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Lacrimal Gland in Sjögren's Syndrome
Lacrimal Gland in Sjo¨gren’s Syndrome Dear Editor: Inflammation of the lacrimal gland is a pivotal event in Sjögren’s syndrome (SS) dry eyes. The diagnostic tools to detect lacrimal gland involvement in SS include biopsy, Schirmer test, and ocular surface staining.1 Lacrimal gland biopsy, which is included in the diagnostic criteria for SS, is an invasive procedure. The development of noninvasive examination techniques will help clinicians evaluate the lacrimal gland status in SS. Eleven right eyes of 11 out of 69 patients with primary SS (1 male, 10 females; mean age: 48.6⫾14.9 years) and 9 right eyes out of 22 age and sex-matched healthy subjects (1 male, 8 females; mean age:44.7⫾11.3 years) in whom confocal microscopy scanning of the lacrimal gland was possible were studied in this single-center, prospective controlled study. The SS diagnosis was based on the revised American-European consensus criteria.1-2 None of the subjects had a history of ocular surgery, other ocular or systemic diseases, or a history of topical/systemic drug or contact lens use that would alter the ocular surface. All subjects had biomicroscopy, tear film break-up time (BUT), Schirmer test I, and vital staining examinations. Lacrimal glands were examined in vivo by using the Heidelberg Retina Tomograph II, Rostock Cornea Module (HRTIIRCM). The subjects assumed an extreme inferonasal gaze. The upper eyelid was retracted upward manually or with a lid retractor (Figure 1, available at http://aaojournal.org). Lacrimal gland confocal scans in SS patients and controls were compared for phenotypic alterations, acinar unit density, diameter, and inflammatory cell density that were manually marked inside each 400 m ⫻ 400 m frame and calculated automatically with an internal software that comes with the Rostock unit. Confocal microscopy scans of lacrimal glands of controls were also compared with lacrimal gland specimens obtained from cadavers. Patients underwent gland biopsy in the operating room with specimens undergoing ex vivo confocal microscopy observations later. All subjects consented to the examination procedures, which were ethic-board reviewed. Data were processed using the Instat 3.0, GraphPad software (San Diego, CA). The Mann-Whitney test was used to compare the examination parameters between the SS patients and controls. Spearman correlation analysis was used to determine the correlation between the glandular inflammatory cell densities, tear quantity, stability, and vital staining. A probability level of less than 5% was considered statistically significant. The tear functions and vital staining scores were significantly worse in SS patients compared with controls (Table 1, available at http://aaojournal.org). Composite photographs constructed from the lacrimal gland in vivo confocal microscopy scans in all subjects revealed lobular architecture, acinar units, intralobular, and interlobular ducts (Figure 2, available at http://aaojournal.org). Ex vivo scans revealed round acinar units comparable to the postmortem histopathological specimens obtained from age- and sexmatched healthy individuals (Figure 3, available at http:// aaojournal.org). In vivo confocal microscopy scans and ex vivo scanning of lacrimal gland biopsy specimens of the same patients showed areas of focal acinar atrophy with fibrosis and interlobular inflammation mainly consisting of
polymorphs (Figure 4, available at http://aaojournal.org). The confocal microscopy parameters of acinar unit density, diameter, and inflammatory cell densities were significantly worse in SS patients compared with controls (Table 2, available at http://aaojournal.org). Spearman correlation analysis showed a significant positive linear correlation between the lacrimal gland inflammatory cell density and corneal fluorescein staining score (r⫽0.53, P⫽0.02), as well as the inflammatory cell density and Rose-Bengal score (r⫽0.66, P⫽0.003). The inflammatory cell density had a significant negative linear correlation with the Schirmer test scores (r⫽⫺0.57; P⫽0.01) and tear film BUT (r⫽⫺0.60; P⫽0.01). In vivo confocal microscopy examination of the lacrimal gland aided in the in vivo visualization of the lacrimalgland acinar units, glandular ducts, and interstitial matrix in healthy individuals and patients. The comparisons of the postmortem specimens and ex vivo confocal microscopy examinations of the same histopathology glass slides confirmed our findings that confocal microscopy effectively demonstrates acinar unit dilatation, interstitial fibrosis, and inflammatory cells. Reported histopathological findings in lacrimal glands of SS patients include periductal and focal inflammatory aggregates and atrophy of acini with fibrosis.3–5 Our observation that in vivo confocal microscopy could reflect the lacrimal gland histopathology strengthen hopes that this technology may be an efficient tool in the noninvasive diagnostics of the lacrimal gland in patients with SS. Acknowledgment. The preliminary work was presented at the 32nd Japan Cornea Conference, February 28 –March 1, 2008, Urayasu, Japan, receiving The Uchida Award for best scientific presentation and innovative scientific work. Drs Sato and Matsumoto contributed equally to the work are joint first authors. ENRIQUE ADAN SATO, MD YUKIHIRO MATSUMOTO, MD MURAT DOGRU, MD MINAKO KAIDO, MD TAIS WAKAMATSU, MD OSAMA M.A. IBRAHIM, MD HIROTO OBATA, MD KAZUO TSUBOTA, MD Tokyo, Japan References 1. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554 – 8. 2. Sánchez-Guerrero J, Pérez-Dosal MR, Cárdenas-Velázquez F, et al. Prevalence of Sjögren’s syndrome in ambulatory patients according to the American-European Consensus Group criteria. Rheumatology 2005;44:235– 40. 3. Pepose JS, Akata RF, Pflugfelder SC, et al. Mononuclear cell phenotypes and immunoglobulin gene rearragements in lacrimal gland biopsies from patients with Sjogren’s syndrome. Ophthalmology 1990;97:1599 – 605. 4. Croxatto JC. Lacrimal systems. In: Rao NA, ed. Biopsy pathology of the eye and ocular anexa. Biopsy pathology series 21. London: Chapman & Hall; 1997:297–316. 5. Obata H. Anatomy and histopathology of the human lacrimal gland. Cornea 2006;25:S82–9.
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Figure 1. The examination of lacrimal gland with confocal microscope. The upper eyelids were retracted upward either manually or with a lid retractor (A). Note the protrusion of the lacrimal gland below upper lid (B, circle).
Table 1. Comparison of Tear Functions of Vital Staining Scores Between Sjögren’s Syndrome Patients and Controls
Schirmer test (mm) Break up time (sec) Fluorescein stain (points) Rose Bengal stain (points)
SS
Control
4.9⫾3.9* 4.1⫾1.4* 4.7⫾3.6* 4.4⫾2.6*
17.6⫾12.5 7.7⫾2.2 0.2⫾0.7 0.1⫾0.3
Note that the tear quantity, tear stability, and vital staining scores were significantly worse in patients compared with the control subjects. SS ⫽ Sjögren’s syndrome. *P⬍0.05 Mann Whitney test.
Figure 2. In vivo confocal microscopy and histopathology specimen merged image of the normal lacrimal gland. Note the corresponding normal lacrimal gland architecture in in vivo confocal microscopy and histopathology: the lobular architecture, acinar units (asteriks), intralobular, and interlobular ducts (arrow).
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Figure 3. Comparison of the histopathology of the lacrimal gland biopsy (A) and ex vivo confocal microscopy image (B) of the same specimen. Note that ex vivo examination of the biopsy specimen by confocal microscopy shows corresponding and consistent findings of acinar units, the nuclei of acinar cells, their lumen, and areas of fatty infiltration in the postmortem specimen (88-year-old healthy man).
Figure 4. Comparison of the histopathology specimen from lacrimal gland biopsy (A, D), ex vivo confocal microscopy examination of the specimen (B), and in vivo confocal microscopy of the same SS patient (C, E). Note also the inflammatory cell infiltration depicted by arrow in lacrimal gland of SS patient. Note also the interlobular fibrosis in the biopsy specimens and areas of perilobular fibrosis (black star) and hyperreflective diffuse white areas of fibrosis (black star) in the confocal scan.
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Ophthalmology Volume 117, Number 5, May 2010 Table 2. Comparison of the Confocal Microscopy Based Parameters; the Acinar Unit Density, the Long Acinar Unit Diameter and Inflammatory Cell Density between Sjögren’s Syndrome Patients and Controls
2
Acinar unit density (glands/mm ) Long Acinar unit diameter (m) Inflammatory cell density (cells/mm2)
SS
Control
19.0⫾6.81* 75.7⫾17.4* 1146⫾692*
66.1⫾69.6 61.5⫾13.2 377⫾152
Note that the acinar unit density was significantly lower in patients than the controls suggesting acinar unit loss. The acinar unit diameter was significantly longer in patients than the controls suggesting probable cystic dilatation of the acini. Note also the significantly higher number of inflammatory cells in glands of patients with SS compared with healthy subjects. SS ⫽ Sjögren’s syndrome. *P⬍0.05 Mann Whitney test.
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polymorphs (Figure 4, available at http://aaojournal.org). The confocal microscopy parameters of acinar unit density, diameter, and inflammatory cell densities were significantly worse in SS patients compared with controls (Table 2, available at http://aaojournal.org). Spearman correlation analysis showed a significant positive linear correlation between the lacrimal gland inflammatory cell density and corneal fluorescein staining score (r⫽0.53, P⫽0.02), as well as the inflammatory cell density and Rose-Bengal score (r⫽0.66, P⫽0.003). The inflammatory cell density had a significant negative linear correlation with the Schirmer test scores (r⫽⫺0.57; P⫽0.01) and tear film BUT (r⫽⫺0.60; P⫽0.01). In vivo confocal microscopy examination of the lacrimal gland aided in the in vivo visualization of the lacrimalgland acinar units, glandular ducts, and interstitial matrix in healthy individuals and patients. The comparisons of the postmortem specimens and ex vivo confocal microscopy examinations of the same histopathology glass slides confirmed our findings that confocal microscopy effectively demonstrates acinar unit dilatation, interstitial fibrosis, and inflammatory cells. Reported histopathological findings in lacrimal glands of SS patients include periductal and focal inflammatory aggregates and atrophy of acini with fibrosis.3–5 Our observation that in vivo confocal microscopy could reflect the lacrimal gland histopathology strengthen hopes that this technology may be an efficient tool in the noninvasive diagnostics of the lacrimal gland in patients with SS. Acknowledgment. The preliminary work was presented at the 32nd Japan Cornea Conference, February 28 –March 1, 2008, Urayasu, Japan, receiving The Uchida Award for best scientific presentation and innovative scientific work. Drs Sato and Matsumoto contributed equally to the work are joint first authors. ENRIQUE ADAN SATO, MD YUKIHIRO MATSUMOTO, MD MURAT DOGRU, MD MINAKO KAIDO, MD TAIS WAKAMATSU, MD OSAMA M.A. IBRAHIM, MD HIROTO OBATA, MD KAZUO TSUBOTA, MD Tokyo, Japan References 1. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554 – 8. 2. Sánchez-Guerrero J, Pérez-Dosal MR, Cárdenas-Velázquez F, et al. Prevalence of Sjögren’s syndrome in ambulatory patients according to the American-European Consensus Group criteria. Rheumatology 2005;44:235– 40. 3. Pepose JS, Akata RF, Pflugfelder SC, et al. Mononuclear cell phenotypes and immunoglobulin gene rearragements in lacrimal gland biopsies from patients with Sjogren’s syndrome. Ophthalmology 1990;97:1599 – 605. 4. Croxatto JC. Lacrimal systems. In: Rao NA, ed. Biopsy pathology of the eye and ocular anexa. Biopsy pathology series 21. London: Chapman & Hall; 1997:297–316. 5. Obata H. Anatomy and histopathology of the human lacrimal gland. Cornea 2006;25:S82–9.
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Ophthalmology Volume 117, Number 5, May 2010
Figure 1. The examination of lacrimal gland with confocal microscope. The upper eyelids were retracted upward either manually or with a lid retractor (A). Note the protrusion of the lacrimal gland below upper lid (B, circle).
Table 1. Comparison of Tear Functions of Vital Staining Scores Between Sjögren’s Syndrome Patients and Controls
Schirmer test (mm) Break up time (sec) Fluorescein stain (points) Rose Bengal stain (points)
SS
Control
4.9⫾3.9* 4.1⫾1.4* 4.7⫾3.6* 4.4⫾2.6*
17.6⫾12.5 7.7⫾2.2 0.2⫾0.7 0.1⫾0.3
Note that the tear quantity, tear stability, and vital staining scores were significantly worse in patients compared with the control subjects. SS ⫽ Sjögren’s syndrome. *P⬍0.05 Mann Whitney test.
Figure 2. In vivo confocal microscopy and histopathology specimen merged image of the normal lacrimal gland. Note the corresponding normal lacrimal gland architecture in in vivo confocal microscopy and histopathology: the lobular architecture, acinar units (asteriks), intralobular, and interlobular ducts (arrow).
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Letters to the Editor
Figure 3. Comparison of the histopathology of the lacrimal gland biopsy (A) and ex vivo confocal microscopy image (B) of the same specimen. Note that ex vivo examination of the biopsy specimen by confocal microscopy shows corresponding and consistent findings of acinar units, the nuclei of acinar cells, their lumen, and areas of fatty infiltration in the postmortem specimen (88-year-old healthy man).
Figure 4. Comparison of the histopathology specimen from lacrimal gland biopsy (A, D), ex vivo confocal microscopy examination of the specimen (B), and in vivo confocal microscopy of the same SS patient (C, E). Note also the inflammatory cell infiltration depicted by arrow in lacrimal gland of SS patient. Note also the interlobular fibrosis in the biopsy specimens and areas of perilobular fibrosis (black star) and hyperreflective diffuse white areas of fibrosis (black star) in the confocal scan.
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Ophthalmology Volume 117, Number 5, May 2010 Table 2. Comparison of the Confocal Microscopy Based Parameters; the Acinar Unit Density, the Long Acinar Unit Diameter and Inflammatory Cell Density between Sjögren’s Syndrome Patients and Controls
2
Acinar unit density (glands/mm ) Long Acinar unit diameter (m) Inflammatory cell density (cells/mm2)
SS
Control
19.0⫾6.81* 75.7⫾17.4* 1146⫾692*
66.1⫾69.6 61.5⫾13.2 377⫾152
Note that the acinar unit density was significantly lower in patients than the controls suggesting acinar unit loss. The acinar unit diameter was significantly longer in patients than the controls suggesting probable cystic dilatation of the acini. Note also the significantly higher number of inflammatory cells in glands of patients with SS compared with healthy subjects. SS ⫽ Sjögren’s syndrome. *P⬍0.05 Mann Whitney test.
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