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Loss of tear duct–associated lymphoid tissue in association with the scarring of symptomatic dacryostenosis
Loss of Tear Duct–associated Lymphoid Tissue in Association with the Scarring of Symptomatic Dacryostenosis Friedrich P. Paulsen, MD, PhD,1 Ulrich Schaudig, MD,2 Steffen Maune, MD, PhD,3 Andreas B. Thale, MD4 Objective: To determine whether organized mucosa-associated lymphoid tissue (MALT) is a normal component of the human efferent tear ducts or is acquired in reaction to chronic inflammation. Design: Nonrandomized comparative (cadaver controlled) study with histopathologic correlations. Materials: Tissue specimens from nasolacrimal ducts of 38 patients undergoing endonasal dacryocystorhinostomy in postinflammatory dacryostenosis with signs of chronic inflammation were analyzed using histologic examination and immunohistochemical studies. Only tissue specimens revealing proliferative sclerotic forms of chronic fibrosis were chosen for the study. Eighty specimens from the lacrimal systems of body donors served as controls. Testing: Tissue specimens from each lacrimal system were prepared and processed with paraffin, sectioned, stained using different histologic methods with an array of specific antibodies, and examined by light microscopy. Main Outcome Parameters: The distribution of intraepithelial and subepithelial defense cells was analyzed to identify plasma cells, secretory immunoglobulins, lymphocytes, dendritic cells, and organized mucosaassociated lymphoid tissue. Results: The presence of secretory immunoglobulin A was demonstrated in subepithelial plasma cells and in the cytoplasm of apical epithelial cells in both chronically inflamed and healthy lacrimal systems. In more than one third of cases from body donors, but in only a few biopsy specimens from patients, organized lymphoid tissue was found with the cytomorphologic and immunophenotypical features of MALT. All other cases showed a diffuse infiltrate of defense cells within the lamina propria. Conclusions: The development of tear duct–associated lymphoid tissue (TALT) is a common feature that is often found in symptomatically normal nasolacrimal ducts. Because TALT seems to be lost associated with the scarring of symptomatic dacryostenosis, it is unlikely that the presence per se of TALT leads to scarring. Future studies are needed to explain the development of TALT. Ophthalmology 2003;110:85–92 © 2003 by the American Academy of Ophthalmology.
The mucous membrane of the lacrimal sac and the nasolacrimal duct is a pseudostratified columnar epithelium. Beneath the epithelium, the lamina propria consists of two strata: loose connective tissue with scattered lymphocytes or groups of lymphocytes and a rich venous plexus situated under the loose connective tissue.1 The latter is comparable Originally received: November 30, 2001. Accepted: May 3, 2002. Manuscript no. 211008 1 Institute of Anatomy, Christian Albrecht University of Kiel, Kiel, Germany. 2 Department of Ophthalmology, University Hospital Eppendorf, Hamburg, Germany. 3 Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University of Kiel, Kiel, Germany. 4 Department of Ophthalmology, Christian Albrecht University of Kiel, Kiel, Germany. Supported by the Deutsche Forschungsgemeinschaft (German Research Foundation, Bonn, Germany) program grant Pa 738/1-3. Reprint requests to Friedrich Paulsen, MD, PhD, Department of Anatomy, Christian Albrecht University of Kiel, Olshausenstrasse 40, D-24098 Kiel, Germany. © 2003 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
to a cavernous body and may facilitate opening and closure of the lumen of the lacrimal passage by shrinkage and swelling of the cavernous body with consecutive regulation of tear outflow.2,3 It has been shown that the mucosa plays a significant role in nonspecific immune defense by producing a mucus layer containing different carbohydrates,4,5 TFF-peptides,6 and antimicrobial peptides.7,8 Recent evidence indicates that the surface of the efferent tear ducts is also an integral part of the specific mucosal immune system and belongs to the mucosa-associated lymphoid tissue (MALT).9,10 However, it is yet not clear whether MALT of the nasolacrimal ducts is a normal component of the human efferent tear ducts. It has been suggested that it may develop in response to bacterial or viral infections or as a result of allergic reactions.9 Moreover, the description of primary low-grade B cell lymphomas in the lacrimal passage makes this question clinically relevant.11–13 To test the hypothesis that MALT of the nasolacrimal ducts is acquired in response to bacterial stimulation, nasolacrimal ducts from cadavers with unknown history of efISSN 0161-6420/03/$–see front matter PII S0161-6420(02)01442-2
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Ophthalmology Volume 110, Number 1, January 2003 ferent tear duct, ocular, and nasal disease were examined along with biopsy specimens from patients with postinflammatory dacryostenosis and compared with a view to the presence of lymphoid tissue with the structure and phenotype of organized MALT.
Material and Methods Eighty lacrimal systems (34 male, 46 female, aged 27–98 years) obtained from 46 cadavers donated to the Department of Anatomy, Christian Albrecht University of Kiel, Germany, and tissue specimens from 38 patients (9 male, 29 female, aged 22– 89 years) undergoing endonasal dacryocystorhinostomy in postinflammatory dacryostenosis without signs of active inflammation were prepared. Before dissection in all body donors, the history was studied, and next of kin were interviewed regarding eye or eye adnexal problems, any common colds during the last weeks of life, or any other diseases that could have affected lacrimal function; all such cases were excluded. Thus, all body donors analyzed in this study were free of recent trauma, eye or nasal infections, or diseases potentially involving or affecting lacrimal function. Apart from four body donors using antihypertensive drugs, four using diuretic drugs, and two using a -blocker, none was on medication. All lacrimal systems and biopsy specimens were obtained 24 hours after death at the latest, fixed in 4% formalin, dehydrated in graded concentrations of ethanol, and embedded in paraffin. Material from surgical procedures was obtained with the permission of the Medical Ethics Committee and used in accordance with the Declaration of Helsinki. Patients were selected from referrals to the Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University of Kiel, Germany, between March 1997 and March 2001. Patients with epiphora were carefully interviewed with regard to the duration of tearing, history of acute or chronic dacryocystitis, and complaints of mucoid discharge in the medial canthal region. After anamnestic exclusion of facial surgery or trauma, allergies, family history of tearing, external eyelid disease, and topical eye medication, eyelid malposition and periocular neoplasm were excluded by a careful ocular examination at the Department of Ophthalmology, Christian Albrecht University of Kiel, Germany. The lacrimal passage was assessed by inspection, palpation, digital expression of lacrimal sac contents, Jones testing, syringing of the upper and lower canaliculus, dacryocystography, and axial and coronal computed tomography in selected cases. Patients revealing punctal or canalicular stenosis were excluded from the study. Moreover, a nasal endoscopic examination was performed in each case at the Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University. No microbiologic tests were performed on the tear fluid of body donors or on that of patients before processing for histologic examination.
Endonasal Dacryocystorhinostomy: Biopsy Technique Endonasal dacryocystorhinostomy was performed using a modified version of the conventional method according to West.14 After resection of the bony walls of the medial part of the frontal process of the maxilla and of the os lacrimale, the periosteum of the fossa lacrimalis and the ductus nasolacrimalis was visible. By partly removing it, a broad entrance was opened into the lacrimal fossa and the nasolacrimal canal. From the lower canaliculus, the lacrimal system was penetrated by pushing a stylet forward to the
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stenotic area. The tissue surrounding the lumen of the lacrimal sac above the stenosis was then opened by scalpel cutting to the stylet. Parts of the incision margins were removed with a small forceps, and a broad exit of the lacrimal sac into the nose was produced. It was then possible to remove the entire stenotic area below this exit by cutting the entire lacrimal system horizontally above and below the stenotic area and extirpating it. Endonasal procedures were performed under endoscopic or microscopic view without destroying important adnexal structures.
Light Microscopy For analysis by light microscopy, frontal and horizontal sections (7 m) were deparaffinized and stained with toluidine blue (pH 8.5), azan, hemalum, and Alcian blue (pH 1). The slides were examined microscopically (Axiophot; Zeiss, Oberkochen, Germany).
Immunohistochemistry Immunohistochemical stains were done with antibodies against immunoglobulin G (IgG) (Dako, E0482), IgM (Dako, M0702, 1:100), IgA (Dako, F0316, 1:20), CD 3 (Dako, A0452, 1:100), CD 20 (L 26, N1502, conc.) (Dako), as well as follicular dendritic cells (KiM4, conc.),15 B cells (KiB5, conc.),16 CD 45RA (KiB3, conc.),17 and CD 68 (KiM1, conc.).18 The Ki-antibodies were provided by the Department of Pathology, Christian Albrecht University of Kiel, Germany. They were applied using a standard peroxidase-labeled streptavidine-biotin technique, either with microwave heating before treatment or using conventional methods with trypsination when appropriate. After counterstaining with hemalum, the sections were finally mounted with Aquatex (Boehringer, Mannheim, Germany). Only immunostaining of IgA was done in addition to this procedure with a fluorescein isothiocyanate– conjugated goat antimouse IgG as the secondary antibody. Three negative control sections were used in each case in which the primary antibody, the secondary antibody, or the streptavidinebiotin complex was omitted. For positive control, sections of human spleen (all other antibodies) were used. All slides were examined with a microscope (Zeiss-Axiophot, Jena, Germany) equipped for epifluorescence.
Results To ensure comparability with surgically obtained specimens, only those parts of lacrimal systems from cadavers were cut serially and investigated that corresponded to those obtained surgically. The possibility that cases classified as “without MALT” did contain MALT in other parts of the lacrimal system can therefore not be excluded for both samples from cadavers and surgically obtained specimens.
Light Microscopy Specimens from Cadavers. The samples exhibited a pseudostratified columnar epithelial lining consisting of a basal cell layer and a superficial columnar layer in most areas (Fig 1). Goblet cells were integrated in the epithelium as solitary cells or as intraepithelial mucous glands (Fig 1). Beneath the epithelium, the lamina propria consisted of loose connective tissue containing many lymphocytes (Fig 1), sometimes arranged in follicles, and an underlying cavernous body. Small subepithelially-located seromucous glands were detected in some samples in addition to epithelial and goblet cells (Fig 2). Specimens Obtained by Surgery. All 38 specimens analyzed by histologic examination revealed chronic inflammation of the
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis
Figure 1. Cross-section through the lining epithelium of the lacrimal sac. The goblet cells show a characteristic arrangement with several cells forming an intraepithelial mucous gland (arrows). Subepithelially, the lamina propria consists of loose connective tissue containing many lymphocytes. l ⫽ lacrimal passage (stain, hemalum; original magnification, ⫻231). Figure 2. Horizontal section through a small gland in the lamina propria of the lacrimal sac. The gland consists of serous (s) and mucous (m) parts (stain, hemalum; original magnification, ⫻363). Figure 3. Cross-section through a tissue specimen of a patient (female, 64 years) demonstrating chronic inflammation with epithelial and subepithelial infiltration of defense cells, loss of intraepithelial goblet cells, basal cell hyperplasia, and beginning squamous metaplasia. l ⫽ lacrimal passage (stain, toluidine blue; original magnification, ⫻239). Figure 4. Section through a tissue specimen of a patient (female, 70 years) demonstrating complete fibrosis of the subepithelial tissue with rarification of blood vessels (v with arrows) (stain, toluidine blue; original magnification, ⫻228).
lacrimal system that had led to different stages of fibrosis, ranging from proliferative sclerotic forms of chronic fibrosis (“moderate”: 18 cases) to total subepithelial fibrosis (“severe”: 20 cases). Tissue specimens from 18 patients demonstrated transitional forms of chronic fibrosis with epithelial and subepithelial infiltration by defense cells that were almost lymphocytes, loss of intraepithelial goblet cells, variable loss of differentiated epithelial cells ranging from denuded epithelium to basal cell hyperplasia (often associated with squamous metaplasia), and increased subepithelial fibroblasts (Fig 3). The specialized blood vessels of the subepithelial cavernous body often showed thickening of the walls with varying degrees of intimal proliferation up to obliteration and reduction. Seven cases were characterized by squamous metaplasia with a total absence of goblet cells. The underlying mucosa had undergone secondary fibrosis with basement membrane thickening (Fig 3). Also visible was a reduction (up to total loss) of the specialized blood vessels of the cavernous body (Fig 4). Tissue specimens from 13 cases showed complete fibrous obliteration of the duct within the osseous canal (no lacrimal passage lumen was found either intraoperatively or histologically). The dissection rims of all surgically obtained specimens
showed a transition from the described changes to a normal double-layered epithelium with integrated goblet cells and intraepithelial mucous glands. The lamina propria contained many lymphocytes, in seven cases arranged in follicles, and an underlying cavernous body.
Lymphocyte, Macrophage, and Immunoglobulin Immunostaining Specimens from Cadavers. In most of the cases investigated there was a diffuse infiltrate of variable intensity within the lamina propria of the samples consisting predominantly of CD3-positive T lymphocytes with scattered CD20- and CD45RA-positive B cells, as well as plasma cells. A few IgM- and IgG-positive plasma cells were also detected in the infiltrate and in the connective tissue between seromucous glands. Solitary CD3-positive T cells and CD45RA-positive B cells were detected inside the epithelium (Fig 5), although the overall extent of infiltration was low. Organized lymphoid tissue was identified in about one third of the cases investigated. The findings are summarized in Figure 6. The youngest person in whom MALT was identified was a 27year-old.
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Figure 5. Immunostaining with KiB3 of a horizontal section through the lining epithelium of the lacrimal sac of a cadaver (male, 88 years). Red staining reveals intraepithelial and subepithelial CD45RA-positive B cells (arrows) (immunostain, anti-CD45RA; original magnification, ⫻456).
MALT was found once in a right lacrimal sac and 4 times in a left one, as well as 13 times in a right nasolacrimal duct, and 9 times in a left one. Either it was distributed at intervals along the investigated segment or only a single follicle was found. MALT was not necessarily present to the same extent in both efferent lacrimal systems. Specimens Obtained by Surgery. Comparable to the cadavers, there was a diffuse infiltrate of variable intensity within the lamina propria of the surgically obtained specimens (Fig 3). The lamina propria consisted of loose connective tissue containing many lymphocytes, sometimes arranged in follicles, and an underlying cavernous body. However, the diffuse infiltrate was only observed in the 18 specimens classified as “moderate.” The specimens classified as “severe” revealed such a diffuse infiltrate only at their dissection rims. The central part consisted of fibrous tissue and was nearly free of detectable defense cells. Only single macrophages or lymphocytes were visible. Organized lymphoid tissue was identified in 10 of the cases investigated (Fig 7). Of these, four belonged to the “moderate” group and six to the “severe” group. The findings are summarized in Figure 8. The youngest person in whom MALT was identified is a 22-year-old. In four cases (two “moderate,” two “severe”) MALT was situated in the area of the prestenotic rim; in six cases (two “moderate,” four “severe”) it was detectable at the poststenotic rim. Organization of MALT in Cadavers and Surgically Obtained Specimens. It must be stated that only secondary follicles revealing a distinct germinal center and a surrounding parafollicular area were counted (Fig 9). Several areas were seen to display more or less developed primary follicles. Such areas were excluded and named MALT by definition.
Figure 6. Distribution of cases with and without organized mucosa-associated lymphoid tissue (MALT) by age in cadavers.
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Figure 7. Tear duct–associated lymphoid tissue (TALT) in a patient (female, 68 years) at the area of the prestenotic rim. TALT of the lacrimal sac with a well-developed germinal center (gc), a mantle zone (m), a marginal zone (mar), and an overlying lymphoepithelium (star). l ⫽ lacrimal passage (stain, azan; original magnification, ⫻213).
No significant male-female differences were seen between lacrimal systems from cadavers and from surgically obtained specimens. Comparable to other mucosal sites, MALT in the lacrimal passage of both cadavers and surgically obtained specimens was characterized by the presence of reactive germinal centers containing tingible-body macrophages (Fig 10), a network of KiM4positive follicular dendritic cells (Fig 11), and CD3-positive T cells (Fig 12). The germinal centers were surrounded by mantle zones and marginal zone cells (Figs 7, and 10). The mantle zones consisted of small CD20-positive lymphocytes (Fig 13) expressing KiB3 and IgM. These lymphocytes merged in a population of small-to-medium-sized B cells with moderately abundant cytoplasm and irregular nucleus outlines, features typical of marginal zone cells (Figs 10, 14). The marginal zone cells exhibited the following immunophenotypes: CD20⫹, CD45RA⫹, CD3-,
Figure 8. Distribution of cases with and without mucosa-associated lymphoid tissue (MALT) by age in chronically inflamed nasolacrimal ducts.
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis
Figure 9. Section through a well-developed germinal center (gc) and a mantle zone (m) of tear duct–associated lymphoid tissue in a patient (female, 48 years) at the area of the poststenotic rim (stain, azan; original magnification, ⫻213).
IgM⫹, and IgA⫹. Some IgG-expressing cells were present, although their occurrence was rare. The marginal zone cells extended into the overlying epithelium to form a characteristic lymphoepithelium (Figs 7, 10, and 14). In the parafollicular area,
Figure 11. Anti-KiM4 immunostaining shows red staining of dendritic cells (arrows) in a germinal center within a lymphoid follicle of the nasolacrimal duct of a patient (male, 32 years) (immunostain, antifollicular dendritic cells; original magnification, ⫻456).
mainly T lymphocytes, some B lymphocytes, and macrophages were present, as well as high endothelial venules.
IgA Immunostaining Specimens from Cadavers. Strong immunoreactivity for IgA was observed in the plasma cells of the lamina propria beneath the epithelium (Fig 15), in the plasma cells of the connective tissue between seromucous glands, and in the secretory products of the mucous membrane and the seromucous glands forming a layer on the lining epithelium. A somewhat weaker immunoreactivity for IgA was seen in the apical epithelial cells (Fig 15) and the serous cells of the seromucous glands. Surgically Obtained Specimens. Immunoreactive plasma cells were visible in the lamina propria of cases revealing moderate forms of chronic fibrosis. In the final states of dacryostenosis, plasma cells were only detected in front of or behind the stenotic area.
Discussion Specific secretory immunity depends on a sophisticated cooperation between the mucosal B cell system and an
Figure 10. Tear duct–associated lymphoid tissue (TALT) in a cadaver (female, 67 years) with a well-developed germinal center (gc), a surrounding mantle zone (m), a marginal zone (mar), and an overlying lymphoepithelium (star). Macrophages (arrows) are stained red by KiM1p. l ⫽ lacrimal passage (immunostain, anti-CD68; original magnification, ⫻363).
Figure 12. Anti-CD3 immunostaining shows red staining of T lymphocytes (arrows) within a lymphoid follicle of the lacrimal sac of a patient (female, 61 years) (immunostain, anti-CD3; original magnification, ⫻456).
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Figure 13. Anti-CD20 immunostaining confirms the cells within the mantle zone as B cells (immunostain, anti-CD20; original magnification, ⫻363). Figure 14. Frontal section through the lining epithelium of the nasolacrimal duct of a patient (female, 66 years) in the area of the poststenotic rim showing subepithelial parts of the marginal zone (mar) of a lymphoid follicle. The epithelium shows features of a lymphoepithelium (star) containing clusters of intraepithelial lymphocytes with irregular nuclei. l ⫽ lacrimal passage (stain, toluidine blue; original magnification, ⫻231). Figure 15. Immunohistochemical evidence of immunoglobulin A (IgA) in the lacrimal sac of a cadaver (female, 83 years). IgA-positive plasma cells (arrows) are located subepithelially. The epithelial cells show weak positivity for IgA, which is also contained in the mucous layer (arrowheads) overlying the epithelium g ⫽ goblet cell, l ⫽ lacrimal passage (immunostain, anti-IgA; original magnification, ⫻363).
epithelial glycoprotein called the secretory component.19 Initial stimulation of Ig-producing B cells is believed to take place mainly in organized MALT.20 It has become evident that considerable regionalization or compartmentalization exists in MALT, perhaps determined by different cellular expression profiles of adhesion molecules and/or the local antigenic repertoire. Antigenic stimulation of B cells results in the generation of predominantly IgA-synthesizing blasts that leave the mucosae by way of efferent lymphatics, pass through the associated lymph nodes into the thoracic duct, and enter the circulation. The cells then return selectively to the lamina propria as plasma cells or memory B cells by means of homing mechanisms.21 Recent findings have shown that MALT is a feature that is regularly found inside the nasolacrimal passage. Here it occurs in 41%9 to 44%10 of healthy unselected
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cadavers with unknown previous history of disease regarding the eye, efferent lacrimal pathway, and nose. Our present findings reveal lymphoid follicles in 34% of the healthy cadavers investigated. On the basis of a definition by Isaacson21 for MALT of the gut wall (i.e., Peyer’s patches) the lymphoid follicles of the lacrimal passage fulfill the criteria for designation as MALT, because they comprise (1) organized mucosal lymphoid tissue, (2) lamina propria, and (3) intraepithelial lymphocytes. The tear duct–associated lymphoid tissue (TALT) comprises a B cell and T cell component. The B cell component consists of a follicle with a center and mantle zone and a more or less well-developed marginal zone. There is also an interfollicular area of T cells with high endothelial venules. The lamina propria is diffusely infiltrated by plasma cells, most of which are synthesizing IgA; and
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis lymphocytes, most of which are T cells with some B cells, macrophages, and other accessory cells. However, compared with MALT of the gastrointestinal tract, it is as yet not known whether M cells occur in TALT. (M cells are highly specialized epithelial cells that facilitate uptake of macromolecular substances from the gut. They are able to present to lymphocytes and macrophages specific, potentially pathogenic epitopes of the macromolecules. The immune system needs this direct contact with the epitopes of the macromolecules to initiate a specific immune response.)22 Also, the functional meaning of the structures is not known, because, in contrast to Peyer’s patches, TALT is only found in a percentage of 30% to 40% of “healthy adult specimens.”9,10,23 As early as 1988, Hyjek et al24 postulated that organized lymphoid tissue from outside the gut was supposed to form MALT in response to antigenic stimulation, which may contribute to an autoimmune condition such as Sjo¨ gren’s syndrome in the salivary gland. Moreover, it was demonstrated that, in the conjunctiva,25 nose,26 larynx,27 and lung,28 –30 MALT is absent in neonates and is acquired in early childhood in response to antigenic stimulation. Animal experiments indicate that the development of gastric-,31 bronchus-,32 or nasopharyngeal-26 associated lymphoid tissues is acquired specifically in response to local infection. By contrast, a retrospective study in specimens removed during surgical procedures on patients with chronic pulmonary inflammation revealed bronchus-associated lymphoid tissue to be generally less prominent than that in animals,33 and Wotherspoon et al25 advise caution when extrapolating animal experimental data to humans, because the distribution and structures of MALT vary among different species. The relevance of our findings is limited by the size of the specimen samples investigated. We cannot exclude the possibility that cases classified as “without TALT” did contain TALT in other parts of the lacrimal system that were not investigated. Moreover, it is not possible to determine decisively whether an inflammation of the lacrimal passage has occurred in specimens from cadavers. However, the congruency between the size of specimens from patients and cadavers and the numbers of lacrimal systems from cadavers investigated partly compensates these disadvantages. Thus these results lead to the assumption that lymphoid tissue, including areas of organized nodular deposits, are common in normal patients. They are probably responsible for processing antigens presented to the mucosal surface. Exactly how they are related to the subsequent fibrosis that leads to ductal stenosis is not clear. However, the lymphoid tissue is lost with development of stenosis. One could argue that this tissue disappears as the result of lack of antigen exposure once scarring is sufficient to prevent normal tear flow through the nasolacrimal duct, or simply that the scarring itself replaces the inflammatory cells. At any rate, a recently published article certainly has put our understanding of MALT in a different light concerning the functional significance of TALT. Alpan et al34 demonstrated that a systemic immune response to orally administered soluble antigens does not depend on the presence of functional GALT, but more likely on initiation of immune response by gut-conditioned dendritic cells.
On the basis of the most recent description of TALT, it has not yet been taken into consideration that antigens drained by the tear fluid themselves might be able to induce a kind of immune deviation. This would be plausible with regard to protection of the cornea against inflammatory destruction analogous to what is observed in the nervous system35 and the anterior eye chamber.36 Conversely, the drainage pathways of antigens from the anterior eye chamber, the location of their presentation, and the passage of the corresponding antigen-presenting cells are unknown at present, especially the role of the TALT9,10,23 and also of the conjunctiva-associated lymphoid tissue,25,37– 41 which together have been designated “eye-associated lymphoid tissue,”10 because the immune privilege of the anterior eye chamber remains unclear. It can be concluded that the development of MALT is a common feature that often is found in symptomatically normal nasolacrimal ducts. Because TALT seems to be lost associated with the scarring of symptomatic dacryostenosis, it is unlikely that the presence per se of TALT leads to scarring. Whether special types of bacteria, viruses, or other factors such as some kind of immune deviation are responsible for the development of TALT in humans needs to be investigated in future prospective and experimental studies. Acknowledgments. The authors gratefully acknowledge gifts of monoclonal anti-Ki antibodies from Professor Dr. med. Dr. H. C. R. Parwaresch (Department of Pathology, Christian Albrecht University of Kiel, Kiel, Germany).
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Ophthalmology Volume 110, Number 1, January 2003 11. Kheterpal S, Chan SY, Batch A, Kirkby GR. Previously undiagnosed lymphoma presenting as recurrent dacryocystitis. Arch Ophthalmol 1994;112:519 –20. 12. White WL, Ferry JA, Harris NL, Grove AS Jr. Ocular adnexal lymphoma. A clinicopathologic study with identification of lymphomas of mucosa-associated lymphoid tissue type. Ophthalmology 1995;102:1994 –2006. 13. Tucker N, Chow D, Stockl F, et al. Clinically suspected primary acquired nasolacrimal duct obstruction: clinicopathologic review of 150 patients. Ophthalmology 1997;104:1882– 6. 14. West JM. A window resection of the nasal duct in case of stenosis. Trans Am Ophthalmol Soc 1909;12:659. 15. Parwaresch MR, Radzun HJ, Hansmann ML, Peters KP. Monoclonal antibody Ki-M4 specifically recognizes human dendritic reticulum cells (follicular dendritic cells) and their possible precursor in blood. Blood 1983;62:585–90. 16. Hansmann ML, Wacker HH, Gralla J, et al. Ki-B5. A monoclonal antibody unrelated to CD45 recognizes normal and neoplastic human B cells in routine paraffin sections. Blood 1991;77:809 –17. 17. Hansmann ML, Wacker HH, Radzun HJ. Paragranuloma is a variant of Hodgkin’s disease with predominance of B-cells. Virchows Arch A Pathol Anat Histopathol 1986;409:171– 81. 18. Radzun HJ, Hansmann ML, Heidebrecht HJ, et al. Detection of a monocyte/macrophage differentiation antigen in routinely processed paraffin-embedded tissues by monoclonal antibody Ki-M1P. Lab Invest 1991;65:306 –15. 19. Brandtzaeg P. Humoral immune response patterns of human mucosae: induction and relation to bacterial respiratory tract infections. J Infect Dis 1992;165(Suppl 1):S167–76. 20. Butcher EC, Picker LJ. Lymphocyte homing and homeostasis. Science 1996;272:60 – 6. 21. Isaacson PG. Extranodal lymphomas: The MALT concept. Verh Dtsch Ges Pathol 1992;76:14 –23. 22. Gebert A, Rothko¨ tter HJ, Pabst R. M cells in Peyer’s patches of the intestine. Int Rev Cytol 1996;167:91–159. 23. Paulsen F, Paulsen J, Thale A, et al. Organized mucosaassociated lymphoid tissue in human nasolacrimal ducts. In: Sullivan DA, ed. Lacrimal Gland, Tear Film and Dry Eye Syndromes 3. New York: Plenum, 2002; in press. 24. Hyjek E, Smith WJ, Isaacson PG. Primary B cell lymphoma of salivary glands and its relationship to myoepithelial sialadenitis. Hum Pathol 1988;19:766 –76. 25. Wotherspoon AC, Hardman-Lea S, Isaacson PG. Mucosaassociated lymphoid tissue (MALT) in the human conjunctiva. J Pathol 1994;174:33–7. 26. Kuper CF, Koornstra PJ, Hameleers DMH, et al. The role of nasopharyngeal lymphoid tissue. Immunol Today 1992;13: 219 –24. 27. Tschernig T, Kleemann WJ, Pabst R. Bronchus-associated
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lymphoid tissue (BALT) in the lungs of children who had died from sudden infant death syndrome and other causes. Thorax 1995;50:658 – 60. Emery JL, Dinsdale F. The postnatal development of lymphoreticular aggregates and lymph nodes in infants’ lungs. J Clin Pathol 1973;26:539 – 45. Gould SJ, Isaacson PG. Bronchus-associated lymphoid tissue (BALT) in human fetal and infant lung. J Pathol 1993;169: 229 –34. Pabst R, Gehrke I. Is the bronchus-associated lymphoid tissue (BALT) an integral structure of the lung in normal mammals including humans? Am J Respir Cell Mol Biol 1990;3:131–5. Wotherspoon AC, Ortiz-Hidalgo C, Falzon MR, Isaacson PG. Helicobacter pylori-associated gastritis and primary B-cell gastric lymphoma. Lancet 1991;338:1175– 6. Delventhal S, Hensel A, Petzoldt K, Pabst R. Effects of microbial stimulation on the number, size and activity of bronchus-associated lymphoid tissue (BALT) structures in the pig. Int J Exp Pathol 1992;73:351–7. Delventhal S, Brandis A, Ostertag H, Pabst R. Low incidence of bronchus-associated lymphoid tissue (BALT) in chronically inflamed human lungs. Virchows Arch B Cell Pathol Incl Mol Pathol 1992;62:271– 4. Alpan O, Rudomen G, Matzinger P. The role of dendritic cells, B cells, and M cells in gut-oriented immune responses. J Immunol 2001;166:4843–52. Wenkel H, Streilein JW, Young MJ. Systemic immune deviation in the brain that does not depend on the integrity of the blood-brain barrier. J Immunol 2000;164:5125–31. Streilein JW, Niederkorn JY. Characterization of the suppressor cell(s) responsible for anterior chamber-associated immune deviation (ACAID) induced in BALB/c mice by P815 cells. J Immunol 1985;134:1381–7. ¨ sterlind G. An investigation into the presence of lymphatic O tissue in the human conjunctiva, and its biologic and clinical importance. Acta Ophthalmol 1944;23:1–79. Axelrod AJ, Chandler JW. Morphologic characteristics of conjunctival lymphoid tissue in the rabbit. In: Silverstein AM, O’Connor GR, eds. Immunology and Immunopathology of the Eye. New York: Masson, 1979:292–301. Dua HS, Gomes JAP, Jindal VK, et al. Mucosa specific lymphocytes in the human conjunctiva, corneoscleral limbus and lacrimal gland. Curr Eye Res 1994;13:87–93. Chodosh J, Nordquist RE, Kennedy RC. Anatomy of mammalian conjunctival lymphoepithelium. In: Sullivan DA, Dartt DA, Meneray MA, eds. Second International Conference on the Lacrimal Gland, Tear Film and Dry Eye Syndromes: Basic Science and Clinical Relevance. New York: Plenum, Adv Exp Med Biol, 1998;438:557– 65. Knop N, Knop E. Conjunctiva-associated lymphoid tissue in the human eye. Invest Ophthalmol Vis Sci 2000;41:1270 –9.
The mucous membrane of the lacrimal sac and the nasolacrimal duct is a pseudostratified columnar epithelium. Beneath the epithelium, the lamina propria consists of two strata: loose connective tissue with scattered lymphocytes or groups of lymphocytes and a rich venous plexus situated under the loose connective tissue.1 The latter is comparable Originally received: November 30, 2001. Accepted: May 3, 2002. Manuscript no. 211008 1 Institute of Anatomy, Christian Albrecht University of Kiel, Kiel, Germany. 2 Department of Ophthalmology, University Hospital Eppendorf, Hamburg, Germany. 3 Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University of Kiel, Kiel, Germany. 4 Department of Ophthalmology, Christian Albrecht University of Kiel, Kiel, Germany. Supported by the Deutsche Forschungsgemeinschaft (German Research Foundation, Bonn, Germany) program grant Pa 738/1-3. Reprint requests to Friedrich Paulsen, MD, PhD, Department of Anatomy, Christian Albrecht University of Kiel, Olshausenstrasse 40, D-24098 Kiel, Germany. © 2003 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
to a cavernous body and may facilitate opening and closure of the lumen of the lacrimal passage by shrinkage and swelling of the cavernous body with consecutive regulation of tear outflow.2,3 It has been shown that the mucosa plays a significant role in nonspecific immune defense by producing a mucus layer containing different carbohydrates,4,5 TFF-peptides,6 and antimicrobial peptides.7,8 Recent evidence indicates that the surface of the efferent tear ducts is also an integral part of the specific mucosal immune system and belongs to the mucosa-associated lymphoid tissue (MALT).9,10 However, it is yet not clear whether MALT of the nasolacrimal ducts is a normal component of the human efferent tear ducts. It has been suggested that it may develop in response to bacterial or viral infections or as a result of allergic reactions.9 Moreover, the description of primary low-grade B cell lymphomas in the lacrimal passage makes this question clinically relevant.11–13 To test the hypothesis that MALT of the nasolacrimal ducts is acquired in response to bacterial stimulation, nasolacrimal ducts from cadavers with unknown history of efISSN 0161-6420/03/$–see front matter PII S0161-6420(02)01442-2
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Ophthalmology Volume 110, Number 1, January 2003 ferent tear duct, ocular, and nasal disease were examined along with biopsy specimens from patients with postinflammatory dacryostenosis and compared with a view to the presence of lymphoid tissue with the structure and phenotype of organized MALT.
Material and Methods Eighty lacrimal systems (34 male, 46 female, aged 27–98 years) obtained from 46 cadavers donated to the Department of Anatomy, Christian Albrecht University of Kiel, Germany, and tissue specimens from 38 patients (9 male, 29 female, aged 22– 89 years) undergoing endonasal dacryocystorhinostomy in postinflammatory dacryostenosis without signs of active inflammation were prepared. Before dissection in all body donors, the history was studied, and next of kin were interviewed regarding eye or eye adnexal problems, any common colds during the last weeks of life, or any other diseases that could have affected lacrimal function; all such cases were excluded. Thus, all body donors analyzed in this study were free of recent trauma, eye or nasal infections, or diseases potentially involving or affecting lacrimal function. Apart from four body donors using antihypertensive drugs, four using diuretic drugs, and two using a -blocker, none was on medication. All lacrimal systems and biopsy specimens were obtained 24 hours after death at the latest, fixed in 4% formalin, dehydrated in graded concentrations of ethanol, and embedded in paraffin. Material from surgical procedures was obtained with the permission of the Medical Ethics Committee and used in accordance with the Declaration of Helsinki. Patients were selected from referrals to the Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University of Kiel, Germany, between March 1997 and March 2001. Patients with epiphora were carefully interviewed with regard to the duration of tearing, history of acute or chronic dacryocystitis, and complaints of mucoid discharge in the medial canthal region. After anamnestic exclusion of facial surgery or trauma, allergies, family history of tearing, external eyelid disease, and topical eye medication, eyelid malposition and periocular neoplasm were excluded by a careful ocular examination at the Department of Ophthalmology, Christian Albrecht University of Kiel, Germany. The lacrimal passage was assessed by inspection, palpation, digital expression of lacrimal sac contents, Jones testing, syringing of the upper and lower canaliculus, dacryocystography, and axial and coronal computed tomography in selected cases. Patients revealing punctal or canalicular stenosis were excluded from the study. Moreover, a nasal endoscopic examination was performed in each case at the Department of Otorhinolaryngology, Head and Neck Surgery, Christian Albrecht University. No microbiologic tests were performed on the tear fluid of body donors or on that of patients before processing for histologic examination.
Endonasal Dacryocystorhinostomy: Biopsy Technique Endonasal dacryocystorhinostomy was performed using a modified version of the conventional method according to West.14 After resection of the bony walls of the medial part of the frontal process of the maxilla and of the os lacrimale, the periosteum of the fossa lacrimalis and the ductus nasolacrimalis was visible. By partly removing it, a broad entrance was opened into the lacrimal fossa and the nasolacrimal canal. From the lower canaliculus, the lacrimal system was penetrated by pushing a stylet forward to the
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stenotic area. The tissue surrounding the lumen of the lacrimal sac above the stenosis was then opened by scalpel cutting to the stylet. Parts of the incision margins were removed with a small forceps, and a broad exit of the lacrimal sac into the nose was produced. It was then possible to remove the entire stenotic area below this exit by cutting the entire lacrimal system horizontally above and below the stenotic area and extirpating it. Endonasal procedures were performed under endoscopic or microscopic view without destroying important adnexal structures.
Light Microscopy For analysis by light microscopy, frontal and horizontal sections (7 m) were deparaffinized and stained with toluidine blue (pH 8.5), azan, hemalum, and Alcian blue (pH 1). The slides were examined microscopically (Axiophot; Zeiss, Oberkochen, Germany).
Immunohistochemistry Immunohistochemical stains were done with antibodies against immunoglobulin G (IgG) (Dako, E0482), IgM (Dako, M0702, 1:100), IgA (Dako, F0316, 1:20), CD 3 (Dako, A0452, 1:100), CD 20 (L 26, N1502, conc.) (Dako), as well as follicular dendritic cells (KiM4, conc.),15 B cells (KiB5, conc.),16 CD 45RA (KiB3, conc.),17 and CD 68 (KiM1, conc.).18 The Ki-antibodies were provided by the Department of Pathology, Christian Albrecht University of Kiel, Germany. They were applied using a standard peroxidase-labeled streptavidine-biotin technique, either with microwave heating before treatment or using conventional methods with trypsination when appropriate. After counterstaining with hemalum, the sections were finally mounted with Aquatex (Boehringer, Mannheim, Germany). Only immunostaining of IgA was done in addition to this procedure with a fluorescein isothiocyanate– conjugated goat antimouse IgG as the secondary antibody. Three negative control sections were used in each case in which the primary antibody, the secondary antibody, or the streptavidinebiotin complex was omitted. For positive control, sections of human spleen (all other antibodies) were used. All slides were examined with a microscope (Zeiss-Axiophot, Jena, Germany) equipped for epifluorescence.
Results To ensure comparability with surgically obtained specimens, only those parts of lacrimal systems from cadavers were cut serially and investigated that corresponded to those obtained surgically. The possibility that cases classified as “without MALT” did contain MALT in other parts of the lacrimal system can therefore not be excluded for both samples from cadavers and surgically obtained specimens.
Light Microscopy Specimens from Cadavers. The samples exhibited a pseudostratified columnar epithelial lining consisting of a basal cell layer and a superficial columnar layer in most areas (Fig 1). Goblet cells were integrated in the epithelium as solitary cells or as intraepithelial mucous glands (Fig 1). Beneath the epithelium, the lamina propria consisted of loose connective tissue containing many lymphocytes (Fig 1), sometimes arranged in follicles, and an underlying cavernous body. Small subepithelially-located seromucous glands were detected in some samples in addition to epithelial and goblet cells (Fig 2). Specimens Obtained by Surgery. All 38 specimens analyzed by histologic examination revealed chronic inflammation of the
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis
Figure 1. Cross-section through the lining epithelium of the lacrimal sac. The goblet cells show a characteristic arrangement with several cells forming an intraepithelial mucous gland (arrows). Subepithelially, the lamina propria consists of loose connective tissue containing many lymphocytes. l ⫽ lacrimal passage (stain, hemalum; original magnification, ⫻231). Figure 2. Horizontal section through a small gland in the lamina propria of the lacrimal sac. The gland consists of serous (s) and mucous (m) parts (stain, hemalum; original magnification, ⫻363). Figure 3. Cross-section through a tissue specimen of a patient (female, 64 years) demonstrating chronic inflammation with epithelial and subepithelial infiltration of defense cells, loss of intraepithelial goblet cells, basal cell hyperplasia, and beginning squamous metaplasia. l ⫽ lacrimal passage (stain, toluidine blue; original magnification, ⫻239). Figure 4. Section through a tissue specimen of a patient (female, 70 years) demonstrating complete fibrosis of the subepithelial tissue with rarification of blood vessels (v with arrows) (stain, toluidine blue; original magnification, ⫻228).
lacrimal system that had led to different stages of fibrosis, ranging from proliferative sclerotic forms of chronic fibrosis (“moderate”: 18 cases) to total subepithelial fibrosis (“severe”: 20 cases). Tissue specimens from 18 patients demonstrated transitional forms of chronic fibrosis with epithelial and subepithelial infiltration by defense cells that were almost lymphocytes, loss of intraepithelial goblet cells, variable loss of differentiated epithelial cells ranging from denuded epithelium to basal cell hyperplasia (often associated with squamous metaplasia), and increased subepithelial fibroblasts (Fig 3). The specialized blood vessels of the subepithelial cavernous body often showed thickening of the walls with varying degrees of intimal proliferation up to obliteration and reduction. Seven cases were characterized by squamous metaplasia with a total absence of goblet cells. The underlying mucosa had undergone secondary fibrosis with basement membrane thickening (Fig 3). Also visible was a reduction (up to total loss) of the specialized blood vessels of the cavernous body (Fig 4). Tissue specimens from 13 cases showed complete fibrous obliteration of the duct within the osseous canal (no lacrimal passage lumen was found either intraoperatively or histologically). The dissection rims of all surgically obtained specimens
showed a transition from the described changes to a normal double-layered epithelium with integrated goblet cells and intraepithelial mucous glands. The lamina propria contained many lymphocytes, in seven cases arranged in follicles, and an underlying cavernous body.
Lymphocyte, Macrophage, and Immunoglobulin Immunostaining Specimens from Cadavers. In most of the cases investigated there was a diffuse infiltrate of variable intensity within the lamina propria of the samples consisting predominantly of CD3-positive T lymphocytes with scattered CD20- and CD45RA-positive B cells, as well as plasma cells. A few IgM- and IgG-positive plasma cells were also detected in the infiltrate and in the connective tissue between seromucous glands. Solitary CD3-positive T cells and CD45RA-positive B cells were detected inside the epithelium (Fig 5), although the overall extent of infiltration was low. Organized lymphoid tissue was identified in about one third of the cases investigated. The findings are summarized in Figure 6. The youngest person in whom MALT was identified was a 27year-old.
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Figure 5. Immunostaining with KiB3 of a horizontal section through the lining epithelium of the lacrimal sac of a cadaver (male, 88 years). Red staining reveals intraepithelial and subepithelial CD45RA-positive B cells (arrows) (immunostain, anti-CD45RA; original magnification, ⫻456).
MALT was found once in a right lacrimal sac and 4 times in a left one, as well as 13 times in a right nasolacrimal duct, and 9 times in a left one. Either it was distributed at intervals along the investigated segment or only a single follicle was found. MALT was not necessarily present to the same extent in both efferent lacrimal systems. Specimens Obtained by Surgery. Comparable to the cadavers, there was a diffuse infiltrate of variable intensity within the lamina propria of the surgically obtained specimens (Fig 3). The lamina propria consisted of loose connective tissue containing many lymphocytes, sometimes arranged in follicles, and an underlying cavernous body. However, the diffuse infiltrate was only observed in the 18 specimens classified as “moderate.” The specimens classified as “severe” revealed such a diffuse infiltrate only at their dissection rims. The central part consisted of fibrous tissue and was nearly free of detectable defense cells. Only single macrophages or lymphocytes were visible. Organized lymphoid tissue was identified in 10 of the cases investigated (Fig 7). Of these, four belonged to the “moderate” group and six to the “severe” group. The findings are summarized in Figure 8. The youngest person in whom MALT was identified is a 22-year-old. In four cases (two “moderate,” two “severe”) MALT was situated in the area of the prestenotic rim; in six cases (two “moderate,” four “severe”) it was detectable at the poststenotic rim. Organization of MALT in Cadavers and Surgically Obtained Specimens. It must be stated that only secondary follicles revealing a distinct germinal center and a surrounding parafollicular area were counted (Fig 9). Several areas were seen to display more or less developed primary follicles. Such areas were excluded and named MALT by definition.
Figure 6. Distribution of cases with and without organized mucosa-associated lymphoid tissue (MALT) by age in cadavers.
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Figure 7. Tear duct–associated lymphoid tissue (TALT) in a patient (female, 68 years) at the area of the prestenotic rim. TALT of the lacrimal sac with a well-developed germinal center (gc), a mantle zone (m), a marginal zone (mar), and an overlying lymphoepithelium (star). l ⫽ lacrimal passage (stain, azan; original magnification, ⫻213).
No significant male-female differences were seen between lacrimal systems from cadavers and from surgically obtained specimens. Comparable to other mucosal sites, MALT in the lacrimal passage of both cadavers and surgically obtained specimens was characterized by the presence of reactive germinal centers containing tingible-body macrophages (Fig 10), a network of KiM4positive follicular dendritic cells (Fig 11), and CD3-positive T cells (Fig 12). The germinal centers were surrounded by mantle zones and marginal zone cells (Figs 7, and 10). The mantle zones consisted of small CD20-positive lymphocytes (Fig 13) expressing KiB3 and IgM. These lymphocytes merged in a population of small-to-medium-sized B cells with moderately abundant cytoplasm and irregular nucleus outlines, features typical of marginal zone cells (Figs 10, 14). The marginal zone cells exhibited the following immunophenotypes: CD20⫹, CD45RA⫹, CD3-,
Figure 8. Distribution of cases with and without mucosa-associated lymphoid tissue (MALT) by age in chronically inflamed nasolacrimal ducts.
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis
Figure 9. Section through a well-developed germinal center (gc) and a mantle zone (m) of tear duct–associated lymphoid tissue in a patient (female, 48 years) at the area of the poststenotic rim (stain, azan; original magnification, ⫻213).
IgM⫹, and IgA⫹. Some IgG-expressing cells were present, although their occurrence was rare. The marginal zone cells extended into the overlying epithelium to form a characteristic lymphoepithelium (Figs 7, 10, and 14). In the parafollicular area,
Figure 11. Anti-KiM4 immunostaining shows red staining of dendritic cells (arrows) in a germinal center within a lymphoid follicle of the nasolacrimal duct of a patient (male, 32 years) (immunostain, antifollicular dendritic cells; original magnification, ⫻456).
mainly T lymphocytes, some B lymphocytes, and macrophages were present, as well as high endothelial venules.
IgA Immunostaining Specimens from Cadavers. Strong immunoreactivity for IgA was observed in the plasma cells of the lamina propria beneath the epithelium (Fig 15), in the plasma cells of the connective tissue between seromucous glands, and in the secretory products of the mucous membrane and the seromucous glands forming a layer on the lining epithelium. A somewhat weaker immunoreactivity for IgA was seen in the apical epithelial cells (Fig 15) and the serous cells of the seromucous glands. Surgically Obtained Specimens. Immunoreactive plasma cells were visible in the lamina propria of cases revealing moderate forms of chronic fibrosis. In the final states of dacryostenosis, plasma cells were only detected in front of or behind the stenotic area.
Discussion Specific secretory immunity depends on a sophisticated cooperation between the mucosal B cell system and an
Figure 10. Tear duct–associated lymphoid tissue (TALT) in a cadaver (female, 67 years) with a well-developed germinal center (gc), a surrounding mantle zone (m), a marginal zone (mar), and an overlying lymphoepithelium (star). Macrophages (arrows) are stained red by KiM1p. l ⫽ lacrimal passage (immunostain, anti-CD68; original magnification, ⫻363).
Figure 12. Anti-CD3 immunostaining shows red staining of T lymphocytes (arrows) within a lymphoid follicle of the lacrimal sac of a patient (female, 61 years) (immunostain, anti-CD3; original magnification, ⫻456).
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Figure 13. Anti-CD20 immunostaining confirms the cells within the mantle zone as B cells (immunostain, anti-CD20; original magnification, ⫻363). Figure 14. Frontal section through the lining epithelium of the nasolacrimal duct of a patient (female, 66 years) in the area of the poststenotic rim showing subepithelial parts of the marginal zone (mar) of a lymphoid follicle. The epithelium shows features of a lymphoepithelium (star) containing clusters of intraepithelial lymphocytes with irregular nuclei. l ⫽ lacrimal passage (stain, toluidine blue; original magnification, ⫻231). Figure 15. Immunohistochemical evidence of immunoglobulin A (IgA) in the lacrimal sac of a cadaver (female, 83 years). IgA-positive plasma cells (arrows) are located subepithelially. The epithelial cells show weak positivity for IgA, which is also contained in the mucous layer (arrowheads) overlying the epithelium g ⫽ goblet cell, l ⫽ lacrimal passage (immunostain, anti-IgA; original magnification, ⫻363).
epithelial glycoprotein called the secretory component.19 Initial stimulation of Ig-producing B cells is believed to take place mainly in organized MALT.20 It has become evident that considerable regionalization or compartmentalization exists in MALT, perhaps determined by different cellular expression profiles of adhesion molecules and/or the local antigenic repertoire. Antigenic stimulation of B cells results in the generation of predominantly IgA-synthesizing blasts that leave the mucosae by way of efferent lymphatics, pass through the associated lymph nodes into the thoracic duct, and enter the circulation. The cells then return selectively to the lamina propria as plasma cells or memory B cells by means of homing mechanisms.21 Recent findings have shown that MALT is a feature that is regularly found inside the nasolacrimal passage. Here it occurs in 41%9 to 44%10 of healthy unselected
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cadavers with unknown previous history of disease regarding the eye, efferent lacrimal pathway, and nose. Our present findings reveal lymphoid follicles in 34% of the healthy cadavers investigated. On the basis of a definition by Isaacson21 for MALT of the gut wall (i.e., Peyer’s patches) the lymphoid follicles of the lacrimal passage fulfill the criteria for designation as MALT, because they comprise (1) organized mucosal lymphoid tissue, (2) lamina propria, and (3) intraepithelial lymphocytes. The tear duct–associated lymphoid tissue (TALT) comprises a B cell and T cell component. The B cell component consists of a follicle with a center and mantle zone and a more or less well-developed marginal zone. There is also an interfollicular area of T cells with high endothelial venules. The lamina propria is diffusely infiltrated by plasma cells, most of which are synthesizing IgA; and
Paulsen et al 䡠 Loss of TALT in Association with Dacryostenosis lymphocytes, most of which are T cells with some B cells, macrophages, and other accessory cells. However, compared with MALT of the gastrointestinal tract, it is as yet not known whether M cells occur in TALT. (M cells are highly specialized epithelial cells that facilitate uptake of macromolecular substances from the gut. They are able to present to lymphocytes and macrophages specific, potentially pathogenic epitopes of the macromolecules. The immune system needs this direct contact with the epitopes of the macromolecules to initiate a specific immune response.)22 Also, the functional meaning of the structures is not known, because, in contrast to Peyer’s patches, TALT is only found in a percentage of 30% to 40% of “healthy adult specimens.”9,10,23 As early as 1988, Hyjek et al24 postulated that organized lymphoid tissue from outside the gut was supposed to form MALT in response to antigenic stimulation, which may contribute to an autoimmune condition such as Sjo¨ gren’s syndrome in the salivary gland. Moreover, it was demonstrated that, in the conjunctiva,25 nose,26 larynx,27 and lung,28 –30 MALT is absent in neonates and is acquired in early childhood in response to antigenic stimulation. Animal experiments indicate that the development of gastric-,31 bronchus-,32 or nasopharyngeal-26 associated lymphoid tissues is acquired specifically in response to local infection. By contrast, a retrospective study in specimens removed during surgical procedures on patients with chronic pulmonary inflammation revealed bronchus-associated lymphoid tissue to be generally less prominent than that in animals,33 and Wotherspoon et al25 advise caution when extrapolating animal experimental data to humans, because the distribution and structures of MALT vary among different species. The relevance of our findings is limited by the size of the specimen samples investigated. We cannot exclude the possibility that cases classified as “without TALT” did contain TALT in other parts of the lacrimal system that were not investigated. Moreover, it is not possible to determine decisively whether an inflammation of the lacrimal passage has occurred in specimens from cadavers. However, the congruency between the size of specimens from patients and cadavers and the numbers of lacrimal systems from cadavers investigated partly compensates these disadvantages. Thus these results lead to the assumption that lymphoid tissue, including areas of organized nodular deposits, are common in normal patients. They are probably responsible for processing antigens presented to the mucosal surface. Exactly how they are related to the subsequent fibrosis that leads to ductal stenosis is not clear. However, the lymphoid tissue is lost with development of stenosis. One could argue that this tissue disappears as the result of lack of antigen exposure once scarring is sufficient to prevent normal tear flow through the nasolacrimal duct, or simply that the scarring itself replaces the inflammatory cells. At any rate, a recently published article certainly has put our understanding of MALT in a different light concerning the functional significance of TALT. Alpan et al34 demonstrated that a systemic immune response to orally administered soluble antigens does not depend on the presence of functional GALT, but more likely on initiation of immune response by gut-conditioned dendritic cells.
On the basis of the most recent description of TALT, it has not yet been taken into consideration that antigens drained by the tear fluid themselves might be able to induce a kind of immune deviation. This would be plausible with regard to protection of the cornea against inflammatory destruction analogous to what is observed in the nervous system35 and the anterior eye chamber.36 Conversely, the drainage pathways of antigens from the anterior eye chamber, the location of their presentation, and the passage of the corresponding antigen-presenting cells are unknown at present, especially the role of the TALT9,10,23 and also of the conjunctiva-associated lymphoid tissue,25,37– 41 which together have been designated “eye-associated lymphoid tissue,”10 because the immune privilege of the anterior eye chamber remains unclear. It can be concluded that the development of MALT is a common feature that often is found in symptomatically normal nasolacrimal ducts. Because TALT seems to be lost associated with the scarring of symptomatic dacryostenosis, it is unlikely that the presence per se of TALT leads to scarring. Whether special types of bacteria, viruses, or other factors such as some kind of immune deviation are responsible for the development of TALT in humans needs to be investigated in future prospective and experimental studies. Acknowledgments. The authors gratefully acknowledge gifts of monoclonal anti-Ki antibodies from Professor Dr. med. Dr. H. C. R. Parwaresch (Department of Pathology, Christian Albrecht University of Kiel, Kiel, Germany).
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Ophthalmology Volume 110, Number 1, January 2003 11. Kheterpal S, Chan SY, Batch A, Kirkby GR. Previously undiagnosed lymphoma presenting as recurrent dacryocystitis. Arch Ophthalmol 1994;112:519 –20. 12. White WL, Ferry JA, Harris NL, Grove AS Jr. Ocular adnexal lymphoma. A clinicopathologic study with identification of lymphomas of mucosa-associated lymphoid tissue type. Ophthalmology 1995;102:1994 –2006. 13. Tucker N, Chow D, Stockl F, et al. Clinically suspected primary acquired nasolacrimal duct obstruction: clinicopathologic review of 150 patients. Ophthalmology 1997;104:1882– 6. 14. West JM. A window resection of the nasal duct in case of stenosis. Trans Am Ophthalmol Soc 1909;12:659. 15. Parwaresch MR, Radzun HJ, Hansmann ML, Peters KP. Monoclonal antibody Ki-M4 specifically recognizes human dendritic reticulum cells (follicular dendritic cells) and their possible precursor in blood. Blood 1983;62:585–90. 16. Hansmann ML, Wacker HH, Gralla J, et al. Ki-B5. A monoclonal antibody unrelated to CD45 recognizes normal and neoplastic human B cells in routine paraffin sections. Blood 1991;77:809 –17. 17. Hansmann ML, Wacker HH, Radzun HJ. Paragranuloma is a variant of Hodgkin’s disease with predominance of B-cells. Virchows Arch A Pathol Anat Histopathol 1986;409:171– 81. 18. Radzun HJ, Hansmann ML, Heidebrecht HJ, et al. Detection of a monocyte/macrophage differentiation antigen in routinely processed paraffin-embedded tissues by monoclonal antibody Ki-M1P. Lab Invest 1991;65:306 –15. 19. Brandtzaeg P. Humoral immune response patterns of human mucosae: induction and relation to bacterial respiratory tract infections. J Infect Dis 1992;165(Suppl 1):S167–76. 20. Butcher EC, Picker LJ. Lymphocyte homing and homeostasis. Science 1996;272:60 – 6. 21. Isaacson PG. Extranodal lymphomas: The MALT concept. Verh Dtsch Ges Pathol 1992;76:14 –23. 22. Gebert A, Rothko¨ tter HJ, Pabst R. M cells in Peyer’s patches of the intestine. Int Rev Cytol 1996;167:91–159. 23. Paulsen F, Paulsen J, Thale A, et al. Organized mucosaassociated lymphoid tissue in human nasolacrimal ducts. In: Sullivan DA, ed. Lacrimal Gland, Tear Film and Dry Eye Syndromes 3. New York: Plenum, 2002; in press. 24. Hyjek E, Smith WJ, Isaacson PG. Primary B cell lymphoma of salivary glands and its relationship to myoepithelial sialadenitis. Hum Pathol 1988;19:766 –76. 25. Wotherspoon AC, Hardman-Lea S, Isaacson PG. Mucosaassociated lymphoid tissue (MALT) in the human conjunctiva. J Pathol 1994;174:33–7. 26. Kuper CF, Koornstra PJ, Hameleers DMH, et al. The role of nasopharyngeal lymphoid tissue. Immunol Today 1992;13: 219 –24. 27. Tschernig T, Kleemann WJ, Pabst R. Bronchus-associated
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