Thursday, November 29, 2012

Abstract: Movement disorders and the eyes.

Twelve years ago, Current Opinion in Ophthalmology published a review titled "Neuro-ophthalmology of movement disorders". It includes no mention of corneal involvement from movement disorders, at least in the abstract.

Below is a review in the same journal, with an identical title, published November 2012. See for yourself the difference.

Dunno about you but I'll take any signs of progress I can find!

Movement disorders commonly present with ocular features. The purpose of this review is to outline neuro-ophthalmologic findings that can help in diagnosis, treatment and determining prognosis in patients with movement disorders.
Common movement disorders with ophthalmic symptoms include extrapyramidal disorders such as Parkinson disease-associated dry eye, decreased blink rate, and vergence dysfunction, and progressive supranuclear palsy-related lid retraction, frequent square-wave jerks and supranuclear gaze palsy. Multisystem atrophy can present with gaze-evoked horizontal or positional downbeat nystagmus and impaired vestibulo-ocular reflex suppression. Genetic disorders such as Huntington disease produce increased saccadic latencies and impaired suppression of saccades to presented stimulus, whereas Wilson disease is associated with saccadic pursuits, increased antisaccade latencies and decreased pursuit gain. Whipple's disease can present with supranuclear gaze palsy and characteristic oculomasticatory myorrhythmia.
Movement disorders commonly present with ocular features. Knowledge of these ocular symptoms can assist the ophthalmologist in diagnosis and treatment of movement disorders.

Curr Opin Ophthalmol. 2012 Nov;23(6):491-6. doi: 10.1097/ICU.0b013e328358ba14.
Clark D, Eggenberger E.
Michigan State University Department of Neurology and Ophthalmology, East Lansing, Michigan, USA.

Abstract: Rebamipide

To investigate the dose response for efficacy of 1% and 2% rebamipide ophthalmic suspension compared with placebo in patients with dry eye.
A randomized, double-masked, multicenter, placebo-controlled, parallel-group, dose-response phase II study.
A total of 308 patients with dry eye.
After a 2-week screening period, patients were randomized to receive placebo or 1% rebamipide or 2% rebamipide administered as 1 drop in each eye 4 times daily for 4 weeks.
The primary objective end point was change in fluorescein corneal staining (FCS) score from baseline to last observation carried forward (LOCF). Secondary objective end points were lissamine green conjunctival staining (LGCS) score, tear film break-up time (TBUT), and the Schirmer's test. Secondary subjective end points included dry eye-related ocular symptoms (foreign body sensation, dryness, photophobia, eye pain, and blurred vision) score and patients' overall treatment impression score.
Rebamipide dose response was observed in FCS, LGCS, and TBUT scores. Both 1% and 2% rebamipide were significantly more effective than the placebo in terms of the change from baseline to LOCF for FCS, LGCS, and TBUT scores. There was no significant difference between the rebamipide and placebo groups from baseline to LOCF in Schirmer's test values, and dose response was not observed. In the predefined dry eye subpopulation with a baseline FCS score of 10 to 15, the mean change from baseline in the 2% rebamipide group was larger than that in the 1% rebamipide group. Change from baseline to LOCF for all 5 dry eye-related ocular symptom scores and patients' overall treatment impression showed significant improvements in the 1% and 2% rebamipide groups compared with the placebo group, except for photophobia in the 1% rebamipide group. No deaths or drug-related serious adverse events occurred in any treatment group. The incidence of ocular abnormalities was similar across the rebamipide and placebo groups.
Rebamipide was effective in treating both objective signs and subjective symptoms of dry eye and were well tolerated in this 4-week study. Although 1% and 2% rebamipide were both efficacious, 2% rebamipide may be more effective than 1% rebamipide in some measures.

Ophthalmology. 2012 Sep 22. pii: S0161-6420(12)00612-4. doi: 10.1016/j.ophtha.2012.06.052. [Epub ahead of print]
Kinoshita S, Awamura S, Oshiden K, Nakamichi N, Suzuki H, Yokoi N; Rebamipide Ophthalmic Suspension Phase II Study Group.
Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Electronic address:

Abstract: Showing why eye doctors need to be more aware of Sjogrens

To assess the prevalence and determine predictors of Sjögren's syndrome (SS) in patients with clinically significant aqueous-deficient dry eye.
Patients enrolled in an industry-sponsored, multicentre clinical trial (NCT00784719) were assessed prospectively for the presence of SS. Ocular testing included Schirmer test, corneal fluorescein staining, conjunctival lissamine green staining, and tear-film breakup time. Review of systems questionnaire, medical history, dry eye questionnaire and laboratory work-up (Sjögren-specific antibody A (SSA), Sjögren-specific antibody B (SSB), rheumatoid factor (RF) and antinuclear antibody (ANA)) were obtained.
Of 327 patients, 38 (11.6%) had SS: 21 (6.4%) with primary SS (pSS), and 17 (5.2%) with secondary SS. Nine patients (3%) were newly diagnosed using the applied diagnostic criteria based on American-European consensus criteria. Patients with SS had significantly worse conjunctival and corneal staining, Schirmer test (with and without anaesthesia), and symptoms compared with patients without SS. pSS Was significantly more likely to occur in patients with positive ANA (OR: 13.9) and RF (OR: 4.8).
Ophthalmologists caring for patients with clinically significant dry eye should have a high index of suspicion for underlying SS and low threshold for serological work-up. RF and ANA are recommended as useful tests in SSA/SSB-negative patients for further diagnostic referral.

Br J Ophthalmol. 2012 Dec;96(12):1498-503. doi: 10.1136/bjophthalmol-2012-301767. Epub 2012 Sep 21.
Liew MS, Zhang M, Kim E, Akpek EK.
Department of Cornea and External Disease Service, Ocular Surface Diseases and Dry Eye Clinic, The Wilmer Eye Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Maumenee #317, Baltimore, MD 21287-9238, USA;

Tuesday, November 27, 2012

Abstract: Nerves of "good" eyes affected in a Zoster case, per confocal

Very interesting report in Ophthalmology... cases of herpes zoster where only one eye is affected clinically, BUT the confocal microscope confirmed significant nerve changes to BOTH eyes.

Makes me wonder whether this is, or is not, unique to herpes zoster.

Herpes zoster ophthalmicus (HZO), thought to be a unilateral disease, results in loss of corneal sensation, leading to neurotrophic keratopathy. This study aimed to analyze bilateral corneal nerve changes in patients with HZO by in vivo confocal microscopy (IVCM) and their correlation with corneal sensation as a measure of nerve function.
Prospective, cross-sectional, controlled, single-center study.
Twenty-seven eyes with the diagnosis of HZO and their contralateral clinically unaffected eyes were studied and compared with normal controls (n = 15).
In vivo confocal microscopy (Confoscan 4; Nidek Technologies, Gamagori, Japan) and corneal esthesiometry (Cochet-Bonnet; Luneau Ophthalmologie, Chartres, France) of the central cornea were performed bilaterally in all patients and controls. Patients were grouped into normal (> 5.5 cm), mild (> 2.5-5.5 cm), and severe (< 2.5 cm) loss of sensation.
Changes in corneal nerve density, total nerve number, main nerve trunks, branching, and tortuosity were evaluated after IVCM and were correlated to corneal sensation, disease duration, and number of recurrences.
Eyes with herpes zoster ophthalmicus had a significant (P < 0.001) decrease in total nerve length (595.8±358.1 vs. 2258.4±989.0 μm/frame), total number of nerves (5.4±2.8 vs. 13.1±3.8), number of main nerve trunks (2.3±1.1 vs. 4.7±1.2), and number of nerve branches (3.2±2.3 vs. 8.4±3.7) as compared with controls. In the contralateral clinically unaffected eyes, total nerve length (1053.1±441.4 μm/frame), total number of nerves (8.3±2.9), and main nerve trunks (3.1±1.0) also were decreased significantly as compared with controls (P < 0.01). Reduced nerve density, total nerve count, main trunks, and tortuosity was correlated significantly with corneal sensation across all subgroups (P < 0.001).
Patients with unilateral HZO demonstrated a profound and significant bilateral loss of the corneal nerve plexus as compared with controls, demonstrating bilateral changes in a clinically unilateral disease. Loss of corneal sensation strongly correlated with subbasal nerve plexus alterations as shown by IVCM.

Ophthalmology. 2012 Sep 19. pii: S0161-6420(12)00671-9. doi: 10.1016/j.ophtha.2012.07.036. [Epub ahead of print]
Hamrah P, Cruzat A, Dastjerdi MH, Prüss H, Zheng L, Shahatit BM, Bayhan HA, Dana R, Pavan-Langston D.
Ocular Surface Imaging Center and Cornea & Refractive Surgery Service, Massachusetts Eye & Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts. Electronic address: