A total of 50 patients with injury to the canalicular system were identified, mean age 32 years (range 16 months - 88 years), 82% were male and 18% female. 82% were adult and 18% were pediatric patients. The most common mechanism of injury in adults was assault (50%) while in children it was accidents with objects (33%). 86% were found to have injury to one canaliculus while 14% had a bicanalicular laceration. 68% of the canaliculi injured were lower lid, 32% were upper lid. 78% of the lacerations were graded as mild or moderate and 22% were severe, with associated medial canthal avulsion or extensive globe or orbital injury. 94% proceeded to repair within 48 hours; in two patients, canalicular intubation could not be achieved intraoperatively. Of the 48 patients who underwent surgical repair, 22% had monocanalicular intubation with the Mini-Monoka and 78% percent had repair with the Crawford tube. All (100%) bicanalicular lacerations were repaired with the bicanalicular Crawford tube. The majority of monocanalicular lacerations (78%) were repaired with either the monocanalicular or bicanalicular Crawford tube; all (100%) of the lacerations repaired with the Mini-manoka were mild. Thirty patients had follow up beyond post-operative month 1, with an average follow-up of 6 months. The average length of intubation was 5.7 months. 93% of patients had successful functional and anatomic outcomes. The most common complication was tube extrusion requiring repositioning or repeat surgery, which occurred at the same rate (17%) with the Mini-Monoka and Crawford tube. In two such instances, one type of stent was replaced for another secondary to patient anatomy. Conclusions: In our experience, most canalicular lacerations are sustained by adult males and are related to assault. The majority of canalicular lacerations are repaired with bicanalicular Crawford tubes within 48 hours. Both methods of repair, Mini Monoka stent and Crawford tube, are effective in achieving good outcome and it is important to be familiar with the use of both

PURPOSE:: Conjunctivochalasis is an age-dependent redundancy or laxity of the conjunctiva. It may result in epiphora (tearing) through mechanical disruption of the normal tear flow or exacerbate dry eye symptoms by disruption of an already unstable tear film. In this study, the authors performed a retrospective analysis of the benefits of a simple medial conjunctival resection for tearing associated with conjunctivochalasis. METHODS:: A review of medical records identified 18 patients (25 eyes) who underwent a medial conjunctivoplasty for tearing between 2000 and 2012. The degree of epiphora was graded for each patient from 0 (no tearing) to 3 (persistent tearing requiring surgical correction). All patients were given an initial preoperative score of 3. Patients were excluded from the study if more than 1 eyelid procedure that would affect the lacrimal pump function was performed at the time of conjunctivoplasty or if clinically significant entropion, ectropion, or nasolacrimal duct obstruction was present at the time of conjunctivoplasty. RESULTS:: At an average of 2.7 months post-conjunctivoplasty (range 4 weeks to 12 months), 80% of patients improved to a score of 2 or better and 60% improved to 1 or better. Six patients ultimately needed an additional surgical procedure for unresolved or recurrent tearing. CONCLUSIONS:: The data suggest that conjunctivoplasty using a simple medial conjunctival resection is an effective treatment for patients with epiphora secondary to conjunctivochalasis.

Rheumatologic diseases are often associated with ophthalmic findings. Familiarity with and recognition of these ophthalmic presentations are important in the management of both the systemic and ocular manifestations of the disease. Identification of ocular signs and symptoms of rheumatologic disease will allow a more comprehensive approach to treatment of patients with rheumatic conditions.

PURPOSE: Antigen-sampling M cells have been identified in conjunctival tissue overlying lymphoid follicles in rabbits and guinea pigs. Conjunctival M cells in the guinea pig display alpha(2-3) sialic acid on their surfaces, as evinced by selective labeling by Maackia amurensis leukoagglutinin (MAL)-I. Haemophilus influenzae strains OM12, which expresses the HMW1 adhesin for alpha(2-3) sialic acid, and Rd KW20, which lacks HMW1, were used to test the hypothesis that conjunctival M cells translocate large microbes. METHODS: Fluorescein-labeled bacteria were instilled into the conjunctival sac for up to 130 minutes. Confocal laser scanning microscopy and electron microscopy were used to visualize bacterial distribution. RESULTS: M cells, but not nonfollicular epithelial cells in the palpebral region, selectively bound and translocated bacteria. By 66 minutes, 423 +/- 165 bacteria/mm(2) of follicle-associated epithelial (FAE) surface were found in three-dimensional reconstructions extending 15.4 mum below the surface. By 127 minutes, the number of bacteria increased to 579 +/- 44/mm(2) of FAE surface and they had moved 50% deeper into the follicle. Coadministration with MAL-I reduced OM12 transport by 61%. Similarly, Rd KW20 uptake was 71% less at 63 minutes and 58% less at 121 minutes, indicating that OM12 uptake is at least partially mediated by binding to alpha(2-3) sialic acid. CONCLUSIONS: Conjunctival M cells are a port of entry for large microbes and may play a role in initiation of mucosal immune responses against commensal or transient ocular bacterial species and may allow the entry of pathogens.

PURPOSE: This study investigates the presence of M cells in the rabbit conjunctiva. Resolving whether the conjunctiva contains M cells is important, because at other mucosal sites, these antigen sampling cells are known to initiate the mucosal immune response and to act as a site of entry for opportunistic pathogens. METHODS: Fluorescent 0.2-microm polystyrene latex beads were either instilled into the conjunctival sac for 20 to 120 minutes in vivo or applied to flat mounts in vitro. Specimens were assessed by epi-fluorescence stereomicroscopy, widefield fluorescence microscopy, confocal scanning laser microscopy, and transmission and scanning electron microscopy. RESULTS: Latex beads preferentially bound to a subpopulation of cells in the epithelium overlying mucosal lymphoid follicles in the fornix region. At 4 degrees C, the beads were associated with the apical surface of cells that had longer, more irregular microvilli than the surrounding epithelial cells. Within 20 minutes of an in vivo exposure, latex beads were internalized by the follicle-associated epithelial cells and with time moved into the underlying follicle region. After 120 minutes of in vivo exposure, latex beads could be found in cervical lymph nodes. CONCLUSIONS: This study demonstrates that the follicle-associated epithelium of the rabbit conjunctiva contains a cell with morphologic characteristics and the ability to bind and translocate latex beads, which make it indistinguishable from antigen sampling M cells in the rabbit cecum and tonsils. Consistent with its hypothesized antigen sampling role, beads that have been translocated by this cell are rapidly transferred to cervical lymph nodes.

Antigen-sampling M cells are found in the follicle-associated epithelium above organized lymphoid tissue in many mucosae. They play a key role in initiating the mucosal immune response and act as a site of entry for opportunistic pathogens. This study investigates the presence of M cells in the Guinea pig conjunctiva. Maackia amurensis leukoagglutinin I and II (MAL-I and MAL-II) were identified as potential conjunctival M cell markers based on a screening of 12 lectins and 5 carbohydrate epitope antibodies on aldehyde-fixed follicles. Biotinylated or fluorescein-conjugated MAL-I was then instilled into conjunctival sacs in vivo for 15-60 min. Specimens were assessed by epi-fluorescence stereomicroscopy, confocal scanning laser microscopy and transmission and scanning electron microscopy (TEM and SEM). Selective labelling of a subset of epithelial cells overlying lymphoid follicles was observed following in vivo exposure to MAL-I. MAL-I labelling was restricted to cells with sparse, irregular microvilli. Cells preferentially labelled with MAL-I were found to internalize the lectin during a 60 min in vivo exposure. MAL-I was transcytosed to basolateral membranes of cells filled with intracellular vesicles during a 45 min in vivo incubation. This study demonstrates that the Guinea pig conjunctiva contains a cell with morphological and functional characteristics of antigen-sampling M cells.

Copper is an essential co-factor for several key metabolic processes. This requirement in humans is underscored by Menkes disease, an X-linked copper deficiency disorder caused by mutations in the copper transporting P-type ATPase, MNK. MNK is located in the trans-Golgi network where it transports copper to secreted cuproenzymes. Increases in copper concentration stimulate the trafficking of MNK to the plasma membrane where it effluxes copper. In this study, a Menkes disease mutation, G1019D, located in the large cytoplasmic loop of MNK, was characterized in transfected cultured cells. In copper-limiting conditions the G1019D mutant protein was retained in the endoplasmic reticulum. However, this mislocalization was corrected by the addition of copper to cells via a process that was dependent upon the copper binding sites at the N-terminal region of MNK. Reduced growth temperature and the chemical chaperone, glycerol, were found to correct the mislocalization of the G1019D mutant, suggesting this mutation interferes with protein folding in the secretory pathway. These findings identify G1019D as the first conditional mutation associated with Menkes disease and demonstrate correction of the mislocalized protein by copper supplementation. Our findings provide a molecular framework for understanding how mutations that affect the proper folding of the MNK transporter in Menkes patients may be responsive to parenteral copper therapy.