Ocular Surface Changes in Patients With Cicatricial Pemphigoid

Abstract

Purpose: : To test the hypothesis that patients with ocular cicatricial pemphigoid (OCP) have a significant degree of conjunctival inflammation and anatomical and immunological changes of the cornea.

Methods: : Early stages OCP patients were identified, and Schirmer test, fluorescein and lissamine green staining, tear break-up time, and impression cytology of the conjunctiva were performed in 8 patients and in 8 age-matched controls. HLA-DR and CD45 expression on conjunctival cells was measured by flow cytometry. The central cornea was examined by in vivo confocal microscopy using a 40x lens and an axial resolution of 5 µm in both groups.

Results: : Statistically significant changes in corneal fluorescein staining (p<0.005), lissamine green conjunctival staining (p<0.005), HLA-DR expression (p<0.005) and CD45 (p<0.005) occurred in the study group compared to controls, while tear secretion did not show any differences. In patients with OCP confocal microscopy images obtained showed a significant lower number of epithelial cells (1238 ± 375 cc/mm²) compared to controls (1691 ± 190 cc/mm², p<0.0001), superficial epithelial cell area considerably higher than normal, reduced nucleus/cytoplasm ratio, halos around the nuclei, and sharp borders. Numerous highly reflective dendritic-like cells were present in the epithelial cell basal layer, and their density correlated with HLA-DR expression. The stroma showed loss of keratocytes, the presence of lacunae, and tortuous subbasal nerves. No differences were recorded in endothelial cells density.

Conclusions: : In OCP the ocular surface is characterized by inflammation of the conjunctiva and immunological and structural changes of the cornea which confirm the importance of local and systemic anti-inflammatory therapy in the early stages of the disease.

Keywords: microscopy: confocal/tunneling • inflammation • conjunctiva