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Aim: The aim of this study was to evaluate the goblet cell density (GCD) of conjunctiva in medically-controlled glaucoma using laser scanning confocal microscopy (LSCM)., Materials and Methods: Fifty-five glaucomatous patients were enrolled and divided into two groups: Group 1 (27 eyes), controlled with one medication; and group 2 (28 eyes), controlled with two medications. Seventeen patients with dry eye disease (DED) and 17 healthy individuals served as controls. Patients completed the Ocular Surface Disease Index (OSDI) questionnaire and underwent determination of tear film break-up time (BUT), corneal staining, and Schirmer test I. For the GCD assessment, 12 high-quality images were acquired from the upper conjunctival epithelium (superior nasal, superior central, and superior temporal sectors)., Results: Overall, GCD was significantly reduced in both glaucoma groups and those with DED compared to healthy controls (p<0.001), with values markedly lower in group 2 compared to group 1 (p<0.05). GCD was not significantly different between those with DED and group 2. A significant negative correlation was found of GCD with OSDI and with BUT (p<0.001; R=-0.795 and R=-0.756, respectively)., Conclusion: Glaucoma therapy leads to a marked reduction of GCs, especially in the associative regimens. Given the negative correlation with tear film function tests, GCD reduction may play a pivotal role in the pathophysiology of the glaucoma-related disease of the ocular surface., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Prostaglandin analogues (PGAs) are a first-line medical treatment for glaucoma because of their powerful intraocular pressure (IOP) lowering effect, few systemic side-effects (SEs), and the once daily administration. Despite the high systemic safety profile, the chronic use of PGAs may induce periocular and ocular surface (OS)-related side effects, which affect a significant proportion of glaucomatous patients. In this review, we summarize the current knowledge about SEs of PGAs on periocular structures and OS, and their implications in clinical practice., Materials and Methods: A comprehensive literature search on the PubMed platform was performed. Two hundred fifty articles fulfilling key words were identified, of which 180 were excluded since they did not concern the effects of PGAs on the periocular tissues and OS, or because of their limited relevance. The following key words were used and combined, to narrow-down the literature: "prostaglandin" and "ocular surface," which identified 184 unique publications, of which 68 were selected; "prostaglandin" and "periocular" which identified 46 unique publications, of which 11 were selected. An additional search was conducted using "prostaglandin" and "Meibomian glands (MGs)", which identified twenty unique publications, of which 8 were selected. Thus, a total of 70 articles were chosen based on their relevance and were included in this review., Results: Prostaglandin-associated peri-orbitopathy, skin pigmentation and hypertrichosis, eyelash growth, and MGs dysfunction are the most frequent modifications of periocular tissues. They are induced by the tissue accumulation of PGAs, and FP receptor stimulation. Without preservatives, PGAs act as stimulators of conjunctival goblet cells, which are the main source of ocular surface mucoproteins, and seem to increase conjunctival epithelium microcysts proposed as in vivo hallmark of the trans-scleral aqueous humour outflow. Additional PGA-induced modifications can be recognized in the cornea, corneo-scleral limbus, conjunctival stroma and, conjunctiva-associated lymphoid tissue, mainly appearing as inflammatory changes. OS epithelia desquamation, chemosis, apoptosis, dendritic cell activation, conjunctival or episcleral vasodilation, and sub-basal nerve plexus disruption were also described in patients receiving preserved PGAs., Conclusion: PGAs induce several modifications of the OS structures and adnexa; nonetheless, none of them significantly reduces the local safety profile of this class of drugs. Moreover, the OS changes do not affect the IOP lowering efficacy of PGAs. On these bases, local SEs of PGAs should not discourage clinicians in using this class of medications because of their efficacy, the systemic safety profile, and the better adherence., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: In glaucoma, conjunctival epithelial microcysts (CEM) have been extensively investigated by means of laser scanning confocal microscopy. In the present case series, we examined eight glaucomatous patients undergoing trabeculectomy to obtain a 3-dimensional (3-D) characterization of CEM., Materials and Methods: Image acquisition was performed in z-scan automatic volume mode by Heidelberg Retina Tomograph III/Rostock Cornea Module and a series of 40 images of 300×300 μm (384×384 pixels) to a maximum depth of 40 μm were acquired throughout the upper bulbar conjunctiva before (at the site planned for surgery) and eight weeks after trabeculectomy. The 3-D volume tissue reconstruction with maximal size of 300×300×40 μm was obtained., Results: In the enface view, CEM appeared as empty, optically clear, round or oval shaped sub-epithelial structures. The 3-D spatial reconstruction showed microcysts as oval-shaped and optically clear elements, which were close, but clearly separated from the epithelium. CEM were embedded in the extra-cellular spaces and located about 10 μm below the epithelial surface. After trabeculectomy, CEM increased density and area especially along the horizontal axis., Conclusion: The 3-D in vivo confocal reconstruction of CEM permits for better clarification of their microscopic anatomy and patho-physiological significance, confirming their involvement in AH flow through the bleb-wall after filtration surgery for glaucoma., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: To evaluate the density of conjunctival goblet cells (GCs) in glaucomatous patients treated with preservative-free (PF) tafluprost, using laser scanning confocal microscopy (LSCM) and impression cytology (IC)., Methods: Thirty glaucomatous patients (30 eyes) naive for therapy and thirty healthy subjects (30 eyes) were enrolled. Conjunctiva was examined by means of Heidelberg Retina Tomography/Rostock cornea module. Afterwards, the specimens for IC were obtained. Patients were randomized to PF-tafluprost (Group 1) or preserved latanoprost (Group 2) and controls to the vehicle of latanoprost (Group 3) or physiological buffered saline solution (Group 4). Both LSCM and IC were performed at baseline, and after the 1st and 6th months of therapy, GC density (GCD) (cells/mm(2) ) was the main outcome measurement., Results:   Baseline. Mean GCD was 240.69 ± 25.43 and 232.65 ± 23.52, for LSCM, and 162.10 ± 23.44 and 164.71 ± 21.03 for IC in Group 1 and 2, respectively. GC density values were not significantly different in Group 3 and 4 (p > 0.05%). Month one. Mean GCD increased to 284.16 ± 43.88 and 230.62 ± 48.32 in Group 1 (p < 0.001) and to 297.86 ± 26.87 and 221.78 ± 43.02 in Group 2 (p < 0.05), measured with LSCM and IC, respectively. In Group 3, GCD decreased to 205.88 ± 25.04 and 139.54 ± 17.37 measured with LSCM and IC, respectively (p < 0.05). Month six. Mean GCD did not change in Group 1 (p > 0.05) whereas it decreased in Group 2 (p < 0.05), compared to month 1. In Group 3, GCD further decreased to 166.32 ± 22.31 and 120.76 ± 11.66, measured with LSCM and IC, respectively (p < 0.05); in Group 4, mean GCD did not change during the study period (p > 0.05)., Conclusions: Treatment with PF tafluprost was associated with an increase in conjunctival GCD in glaucomatous eyes naïve for therapy. Further studies are mandatory to verify this finding because its validation may have important consequences in the medical management of glaucoma., (© 2013 Acta Ophthalmologica Scandinavica Foundation. Published by Blackwell Publishing Ltd.)

Aim: To assess the epithelial features of the bulbar conjunctiva using in vivo confocal microscopy in patients with glaucoma undergoing canaloplasty., Methods: Thirty consecutive patients with glaucoma were enrolled. Canaloplasty was considered successful if the preoperative intraocular pressure (IOP) was reduced by one-third. The conjunctiva was examined using confocal laser-scanning microscopy 1 week before (baseline) and 12 weeks after surgery. The mean density (MMD, cysts/mm(2)) and mean area (MMA, μm(2)) of conjunctival microcysts and IOP were measured. Anterior segment optical coherence tomography was performed to evaluate post-operative trabecular distension and scleral modifications at the surgery site., Results: Twelve weeks after surgery, canaloplasty was successful in 23 patients (group 1) but unsuccessful in 7 (group 2). At baseline, IOP was 28.1±2.98 and 28.3±2.81 mm Hg, MMD was 10.61±4.31 and 11.35±5.6 and MMA was 2845.02±411.85 and 2700.56±518.85 in groups 1 and 2, respectively (p>0.05). Twelve weeks after canaloplasty, mean IOP was 13.2±4.48 (p<0.05) and 24.6±3.48 mm Hg in groups 1 and 2, respectively. In group 1, MMD and MMA were 37.86±21.4 and 11997.84±8630.35, respectively, a fourfold increase compared to baseline (p<0.001); no significant differences were found in group 2. Conjunctival bleb was not documented in any case., Conclusions: Conjunctival microcysts were evident in all glaucomatous eyes prior to surgery, and tended to increase in density and surface area after successful canaloplasty. These findings indicated enhanced aqueous humour filtration across the sclera and conjunctiva after canaloplasty.

Objectives: To evaluate the microscopic epithelial features seen with in vivo confocal microscopy (IVCM) of bulbar conjunctiva in glaucomatous patients undergoing trabeculectomy with mitomycin C in order to elucidate modifications., Methods: Fifteen eyes of 15 consecutive Caucasian patients affected with primary open-angle glaucoma (POAG) undergoing trabeculectomy and 10 eyes of 10 glaucomatous patients (controls) under medical therapy were enrolled. Eyes were examined using a digital confocal laser-scanning microscope (HRT II Rostock Cornea Module) at baseline and after 6 weeks. The mean microcyst density (MMD: cysts/mm(2)) and microcyst area (MMA: mum(2)) were the main outcome measurements., Results: Before surgery, the mean intraocular pressure (IOP) was 25.1 (SD 3.2) mm Hg. MMD and MMA were 22.4 (11.9) and 4696.0 (3608.1), respectively. After trabeculectomy, the mean IOP was 16.1 (1.7) mm Hg. A marked increase in both MMD and MMA, with values of 103.1 (22.6) and 29 489.3 (12 954.9), respectively, was observed. In the control group at baseline, the mean IOP was 15.7 (1.9) mm Hg, and the microcyst parameters did not differ from eyes undergoing filtering surgery. After 6 weeks, IOP and microcysts parameters did not show any significant modifications., Conclusions: Conjunctival epithelial microcysts were demonstrable in glaucomatous eyes under medical therapy prior to trabeculectomy. The filtering procedure increased microcysts density and surface at bleb site indicating a marked postsurgical enhancement of aqueous filtration across conjunctiva.

Purpose: The study was conducted to analyze, by in vivo confocal microscopy (IVCM), the conjunctival epithelial characteristics in untreated ocular hypertension (OH) and in topically treated primary open-angle glaucoma (POAG)., Methods: The study included 30 eyes affected with untreated OH, 96 eyes with POAG receiving medical therapy, and 15 healthy control eyes. The main outcome measures were the mean density and the mean area of conjunctival epithelium microcysts. The relations among the microscopic parameters intraocular pressure (IOP), and age in both hypertensive and glaucomatous eyes and between mean defect (MD) of visual fields and the time on therapy in patients with glaucoma were analyzed., Results: There was no evidence of conjunctival microcysts in any of the healthy eyes examined; conversely, conjunctival microcysts were found in all ocular hypertensive eyes (mean microcyst density of 19.7 +/- 3.5 cysts/mm(2) and mean total microcyst area of 4063.6 +/- 921.2 mum(2)). All patients with POAG showed conjunctival microcysts (mean density of 28.7 +/- 2.7 cysts/mm(2) and a mean total microcyst area of 6564.2 +/- 671.4 mum(2)). No significant differences were found between OH and POAG subjects for microcyst parameters and no significant relations were found in either OH or POAG eyes for microcyst density, area, IOP, MD, and time on therapy., Conclusions: The results of the study show that conjunctival microcysts are features present in all hypertensive and glaucomatous eyes. Based on these findings, conjunctiva could be an additional potential target tissue available for the investigation by a noninvasive in vivo approach of glaucoma-induced pathologic modifications.

Purpose: To provide a microscopic and macroscopic analysis by a clinical, in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) assessment of filtering blebs after glaucoma surgery., Material and Methods: We retrospectively analyzed 60 eyes of 48 glaucomatous patients by slit-lamp, IVCM, and AS-OCT examinations. Patients were divided into 2 groups: successful blebs (group 1, 16 patients, 27 eyes) were defined as a one-third reduction in preoperative intraocular pressure without antiglaucoma medications and failed blebs (group 2, 32 patients, 33 eyes) as a less than one-third reduction in preoperative intraocular pressure without therapy. The examinations were performed from 1 to 96 months postoperatively., Results: Diffuse or cystic clinical patterns were indicative for good functionality whereas flat or encapsulation was indicative for poor functionality. When comparing successful with failed blebs, the IVCM analysis showed a greater number (P=0.014), density (P=0.009), and total area of epithelial microcysts (P=0.017) and a lower density of connective tissue (P=0.006). The AS-OCT analysis showed a lower degree of bleb wall reflectivity (P<0.001). A significant correlation was found between the clinical and AS-OCT parameters, particularly for the cystic (100%) and diffuse (74%) patterns., Conclusions: All IVCM parameters did correlate well with the bleb functionality whereas, among the AS-OCT parameters, only the bleb wall reflectivity was significantly related to the filtering capability. Clinical and AS-OCT bleb classification showed a significant degree of concordance. As a consequence, simultaneous approach by clinical, microscopic, and tomographic assessment improves the clinician's ability in the postsurgery understanding and management of blebs.

Purpose: To provide an in vivo confocal microscopy (IVCM) and impression cytology analysis of preserved-and unpreserved levobunolol-induced changes of conjunctival epithelium., Methods: 27 eyes of 27 patients were consecutively randomized to receive preserved or unpreserved levobunolol; all patients had a recent diagnosis of primary open angle glaucoma (POAG) or ocular hypertension and were not previously treated with topical medications. IVCM and impression cytology were performed before and after six months of therapy. Goblet cells density and a conjunctival epithelium regularity index were considered in the IVCM analysis, whereas impression cytology specimens were graded and scored in accordance with Nelson's method., Results: After six months of therapy, IVCM and impression cytology parameters showed significant differences with respect to baseline in both groups (p<0.001); significant differences were also found between the two groups (p<0.001). The IVCM analysis showed a goblet cells density reduction (61% and 17% from baseline, respectively in group 1 and 2) (p<0.001) and an higher index of epithelial regularity (p<0.001) in both groups; the impression cytology analysis showed an higher score in both groups (p<0.001)., Conclusions: All the IVCM and impression cytology parameters correlated well with the conjunctival modifications induced by the topical therapy, suggesting the less toxicity of unpreserved drugs.