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Tear film and meibomian gland functions in psoriasis
SURVEY OF OPHTHALMOLOGY
VOLUME
41.
NUMBER
6
l
MAY-JUNE
1997
ELSEVIER
CURRENT OPHTHALMOLOGY WILLIAM V. GOOD, EDITOR
Medical Decisions: 98:1182-1184,1996
An Appeal
for Reasonableness,
by William
A. Silverman.
Pediatrics
The arrival of penicillin after World War II revolutionized the nature of medicine. With the advent of this and other “miracle agents,” such as streptomycin, steroids, and polio vaccine, physicians suddenly acquired an enormous increase in power to change the natural course of disease. Concomitantly, physicians’ confidence in their powers of intervention swelled and they assumed an almost autocratical role in the decisionmaking process. In neonatology, for example, doctors adopted a single-minded fix-it-at-all-costs approach to medicine, often overriding the personal values or preferences of the infant’s parents. While one cannot discount that technical advances in medicine have significantly lowered infant mortality rates, we must not lose sight of the fact that the nature of diseaseis often more complicated than life or death. Most complex disorders are not easily fixed and some solutions only serve to prolong pain and suffering. Of equal importance as the duration of life for many is the quality of life. As well as physical health, there are social, legal, occupational, religious, and aesthetic concerns that contribute to one’s total well-being. In the first half of the century, medicine’s “Golden Age,” the medical profession wasthe epitome of dedication and compassionate concern. Drawing from this storied past, a reasonable approach to medicine acknowledges that its impressive technical gains carry with them an equally great responsibility to address the personal needs of those involved. (Author’s address:William A. Silverman, MD, 90 La Cuesta Drive, Greenbrae, CA 949041253.)
Comment Reasonablenesshas an intuitive appeal, for who among us would choose to be judged asunreasonable? Dr. Silverman’s comments go beyond this simplistic assessmentto remind us that the technology of the medical care system must be applied within the context of society and for the benefit of the individual patient and family. This is particularly evident at the extremes of neonatology and gerontology, but applies equally to the full span of life and the total spectrum of health care. BRADLEY R. STRAATSMA, MD Los ANGELES, CALIFORNIA, USA
Tear Film and Meibomian Gland Functions in Psoriasis, by N. Zengin, H. Tol, S. Balevi, et al. Acta Ophthalmol &and 74358-360, 1996 Tear secretion, tear film stability, and meibomian gland function (plugging, volume, and thickness) were assessedin patients with psoriasisvulgaris (N = 70). As compared to that of the healthy controls (N = 125), the mean Schirmer I value of psoriatic patients was in normal ranges, whereas tear film break-up time wassignificantly lowered. When evaluating meibomian gland function, psoriatic patients were found to have higher plugging and thickness indices but a normal volume of meibomian gland secretion. These findings suggested an obstructive type of meibomian gland dysfunction in psoriatic patients, which might result from increased turnover of the epithelia lining the meibomian gland duct. (Author’s address:Nazmi Zengin, MD, Rauf Denktas Cad., Platin Sitesi, 9. Giris No: 3, 42060 Konya, Turkey.)
0 1997 by Elsevier Science Inc. All rights reserved.
0039-6257/97/$17.00
PII SOO39-6257(97)00032-5
CURRENT
Surv Ophthalmol41 (6) May-June 1997
OPHTHALMOLOGY
501
Comment Given the prevalence of psoriasis (about 2% of the population), and the strong connection between eye and skin disease, it has always been a little surprising to me that we do not recognize more frequent ocular manifestations of psoriasis. We are all familiar with the occasional severe iritis in HLA-B27 positive patients with psoriatic arthritis, and the frequently mentioned (but rarely seen) conjunctivitis and lid lesions. It may be that the ocular manifestations of psoriasisare common, but also very subtle. Dr. Zengin and his colleagues support this conclusion. In a well-designed, well-controlled study involving 70 patients with psoriasisvulgaris, this group of ophthalmologists and dermatologists in Turkey have evaluated the tear status and meibomian gland secretions using simple, familiar office procedures. They found that psoriasis patients had increased meibomian gland plugging and rapid tear break-up time. In other words, psoriatic patients have a high incidence of meibomian gland dysfunction, just like rosacea patients. What is equally interesting is that in most other respects, tears of psoriasispatients are just like nonpsoriatic control patients. There wasno difference, for example, in Schirmer tests between the psoriasisand control populations. This is interesting, since it is sometimes taught that there is a connection between dry eye and blepharitis/meibomitis. Yet blepharitis does not seem to be unduly common in dry eye patients, and lots of patients with severe blepharitis have no hint of dry eye. There is a useful take-home messagehere. Ask your external diseasepatients about ongoing skin conditions, like psoriasisand rosacea. Attention to lid diseasemay be helpful in the management of these individuals. MITCHELL H. FRIEDI.AENDER, MD LA JOI,I,A, CAWORNJA, USA
Anomalies et Complications Vasculaires dans les Drusen du Nerf Optique (Vascular Papillary Anomalies and Complications of Optic Disk Drusen), by F.-X. Borruat and M. D. Sanders. Klin MonatsbZAugenheiZkd English Abstracts.)
208294-296,
1996. (Article in French with German and
Bar~~ound. Drusen of the optic disk are associated with slowly progressive optic neuropathy, characterized by accumulation of acellular laminated concretions in the prelaminar portion of the optic nerve. Papillary hemorrhages and vascular shunts have been reported with disk drusen, but their frequency and clinical significance are not well known. Methods. Fundus photographs of 116 patients with disk drusen referred to the National Hospital for Neurology and Neurosurgery, London, between 1965 and 1991 were studied retrospectively. Results.Hemorrhages were found in 23 eyes from 16/116 (13.8%) patients. Most cases (68.8%, 11/16 cases) occurred in patients with buried drusen, and most hemorrhages were deeply located. Vascular shunts were present in 6.9% (8/ 116 cases), most frequently in patients with exposed drusen (6/8 cases),most being of the venous type (“r/8 cases). Discussion. Vascular anomalies are not rare in disk drusen, as 20.7% (24/l 16 cases)in our study presented either disk hemorrhages or shunt vessels.Their presence supports the hypothesis of the slowly progressive nature of disk drusen and the more advanced stage of optic neuropathy in such eyes. (Author’s address: Dr. F.-X. Borruat, Hopital Ophtalmique Jules Gonin, Avenue de France 15, CH-1004 Lausanne, Switzerland.)
Comment In a review of fundus photographs collected over 25 years, the authors identified 116 patients with optic nerve head drusen. Twenty-two percent of the patients had been completely free of symptoms at the time of examination. In the others, the principal symptoms included headache, visual disturbance, and orbital pain. The optic nerve head drusen were buried in 52% and exposed in 48%. In the former group the average age was 25 years and in the latter group it was 38 years, this difference being statistically significant. Visual acuity was normal in 91% of 89 eyes with buried drusen and 76% of 80 eyes with exposed drusen. Visual fields were normal in 68% of 41 patients with buried drusen and 53% of 49 patients with exposed drusen. Optic disk hemorrhages were identified in 14% (16/ 116) of patients, mostly occurring in association with buried drusen and being deep peripapillary hemorrhages. Vascular shunts were identified in 7% (8/116) of patients, mostly in association with exposed drusen and in all but one case being venous collaterals. Vascular abnormalities were statistically significantly associated with visual field loss, but not with reduction in visual acuity.
VOLUME
41.
NUMBER
6
l
MAY-JUNE
1997
ELSEVIER
CURRENT OPHTHALMOLOGY WILLIAM V. GOOD, EDITOR
Medical Decisions: 98:1182-1184,1996
An Appeal
for Reasonableness,
by William
A. Silverman.
Pediatrics
The arrival of penicillin after World War II revolutionized the nature of medicine. With the advent of this and other “miracle agents,” such as streptomycin, steroids, and polio vaccine, physicians suddenly acquired an enormous increase in power to change the natural course of disease. Concomitantly, physicians’ confidence in their powers of intervention swelled and they assumed an almost autocratical role in the decisionmaking process. In neonatology, for example, doctors adopted a single-minded fix-it-at-all-costs approach to medicine, often overriding the personal values or preferences of the infant’s parents. While one cannot discount that technical advances in medicine have significantly lowered infant mortality rates, we must not lose sight of the fact that the nature of diseaseis often more complicated than life or death. Most complex disorders are not easily fixed and some solutions only serve to prolong pain and suffering. Of equal importance as the duration of life for many is the quality of life. As well as physical health, there are social, legal, occupational, religious, and aesthetic concerns that contribute to one’s total well-being. In the first half of the century, medicine’s “Golden Age,” the medical profession wasthe epitome of dedication and compassionate concern. Drawing from this storied past, a reasonable approach to medicine acknowledges that its impressive technical gains carry with them an equally great responsibility to address the personal needs of those involved. (Author’s address:William A. Silverman, MD, 90 La Cuesta Drive, Greenbrae, CA 949041253.)
Comment Reasonablenesshas an intuitive appeal, for who among us would choose to be judged asunreasonable? Dr. Silverman’s comments go beyond this simplistic assessmentto remind us that the technology of the medical care system must be applied within the context of society and for the benefit of the individual patient and family. This is particularly evident at the extremes of neonatology and gerontology, but applies equally to the full span of life and the total spectrum of health care. BRADLEY R. STRAATSMA, MD Los ANGELES, CALIFORNIA, USA
Tear Film and Meibomian Gland Functions in Psoriasis, by N. Zengin, H. Tol, S. Balevi, et al. Acta Ophthalmol &and 74358-360, 1996 Tear secretion, tear film stability, and meibomian gland function (plugging, volume, and thickness) were assessedin patients with psoriasisvulgaris (N = 70). As compared to that of the healthy controls (N = 125), the mean Schirmer I value of psoriatic patients was in normal ranges, whereas tear film break-up time wassignificantly lowered. When evaluating meibomian gland function, psoriatic patients were found to have higher plugging and thickness indices but a normal volume of meibomian gland secretion. These findings suggested an obstructive type of meibomian gland dysfunction in psoriatic patients, which might result from increased turnover of the epithelia lining the meibomian gland duct. (Author’s address:Nazmi Zengin, MD, Rauf Denktas Cad., Platin Sitesi, 9. Giris No: 3, 42060 Konya, Turkey.)
0 1997 by Elsevier Science Inc. All rights reserved.
0039-6257/97/$17.00
PII SOO39-6257(97)00032-5
CURRENT
Surv Ophthalmol41 (6) May-June 1997
OPHTHALMOLOGY
501
Comment Given the prevalence of psoriasis (about 2% of the population), and the strong connection between eye and skin disease, it has always been a little surprising to me that we do not recognize more frequent ocular manifestations of psoriasis. We are all familiar with the occasional severe iritis in HLA-B27 positive patients with psoriatic arthritis, and the frequently mentioned (but rarely seen) conjunctivitis and lid lesions. It may be that the ocular manifestations of psoriasisare common, but also very subtle. Dr. Zengin and his colleagues support this conclusion. In a well-designed, well-controlled study involving 70 patients with psoriasisvulgaris, this group of ophthalmologists and dermatologists in Turkey have evaluated the tear status and meibomian gland secretions using simple, familiar office procedures. They found that psoriasis patients had increased meibomian gland plugging and rapid tear break-up time. In other words, psoriatic patients have a high incidence of meibomian gland dysfunction, just like rosacea patients. What is equally interesting is that in most other respects, tears of psoriasispatients are just like nonpsoriatic control patients. There wasno difference, for example, in Schirmer tests between the psoriasisand control populations. This is interesting, since it is sometimes taught that there is a connection between dry eye and blepharitis/meibomitis. Yet blepharitis does not seem to be unduly common in dry eye patients, and lots of patients with severe blepharitis have no hint of dry eye. There is a useful take-home messagehere. Ask your external diseasepatients about ongoing skin conditions, like psoriasisand rosacea. Attention to lid diseasemay be helpful in the management of these individuals. MITCHELL H. FRIEDI.AENDER, MD LA JOI,I,A, CAWORNJA, USA
Anomalies et Complications Vasculaires dans les Drusen du Nerf Optique (Vascular Papillary Anomalies and Complications of Optic Disk Drusen), by F.-X. Borruat and M. D. Sanders. Klin MonatsbZAugenheiZkd English Abstracts.)
208294-296,
1996. (Article in French with German and
Bar~~ound. Drusen of the optic disk are associated with slowly progressive optic neuropathy, characterized by accumulation of acellular laminated concretions in the prelaminar portion of the optic nerve. Papillary hemorrhages and vascular shunts have been reported with disk drusen, but their frequency and clinical significance are not well known. Methods. Fundus photographs of 116 patients with disk drusen referred to the National Hospital for Neurology and Neurosurgery, London, between 1965 and 1991 were studied retrospectively. Results.Hemorrhages were found in 23 eyes from 16/116 (13.8%) patients. Most cases (68.8%, 11/16 cases) occurred in patients with buried drusen, and most hemorrhages were deeply located. Vascular shunts were present in 6.9% (8/ 116 cases), most frequently in patients with exposed drusen (6/8 cases),most being of the venous type (“r/8 cases). Discussion. Vascular anomalies are not rare in disk drusen, as 20.7% (24/l 16 cases)in our study presented either disk hemorrhages or shunt vessels.Their presence supports the hypothesis of the slowly progressive nature of disk drusen and the more advanced stage of optic neuropathy in such eyes. (Author’s address: Dr. F.-X. Borruat, Hopital Ophtalmique Jules Gonin, Avenue de France 15, CH-1004 Lausanne, Switzerland.)
Comment In a review of fundus photographs collected over 25 years, the authors identified 116 patients with optic nerve head drusen. Twenty-two percent of the patients had been completely free of symptoms at the time of examination. In the others, the principal symptoms included headache, visual disturbance, and orbital pain. The optic nerve head drusen were buried in 52% and exposed in 48%. In the former group the average age was 25 years and in the latter group it was 38 years, this difference being statistically significant. Visual acuity was normal in 91% of 89 eyes with buried drusen and 76% of 80 eyes with exposed drusen. Visual fields were normal in 68% of 41 patients with buried drusen and 53% of 49 patients with exposed drusen. Optic disk hemorrhages were identified in 14% (16/ 116) of patients, mostly occurring in association with buried drusen and being deep peripapillary hemorrhages. Vascular shunts were identified in 7% (8/116) of patients, mostly in association with exposed drusen and in all but one case being venous collaterals. Vascular abnormalities were statistically significantly associated with visual field loss, but not with reduction in visual acuity.