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PURPOSE: To study the effect of injecting botulinum toxin into the region of Riolan's muscle in three conditions, namely the typical form of essential blepharospasm, the palpebral form of essential blepharospasm and hemifacial spasm. METHOD: Six patients with the typical form of essential blepharospasm and 4 patients with the palpebral form of essential blepharospasm, all of whom had previously been treated with conventional bilateral periorbital injections, were treated with injections of the toxin into the region of Riolan's muscle at the medial and lateral extremities of the upper lids. Thirty patients with hemifacial spasm, all of whom had previously been treated with conventional periorbital injections, were treated with injections of the toxin into the region of Riolan's muscle at the medial and lateral extremities of the upper lid on the affected side. RESULTS: Five of 6 patients with typical essential blepharospasm preferred the Riolan's injections and one had no preference. All of the four patients with the palpebral form of essential blepharospasm preferred the Riolan's injections. They, previously, had hardly been able to open their eyes. Twenty-six of the patients with hemifacial spasm preferred the Riolan's injections; the other 4 decided to continue with periorbital injections. The amount of toxin used in this new method of treatment is considerably less than that used in conventional methods for these diseases. CONCLUSION: Riolan's injections of botulinum toxin are the preferred modality of treatment for all types of blepharospasm and cost considerably less.

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Keratocytes from the bovine cornea secrete a factor(s) that stimulates the proliferation of corneal epithelial cells. The novel finding of this study is that this stimulation was only achieved if the epithelial cells were already proliferating. Cells which had stopped growing could not be stimulated to re-enter the growth cycle. This stimulation was not reciprocal; the growth of keratocytes was not stimulated by factor(s) secreted by the epithelium, whereas epithelial factors were able to stimulate the proliferation of thermocytes. The importance of these non-reciprocal growth responses to corneal wound healing and immune response is discussed.

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The concentrations of tear lysozyme, lactoferrin, ceruloplasmin, IgA, and IgG have been estimated in patients with dry eyes at the same time as semiquantitative bacterial culture was performed of the conjunctivae and lids. Staphylococcal isolations were quantified and biotyped. There was no increased conjunctival colonisation by any particular biotype of Staphylococcus aureus or Staph. epidermidis, and similar numbers of conjunctivae were sterile as in controls (33%); neither were any pathogens such as pneumococci or haemophili isolated. We consider that the conjunctiva of the dry eye, without the lacrimal secretion components of lysozyme and lactoferrin, has an alternative protective antibacterial mechanism which is derived from serum proteins via chronically inflamed vessels.

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The diagnosis of moderate degrees of tear depletion is difficult using conventional tests such as the Schirmer test, clinical evidence and even a confirmatory test such as the lysozyme test. We have refined the lysozyme test using quantitative techniques and calibrated standards. We found this satisfactory on a population basis, but not on an individual basis. We developed an ELISA test for assaying five tear proteins 'lysozyme, lactoferrin, ceruloplasmin, IgA and IgG' which gives a much more accurate assessment of dryness on an individual patient level.

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After oral administration of tetracycline fluorescence has been detected in biopsy specimens taken from human and animal conjunctiva. The fluorescence is not uniform but appears to be concentrated in the goblet cells, around the blood vessels, and in a thin film on the external surface of the epithelium. Immersion studies suggest there is a selective binding to the surface of the conjunctiva.

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This paper considers the dubious role of asymptomatic marginal reduction of tear production in the aetiology of contact lens intolerance and how in the light of our present knowledge and the tests available it is difficult to identify such marginal underproduction of tears. Contact lenses have a possible therapeutic role in the management of established dry eyes with and without conjunctival scarring and destructive corneal changes. All soft contact lenses have been shown to lose a considerable percentage of their fully hydrated water content when put in any eye and the presence of a contact lens in an eye has been shown to increase tear evaporation, irrespective of evaporation from the contact lens. Soft contact lenses would appear to be able to withstand considerable dehydration and yet maintain their optical quality and in the eye with inadequate tears a lens of lower water content will remain hydrated to a reasonable extent for a longer period than one of a higher water content. Contact lenses may be necessary in the dry eye to provide an optical surface to the cornea when it is the site of destructive changes. In the case of the severely dry eye it may be necessary to use a silicone soft lens with no water content in order to obviate the problems of dehydration. There are considerable dangers in such eyes with and without conjunctival and corneal destructive changes and a decision to fit a lens should not be taken lightly and without adequate provision for close follow up.

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Concentrations of lysozyme, lactoferrin, ceruloplasmin, IgA, and IgG have been measured in tears by the ELISA (enzyme-linked immunosorbent assay) technique. Tears were collected on weighed filter paper discs, after which they were eluted into buffer and transported frozen to a remote laboratory for assay. Patients with sicca, questionably dry eyes and ocular pemphigoid were sampled, as were 54 normal volunteers. Tear protein profiles were established which were unique for each condition and clearly differed from the normal controls. The assay developed is considered suitable for other proteins such as IgE, and could also be used for monitoring the effects of drugs on the lacrimal gland.

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This paper describes changes in the ultrastructure of the human conjunctiva which follows its denervation. The changes are mainly seen in the mucus-producing subsurface vesicles, the surface microvilli, and the intercellular spaces. Some tentative suggestions are made as to how these changes may influence the stability of the tear film in the anaesthetic state.

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Thirty-two patients with raised intraocular pressure were treated for 1 year with topical timolol 0.5% twice daily. There was satisfactory pressure reduction on this drug alone in 25 patients. The tear flow (modified Schirmer I test) was measured, and the tear lysozyme concentration was assayed before, and at 3, 6, and 12 months after beginning treatment. No subjective symptoms occurred and no side effects were recorded. The tear flow and tear lysozyme concentration were not significantly reduced.

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This paper is concerned with the recognition of the dry eye when the clinical diagnosis is in doubt and other external eye diseases may be present. Papillary conjunctivitis is common to the dry eye as well as other pathological conditions and confuses the diagnosis. We have correlated the factors involved in the assessment for dryness. We have shown that particulate matter in the unstained tear film is associated with low tear lysozyme concentration. Tear flow and tear lysozyme are not necessarily interrelated, but a low lysozyme concentration (tear lysozyme ratio < 1.0) is associated with keratoconjunctivitis sicca. The Schirmer I test can produce false positive results, and we have suggested a modification to overcome this. This modified test will detect the eye with severely depleted lysozyme secretion, but it is unreliable for detecting the eye with moderately depleted secretion. We find that its lowest normal limit should be considered as 6 mm.

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We have developed a method for assaying the concentration of tear lysozyme using eluates of tear fluid collected on filter paper discs. Specimens can be stored and transported to remote laboratories for assay. We have shown that the 'indirect' or eluate method gives statistically comparable results to the 'direct' method using fresh, neat tear fluid.

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Patients who had received long-term therapy with practolol and other beta-adrenergic receptor blocking drugs were examined ophthalmologically. Tear lysozyme concentration and serum autoantibodies (antinuclear antibodies, DNA-binding antibodies and intercellular cement substance antibodies) were measured. It was found that beta-adrenergic receptor blocking drugs may have a pharmacological effect on the lachrymal glands, but this was not associated with dry eyes or adverse reaction. Practolol was found to be capable of reducing tear lysozyme concentrations to very low levels, and this was initially associated with high titres of ICC antibody. No other drug tested produced these effects.

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Mucous glycoproteins play an important role in maintaining the normal surface of the eye. Changes in the physical properties and chemical composition occur in disease with increased viscosity and a shift in the type of acid glycoprotein towards a predominance of sulphomucin causing some of the distinctive clinical features seen in dry eyes, superior limbic keratitis (SLK), vernal catarrh, and neuroparalytic keratitis.

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Four modalities of corneal contact lens fitting in keratoconus have been considered: 1. The large alignment lens. 2. The large flat lens. 3. The small lens fitting flat on the apex of the cone. 4. The lens lid attachment technique. The lens lid attachment technique is considered in some detail and its particular merits discussed.

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An accurate method of assaying the tear lysozyme concentration in units of activity/mul has been developed. Normal physiological levels which vary with age have been determined. It has been demonstrated that measurement of the volume of tear fluid collected and assay with a calibrated standard are essential for the accurate determination of the precise concentration of lysozyme in the tear fluid. Tear lyozyme concentration can be used as an index of lacrimal gland function, and in the diagnosis of the sicca syndrome and associated conditions. We believe that this method of tear lyozyme assay has important applications in drug toxicity states in humans (for example, practolol toxicity) and also in animal drug toxicity studies.

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