**Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye" at Senile and Complicated Cataracts**

Artashes A. Zilfyan and Arto V. Zilfyan

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/58229

### **1. Introduction**

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[130] Roberts, P. D, Spiros, A, &Geerts, H. Simulations of symptomatic treatments for Alz‐ heimer's disease: computational analysis of pathology and mechanisms of drug ac‐

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173, 339–352

542 Ophthalmology - Current Clinical and Research Updates

Nowadays, in current biology and medicine the subject of wide discussion present paracrine and autocrine immune, endocrine and mediatory mechanisms functioning of which in all the integrative systems of the organism are realized due to principles of interregulation and interdependence. It is not excluded that similar mechanisms are also engaged in eye tunics, moreover that the hematoophthalmic barrier is characterized by a more stable selective permeability (as compared to other histohematic barriers) towards a wide range of endoge‐ nous active biological compounds of immune, hormonal and mediatory origin.

In this concern, to our mind, studies aimed at elucidation of autonomous mechanisms engaged in sustaining the immune and endocrine homeostasis in the eye tunics are rather promising.

Hence, during the last 40 years the subject of special investigation became scientific research works relevant to the aspects of pathogenesis "active immunological tolerance" originating in eye tunics as a response to baring of antigenic determinants in eye tunics and tissues at a wide range of ophthalmological diseases. The entire symptom complex of *in situ* occurring immu‐ nological reactions is defined in modern ophthalmology as "anterior chamber associated immune deviation" (ACAID).

At the same time, regional mechanisms responsible for ACAID function are studied rather insufficiently.

In the mentioned aspect, cells identified in certain eye tunics should become the subject of specific discussion; besides their "main functions' these cells are provided with the immune,

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

hormonal and mediatory activity as well. The matter is *in situ* synthesis of transforming growth factor-β-2, cortisol, fibronectin, availability of receptors to prolactin and prostaglandins E2.

processes development in tunics and fluid sections (slices) of an eye under conditions of a wide

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

http://dx.doi.org/10.5772/58229

545

At the same time, this term first of all reflects the state of "local immune homeostasis" under conditions of normal functioning of an eye. The complete cascade of local protective/adaptive mechanisms is aimed to form immunological processes, which in total are defined as anterior chamber associated immune deviation (ACAID). To our mind based on available scientific publications, the general scheme of immunopathological process can be presented as the

**1.** As a result of interaction of different pathogenetic factors there occurs "baring" (uncov‐ ering) of antigenic determinants (Orge Y., Gungor S., 1984; D'Orazio T., Niederkorn J.,

**2.** As a response to acquiring of antigenic properties by tissues of an eye in the region of damage (injury) there occurs no activation of the antibody formation process, as reactions of active immunological tolerance there prevail to dominate (Murray P. et al., 1990;

**3.** No formation of immune complexes occurs as under conditions of pathology there is engaged the regional mechanism preventing activation of the compliment (Streilein J.,

**4.** Mechanisms of immune suppression (inhibition of antibody formation) are conditioned by targeted (directed) activation of T-suppressory and killer (killing) subpopulation

**5.** Directed activation of T-killer lymphocytes occurs due to production of TGFβ (Streilein J.

**6.** The high level of CD8 is mainly conditioned by the fact that in the region of eye tissues damage there occurs activation of the main histocompatibility class I complex, which functions as the initial factor ensuring triggering of receptor mechanisms underlying activation and proliferation of T-killer lymphocyte populations (Nishi O. et al., 1982;

It should be emphasized that certain pathogenetic mechanisms/links underlying induction and course of ACAID in case of non-complicated and complicated cataracts are currently the subject of a wide discussion (Orge Y., Gungor S., 1984; Uenoyama K. et al., 1989; Streilein J. et al., 1992; Zhou Z. et al., 1996; Cinatl et al., 2000; Robinson M. et al., 2000; Kawakami M. et al.,

As a rule, the main reason of ACAID induction is 1-or 2-stage surgical intervention, as a result of which there occurs "baring" (uncovering) of antigenic determinants of lens tissues. As a result, in the "immunocompetent" tunics of an eye there occurs the synthesis of specific autoantibodies targeted to tissues of lens; by this latter are caused local processes of autoim‐ mune aggression are caused being conditioned by the damaging action of both autoantibodies

Martin W. et al., 1995; Bakunowicz L. et al., 1997; Muhaya M. et al., 1999).

Lightman S., Towler H., 1992; Fu T. et al., 2004; Kitaichi N. et al., 2005).

range of ophthalmologic maladies.

Stein-Streilein J., 2000).

and locally formed immune complexes.

2005).

following chronologically occurring stages:

1998; Sonoda A. et al., 2000; Camelo S. et al., 2005).

(Wilbanks C., Streilein J., 1990; Muhaya M. et al., 1999).

et al., 1992; Abrahamian A. et al., 1995; Fleenor D. et al., 2006).

This chapter will bring to the attention of readers the analysis of scientific evidence and our own research findings obtained during the last 10 years in respect of possible regional immune, hormonal and mediatory mechanisms engaged in formation and abolition of ACAID function.

To avoid artificially expanded volume of this chapter, we considered to be expedient to supplement the narrative description of own research results with Tables and Schemes, excluding all the methodic approaches to selection of patient cohorts, methods of investigation, which were comprehensively presented within our previous studies (Zilfyan A., 2009; 2012; 2013).

We should only mention those groups of patients under study in the aqueous humor of which we determined the spectrum of the above-mentioned endogenously active substances of the immune, hormonal and mediatory nature.

The first (control) group included patients with senile non-complicated cataract, the second group involved patients with cataracts occurring on the background of primary open-angle glaucoma and the third group embraced patients with cataracts on the background of glaucoma and pseudoexfoliative syndrome, the fourth group made patients with cataracts on the background of "arterial hypertension", the fifth group – cataracts on the background of diabetes mellitus and the sixth group was composed of patients with cataract on the back‐ ground of previous eye injury.

To our mind, it was rather reasonable that we did not include in the current chapter issues dealing with the role of intracorporeal resident gram-negative and gram-positive microor‐ ganisms, as well as viruses, *Chlamidiae*, *Toxoplasmas*, etc. Despite the bulk of evidence-fre‐ quently of contradictory character – mechanisms of "bacterial translocation" of the abovementioned microorganisms in the aspect of their passage through the hematoophthalmic barrier and/or penetration of their secretion and decomposition products into the eye tunics are almost none-investigated.

Similar approach was used by us regarding the role of pro-and anti-inflammatory immuno‐ cytokines, because of a known controversy of available scientific data on their role in mecha‐ nisms responsible for formation of reactions responsible for ACAID function. The controversial character of scientific publications to a known extent is connected with dosedependent and pleiotropic potencies of immunocytokines even towards the same "immuno‐ competent" cells localized in the eye tunics.

### **2. Immune shifts in mechanisms of formation and abolition of the active immunological tolerance responsible for ACAID function**

The term "immune privilege of an eye" implies the entire complex of regional immune cellmediated and humoral reactions aimed at prevention of inflammatory and dystrophic processes development in tunics and fluid sections (slices) of an eye under conditions of a wide range of ophthalmologic maladies.

hormonal and mediatory activity as well. The matter is *in situ* synthesis of transforming growth factor-β-2, cortisol, fibronectin, availability of receptors to prolactin and prostaglandins E2.

This chapter will bring to the attention of readers the analysis of scientific evidence and our own research findings obtained during the last 10 years in respect of possible regional immune, hormonal and mediatory mechanisms engaged in formation and abolition of ACAID function. To avoid artificially expanded volume of this chapter, we considered to be expedient to supplement the narrative description of own research results with Tables and Schemes, excluding all the methodic approaches to selection of patient cohorts, methods of investigation, which were comprehensively presented within our previous studies (Zilfyan A., 2009; 2012;

We should only mention those groups of patients under study in the aqueous humor of which we determined the spectrum of the above-mentioned endogenously active substances of the

The first (control) group included patients with senile non-complicated cataract, the second group involved patients with cataracts occurring on the background of primary open-angle glaucoma and the third group embraced patients with cataracts on the background of glaucoma and pseudoexfoliative syndrome, the fourth group made patients with cataracts on the background of "arterial hypertension", the fifth group – cataracts on the background of diabetes mellitus and the sixth group was composed of patients with cataract on the back‐

To our mind, it was rather reasonable that we did not include in the current chapter issues dealing with the role of intracorporeal resident gram-negative and gram-positive microor‐ ganisms, as well as viruses, *Chlamidiae*, *Toxoplasmas*, etc. Despite the bulk of evidence-fre‐ quently of contradictory character – mechanisms of "bacterial translocation" of the abovementioned microorganisms in the aspect of their passage through the hematoophthalmic barrier and/or penetration of their secretion and decomposition products into the eye tunics

Similar approach was used by us regarding the role of pro-and anti-inflammatory immuno‐ cytokines, because of a known controversy of available scientific data on their role in mecha‐ nisms responsible for formation of reactions responsible for ACAID function. The controversial character of scientific publications to a known extent is connected with dosedependent and pleiotropic potencies of immunocytokines even towards the same "immuno‐

**2. Immune shifts in mechanisms of formation and abolition of the active**

The term "immune privilege of an eye" implies the entire complex of regional immune cellmediated and humoral reactions aimed at prevention of inflammatory and dystrophic

**immunological tolerance responsible for ACAID function**

2013).

immune, hormonal and mediatory nature.

544 Ophthalmology - Current Clinical and Research Updates

ground of previous eye injury.

are almost none-investigated.

competent" cells localized in the eye tunics.

At the same time, this term first of all reflects the state of "local immune homeostasis" under conditions of normal functioning of an eye. The complete cascade of local protective/adaptive mechanisms is aimed to form immunological processes, which in total are defined as anterior chamber associated immune deviation (ACAID). To our mind based on available scientific publications, the general scheme of immunopathological process can be presented as the following chronologically occurring stages:


It should be emphasized that certain pathogenetic mechanisms/links underlying induction and course of ACAID in case of non-complicated and complicated cataracts are currently the subject of a wide discussion (Orge Y., Gungor S., 1984; Uenoyama K. et al., 1989; Streilein J. et al., 1992; Zhou Z. et al., 1996; Cinatl et al., 2000; Robinson M. et al., 2000; Kawakami M. et al., 2005).

As a rule, the main reason of ACAID induction is 1-or 2-stage surgical intervention, as a result of which there occurs "baring" (uncovering) of antigenic determinants of lens tissues. As a result, in the "immunocompetent" tunics of an eye there occurs the synthesis of specific autoantibodies targeted to tissues of lens; by this latter are caused local processes of autoim‐ mune aggression are caused being conditioned by the damaging action of both autoantibodies and locally formed immune complexes.

The activation of reactions of local humoral immunity is accompanied by significant increase of IgG levels in aqueous humor (in anterior and posterior chambers of eyes), due to which the aqueous humor is a rather informative media for studies on mechanisms of both formation and abolition of ACAID. At the same time, all the above-mentioned links underlying abolition of ACAID in case of cataracts are studied rather insufficiently.

relatively high levels of IgG revealed in the aqueous humor of the specified cohort of patients

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

**II** 16.82 ±2.20 <0.005 **III** 25.05 ±2.25 <0.0005 **IV** 8.75 ±1.71 "/>0.40 **V** 10.1 ±0.74 <0.25 **VI** 14.57 ±2.05 <0.025

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

It appears, that in this precise case the intercellular mechanisms, which are conditioned by the cooperative activity of B-helper subpopulations and B-lymphocytic populations in the immune competent eye tunics and, first of all, of the ciliary body, are engaged in eye tunics; these latter eventually bring to the synthesis of anti-tissue autoantibodies. The performed 2 factor correlation analysis also signifies in favour of this circumstance: strong direct correlation dependence was revealed between CD4 and IgG high levels in the aqueous humor of patients of the II and III study groups (correlation index made-0.891 and-0.935, appropriately). It should be mentioned that similar picture of immunological shifts was also observed in study group VI, i.e. at cataracts occurring on the background of trauma. Therefore, it is not excluded that prior trauma can be considered as a provoking factor bringing forth impairment of the immune homeostasis. In the aqueous humor of patients from all other study groups of complicated cataracts (groups IV and V) we registered CD8, CD4 and IgG indices similar to those registered

The results of performed immunological analysis for IgG determination in aqueous humor of patients with senile and complicated cataracts are conformed by available data of scientific publications. In particular, N. Stambuk et al. (1994) established that IgG level in aqueous humor of patients with complicated cataracts was significantly higher than in patients with senile

Thus performed, the comparative analysis in all study groups, though with due circumspec‐ tion, signifies that at senile cataracts and, in all probability, at cataracts occurring on the background of diabetes mellitus and arterial hypertension during the pre-surgery period the regional immune homeostasis is not disturbed, i.e. only those mechanisms are engaged, which

**I** 9.025 ±0.73

**Table 2.** IgG content (*IU/ml*) in the aqueous humor of patients with senile and complicated cataracts.

in the aqueous humor of patients with senile cataracts.

ensure the function of ACAID at norm.

**IgG content** *M m p*

http://dx.doi.org/10.5772/58229

547

signified to this latter (Table 2).

**Study groups (n=40)**

senile cataracts).

cataracts.

It should be emphasized that regional immune mechanisms responsible for *in situ* formation of the active immunological tolerance, which ensures the ACAID function, is most compre‐ hensively studied at senile non-complicated cataracts. At the same time, only single, sometimes even contradictory evidence is available on the course of the regional immune reactions engaged at complicated cataracts.

In our previous investigation (Zilfyan A., 2009) we studied the shifts of CD4, CD8 and IgG in the aqueous humor of patients with complicated cataracts: at cataracts on the background of primary open-angle glaucoma, pseudoexpfoliative glaucoma, diabetes mellitus, arterial hypertension, prior eye trauma.

The results of enzyme immunoassays for CD4 and CD8 in aqueous humor of patients are presented as Table 1.


Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 1.** The content of CD4 (*unit/ml*) and CD8 (*unit/ml*) in aqueous humor of patients with senile and complicated cataracts.

As obvious from the Table, at complicated cataracts (study groups II and III) already in presurgery period in the aqueous humor there was a marked decrease of CD8 on the background of CD4 increase in the aqueous humor of the same cohort of patients.

It is rather remarkable that upon the 2-factor statistical analysis strong reverse correlation dependence was revealed between the studied indices (correlation index made-0.893 and-0.940, appropriately). Apparently, at complicated cataracts in study groups II and III the antigenic determinants in post-barrier eye tunics were bared already in pre-surgery period;


relatively high levels of IgG revealed in the aqueous humor of the specified cohort of patients signified to this latter (Table 2).

The activation of reactions of local humoral immunity is accompanied by significant increase of IgG levels in aqueous humor (in anterior and posterior chambers of eyes), due to which the aqueous humor is a rather informative media for studies on mechanisms of both formation and abolition of ACAID. At the same time, all the above-mentioned links underlying abolition

It should be emphasized that regional immune mechanisms responsible for *in situ* formation of the active immunological tolerance, which ensures the ACAID function, is most compre‐ hensively studied at senile non-complicated cataracts. At the same time, only single, sometimes even contradictory evidence is available on the course of the regional immune reactions

In our previous investigation (Zilfyan A., 2009) we studied the shifts of CD4, CD8 and IgG in the aqueous humor of patients with complicated cataracts: at cataracts on the background of primary open-angle glaucoma, pseudoexpfoliative glaucoma, diabetes mellitus, arterial

The results of enzyme immunoassays for CD4 and CD8 in aqueous humor of patients are

**II** 28.4 ±3.6 <0.0005 22.05 ±5.4 <0.0005 **III** 30.2 ±2.9 <0.0005 18.15 ±2.3 <0.0005 **IV** 14.2 ±2.4 *<0.25* 48.8 ±4.2 <0.25 **V** 11.0 ±2.5 "/>0.4 50.21 ±2.54 <0.4 **VI** 17.5 ±2.0 <0.025 33.7 ±4.99 <0.005 Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

**Table 1.** The content of CD4 (*unit/ml*) and CD8 (*unit/ml*) in aqueous humor of patients with senile and complicated

As obvious from the Table, at complicated cataracts (study groups II and III) already in presurgery period in the aqueous humor there was a marked decrease of CD8 on the background

It is rather remarkable that upon the 2-factor statistical analysis strong reverse correlation dependence was revealed between the studied indices (correlation index made-0.893 and-0.940, appropriately). Apparently, at complicated cataracts in study groups II and III the antigenic determinants in post-barrier eye tunics were bared already in pre-surgery period;

of CD4 increase in the aqueous humor of the same cohort of patients.

**I** 10.7 ± 2.1 53.9 ±5.3

**Indices studied CD4 CD8** *M m p M m p*

of ACAID in case of cataracts are studied rather insufficiently.

engaged at complicated cataracts.

546 Ophthalmology - Current Clinical and Research Updates

hypertension, prior eye trauma.

presented as Table 1.

**Study groups (n=40)**

senile cataracts).

cataracts.

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 2.** IgG content (*IU/ml*) in the aqueous humor of patients with senile and complicated cataracts.

It appears, that in this precise case the intercellular mechanisms, which are conditioned by the cooperative activity of B-helper subpopulations and B-lymphocytic populations in the immune competent eye tunics and, first of all, of the ciliary body, are engaged in eye tunics; these latter eventually bring to the synthesis of anti-tissue autoantibodies. The performed 2 factor correlation analysis also signifies in favour of this circumstance: strong direct correlation dependence was revealed between CD4 and IgG high levels in the aqueous humor of patients of the II and III study groups (correlation index made-0.891 and-0.935, appropriately). It should be mentioned that similar picture of immunological shifts was also observed in study group VI, i.e. at cataracts occurring on the background of trauma. Therefore, it is not excluded that prior trauma can be considered as a provoking factor bringing forth impairment of the immune homeostasis. In the aqueous humor of patients from all other study groups of complicated cataracts (groups IV and V) we registered CD8, CD4 and IgG indices similar to those registered in the aqueous humor of patients with senile cataracts.

The results of performed immunological analysis for IgG determination in aqueous humor of patients with senile and complicated cataracts are conformed by available data of scientific publications. In particular, N. Stambuk et al. (1994) established that IgG level in aqueous humor of patients with complicated cataracts was significantly higher than in patients with senile cataracts.

Thus performed, the comparative analysis in all study groups, though with due circumspec‐ tion, signifies that at senile cataracts and, in all probability, at cataracts occurring on the background of diabetes mellitus and arterial hypertension during the pre-surgery period the regional immune homeostasis is not disturbed, i.e. only those mechanisms are engaged, which ensure the function of ACAID at norm.

At the same time, based on the studies performed by the above-mentioned authors (Lightman S., Towler H., 1992; Sonoda A. et al., 2000; Fu T. et al., 2004; Camelo S. et al., 2005; Kitaichi N. et al., 2005) it is difficult to consider if there is adequacy of inflammatory process, which occurs in eye post-barrier tunics as a response to surgery-related trauma, to what extent the local protective mechanisms work characterizing the immune deviation as related to "bared" autoantigens of the specified tunics. To our mind, it is possible to judge about the character and intensity of the inflammatory process in eye post-barrier tissues only under conditions of the lens transplantation into heterogenous sites of the organism. This problem was successfully solved by Japanese researchers already in 1989 (Uenoyama K. et al., 1989). The authors performed experiments aimed to study tissue specific shifts upon lens transplantation into the eye and intraperitoneally. Due to the complex approach with the use of cytological, immunehistochemical and electron microscopy methods the authors revealed that the degree of inflammatory reaction, the intensity of lymphomacrophagial infiltration were considerably more expressed at the site of lens transplantation, i.e.-in the peritoneum.

realization: through regulation of the regional immune homeostasis and potentiating the adrenergic effect towards the system of vascularization in specific eye tunics (Jacob E. et al.,

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

http://dx.doi.org/10.5772/58229

549

Nowadays, the role of prolactin appears more disputable. At cataracts and uveitides the presence of prolactin was revealed in the anterior chamber of the eye (Pleyer U. et al., 1991). Efforts were done to interpret biological effects of prolactin within the specific eye structures functioning. In particular, S. Duenas and co-workers (2004) allow for the possibility of intraocular synthesis of prolactin within the blood vessels of retina. At retinopathies, the mentioned authors revealed a high level of prolactin in the anterior chamber of the eye. It is important to emphasize that authors did not reveal any correlation dependence between prolactin levels in the anterior chamber of the eye and in blood serum. Despite the fact that of prolactin revealment in tunics and liquid media of the eye, the role of this hormone in the

To our mind, the role of in situ produced hormones, cortisol and prolactin, in eye tissues is more versatile and is far beyond the functions ensuring processes of ion exchange and

We propose a hypothesis according to which cortisol and prolactin play an important role in establishment of ACAID function through modulation of immunological processes in the aspects of both activation and/or inhibition of specific T-and B-populations and also targeted

The mentioned supposition is confirmed by literary data, according to which in the mamma‐ lian organism cortisol and prolactin possess immunomodulatory functions. In particular, it is established that prolactin and cortisol at physiological concentrations maintain the stability of the immune homeostasis. However, at high concentrations cortisol acts as a factor that selectively inhibits the activity of T-killer and T-helper cytotoxic lymphocytes (Pazirandeh A. et al., 2002; Lindeman D., Racke K., 2003; Visser J. et al., 2003), while prolactin activates a number of cytokines (IL-I, VI, TNF, as well as γ-IFN in central and periphery organs of immunogenesis (Matera L., 1986; Yarilin A., Belyakov I., 1996). Furthermore, prolactin – in a dose dependent mode – activates B-lympocytic population (Berczi I. et al., 1981; McMurrey R.

As shown by the results of our earlier performed immune enzyme assays (Zilfyan A., 2009; 2012; 2013) (Table 3) in the aqueous humor of patients with complicated cataracts (cataract occurring on the background of primary open-angle and pseudoexfoliative glaucoma and cataract occurring on the background of preceding trauma) the level of cortisol significantly

The highest indices were recorded by us in aqueous humor of the III group patients: at cataracts

Until present it was considered to be established that the main function of cortisol in the eye tunics was to regulate the intraocular pressure (Jacob E. et al., 1996; Rauz S. et al., 2001). At the same time, due to results obtained, a supposition might be done: the revealed high concen‐

1996; Rauz S. et al., 2001).

integrative activity of the eye remains unstudied.

synthesis of cytokines with adaptogenic spectrum of action.

occurring on the background of pseudoexfoliative glaucoma.

intraocular pressure regulation.

et al., 1991; Lahat N. et al., 1993).

increased as compared to control.

At the same time, even in patient with senile non-complicated cataract the surgery-related trauma might provoke disturbance of ACAID function, because as a response to baring of eye tunics antigenic determinants there occurrs the regional autoimmune process. The postsurgery period in those patients and the performed corrective therapy in the prevailing majority of cases proceed without complications; this latter allows us considering that the traumatic injury occurring in the course of surgery intervention is fraught with development of *in situ* immunopathological disorders, which are of exceptionally temporary, transient character.

## **3. Cortisol-and prolactin-dependent mechanisms responsible for formation and abolition of the ACAID function**

In current scientific publications there is only scarce evidence according to which in certain eye tunics the cells of epithelial genesis and fibroblastic line – apart from their main function – also possess the hormone-producing property to synthesize cortisol (Chong A., Aw S., 1986). Due to experimental studies (Southern A. et al., 1979), the presence of receptors to glucocorticoids in cells of ciliary body and the cornea was established, whereas translocation of glucocorticoids from the surface towards the cell nuclei occurred during a rather short period of time. It is reasonable to mention another circumstance of no less importance. The authors failed to reveal similar mechanism of reception and translocation, which is character‐ istic for glucocorticoids, as related to a wide range of hormones: testosterone, estradiol, progesterone, T3 and T4. It was established that biological effects of cortisol are realized within the sclera, cornea, ciliary body and, mostly important, in the lens capsule (Kasavina B. et al., 1977). According to S. Rauz and associates (2001; 2003), cortisol is secreted in the ciliary body of both actually healthy contingent and in patients with the primary open-angle glaucoma.

Currently, the opinion dominates that the fundamental function of cortisol in eye tunics is sustaining the optimal level of intraocular pressure. Furthermore, this function has a dual realization: through regulation of the regional immune homeostasis and potentiating the adrenergic effect towards the system of vascularization in specific eye tunics (Jacob E. et al., 1996; Rauz S. et al., 2001).

At the same time, based on the studies performed by the above-mentioned authors (Lightman S., Towler H., 1992; Sonoda A. et al., 2000; Fu T. et al., 2004; Camelo S. et al., 2005; Kitaichi N. et al., 2005) it is difficult to consider if there is adequacy of inflammatory process, which occurs in eye post-barrier tunics as a response to surgery-related trauma, to what extent the local protective mechanisms work characterizing the immune deviation as related to "bared" autoantigens of the specified tunics. To our mind, it is possible to judge about the character and intensity of the inflammatory process in eye post-barrier tissues only under conditions of the lens transplantation into heterogenous sites of the organism. This problem was successfully solved by Japanese researchers already in 1989 (Uenoyama K. et al., 1989). The authors performed experiments aimed to study tissue specific shifts upon lens transplantation into the eye and intraperitoneally. Due to the complex approach with the use of cytological, immunehistochemical and electron microscopy methods the authors revealed that the degree of inflammatory reaction, the intensity of lymphomacrophagial infiltration were considerably

At the same time, even in patient with senile non-complicated cataract the surgery-related trauma might provoke disturbance of ACAID function, because as a response to baring of eye tunics antigenic determinants there occurrs the regional autoimmune process. The postsurgery period in those patients and the performed corrective therapy in the prevailing majority of cases proceed without complications; this latter allows us considering that the traumatic injury occurring in the course of surgery intervention is fraught with development of *in situ* immunopathological disorders, which are of exceptionally temporary, transient

more expressed at the site of lens transplantation, i.e.-in the peritoneum.

548 Ophthalmology - Current Clinical and Research Updates

**3. Cortisol-and prolactin-dependent mechanisms responsible for**

In current scientific publications there is only scarce evidence according to which in certain eye tunics the cells of epithelial genesis and fibroblastic line – apart from their main function – also possess the hormone-producing property to synthesize cortisol (Chong A., Aw S., 1986). Due to experimental studies (Southern A. et al., 1979), the presence of receptors to glucocorticoids in cells of ciliary body and the cornea was established, whereas translocation of glucocorticoids from the surface towards the cell nuclei occurred during a rather short period of time. It is reasonable to mention another circumstance of no less importance. The authors failed to reveal similar mechanism of reception and translocation, which is character‐ istic for glucocorticoids, as related to a wide range of hormones: testosterone, estradiol, progesterone, T3 and T4. It was established that biological effects of cortisol are realized within the sclera, cornea, ciliary body and, mostly important, in the lens capsule (Kasavina B. et al., 1977). According to S. Rauz and associates (2001; 2003), cortisol is secreted in the ciliary body of both actually healthy contingent and in patients with the primary open-angle glaucoma. Currently, the opinion dominates that the fundamental function of cortisol in eye tunics is sustaining the optimal level of intraocular pressure. Furthermore, this function has a dual

**formation and abolition of the ACAID function**

character.

Nowadays, the role of prolactin appears more disputable. At cataracts and uveitides the presence of prolactin was revealed in the anterior chamber of the eye (Pleyer U. et al., 1991). Efforts were done to interpret biological effects of prolactin within the specific eye structures functioning. In particular, S. Duenas and co-workers (2004) allow for the possibility of intraocular synthesis of prolactin within the blood vessels of retina. At retinopathies, the mentioned authors revealed a high level of prolactin in the anterior chamber of the eye. It is important to emphasize that authors did not reveal any correlation dependence between prolactin levels in the anterior chamber of the eye and in blood serum. Despite the fact that of prolactin revealment in tunics and liquid media of the eye, the role of this hormone in the integrative activity of the eye remains unstudied.

To our mind, the role of in situ produced hormones, cortisol and prolactin, in eye tissues is more versatile and is far beyond the functions ensuring processes of ion exchange and intraocular pressure regulation.

We propose a hypothesis according to which cortisol and prolactin play an important role in establishment of ACAID function through modulation of immunological processes in the aspects of both activation and/or inhibition of specific T-and B-populations and also targeted synthesis of cytokines with adaptogenic spectrum of action.

The mentioned supposition is confirmed by literary data, according to which in the mamma‐ lian organism cortisol and prolactin possess immunomodulatory functions. In particular, it is established that prolactin and cortisol at physiological concentrations maintain the stability of the immune homeostasis. However, at high concentrations cortisol acts as a factor that selectively inhibits the activity of T-killer and T-helper cytotoxic lymphocytes (Pazirandeh A. et al., 2002; Lindeman D., Racke K., 2003; Visser J. et al., 2003), while prolactin activates a number of cytokines (IL-I, VI, TNF, as well as γ-IFN in central and periphery organs of immunogenesis (Matera L., 1986; Yarilin A., Belyakov I., 1996). Furthermore, prolactin – in a dose dependent mode – activates B-lympocytic population (Berczi I. et al., 1981; McMurrey R. et al., 1991; Lahat N. et al., 1993).

As shown by the results of our earlier performed immune enzyme assays (Zilfyan A., 2009; 2012; 2013) (Table 3) in the aqueous humor of patients with complicated cataracts (cataract occurring on the background of primary open-angle and pseudoexfoliative glaucoma and cataract occurring on the background of preceding trauma) the level of cortisol significantly increased as compared to control.

The highest indices were recorded by us in aqueous humor of the III group patients: at cataracts occurring on the background of pseudoexfoliative glaucoma.

Until present it was considered to be established that the main function of cortisol in the eye tunics was to regulate the intraocular pressure (Jacob E. et al., 1996; Rauz S. et al., 2001). At the same time, due to results obtained, a supposition might be done: the revealed high concen‐


As seen in studies performed by our group a conclusion might be drawn that in organisms of mammals cortisol plays an important role in processes promoting ACAID functioning (Zilfyan

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Moreover, at complicated cataracts (groups II, III and IV), especially at cataracts occurring on the background of the open-angle and pseudoexfoliative glaucoma, we should assign to cortisol an important role in mechanisms infringing the normal course of immunological reactions in tunics and the anterior chamber of an eye ensuring ACAID – in the aspect of

Significant shifts were also observed on the part of prolactin determined in the aqueous humor of patients with complicated cataracts. In particular, in the aqueous humor of patients with complicated cataracts (study groups II, III and VI) relatively high level of prolactin was recorded. In the remaining patients with complicated cataracts (study groups IV, V) indices of prolactin were similar to those determined in aqueous humor of patients with senile cataracts

> **Prolactin content aqueous humor blood serum** *M m p M m p*

abolishing the processes promoting *in situ* active and immunological tolerance.

**I** 0.34 ±0.045 7.0 ±3.6

**II** 1.10 ±0.08 <0.0005 9.5 ±1.6 <0.10 **III** 2.23 ±0.22 <0.0005 9.1 ±2.2 <0.25 **IV** 0.300 ±0.046 *<0.40* 7.50 ±0.57 <0.25 **V** 0.49 ±0.09 <0.10 6.40 ±1.45 <0.40 **VI** 14.05 ±0.07 *p*<0.0005 10.90 ±3.66 <0.25

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

**Table 4.** The content of prolactin (*ng/ml*) in aqueous humor and blood serum of patients with senile and complicated

In the available literature the evidence on the role of prolactin in mechanisms of ACAID

At the same time it is known that the organism of mammals prolactin possesses a profound stimulant action towards the specific subpopulations of lymphocytes and the cells of monocyte and lymphocyte line – in the aspect of synthesizing a number of immunocytokines: tumor necrosis factor alpha,-beta (TNFα,β), interleukins-IL-I, IL-II, IL-VI and γ-interferon. It is known that at senile and complicated cataracts relatively high levels of some pro-and anti-inflamma‐ tory cytokines (TNF, IL-I, IL-II, IL-IV, IL-VI, IL-X) are determined in the aqueous humor (Stambuk N. et al., 1994; Slepova O.S. et al., 1998; Patel J. et al., 2006; Sawada H., et al., 2010).

A., 2009; Zilfyan A.A., Zilfyan A.V., 2013).

(Table 4).

**Study groups (n=40)**

senile cataracts).

formation is lacking.

cataracts.

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 3.** The content of cortisol (*pg/ml*) in blood serum and aqueous humor of patients with senile and *complicated cataracts.*

trations of cortisol in the aqueous humor of patients from study groups II, VI and, especially, from group III might produce alterative (damaging) action towards immunocompetent cells of the anterior chamber of the eye, because the cytotoxic effect of cortisol immunocompetent cells of organs of immunogenesis and blood is considered to be established long ago (Bell P., Munck A., 1973; Carr D., Blalock J. et al., 1989). Moreover, we considered it reasonable to the interpret data obtained on shifts of cortisol content in aqueous humor of patients with cataracts taking into account rather informative evidence on dose-dependent impact of cortisol towards the functional state of lymphocytic populations (Pazirandeh A. et al., 2002). The authors studied the direct hormonal influence of endogenous levels of glucocorticoids to thymocytes and peripheral T-lymphocytic subpopulations in transgenic mice with the altered sensitivity to glucocorticoids. According to mentioned researchers, 2-fold increase of sensitivity to glucocorticoids in the organism of transgenic mice was accompanied with the profound alterative changes in thymocytes followed by a marked increase in number of all T-lympho‐ cytic subpopulations in the cortical layer of thymus.

To our mind, it is not ruled out that in mechanisms of ACAID formation and functioning precisely similar cortisol-dependent mechanism of reactions balanced functioning – simulta‐ neously ensuring processes of proliferation and apoptosis of T-lymphocytic subpopulations in tunics and anterior chamber of an eye – is engaged.

At the same time, we cannot exclude that cortisol high concentrations recorded by us in the aqueous humor of patients from study groups II, III and VI might be the provoking factor in the aspect of an abrupt enhancement of apoptosis processes in the immunocompetent cells of eye tunics and the cells of inflammatory reaction in the anterior chamber of the eye.

As seen in studies performed by our group a conclusion might be drawn that in organisms of mammals cortisol plays an important role in processes promoting ACAID functioning (Zilfyan A., 2009; Zilfyan A.A., Zilfyan A.V., 2013).

Moreover, at complicated cataracts (groups II, III and IV), especially at cataracts occurring on the background of the open-angle and pseudoexfoliative glaucoma, we should assign to cortisol an important role in mechanisms infringing the normal course of immunological reactions in tunics and the anterior chamber of an eye ensuring ACAID – in the aspect of abolishing the processes promoting *in situ* active and immunological tolerance.

Significant shifts were also observed on the part of prolactin determined in the aqueous humor of patients with complicated cataracts. In particular, in the aqueous humor of patients with complicated cataracts (study groups II, III and VI) relatively high level of prolactin was recorded. In the remaining patients with complicated cataracts (study groups IV, V) indices of prolactin were similar to those determined in aqueous humor of patients with senile cataracts (Table 4).


trations of cortisol in the aqueous humor of patients from study groups II, VI and, especially, from group III might produce alterative (damaging) action towards immunocompetent cells of the anterior chamber of the eye, because the cytotoxic effect of cortisol immunocompetent cells of organs of immunogenesis and blood is considered to be established long ago (Bell P., Munck A., 1973; Carr D., Blalock J. et al., 1989). Moreover, we considered it reasonable to the interpret data obtained on shifts of cortisol content in aqueous humor of patients with cataracts taking into account rather informative evidence on dose-dependent impact of cortisol towards the functional state of lymphocytic populations (Pazirandeh A. et al., 2002). The authors studied the direct hormonal influence of endogenous levels of glucocorticoids to thymocytes and peripheral T-lymphocytic subpopulations in transgenic mice with the altered sensitivity to glucocorticoids. According to mentioned researchers, 2-fold increase of sensitivity to glucocorticoids in the organism of transgenic mice was accompanied with the profound alterative changes in thymocytes followed by a marked increase in number of all T-lympho‐

**Table 3.** The content of cortisol (*pg/ml*) in blood serum and aqueous humor of patients with senile and *complicated*

**II** 23.38 ±1.46 <0.0005 64.84 ±7.28 <0.25 **III** 30.4 ±1.56 <0.0005 50.70 ±6.91 <0.25 **IV** 14.10 ±0.61 *<0.1* 115.60 ±16.88 <0.005 **V** 9.70 ±2.69 <0.25 70.50 ±10.41 <0.25 **VI** 14.05 ±0.69 <0.25 68.60 ±8.13 <0.25 Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

**I** 12.90 ± 0.64 56.90 ±4.15

**Cortisol content aqueous humor blood serum** *M m p M m p*

To our mind, it is not ruled out that in mechanisms of ACAID formation and functioning precisely similar cortisol-dependent mechanism of reactions balanced functioning – simulta‐ neously ensuring processes of proliferation and apoptosis of T-lymphocytic subpopulations

At the same time, we cannot exclude that cortisol high concentrations recorded by us in the aqueous humor of patients from study groups II, III and VI might be the provoking factor in the aspect of an abrupt enhancement of apoptosis processes in the immunocompetent cells of

eye tunics and the cells of inflammatory reaction in the anterior chamber of the eye.

cytic subpopulations in the cortical layer of thymus.

**Study groups (n=40)**

550 Ophthalmology - Current Clinical and Research Updates

senile cataracts).

*cataracts.*

in tunics and anterior chamber of an eye – is engaged.

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 4.** The content of prolactin (*ng/ml*) in aqueous humor and blood serum of patients with senile and complicated cataracts.

In the available literature the evidence on the role of prolactin in mechanisms of ACAID formation is lacking.

At the same time it is known that the organism of mammals prolactin possesses a profound stimulant action towards the specific subpopulations of lymphocytes and the cells of monocyte and lymphocyte line – in the aspect of synthesizing a number of immunocytokines: tumor necrosis factor alpha,-beta (TNFα,β), interleukins-IL-I, IL-II, IL-VI and γ-interferon. It is known that at senile and complicated cataracts relatively high levels of some pro-and anti-inflamma‐ tory cytokines (TNF, IL-I, IL-II, IL-IV, IL-VI, IL-X) are determined in the aqueous humor (Stambuk N. et al., 1994; Slepova O.S. et al., 1998; Patel J. et al., 2006; Sawada H., et al., 2010).

In consideration of the existing immune endocrine interrelations of prolactin and proinflam‐ matory cytokines we can suppose that relatively high prolactin concentrations revealed by us in the aqueous humor of study groups II and III patients might be the cause of the enhanced synthesis of proinflammatory cytokines by immonocompetent cells of some eye tunics and cells of lymphocyte-monocyte line localized in the aqueous humor. This is one of the probable prolactin-dependent mechanisms underlying infringement of ACAID function at complicated cataracts.

H. et al., 2010; Wordinger R.J. et al., 2007). The enhanced synthesis of fibronectin in the mentioned eye tunics might bring to activation of fibroplastic processes finally terminating in fibrosis of the eye tunics, including the lens. However, the role of fibronectin in processes of ACAID function formation and abolition is not studied. At the same time it is considered to be established that fibronectin might enhance phagocytosis; on the surface of macrophages there are receptors to fibronectin (Kuznik B. et al., 1989). Therefore, it is not excluded that fibronectin at a number of eye diseases might play a leading role in activation of macrophages of the eye tunics and the anterior chamber of the eye: both in the aspect of phagocytosis and synthesis of pro-inflammatory cytokines: interleukin-I (IL-I) and tumor necrosis factors alpha

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

As demonstrated by our results of the performed immune enzyme assays, in patients of the study group II, i.e. at cataracts occurring on the background of primary open-angle and pseudoexfoliative glaucoma, relatively high indices of fibronectin were revealed in the

> **II** 20.71 ±2.37 <0.005 **III** 33.83 ±5.97 <0.005 **IV** 13.43 ±2.57 *<0.25* **V** 12.76 ±1.14 *<0.25* **VI** 12.04 ±1.12 <0.40

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

**Table 5.** The content of fibronectin (*ng/ml*) in the aqueous humor of patients with senile and complicated cataracts.

The highest indices of the cytokine were recorded by us in the aqueous humor of patients with cataract occurring on the background of pseudoexfoliative glaucoma (as compared to indices

In all other study groups of patients with complicated cataracts low indices of fibronectin were determined in the aqueous humor; these indices were similar to those recorded in the aqueous

Let us consider the role of fibronectin in processes of ACAID function formation and abolition. It is considered to be established that macrophages of eye tunics and aqueous humor play a role of in processes of pro-and anti-inflammatory cytokines synthesis; the balanced synthesis

of mentioned cytokines ensures the normal course of reactions supporting ACAID.

**Fibronectin content** *M m p*

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553

and beta (TNF-α,β) (Slepova O. et al., 1998; Sawada H. et al., 2010).

**I** 11.26 ± 0.099

aqueous humor (Table 5).

senile cataracts).

of the control group).

humor of patients with senile cataracts.

**Study groups (n=40)**

Under conditions of pathology, i.e. at complicated cataracts, in the anterior chamber of the eye there might be also engaged another prolactin-dependent mechanism bringing to ACAID abolition. It is not excluded that prolactin acts as a co-factor participating in activation of *in situ* reaction of humoral immunity through the selective effect to B-cellular populations of eye tunics and the inflammatory exudates of the anterior chamber of the eye. Apparently, under conditions of increased prolactin content in the aqueous humor with precedent baring of antigenic determinants of eye tunics, prolactin in its turn stimulates the antigen-dependent function of B-lymphocyte populations. In favour of the proposed supposition also signify rather informative literary data depicting a direct dose-dependent stimulant effect of prolactin to the B-lymphocyte populations (Berczi I. et al., 1981; McMurray R. et al., 1991; Lahat N. et al., 1993).

On the base of our own findings and comparing them with the available scientific data on the role of prolactin in the immunological processes and its revealment in the anterior chamber of the eyes the following conclusion might be drawn. Prolactin-dependent mechanisms, which, on the one hand, stimulate the local synthesis of proinflammatory cytokines and, on the other hand, activate processes of *in situ* B-lymphocyte populations proliferation and thus worsen the course of an earlier developed autoimmune process in post-barrier tunics and the anterior chamber of the eye, are also engaged in mechanisms of ACAID abolition at complicated cataracts.

## **4. Fibronectin and prostaglandins E2-dependent mechanisms responsible for abolition of reactions promoting the ACAID function**

In our previous studies (Zilfyan A., 2009; 2012) data were presented on the important role of fibronectin and PgE2 produced in the eye tunics regarding the mechanisms of disorders in the drainage function of the trabecular meshwork and the increase of intraocular pressure at complicated cataracts: cataracts occurring on the background of primary open-angle and pseudoexfoliative glaucoma.

At the same time, till present, the role of fibronectin and prostaglandins E2 (PgE2) at senile noncomplicated cataract and complicated cataracts never became the subject of a special investi‐ gation.

Only scarce evidence is available that fibronectin is produced by keratocytes of the cornea, ciliary body and cells of the trabecular meshwork of the eye (Tripathi B., et al., 2004; Hindman H. et al., 2010; Wordinger R.J. et al., 2007). The enhanced synthesis of fibronectin in the mentioned eye tunics might bring to activation of fibroplastic processes finally terminating in fibrosis of the eye tunics, including the lens. However, the role of fibronectin in processes of ACAID function formation and abolition is not studied. At the same time it is considered to be established that fibronectin might enhance phagocytosis; on the surface of macrophages there are receptors to fibronectin (Kuznik B. et al., 1989). Therefore, it is not excluded that fibronectin at a number of eye diseases might play a leading role in activation of macrophages of the eye tunics and the anterior chamber of the eye: both in the aspect of phagocytosis and synthesis of pro-inflammatory cytokines: interleukin-I (IL-I) and tumor necrosis factors alpha and beta (TNF-α,β) (Slepova O. et al., 1998; Sawada H. et al., 2010).

In consideration of the existing immune endocrine interrelations of prolactin and proinflam‐ matory cytokines we can suppose that relatively high prolactin concentrations revealed by us in the aqueous humor of study groups II and III patients might be the cause of the enhanced synthesis of proinflammatory cytokines by immonocompetent cells of some eye tunics and cells of lymphocyte-monocyte line localized in the aqueous humor. This is one of the probable prolactin-dependent mechanisms underlying infringement of ACAID function at complicated

Under conditions of pathology, i.e. at complicated cataracts, in the anterior chamber of the eye there might be also engaged another prolactin-dependent mechanism bringing to ACAID abolition. It is not excluded that prolactin acts as a co-factor participating in activation of *in situ* reaction of humoral immunity through the selective effect to B-cellular populations of eye tunics and the inflammatory exudates of the anterior chamber of the eye. Apparently, under conditions of increased prolactin content in the aqueous humor with precedent baring of antigenic determinants of eye tunics, prolactin in its turn stimulates the antigen-dependent function of B-lymphocyte populations. In favour of the proposed supposition also signify rather informative literary data depicting a direct dose-dependent stimulant effect of prolactin to the B-lymphocyte populations (Berczi I. et al., 1981; McMurray R. et al., 1991; Lahat N. et

On the base of our own findings and comparing them with the available scientific data on the role of prolactin in the immunological processes and its revealment in the anterior chamber of the eyes the following conclusion might be drawn. Prolactin-dependent mechanisms, which, on the one hand, stimulate the local synthesis of proinflammatory cytokines and, on the other hand, activate processes of *in situ* B-lymphocyte populations proliferation and thus worsen the course of an earlier developed autoimmune process in post-barrier tunics and the anterior chamber of the eye, are also engaged in mechanisms of ACAID abolition at complicated

**4. Fibronectin and prostaglandins E2-dependent mechanisms responsible**

In our previous studies (Zilfyan A., 2009; 2012) data were presented on the important role of fibronectin and PgE2 produced in the eye tunics regarding the mechanisms of disorders in the drainage function of the trabecular meshwork and the increase of intraocular pressure at complicated cataracts: cataracts occurring on the background of primary open-angle and

At the same time, till present, the role of fibronectin and prostaglandins E2 (PgE2) at senile noncomplicated cataract and complicated cataracts never became the subject of a special investi‐

Only scarce evidence is available that fibronectin is produced by keratocytes of the cornea, ciliary body and cells of the trabecular meshwork of the eye (Tripathi B., et al., 2004; Hindman

**for abolition of reactions promoting the ACAID function**

cataracts.

552 Ophthalmology - Current Clinical and Research Updates

al., 1993).

cataracts.

gation.

pseudoexfoliative glaucoma.

As demonstrated by our results of the performed immune enzyme assays, in patients of the study group II, i.e. at cataracts occurring on the background of primary open-angle and pseudoexfoliative glaucoma, relatively high indices of fibronectin were revealed in the aqueous humor (Table 5).


Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 5.** The content of fibronectin (*ng/ml*) in the aqueous humor of patients with senile and complicated cataracts.

The highest indices of the cytokine were recorded by us in the aqueous humor of patients with cataract occurring on the background of pseudoexfoliative glaucoma (as compared to indices of the control group).

In all other study groups of patients with complicated cataracts low indices of fibronectin were determined in the aqueous humor; these indices were similar to those recorded in the aqueous humor of patients with senile cataracts.

Let us consider the role of fibronectin in processes of ACAID function formation and abolition. It is considered to be established that macrophages of eye tunics and aqueous humor play a role of in processes of pro-and anti-inflammatory cytokines synthesis; the balanced synthesis of mentioned cytokines ensures the normal course of reactions supporting ACAID.


were recorded in the aqueous humor; these indices were similar to those determined in aqueous humor of the control group patients. The high level of PgE2 at complicated cataracts (study groups II, III, VI) might be considered as a factor bringing to disorder of the eye trabecular meshwork drainage function; moreover that on its cells receptors to PgE2 were revealed. Despite the presence of receptors to PgE2 in different eye tunics, epithelial cells of the lens capsule are the only possible source of PgE2 local synthesis. Therefore, it is not ruled out that in complicated cataracts the lens cells are engaged in an enhanced synthesis of E2 group prostaglandins, which might influence the course and duration of reactions promoting

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555

Our supposition is also grounded by data of scientific publications dealing with the functional activity of PgE2 towards the numerous integrative systems of the organism, including the immune system. In particular, it is considered to be established long ago, that PgE2 inhibit the synthesis of cytotoxic lymphocytes: T-suppressor and T-killer lymphocyte subpopulations. Hence, it is not excluded, that the high level of PgE2 in the aqueous humor of patients with complicated cataracts (study groups II, III and VI) might be considered as a factor producing immunosuppressive action to cytotoxic lymphocytes localized in eye tunics and the aqueous humor; the latter is fraught with abolishing the reactions responsible for *in situ* abolition of

This is the precise reason for formation of "favourable" conditions for *in situ* intensification of autoimmune reactions in the post-surgery period under conditions of infringed integrity of the lens capsule and baring of its antigenic determinants; moreover, at complicated cataracts the immune stimulant mechanisms aimed at activation of T-cytotoxic lymphocytes is infringed

The investigation of E.L. Nelson (1976) also signified to the important role of prostaglandins in induction of local inflammatory processes. According to author, different traumatic injuries of the eye are followed with the enhanced synthesis of E2 and F2α in the iris and other eye tissues, as a result of which the content of mentioned prostaglandins in the aqueous humor is significantly increased. The enhancement of mentioned processes is accompanied with vasodilatation, increased permeability of micro-vessels, and increased protein content in the

Apart from this, the mentioned author proposed a supposition, according to which at trau‐ matic injuries of the eye leucocytes of inflammatory exudates in the aqueous humor might

Furthermore, as considered by the authors, the cascade of molecular and cellular processes at induction of inflammatory process in eye tunics is eventually terminated by the reaction that, to a considerable degree, is conditioned by prostaglandins. On the other hand, the high level of PgE2 in the aqueous humor, to a known extent, reflects *in situ* formation of protectiveadaptive mechanisms – in the aspect of correlation of synthesis processes of specific pro-

It is a common knowledge that prostaglandins of E and F group inhibit the synthesis of IL I in macrophages and leucocytes. Apparently, the similar mechanism is engaged in post-barrier

inflammatory cytokines produced in the post-barrier tunics of the eye as well.

abolition of the ACAID function.

already at the pre-surgery stage.

serve as a source of prostaglandins synthesis.

ACAID function.

aqueous humor.

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to senile cataracts).

**Table 6.** Shifts in content of PgE2 (*pg/ml*) in the aqueous humor of patients with senile and complicated cataracts.

As already mentioned by us earlier, at a number of diseases, including the complicated cataracts, this balance is broken and macrophages begin to produce immunocytokines – primarily of the proinflammatory – character: TNF2 and IL I. Therefore, a role of no less importance should be assigned to macrophages in processes of abolishing reactions respon‐ sible for ACAID function.

At the same time, it is considered to be established that fibronectin has an ability to activate the cytokine function of macrophages. Hence, it is not excluded that at complicated cataracts fibronectin-dependent mechanisms are engaged in mechanisms of ACAID functions infringe‐ ment; specified mechanisms are realized at the level of the regional monocyte-macrophageal system.

In our further research the shifts in PgE2content in the aqueous humor of patients with senile and complicated cataracts were studied. There is only rather scarce literature on synthesis of prostaglandins in eye tunics. The local synthesis of prostaglandins was revealed only in epithelial cells of the lens capsule and was proved by experiments of O. Nishi and co-workers (1982), who performed model *in vitro* tests; in case of cataract surgery the isolated lens was placed in the incubation medium. Alongside with incubation time increase the content of prostaglandins in the incubation medium markedly increased. At the same time, in some eye tunics – the ciliary body, retina, sclera and trabecular meshwork of the anterior chamber angle receptors to PgE2 were identified (Toris C. et al., 2008). The role of PgE2 in maintaining the drainage function is widely discussed (Podos S. et al., 1972).

However, the role of PgE2 in mechanisms of ACAID formation and infringement is almost not investigated. As shown by results of our own studies, the level of PgE2 in aqueous humor of patients from study groups II, III and VI markedly increased as compared to the level of PgE2 in the aqueous humor of the control group patients (Table 6).

The highest values were observed in aqueous humor of patients with cataract on the back‐ ground of pseudoexfoliative glaucoma. In all other groups of complicated cataracts low indices were recorded in the aqueous humor; these indices were similar to those determined in aqueous humor of the control group patients. The high level of PgE2 at complicated cataracts (study groups II, III, VI) might be considered as a factor bringing to disorder of the eye trabecular meshwork drainage function; moreover that on its cells receptors to PgE2 were revealed. Despite the presence of receptors to PgE2 in different eye tunics, epithelial cells of the lens capsule are the only possible source of PgE2 local synthesis. Therefore, it is not ruled out that in complicated cataracts the lens cells are engaged in an enhanced synthesis of E2 group prostaglandins, which might influence the course and duration of reactions promoting abolition of the ACAID function.

Our supposition is also grounded by data of scientific publications dealing with the functional activity of PgE2 towards the numerous integrative systems of the organism, including the immune system. In particular, it is considered to be established long ago, that PgE2 inhibit the synthesis of cytotoxic lymphocytes: T-suppressor and T-killer lymphocyte subpopulations. Hence, it is not excluded, that the high level of PgE2 in the aqueous humor of patients with complicated cataracts (study groups II, III and VI) might be considered as a factor producing immunosuppressive action to cytotoxic lymphocytes localized in eye tunics and the aqueous humor; the latter is fraught with abolishing the reactions responsible for *in situ* abolition of ACAID function.

As already mentioned by us earlier, at a number of diseases, including the complicated cataracts, this balance is broken and macrophages begin to produce immunocytokines – primarily of the proinflammatory – character: TNF2 and IL I. Therefore, a role of no less importance should be assigned to macrophages in processes of abolishing reactions respon‐

**Table 6.** Shifts in content of PgE2 (*pg/ml*) in the aqueous humor of patients with senile and complicated cataracts.

Notes: *M* – mean; *m* – standard error of mean; *p* – confidence interval (indices of complicated cataracts as related to

**II** 66.11 ±7.40 <0.01 **III** 76.64 ±7.78 <0.005 **IV** 48.03 ±3.02 *<0.25* **V** 49.60 ±6.37 *<0.25* **VI** 58.96 ±2.81 <0.25

**I** 43.05 ± 4.13

**Prostaglandins E2 content** *M m p*

At the same time, it is considered to be established that fibronectin has an ability to activate the cytokine function of macrophages. Hence, it is not excluded that at complicated cataracts fibronectin-dependent mechanisms are engaged in mechanisms of ACAID functions infringe‐ ment; specified mechanisms are realized at the level of the regional monocyte-macrophageal

In our further research the shifts in PgE2content in the aqueous humor of patients with senile and complicated cataracts were studied. There is only rather scarce literature on synthesis of prostaglandins in eye tunics. The local synthesis of prostaglandins was revealed only in epithelial cells of the lens capsule and was proved by experiments of O. Nishi and co-workers (1982), who performed model *in vitro* tests; in case of cataract surgery the isolated lens was placed in the incubation medium. Alongside with incubation time increase the content of prostaglandins in the incubation medium markedly increased. At the same time, in some eye tunics – the ciliary body, retina, sclera and trabecular meshwork of the anterior chamber angle receptors to PgE2 were identified (Toris C. et al., 2008). The role of PgE2 in maintaining the

However, the role of PgE2 in mechanisms of ACAID formation and infringement is almost not investigated. As shown by results of our own studies, the level of PgE2 in aqueous humor of patients from study groups II, III and VI markedly increased as compared to the level of

The highest values were observed in aqueous humor of patients with cataract on the back‐ ground of pseudoexfoliative glaucoma. In all other groups of complicated cataracts low indices

drainage function is widely discussed (Podos S. et al., 1972).

PgE2 in the aqueous humor of the control group patients (Table 6).

sible for ACAID function.

**Study groups (n=40)**

554 Ophthalmology - Current Clinical and Research Updates

system.

senile cataracts).

This is the precise reason for formation of "favourable" conditions for *in situ* intensification of autoimmune reactions in the post-surgery period under conditions of infringed integrity of the lens capsule and baring of its antigenic determinants; moreover, at complicated cataracts the immune stimulant mechanisms aimed at activation of T-cytotoxic lymphocytes is infringed already at the pre-surgery stage.

The investigation of E.L. Nelson (1976) also signified to the important role of prostaglandins in induction of local inflammatory processes. According to author, different traumatic injuries of the eye are followed with the enhanced synthesis of E2 and F2α in the iris and other eye tissues, as a result of which the content of mentioned prostaglandins in the aqueous humor is significantly increased. The enhancement of mentioned processes is accompanied with vasodilatation, increased permeability of micro-vessels, and increased protein content in the aqueous humor.

Apart from this, the mentioned author proposed a supposition, according to which at trau‐ matic injuries of the eye leucocytes of inflammatory exudates in the aqueous humor might serve as a source of prostaglandins synthesis.

Furthermore, as considered by the authors, the cascade of molecular and cellular processes at induction of inflammatory process in eye tunics is eventually terminated by the reaction that, to a considerable degree, is conditioned by prostaglandins. On the other hand, the high level of PgE2 in the aqueous humor, to a known extent, reflects *in situ* formation of protectiveadaptive mechanisms – in the aspect of correlation of synthesis processes of specific proinflammatory cytokines produced in the post-barrier tunics of the eye as well.

It is a common knowledge that prostaglandins of E and F group inhibit the synthesis of IL I in macrophages and leucocytes. Apparently, the similar mechanism is engaged in post-barrier eye tunics both at norm and in case of some eye diseases. The following fact signifies in favour of the latter circumstance: at endotoxin-induced experimental uveitis in rabbit despite the expressed inflammatory reaction in post-barrier eye tunics the level of IL-I in the aqueous humor did not increase (Kulkarni P.S., 1991). It is not excluded that PgE2 serve as a factor preventing the increase of IL-I and IL-II production in immunocompetent cells.

of mentioned hormones and PgE2 are conditioned by their "non-arrival" from the periphery (as a result of increase in hematoophthalmic barrier permeability), or most likely, as a result

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

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557

According to the proposed concept, relatively high concentrations of the above-mentioned biologically active compounds might act as endogenous factors activating *in situ* reactions of humoral immunity, because their selective influence towards the immune competent cells Thelpers and B-cellular populations is considered to be established (Goodwin J., Ceuppens J.,

Thus, in cases of complicated cataracts we revealed earlier unknown mediatory mechanisms engaged in launching the humoral immunity reactions, which apart the surgery-related trauma produce rather unfavourable impacts to the course of the regional pathological process. In the light of data thus obtained, the role of TGFβ-2 in glaucomatous pathogenesis should be considered from the alternative standpoint. In particular, TGFβ-2 produced in the cornea and the ciliary body stimulates *in situ* synthesis of insulin-like growth factor-1 (IGF-1) and fibronectin, i.e. precisely those cytokines the excessive concentrations of which are considered as *provoking* factors hindering the normal outflow of the aqueous humor; this latter is fraught

Our previous studies also signify to the existence / presence of the similar TGFβ-2-dependent mechanism (Zilfyan A., 2013); it was demonstrated that at complicated cataracts on the background of glaucoma and pseudoexfoliative syndrome high concentrations of fibronectin and IGF-1 are determined in the aqueous humor (compared to those recorded in the aqueous

Hence, the role of TGFβ-2 in pathogenesis of cataracts and glaucomas is far from being unam‐ biguous. In particular, on the one hand, in senile non-complicated cataract TGFβ-2 modulates in the eye tunics processes of active immune tolerance aimed at prevention of autoimmune aggression against the antigenic determinants of the lens; on the other hand,-the same cytokine produced a rather unfavourable impact to the course and duration of glaucomas through its direct and/or indirect impact to the processes of fibronectin and IGF-1 enhanced synthesis in the trabecular meshwork of the eye. The excessive accumulation of both cytokines brings to impaired function of the eye anterior chamber trabecular meshwork, thus eventually accom‐

On the basis of studies performed, within the entire context of available published data, from the qualitatively new positions we should consider the established, earlier unknown, TGFβ-2 independent hormonal mediatory mechanisms underlying the abolition of reactions respon‐ sible for ACAID formation and the increase of intraocular pressure at complicated cataracts.

Currently existing term "immune privilege of an eye" is mostly associated with evolutionary secured mechanisms, which ensure the regional immune homeostasis in eye tunics and in the

of the enhanced synthesis in the eye tunics.

1983; McMurray R. et al., 1991; Lahat N. et al., 1993;).

with the increase of aqueous humor in glaucoma.

panied by the increase of intraocular pressure.

**6. Conclusion**

humor of patients with senile non-complicated cataract).

## **5. The role of transforming growth factor in pathogenesis of cataracts and glaucomas**

Nowadays rather informative evidence is available on the role of TGFβ-2 in the mechanisms of immunological tolerance activation at senile and complicated cataracts. High regional immunological tolerance in eye tunics is ensured through the enhanced TGFβ-2 synthesis by the cells of eye tunics: ciliary body, cornea, and retina (Stefan C. et al., 2008; Dawes L. et al., 2009; Hindman H. et al., 2010; Pattabiraman P., Rao P., 2010).

It is established that the active immunological tolerance at senile non-complicated cataracts is targeted at activation of T-helper and T-suppressor subpopulations in immune competent cells of the eye; these latter play an important role in prevention of autoimmune reactions aimed to produce antibodies against the lens tissues (Streilein J. et al., 1992; Wilbanks G. et al., 1992).

In the most relief mode the entire cascade of immunological shifts is presented in the aqueous humor of patients with senile and complicated cataracts, as a result of which currently the aqueous humor is considered as a rather informative bio-object characterizing the course of immunological reactions responsible for anterior chamber associated immune deviation (ACAID) formation.

In the specified aspect there are rather informative scientific publications, according to which at senile non-complicated cataracts during the post-surgery period is engaged the similar TGFβ-2-dependent mechanism that underlies the suppresson of local humoral immunity reactions through *in situ* activation of cytotoxic lymphocytes (Fleenor D. et al., 2006; Streilein J. et al., 1992).

At the same time our own investigation (Zilfyan A., 2009) allowed establishing that unlike senile non-complicated cataracts occurring on the background of glaucoma and pseudoexfo‐ liative syndrome already in the pre-surgery period in eye tunics there originated immunopa‐ thological disorders manifested as activation of reactions responsible for antibody formation (high level of CD4 and IgG in the aqueous humor – on the background of a marked decrease in CD8 level).

Data obtained signify in favour of the fact, according to which TGFβ-2-dependent mechanism engaged in ACAID formation is actually not the single one at complicated cataracts (Zilfyan A.A., Zilfyan A.V., 2013).

Thus, our studies revealed that at complicated cataracts in the aqueous humor there is a marked increase of cortisol, prolactin and PgE2 (Zilfyan A., 2009; 2012). Moreover, high concentrations of mentioned hormones and PgE2 are conditioned by their "non-arrival" from the periphery (as a result of increase in hematoophthalmic barrier permeability), or most likely, as a result of the enhanced synthesis in the eye tunics.

According to the proposed concept, relatively high concentrations of the above-mentioned biologically active compounds might act as endogenous factors activating *in situ* reactions of humoral immunity, because their selective influence towards the immune competent cells Thelpers and B-cellular populations is considered to be established (Goodwin J., Ceuppens J., 1983; McMurray R. et al., 1991; Lahat N. et al., 1993;).

Thus, in cases of complicated cataracts we revealed earlier unknown mediatory mechanisms engaged in launching the humoral immunity reactions, which apart the surgery-related trauma produce rather unfavourable impacts to the course of the regional pathological process.

In the light of data thus obtained, the role of TGFβ-2 in glaucomatous pathogenesis should be considered from the alternative standpoint. In particular, TGFβ-2 produced in the cornea and the ciliary body stimulates *in situ* synthesis of insulin-like growth factor-1 (IGF-1) and fibronectin, i.e. precisely those cytokines the excessive concentrations of which are considered as *provoking* factors hindering the normal outflow of the aqueous humor; this latter is fraught with the increase of aqueous humor in glaucoma.

Our previous studies also signify to the existence / presence of the similar TGFβ-2-dependent mechanism (Zilfyan A., 2013); it was demonstrated that at complicated cataracts on the background of glaucoma and pseudoexfoliative syndrome high concentrations of fibronectin and IGF-1 are determined in the aqueous humor (compared to those recorded in the aqueous humor of patients with senile non-complicated cataract).

Hence, the role of TGFβ-2 in pathogenesis of cataracts and glaucomas is far from being unam‐ biguous. In particular, on the one hand, in senile non-complicated cataract TGFβ-2 modulates in the eye tunics processes of active immune tolerance aimed at prevention of autoimmune aggression against the antigenic determinants of the lens; on the other hand,-the same cytokine produced a rather unfavourable impact to the course and duration of glaucomas through its direct and/or indirect impact to the processes of fibronectin and IGF-1 enhanced synthesis in the trabecular meshwork of the eye. The excessive accumulation of both cytokines brings to impaired function of the eye anterior chamber trabecular meshwork, thus eventually accom‐ panied by the increase of intraocular pressure.

On the basis of studies performed, within the entire context of available published data, from the qualitatively new positions we should consider the established, earlier unknown, TGFβ-2 independent hormonal mediatory mechanisms underlying the abolition of reactions respon‐ sible for ACAID formation and the increase of intraocular pressure at complicated cataracts.

### **6. Conclusion**

eye tunics both at norm and in case of some eye diseases. The following fact signifies in favour of the latter circumstance: at endotoxin-induced experimental uveitis in rabbit despite the expressed inflammatory reaction in post-barrier eye tunics the level of IL-I in the aqueous humor did not increase (Kulkarni P.S., 1991). It is not excluded that PgE2 serve as a factor

**5. The role of transforming growth factor in pathogenesis of cataracts and**

Nowadays rather informative evidence is available on the role of TGFβ-2 in the mechanisms of immunological tolerance activation at senile and complicated cataracts. High regional immunological tolerance in eye tunics is ensured through the enhanced TGFβ-2 synthesis by the cells of eye tunics: ciliary body, cornea, and retina (Stefan C. et al., 2008; Dawes L. et al.,

It is established that the active immunological tolerance at senile non-complicated cataracts is targeted at activation of T-helper and T-suppressor subpopulations in immune competent cells of the eye; these latter play an important role in prevention of autoimmune reactions aimed to produce antibodies against the lens tissues (Streilein J. et al., 1992; Wilbanks G. et al., 1992). In the most relief mode the entire cascade of immunological shifts is presented in the aqueous humor of patients with senile and complicated cataracts, as a result of which currently the aqueous humor is considered as a rather informative bio-object characterizing the course of immunological reactions responsible for anterior chamber associated immune deviation

In the specified aspect there are rather informative scientific publications, according to which at senile non-complicated cataracts during the post-surgery period is engaged the similar TGFβ-2-dependent mechanism that underlies the suppresson of local humoral immunity reactions through *in situ* activation of cytotoxic lymphocytes (Fleenor D. et al., 2006; Streilein

At the same time our own investigation (Zilfyan A., 2009) allowed establishing that unlike senile non-complicated cataracts occurring on the background of glaucoma and pseudoexfo‐ liative syndrome already in the pre-surgery period in eye tunics there originated immunopa‐ thological disorders manifested as activation of reactions responsible for antibody formation (high level of CD4 and IgG in the aqueous humor – on the background of a marked decrease

Data obtained signify in favour of the fact, according to which TGFβ-2-dependent mechanism engaged in ACAID formation is actually not the single one at complicated cataracts (Zilfyan

Thus, our studies revealed that at complicated cataracts in the aqueous humor there is a marked increase of cortisol, prolactin and PgE2 (Zilfyan A., 2009; 2012). Moreover, high concentrations

preventing the increase of IL-I and IL-II production in immunocompetent cells.

2009; Hindman H. et al., 2010; Pattabiraman P., Rao P., 2010).

**glaucomas**

556 Ophthalmology - Current Clinical and Research Updates

(ACAID) formation.

J. et al., 1992).

in CD8 level).

A.A., Zilfyan A.V., 2013).

Currently existing term "immune privilege of an eye" is mostly associated with evolutionary secured mechanisms, which ensure the regional immune homeostasis in eye tunics and in the eye liquid media both at norm and pathology. In particular, at cataracts in some eye tunics there are engaged mechanisms promoting the "active immunological tolerance" that is selectively targeted against the "bared" (revealed) antigenic determinants of the lens tissues. In modern ophthalmology the symptom complex of immune reactions occurring in eye tunics is defined as "anterior chamber associated immune deviation – ACAID".

Hence, it is considered to be proved that at senile non-complicated cataracts in the post-surgery period there are *in situ* activated immune processes, which manifest as activation of cytotoxic lymphocytes (T-suppressors and T-killers) due to which the "active immunological tolerance" is formed averting the processes of autoimmune aggression against the bared antigenic tissues of the lens.

Based on the evidence of available modern literature and our own research findings new earlier unknown hormonal mediatory mechanisms appear to the proscenium of the stage; those mechanisms at complicated cataracts are responsible for abolition of reactions promoting the ACAID function.

Thereupon, from qualitatively new positions should be considered the role of cortisol, prolactin fibronectin, TGFβ-2 and PgE2, which are produced in specific eye tunics, in mecha‐ nisms of *in situ* realization of the immune reactions responsible for ACAID formation and abolition. It should be emphasized that all the above-mentioned biologically active substances in case of complicated cataracts (cataracts on the background of anterior open-angle glaucoma and pseudoexfoliative glaucoma) act as "provoking" factors, which take an active part in both impairment of the eye trabecular meshwork drainage function and the increase of intraocular pressure.

As a result of the targeted stimulation of T-suppressor and T-killer subpopulations there occurs an active immunological tolerance (AIT) against the bared antigenic determinants of lens tissues, in particular through inhibition of activity in T-helper subpopulation of lymphocytes. The second mechanism is associated with *in situ* activation of the main histocompatibility

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

http://dx.doi.org/10.5772/58229

559

The third mechanism is associated with *in situ* inactivation of the complement (C); therefore,

As a result, one of the possible mechanisms of autoaggression is excluded through deposition of the immune complexes on the lens tissues followed by their subsequent impairment.

According to the bulk of scientific data, similar mechanism is engaged in the post-surgery

From the result of our investigations we do not exclude that ACAID function is also engaged in cataracts occurring on the background of diabetes mellitus and arterial hypertension, because in both cases the recovery process was without complications, even without the aseptic

Thus performed, our studies allowed establishing that at specific types of complicated cataracts (cataract on the background of primary open-angle and pseudoexfoliative glaucoma) regional immune mechanisms responsible for ACAID function were impaired (Scheme 2).

Thus, in both cases after the performed phacoemulsification of cataract (PhEC) and baring of antigenic determinants of the lens tissues (BADLT) the aqueous humor levels of cortisol (Cor)

complex class 1 (MHC-1) with the subsequent activation of T-killer subpopulations.

**Scheme 1.** Regional immune andmediatory mechanisms responsible for ACAID function.

the formation of immune complexes (IC) does not occur.

period at senile non-complicated cataracts.

autoimmune iridocyclitis.

At the same time, in complicated cataracts the specified factors might take an active part in abolishing the reactions providing the "active immunological tolerance" through *in situ* activity of cytotoxic lymphocytes and activation of autoimmune processes targeted against the antigenic determinants of the eye tissues and tunics.

Based on the analysis of the available literature and the presented own studies we consider it purposeful to present to the attention of the readers the main regional immune and hormonalmediatory mechanisms responsible for ACAID formation and abolition in senile and compli‐ cated cataracts also depicting them in detail as summary Schemes 1 and 2.

Immune and hormonal-mediatory factors engaged in ACAID formation at non-complicated cataracts are presented as Scheme 1.

During the surgery intervention for phacoemulsification of cataract (PhEC) there occurs baring of antigenic determinants of the lens tissues (BADLT). According to available evidence of scientific publications, 3 mechanisms are engaged in ACAID formation.

The first mechanism is associated with the activation of TGFβ-2 synthesis in the eye cornea, ciliary body and retina as a result of which there occurs stimulation of cytotoxic lymphocytes (T-ct).

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"… http://dx.doi.org/10.5772/58229 559

**Scheme 1.** Regional immune andmediatory mechanisms responsible for ACAID function.

eye liquid media both at norm and pathology. In particular, at cataracts in some eye tunics there are engaged mechanisms promoting the "active immunological tolerance" that is selectively targeted against the "bared" (revealed) antigenic determinants of the lens tissues. In modern ophthalmology the symptom complex of immune reactions occurring in eye tunics

Hence, it is considered to be proved that at senile non-complicated cataracts in the post-surgery period there are *in situ* activated immune processes, which manifest as activation of cytotoxic lymphocytes (T-suppressors and T-killers) due to which the "active immunological tolerance" is formed averting the processes of autoimmune aggression against the bared antigenic tissues

Based on the evidence of available modern literature and our own research findings new earlier unknown hormonal mediatory mechanisms appear to the proscenium of the stage; those mechanisms at complicated cataracts are responsible for abolition of reactions promoting the

Thereupon, from qualitatively new positions should be considered the role of cortisol, prolactin fibronectin, TGFβ-2 and PgE2, which are produced in specific eye tunics, in mecha‐ nisms of *in situ* realization of the immune reactions responsible for ACAID formation and abolition. It should be emphasized that all the above-mentioned biologically active substances in case of complicated cataracts (cataracts on the background of anterior open-angle glaucoma and pseudoexfoliative glaucoma) act as "provoking" factors, which take an active part in both impairment of the eye trabecular meshwork drainage function and the increase of intraocular

At the same time, in complicated cataracts the specified factors might take an active part in abolishing the reactions providing the "active immunological tolerance" through *in situ* activity of cytotoxic lymphocytes and activation of autoimmune processes targeted against the

Based on the analysis of the available literature and the presented own studies we consider it purposeful to present to the attention of the readers the main regional immune and hormonalmediatory mechanisms responsible for ACAID formation and abolition in senile and compli‐

Immune and hormonal-mediatory factors engaged in ACAID formation at non-complicated

During the surgery intervention for phacoemulsification of cataract (PhEC) there occurs baring of antigenic determinants of the lens tissues (BADLT). According to available evidence of

The first mechanism is associated with the activation of TGFβ-2 synthesis in the eye cornea, ciliary body and retina as a result of which there occurs stimulation of cytotoxic lymphocytes

cated cataracts also depicting them in detail as summary Schemes 1 and 2.

scientific publications, 3 mechanisms are engaged in ACAID formation.

antigenic determinants of the eye tissues and tunics.

cataracts are presented as Scheme 1.

is defined as "anterior chamber associated immune deviation – ACAID".

of the lens.

pressure.

(T-ct).

ACAID function.

558 Ophthalmology - Current Clinical and Research Updates

As a result of the targeted stimulation of T-suppressor and T-killer subpopulations there occurs an active immunological tolerance (AIT) against the bared antigenic determinants of lens tissues, in particular through inhibition of activity in T-helper subpopulation of lymphocytes.

The second mechanism is associated with *in situ* activation of the main histocompatibility complex class 1 (MHC-1) with the subsequent activation of T-killer subpopulations.

The third mechanism is associated with *in situ* inactivation of the complement (C); therefore, the formation of immune complexes (IC) does not occur.

As a result, one of the possible mechanisms of autoaggression is excluded through deposition of the immune complexes on the lens tissues followed by their subsequent impairment.

According to the bulk of scientific data, similar mechanism is engaged in the post-surgery period at senile non-complicated cataracts.

From the result of our investigations we do not exclude that ACAID function is also engaged in cataracts occurring on the background of diabetes mellitus and arterial hypertension, because in both cases the recovery process was without complications, even without the aseptic autoimmune iridocyclitis.

Thus performed, our studies allowed establishing that at specific types of complicated cataracts (cataract on the background of primary open-angle and pseudoexfoliative glaucoma) regional immune mechanisms responsible for ACAID function were impaired (Scheme 2).

Thus, in both cases after the performed phacoemulsification of cataract (PhEC) and baring of antigenic determinants of the lens tissues (BADLT) the aqueous humor levels of cortisol (Cor)

**Author details**

Artashes A. Zilfyan1

**References**

and Arto V. Zilfyan2\*

1 Scientific-Research Center, Yerevan State Medical University, Yerevan, Armenia

Regional Immune, Hormonal and Mediatory Mechanisms Responsible for Function of "Immune Privilege of an Eye"…

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561

[1] Abrahamian A., Xi M., Donnelly J., Rockey J. Effect of interferon-gamma on the ex‐ pression of transforming growth factor-beta by human corneal fibroblasts: role in

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[3] Bell P., Munck A. Steroid-binding properties and stabilization of cytoplasmic gluco‐

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\*Address all correspondence to: namj@ysmu.am

2 "Shengаvit" Medical Center, Yerevan, Armenia

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**Scheme 2.** Regional immune and hormonal mediatory mechanisms responsible for abolishing the ACAID function at complicated cataracts.

and PgE2 increased. Both factors had unidirectional cytotoxic action towards the specific lymphocytic subpopulations – T-suppressors and T-killers (T-s, T-k). Hence, there occurred the abolition of the immunosuppressive action of those latter to the T-helper subpopulation of lymphocytes (T-h). Against this background we recorded high concentrations of prolactin (PRL) and fibronectin (FN) in the aqueous humor. The FN high level was conditioned by the stimulant influence of transforming growth factor beta-2 (TGFβ-2) towards the eye cornea cells and the trabecular meshwork. Both factors, prolactin (PRL) and fibronectin (FN), activate Thelper subpopulation of lymphocytes (T-h). As a result of surgery-related impairment of the lens tissues on the background of cytotoxic lymphocytes-abolished suppression there occurs stimulation of T-helper subpopulation that is fraught with formation of autoantibodies (AA) against the impaired tissues of lens followed with their autoimmunoaggrression towards both impaired and "structurally" preserved tissues of lens.

As a rule, such a complication as aseptic autoimmune iridocyclitis developed in the specified contingent of patients during the post-surgery period.

Undoubtedly, the presented Schemes 1 and 2 are not ultimate; moreover, they are not com‐ prehensive. These Schemes should be supplemented (enriched) with new evidence on the role of earlier unknown biologically active substances of immune, hormonal, mediatory genesis, which are produced in eye tunics, in formation of in situ reactions responsible for formation and abolition of the ACAID function.

### **Author details**

Artashes A. Zilfyan1 and Arto V. Zilfyan2\*


### **References**

and PgE2 increased. Both factors had unidirectional cytotoxic action towards the specific lymphocytic subpopulations – T-suppressors and T-killers (T-s, T-k). Hence, there occurred the abolition of the immunosuppressive action of those latter to the T-helper subpopulation of lymphocytes (T-h). Against this background we recorded high concentrations of prolactin (PRL) and fibronectin (FN) in the aqueous humor. The FN high level was conditioned by the stimulant influence of transforming growth factor beta-2 (TGFβ-2) towards the eye cornea cells and the trabecular meshwork. Both factors, prolactin (PRL) and fibronectin (FN), activate Thelper subpopulation of lymphocytes (T-h). As a result of surgery-related impairment of the lens tissues on the background of cytotoxic lymphocytes-abolished suppression there occurs stimulation of T-helper subpopulation that is fraught with formation of autoantibodies (AA) against the impaired tissues of lens followed with their autoimmunoaggrression towards both

**Scheme 2.** Regional immune and hormonal mediatory mechanisms responsible for abolishing the ACAID function at

As a rule, such a complication as aseptic autoimmune iridocyclitis developed in the specified

Undoubtedly, the presented Schemes 1 and 2 are not ultimate; moreover, they are not com‐ prehensive. These Schemes should be supplemented (enriched) with new evidence on the role of earlier unknown biologically active substances of immune, hormonal, mediatory genesis, which are produced in eye tunics, in formation of in situ reactions responsible for formation

impaired and "structurally" preserved tissues of lens.

contingent of patients during the post-surgery period.

and abolition of the ACAID function.

complicated cataracts.

560 Ophthalmology - Current Clinical and Research Updates


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[36] Pleyer U., Gupta D., Weidle E., Lisch W., Zierhut M., Thiel H. Elevated prolactin lev‐ els in human aqueous humor of patients with anterior uveitis. Graefes. Arch. Clin. Exp. Ophthalmol. 1991; 229(5): 447-451.

[48] Streilein J., Stein-Streilein J. Does innate immune privilege exist? J. Leukoc. Biol. 2000;

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[49] Streilein J., Wilbanks G., Taylor A., Cousins S. Eye-derived cytokines and the immu‐ nosuppressive intraocular microenvironment: a review. Curr. Eye Res. 1992:

[50] Toris C.B., Gabelt B.T., Kaufman P.L. Update on the mechanism of action of topical prostaglandins for intraocular pressure reduction. Surv. Ophthalmol. 2008; 53:

[51] Tripathi B.J., Tripathi R.C., Chen J., Gotsis S., Li J. Trabecular cell expression of fibro‐ nectin and MMP-3 is modulated by aqueous humor growth factors. Exp. Eye Res.

[52] Uenoyama K., Kanagawa R., Tamura M., Matoba M., Enomoto Y., Ohmi S. Experi‐ mental intraocular lens implantation in the rabbit eye and in the mouse peritoneal space. Part IV: Cell adhesion, fibroblast-like cell, and lymphocytic cluster observed

[53] Visser J. Sparing interleukin-10 receptor expression by glucocorticoids is a prerequi‐ site for the synergistic immunosuppressive effects of interleukin-10 and glucocorti‐

[54] Wilbanks G., Mammolenti M., Streilein J. Studies on the induction of anterior cham‐ ber-associated immune deviation (ACAID). III. Induction of ACAID depends upon intraocular transforming growth factor-beta. Eur. J. Immunol. 1992; 22(1): 165-173.

[55] Wilbanks G., Streilein J. Characterization of suppressor cells in anterior chamber-as‐ sociated immune deviation (ACAID) induced by soluble antigen. Evidence of two functionally and phenotypically distinct T-suppressor cell populations. Immunol.

[56] Wordinger R.J., Fleenor D.L., Hellberg P.E., Pang I.H., Tovar T.O., Zode G.S., Fuller J.A., Clark A.F. Effects of TGF-beta2, BMP-4, and gremlin in the trabecular mesh‐ work: implications for glaucoma. Invest. Ophthalmol. Vis. Sci. 2007 Mar; 48(3):

[57] Yarilin A., Belyakov I. [Thymus as an organ of endocrine system][Article in Russian].

[58] Zhou Z., He S., Liang Y. An experimental study of pathomorphology in the iris and ciliary body after intraocular lens implantation. Zhonghua Yan Ke Za Zhi. 1996;

[59] Zilfyan A.A. Modern Aspects of Glaucoma Pathogenesis Local Factors for Develop‐ ment of Primary Open-Angle Glaucoma Associated with Impairment of Secretory Functions of the Eye Membranes. Chapter 5 in: "Glaucoma ‒ Basic and Clinical As‐

pects". Edited by Shimon Rumelt. INTECH. Croatia. 2013. P. 75-102.

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[36] Pleyer U., Gupta D., Weidle E., Lisch W., Zierhut M., Thiel H. Elevated prolactin lev‐ els in human aqueous humor of patients with anterior uveitis. Graefes. Arch. Clin.

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**Chapter 23**

**Paranasal Sinus Mucoceles – Opthalmic Manifestations,**

Langeback first described paranasal sinus mucoceles in 1820. It was only in the early 1900s that mucoceles were given their name by Rollet and popularized by Gerber, who published 178 cases. In 1995, Lambert attributed frontal or ethmoid mucoceles as the most common nasal

A mucocele is an epithelial-lined mucus containing sac that fills a paranasal sinus and is able to expand by alternative bone resorption and bone formation. A mucocele occurs when a sinus ostium or a compartment of a septated sinus becomes obstructed, thus causing the sinus cavity to become filled with mucus or to become airless. Paranasal sinus mucoceles may result from inflammation, tumor, trauma or surgical manipulation [2].Because of the anatomic proximity of the orbit, the pathologic process of paranasal sinus mucocele will easily affect the orbit [3,4]. Anatomically, the frontal, ethmoid, sphenoid and maxillary sinuses all interface with the orbit. The maxillary sinus shares the floor of the orbit, the frontal sinus is part of the orbital roof, the ethmoid extends along most of the medial wall of orbit and the sphenoid almost completely surrounds the orbital apex [3, 4]. Thus, mucoceles of the paranasal sinuses can easily affect the orbit and cause ophthalmic symptoms such as proptosis, blurred vision and displacement of globe [4,5]. Patients with paranasal mucoceles with orbital symptoms are often seen by the ophthalmologist first and then referred to otorhinolaryngologist [5].Occasionally they can

It is essential to differentiate a mucocele from a mucus retention cyst. A mucus retention cyst is just a fluid filled sac along the sinus lining which does not expand and push into the eye socket, nose or brain and does not cause problems in the vast majority of cases. Notably, mucus

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Radiological Imaging, Endoscopic Endonasal**

**Marsupilization and Outcome**

Additional information is available at the end of the chapter

Balwant Singh Gendeh

http://dx.doi.org/10.5772/58331

condition to produce proptosis [1]

present with intracranial complications.

**1. Introduction**


## **Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic Endonasal Marsupilization and Outcome**

Balwant Singh Gendeh

[60] Zilfyan A.A. Shifts in content of fibronectin, insulin-like growth factor-1 and E2 pros‐ taglandins in aqueous humor in case of senile and complicated cataracts. The New

[61] Zilfyan A.A. The role of cortisol, prolactin, CD4 and CD8 in induction of anterior chamber associated immune deviation (ACAID) in case of cataracts. The New Arme‐

[62] Zilfyan A.A., Zilfyan A.V. Hormonal-Mediatory Mechanisms in the Process of Ante‐ rior Chamber Associated Immune Deviation. The New Armenian Medical Journal.

Armenian Medical Journal. 2012; 6(3): 34-41.

nian Medical Journal. 2009; 3(1): 59-67.

2013; 7(3): 85-88.

566 Ophthalmology - Current Clinical and Research Updates

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/58331

### **1. Introduction**

Langeback first described paranasal sinus mucoceles in 1820. It was only in the early 1900s that mucoceles were given their name by Rollet and popularized by Gerber, who published 178 cases. In 1995, Lambert attributed frontal or ethmoid mucoceles as the most common nasal condition to produce proptosis [1]

A mucocele is an epithelial-lined mucus containing sac that fills a paranasal sinus and is able to expand by alternative bone resorption and bone formation. A mucocele occurs when a sinus ostium or a compartment of a septated sinus becomes obstructed, thus causing the sinus cavity to become filled with mucus or to become airless. Paranasal sinus mucoceles may result from inflammation, tumor, trauma or surgical manipulation [2].Because of the anatomic proximity of the orbit, the pathologic process of paranasal sinus mucocele will easily affect the orbit [3,4]. Anatomically, the frontal, ethmoid, sphenoid and maxillary sinuses all interface with the orbit. The maxillary sinus shares the floor of the orbit, the frontal sinus is part of the orbital roof, the ethmoid extends along most of the medial wall of orbit and the sphenoid almost completely surrounds the orbital apex [3, 4]. Thus, mucoceles of the paranasal sinuses can easily affect the orbit and cause ophthalmic symptoms such as proptosis, blurred vision and displacement of globe [4,5]. Patients with paranasal mucoceles with orbital symptoms are often seen by the ophthalmologist first and then referred to otorhinolaryngologist [5].Occasionally they can present with intracranial complications.

It is essential to differentiate a mucocele from a mucus retention cyst. A mucus retention cyst is just a fluid filled sac along the sinus lining which does not expand and push into the eye socket, nose or brain and does not cause problems in the vast majority of cases. Notably, mucus

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

retention cysts in the sinuses are more common than expected. Infact, about 30-40% of the population with absolutely no complaints of sinus problems will have cysts of the paranasal sinuses when they have CT scans performed. Most retention cysts of sinuses spontaneously shrink or do not change in size over the long term [6]. In the absence of associated complaints "wait and see" may be the appropriate management strategy for these retention cysts.

**Patient / Age/sex/**

**race Presentation**

3. 40/M/M Nasal block,

4. 55/F/M Headaches with,

5. 59/M/Bengali Headaches,

6. 73/M/C Reduced vision,

7. 75/F/C Left epiphora

8. 71/F/C Right nasal

rhinorrhoea with anosmia

right diplopia

proptosis with reduced left eye movement

eye pain, headaches with nasal blockage

with swelling at medial cantus

blockage, rhinorrhea, sneezing with epiphora

**Sinus**

**involvement on endoscopy**

Right frontal sinus involvement with bilateral nasal polyposis

Right ethmoid sinuses involvement

Bilateral frontal sinus involvement

Sphenoid sinus involvement

Left Fronto-Ethmoid sinuses involvement

Right maxillary sinus involvement

orbital roof involvement

CT & MRI: Expansile right ethmoidal mass with thinning of lamina papyracea

CT: Expansile mass involving bilateral frontal sinuses

CT: Expansile mass within sphenoid sinus compressing on optic nerves

CT: Opacification of left frontal and ethmoidal sinuses

CT: Hypodense mass in right maxillary sinus with remodeling of maxillary wall and hard plate

CR & MRI: Right frontal expansile cystic mass with intracranial extension, no evidence of mass effect or ring enhancement

Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic…

**Imaging Surgery Follow-up**

Endoscopic right frontal sinusotomy and bilateral ethmoidectomy with marsupilization

Endoscopic anterior and posterior ethmoidectomy with marsupilization

Endoscopic drainage of bilateral frontal mucopyocele with marsupilization

sphenoethmoidectom y and marsupialization

Endoscopic left frontal sinustomy with anterior and posterior ethmoidectomy with marsupialization

Endoscopic right MMA with Marsupialization

Endoscopic

Symptoms improvement with no evidence of recurrence of nasal polyps at 6 month follow-up

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569

Symptom free at 6 month follow up with no evidence of recurrence

Symptom free at 6 month follow up with no evidence of recurrence

Symptom free at 1 year follow up with no evidence of recurrence

Symptom free at 1 year follow up with no evidence of recurrence

Symptom free at 6 months follow up with no evidence of recurrence

### **2. Material and methods**

From 2005 to 2012, 13 patients with paranasal sinus mucoceles were treated with wide endoscopic endonasal marsupilization at the UKM Medical Center in Kuala Lumpur, Malay‐ sia. Review of the patients' complete medical records, including out-patient clinical records, operative notes and reports of imaging and histopathology were performed. The radiological imaging (CT/MRI) on preoperative coronal and axial views were reviewed.

### **3. Results**

The demographic data on the 13 patients includes the age, sex, race, clinical presentation, type of radiological imaging performed, the surgical details and the post-operative follow-up are listed in Table 1. The most common sinus involved was the frontal, followed by the ethmoid, maxillary and sphenoid (Table 2). The most common clinical presentation was headache followed by eye and nasal symptoms (Table 3). Figure 1 shows a radiological image of a right ethmoidal mucocele in an adult patient with diplopia and headache. Figure 2 shows a radiological image of a gross right frontal mucocele in an adult patient with headache, reduced vision and proptosis. Figure 3 shows a radiological image of a sphenoid mucocele in a child with headache and vomiting. Figure 4 shows a radiological image of left maxillary mucocele in an adult patient with nasal blockage and foul smelling discharge.



retention cysts in the sinuses are more common than expected. Infact, about 30-40% of the population with absolutely no complaints of sinus problems will have cysts of the paranasal sinuses when they have CT scans performed. Most retention cysts of sinuses spontaneously shrink or do not change in size over the long term [6]. In the absence of associated complaints "wait and see" may be the appropriate management strategy for these retention cysts.

From 2005 to 2012, 13 patients with paranasal sinus mucoceles were treated with wide endoscopic endonasal marsupilization at the UKM Medical Center in Kuala Lumpur, Malay‐ sia. Review of the patients' complete medical records, including out-patient clinical records, operative notes and reports of imaging and histopathology were performed. The radiological

The demographic data on the 13 patients includes the age, sex, race, clinical presentation, type of radiological imaging performed, the surgical details and the post-operative follow-up are listed in Table 1. The most common sinus involved was the frontal, followed by the ethmoid, maxillary and sphenoid (Table 2). The most common clinical presentation was headache followed by eye and nasal symptoms (Table 3). Figure 1 shows a radiological image of a right ethmoidal mucocele in an adult patient with diplopia and headache. Figure 2 shows a radiological image of a gross right frontal mucocele in an adult patient with headache, reduced vision and proptosis. Figure 3 shows a radiological image of a sphenoid mucocele in a child with headache and vomiting. Figure 4 shows a radiological image of left maxillary mucocele

imaging (CT/MRI) on preoperative coronal and axial views were reviewed.

in an adult patient with nasal blockage and foul smelling discharge.

**Sinus**

**involvement on endoscopy**

Left frontal and ethmoid sinuses involvement

Right frontal sinus involvement

CT: Expansile cystic mass Lt fronto ethmoid region

CT: Expansile cystic lesion pushing interfrontal sinus septum with

**Imaging Surgery Follow-up**

Symptom free at 1 year follow up with no sign of recurrence

Symptom free at 1 year follow up with no evidence of recurrence

Endoscopic marsupialization of fronto-ethmoidal mucocele

Bicoronal flap cranialization with endoscopic endonasal frontal sinusotomy and marsupilization

**2. Material and methods**

568 Ophthalmology - Current Clinical and Research Updates

**3. Results**

**Patient / Age/sex/**

**race Presentation**

1. 40/M/C supra orbital

2. 59/M/C Right frontal

swelling, no diplopia or nasal symptoms

swelling with diplopia


Frontal Ethmoid Maxillary Sphenoid

Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic…

Reduced eye

movement Nasal symptoms Vomiting

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571

Number of cases 6 4 3 3

Number of cases 7 2 5 3 2 5 1

Fig 1: Coronal CT imaging of patient number 4 showing a right iatrogenic frontoethmoid mucocele with intraoperative endoscopic drainage and follow up at 3 months post surgery showing a patent frontal sinustomy

**Figure 2.** Picture of patient number 10 showing gross right protosis and the respective axial and coronal MRI sections

revealing expansile frontal sinus lesion with loss of scalloping suggestive of a mucocele

**Figure 1.** Coronal CT imaging of patient number 4 showing a right iatrogenic frontoethmoid mucocele with intrao‐

perative endoscopic drainage and follow up at 3 months post surgery showing a patent frontal sinustomy

Reduced vision

**Table 2.** Sites of involvement of paranasal sinuses

**Table 3.** Clinical presentation of head and eye symptoms

Headache Diplopia Proptosis

Rt– Right

Lt – Left

MMA – Middle meatal antrostomy

**Table 1.** Dermographic presentation of 13 patients with paranasal sinus mucocele

Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic… http://dx.doi.org/10.5772/58331 571


**Table 2.** Sites of involvement of paranasal sinuses

**Patient / Age/sex/**

**race Presentation**

9. 63/F/C Pain left eye with

570 Ophthalmology - Current Clinical and Research Updates

10. 39/M/I Headaches with

11. 8/M/I Headaches with

12. 62/M/C Lt nasal blockage

13. 58/M/M Rt nasal blockage

Race-M (Malay), C (Chinese), I (Indian)

MMA – Middle meatal antrostomy

M – Male F – Female

Rt– Right Lt – Left

reduced vision and headaches

right protosis, and

diplopia

vomitting

with foul smelling nasal discharge

with foul smelling nasal discharge

**Sinus**

**involvement on endoscopy**

> CT & MRI: Bilateral opacity of ethmoid and sphenoid sinuses with evidence of compression of optic nerve and cavernous sinus

MRI: Opacity within right frontal sinus with mass effect on right superior and medial wall

MRI: Expansile mass within sphenoid sinus involving the sphenoethmoidal

CT: Expansile left maxillary mass

CT: Expansile right maxillary

mass

recess

Left spheno-Ethmmoid sinuses involvement

Right frontal sinus involvement

Sphenoid sinus involvement

Left maxillary sinus involvement

Right maxillary sinus involvement

**Table 1.** Dermographic presentation of 13 patients with paranasal sinus mucocele

**Imaging Surgery Follow-up**

ethmosphenoidectom

Symptom free at 1 year follow up with no evidence of recurrence

Symptoms improvement with no evidence of recurrence at 1 year follow up

Symptoms improved with no recurrence at 3 months

Post DXT NPC with no recurrence at 3 months

Symptoms improved with no recurrence at 6 months

marsupialization

Endoscopic right frontal sinusotomy with marsupialization

Endoscopic

y with

sphenoethmoidectom

marsupialization

Endoscopic wide left

Endoscopic wide right

MMA with marsupilization

MMA with marsupilization

Endoscopic

y with


**Table 3.** Clinical presentation of head and eye symptoms

**Figure 1.** Coronal CT imaging of patient number 4 showing a right iatrogenic frontoethmoid mucocele with intrao‐ perative endoscopic drainage and follow up at 3 months post surgery showing a patent frontal sinustomy

Fig 1: Coronal CT imaging of patient number 4 showing a right iatrogenic frontoethmoid mucocele with intraoperative endoscopic drainage and follow up at 3 months post surgery showing a patent frontal sinustomy

**Figure 2.** Picture of patient number 10 showing gross right protosis and the respective axial and coronal MRI sections revealing expansile frontal sinus lesion with loss of scalloping suggestive of a mucocele

for maxillary mucocele; initially complete ethmoidectomy followed by removal of anteroinferior wall of the sphenoid mucocele and marsupilizing the cavity for ethmoid and sphenoid mucocele;uncinectomy, anterior ethmoidectomy and widening of the frontal recess (Draf type 2 procedure) and marsupilization for fronto-ethmoid mucocele.Patients' are observed at weekly follow-up with secretion aspirated and sinonasal washing with saline solution upto one month post-surgery. Patients are checked upon at follow-ups every three months for first

Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic…

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573

Paranasal sinus mucoceles are rare in children but relatively common in adults. In the literature, the etiologies of pediatric mucoceles have focused on impaired secretion process such as cystic fibrosis, pathological pneumatization processus, atopy and trauma, [7,8].

Mucoceles are commonly caused by post-operative ostial obstruction or secondary to trauma but can also present as primary disease. Paranasal sinus mucoceles predorminently occur in the fronto-ethmoid region (64%), followed by the maxillary sinus (18.6%), the sphenoid sinus (8.4%) and the posterior ethmoid sinus (6.7%) [9] which was similar to that in our study. Another common site for occurrence of mucocele is within the supraorbital ethmoid region. Primary sphenoid mucoceles can be found in association with chronic ethmoid sinusitis and/

In the literature review, proptosis, periorbital pain and impairment of ocular mobility were the most common manifestations of mucoceles in the anterior paranasal sinuses while blurred vision and impairment of ocular mobility [11] were frequently seen in mucoceles in the posterior sinuses. Mucoceles of the anterior paranasal sinuses may expand the anterior and medial sinus walls, pushing the globe outward and downward and restrict movement of the extraocular muscles, thus causing proptosis and impairment of ocular mobility [4, 12, 13].

The natural development of sinus mucoceles consists of gradual expansion. This slow growing expansion can result in bone remodeling, bulging and erosion and reaches adjacent structures such as other sinuses, orbit, clivus, skull base or brain. In case of an intracranial complication, infection may even lead to conditions such as meningitis, subdural or brain abcess [14]. By extension into adjacent structures, the mucocele gives rise to a variety of clinical manifesta‐ tions. The most common symptoms reported are headaches, facial pain, anosmia, ocular displacement, ocular palsy and visual failure. Visual symptoms in patients with sphenoid mucocele include diplopia, ocular muscle paresis, exopthalmus and complete visual loss [15, 16, 17, 18]. One should also be aware of unusual presentation including hypopituitarism [19,

The anatomical proximity and fragility of the orbital structures explains the high occurrence of ocular complications in sinusopathy. As the optic nerve enters the orbital apex from the intracranial portion, the nerve is encompassed by the narrow bony canal and is in close proximity to the posterior ethmoid and/or sphenoid sinus. In majority of cases the bony wall

or nasal polyposis and are uncommon in isolation [10].

year than once a year.

**4. Discussion**

20, 21].

**Figure 3.** Axial views and coronal sections of T1 and T2 weighted MRI images of patient number 11 showing an ex‐ pansile sphenoid lesion suggestive of mucocele in a 8-year Indian male.

**Figure 4.** Axial views and coronal sections of CT images of patient number 12 showing a left expansile mass in the maxillary sinus suggestive of a mucocele in a 62 year male Chinese.

#### **3.1. Surgical technique**

All patients were operated under general aneasthesia. The patient is placed in supine position with head slightly elevated. Packing that has been soaked in a 4% cocaine solution is placed in the nasal cavity to initiate mucosal vasoconstriction. Both eyes are exposed in the surgical field. Under endoscopic visualization, submucosal injections of 1% lidocaine with epinephrine are administred along the lateral nasal wall and middle turbinate. Briefly the endoscopic endonasal marsupilization is as follows: wide middle meatal antrostomy and marsupilization for maxillary mucocele; initially complete ethmoidectomy followed by removal of anteroinferior wall of the sphenoid mucocele and marsupilizing the cavity for ethmoid and sphenoid mucocele;uncinectomy, anterior ethmoidectomy and widening of the frontal recess (Draf type 2 procedure) and marsupilization for fronto-ethmoid mucocele.Patients' are observed at weekly follow-up with secretion aspirated and sinonasal washing with saline solution upto one month post-surgery. Patients are checked upon at follow-ups every three months for first year than once a year.

### **4. Discussion**

**Figure 3.** Axial views and coronal sections of T1 and T2 weighted MRI images of patient number 11 showing an ex‐

**Figure 4.** Axial views and coronal sections of CT images of patient number 12 showing a left expansile mass in the

All patients were operated under general aneasthesia. The patient is placed in supine position with head slightly elevated. Packing that has been soaked in a 4% cocaine solution is placed in the nasal cavity to initiate mucosal vasoconstriction. Both eyes are exposed in the surgical field. Under endoscopic visualization, submucosal injections of 1% lidocaine with epinephrine are administred along the lateral nasal wall and middle turbinate. Briefly the endoscopic endonasal marsupilization is as follows: wide middle meatal antrostomy and marsupilization

pansile sphenoid lesion suggestive of mucocele in a 8-year Indian male.

572 Ophthalmology - Current Clinical and Research Updates

maxillary sinus suggestive of a mucocele in a 62 year male Chinese.

**3.1. Surgical technique**

Paranasal sinus mucoceles are rare in children but relatively common in adults. In the literature, the etiologies of pediatric mucoceles have focused on impaired secretion process such as cystic fibrosis, pathological pneumatization processus, atopy and trauma, [7,8].

Mucoceles are commonly caused by post-operative ostial obstruction or secondary to trauma but can also present as primary disease. Paranasal sinus mucoceles predorminently occur in the fronto-ethmoid region (64%), followed by the maxillary sinus (18.6%), the sphenoid sinus (8.4%) and the posterior ethmoid sinus (6.7%) [9] which was similar to that in our study. Another common site for occurrence of mucocele is within the supraorbital ethmoid region. Primary sphenoid mucoceles can be found in association with chronic ethmoid sinusitis and/ or nasal polyposis and are uncommon in isolation [10].

In the literature review, proptosis, periorbital pain and impairment of ocular mobility were the most common manifestations of mucoceles in the anterior paranasal sinuses while blurred vision and impairment of ocular mobility [11] were frequently seen in mucoceles in the posterior sinuses. Mucoceles of the anterior paranasal sinuses may expand the anterior and medial sinus walls, pushing the globe outward and downward and restrict movement of the extraocular muscles, thus causing proptosis and impairment of ocular mobility [4, 12, 13].

The natural development of sinus mucoceles consists of gradual expansion. This slow growing expansion can result in bone remodeling, bulging and erosion and reaches adjacent structures such as other sinuses, orbit, clivus, skull base or brain. In case of an intracranial complication, infection may even lead to conditions such as meningitis, subdural or brain abcess [14]. By extension into adjacent structures, the mucocele gives rise to a variety of clinical manifesta‐ tions. The most common symptoms reported are headaches, facial pain, anosmia, ocular displacement, ocular palsy and visual failure. Visual symptoms in patients with sphenoid mucocele include diplopia, ocular muscle paresis, exopthalmus and complete visual loss [15, 16, 17, 18]. One should also be aware of unusual presentation including hypopituitarism [19, 20, 21].

The anatomical proximity and fragility of the orbital structures explains the high occurrence of ocular complications in sinusopathy. As the optic nerve enters the orbital apex from the intracranial portion, the nerve is encompassed by the narrow bony canal and is in close proximity to the posterior ethmoid and/or sphenoid sinus. In majority of cases the bony wall between the nerve and the sinuses is as thin as 40-60um [22, 23]. Intracranially the optic nerve is covered by the pia mater, arachnoid and CSF. As the nerve enters the canal, it is surrounded by two layers of nerve sheath, the outer which is continuous with the periorbita and the inner which en sheaths the nerve to the eyeball. The optic nerve canal can be identified as a semi‐ circular tube when viewed from the inside of the posterior ethmoid or sphenoid sinus. Since the optic nerve canal contains the nerve and two layers of nerve sheath without any soft tissues such as fat, pressure due to expansion of the mucocele may easily impact the nerve if the thin protecting bony wall is resorbed or if it is dehiscent congenitally.

preserves the sinus architecture and produces good long-term results with adequate postoperative care. Some conditions are not suitable for endoscopic surgery alone including a far laterally placed frontal mucocele, hypertrophic bone occluding the area of the fronto-nasal recess and a mucocele arising secondarily from a malignancy [33]. With respect to patient number 2, the extensive mucocele with intraorbital extension was removed using both an

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The paranasal sinus mucocele is widely opened and a sufficient part of the wall or outflow pathway is resected for adequate drainage and ventilation. With exposure of the dura or periorbital wall, the wall of the mucocele acts as a cover and no attempts are made to remove this mucosal lining to protect the orbit, optic nerve, dura and carotid artery. On adequate marsu‐ pilization of the mucocele, one should expect a rapid improvement of visual acuity but in cases with complete loss of vision prior to surgery, the prognosis may be much poorer. The micro‐ debrider is used in endonasal surgery with great easiness and good surgical outcome. The degree of improvement of the visual acuity after mucocele marsupilization depends on the severity of the initial loss prior to surgery, the mode of development and the location of the mucocele and the time from onset of the opthalmological disorder until the surgical marsu‐ pilization [9]. Prompt surgical treatment is necessary in order to avoid permanent visual impairment and other sequel [3, 18]. If vision is seriously impaired, immediate surgery should

endoscopic and an external approach through bicoronal flap and cranialization [34].

be performed, preferably within 24 hours after the onset of visual disturbances [35].

The differential diagnosis of mucocele includes paranasal sinus tumors as shown in Table 4.

Antrochonal polyp Mesenchymal tumors (fibroma, lipoma, myxoma)

Fungal disease Vasiform tumors (hemangioma, aneurysmal bone cyst,

Cholesterol granuloma Tumors of muscle origin (leiomyoma, rhabdomyoma)

Antrolithiasis Fibroosseous lesions (osteoma, ossifying fibroma, fibrous

Eosinophilic angiocentric fibrosis Neuroectodermal tumors (schwannoma, neurofibroma)

hemangiopericytoma)

dysplasia, osteoblastoma)

**5. Differential diagnosis**

**Non-neoplastic Neoplastic** Mucosal cyst Papillomas

Hematoma Odontogenic tumors

**Table 4.** Classification of benign lesions of the paranasal sinus tumors

**5.1. Paranasal sinus tumors**

Blurred vision is more often associated with mucoceles in the posterior than anterior paranasal sinuses and can affect the optic or other cranial nerves via two pathways. Firstly, expansion of the paranasal sinus wall may compress the optic nerve or compromise its blood supply with subsequent optic atrophy [12, 24, 25]. Secondly, optic neuritis may result from direct spread of suppuration from adjacent paranasal sinuses via bone loss or bone fissure [12, 26]. Both optic nerve compression and neuritis can cause deterioration of visual acuity [12, 26]. Besides the optic nerve, other cranial nerves (abducent or oculomotor) passing through the orbital apex or superior orbital fissure may be involved, thus resulting in impairment of ocular mobility [12, 25, 26, 27].

In a review of 47 patients suffering from ethmoid or sphenoid mucoceles, Moriyama et al [28] highlighted 70 per cent of patients first sought help from the ophthalmology department. The mucocele may compress the optic canal and cause visual disturbances, leading to loss of eye sight in severe cases. Further to direct pressure, ischemia or venous congestion around the optic nerve subsequently occurs [28]. Besides compression and its local effects, inflammation due to infection of the mucocele can spread to the nerve through zones of bony erosion. Therefore, the visual loss may be due to a local inflammatory response which responds to steroid therapy [29] but further diagnosis and immediate surgical drainage are imperative.

Preoperative diagnosis is usually based on CT and MRI. On CT scan, mucoceles usually fill a sinus structure and bulge against adjacent anatomical structures, but without infiltration and usually the bony margins of the lesion are well defined. MRI of mucoceles in both T1 and T2 weighted images show variable signal intensities as depicted in Fig 3. CT scans are preferable for definitive evaluation, assessment of bony involvement and presurgical planning. MRI scans are helpful in the evaluation of orbital or intracranial extension and in ruling out a neoplasm or fungus disease [30]. Therefore, CT and MRI imaging are complementary for the diagnostic evaluation of an expansile mass around the posterior ethmoid and sphenoid sinus. In the differential diagnosis, one should rule out a mucopyocele, sinus malignancy, hypophy‐ seal tumor, craniopharyngioma, meningioma or optic nerve glioma, intracranial chordo‐ ma,cholesteatoma and neoplastic lesions of nasopharynx.

An urgent surgical intervention is advocated in a paranasal sinus mucocele with vision loss. The endoscopic endonasal approach is the most convenient for the treatment of mucocele in view of easy access, lower morbidity and a reduction in potential complications compared to intracranial route [31]. Several recent literatures have reported successful results in the management of mucoceles with endoscopic marsupilization as the main choice of treatment [32]. It has the advantage of magnification of the operative field, is minimally invasive, preserves the sinus architecture and produces good long-term results with adequate postoperative care. Some conditions are not suitable for endoscopic surgery alone including a far laterally placed frontal mucocele, hypertrophic bone occluding the area of the fronto-nasal recess and a mucocele arising secondarily from a malignancy [33]. With respect to patient number 2, the extensive mucocele with intraorbital extension was removed using both an endoscopic and an external approach through bicoronal flap and cranialization [34].

The paranasal sinus mucocele is widely opened and a sufficient part of the wall or outflow pathway is resected for adequate drainage and ventilation. With exposure of the dura or periorbital wall, the wall of the mucocele acts as a cover and no attempts are made to remove this mucosal lining to protect the orbit, optic nerve, dura and carotid artery. On adequate marsu‐ pilization of the mucocele, one should expect a rapid improvement of visual acuity but in cases with complete loss of vision prior to surgery, the prognosis may be much poorer. The micro‐ debrider is used in endonasal surgery with great easiness and good surgical outcome. The degree of improvement of the visual acuity after mucocele marsupilization depends on the severity of the initial loss prior to surgery, the mode of development and the location of the mucocele and the time from onset of the opthalmological disorder until the surgical marsu‐ pilization [9]. Prompt surgical treatment is necessary in order to avoid permanent visual impairment and other sequel [3, 18]. If vision is seriously impaired, immediate surgery should be performed, preferably within 24 hours after the onset of visual disturbances [35].

### **5. Differential diagnosis**

### **5.1. Paranasal sinus tumors**

between the nerve and the sinuses is as thin as 40-60um [22, 23]. Intracranially the optic nerve is covered by the pia mater, arachnoid and CSF. As the nerve enters the canal, it is surrounded by two layers of nerve sheath, the outer which is continuous with the periorbita and the inner which en sheaths the nerve to the eyeball. The optic nerve canal can be identified as a semi‐ circular tube when viewed from the inside of the posterior ethmoid or sphenoid sinus. Since the optic nerve canal contains the nerve and two layers of nerve sheath without any soft tissues such as fat, pressure due to expansion of the mucocele may easily impact the nerve if the thin

Blurred vision is more often associated with mucoceles in the posterior than anterior paranasal sinuses and can affect the optic or other cranial nerves via two pathways. Firstly, expansion of the paranasal sinus wall may compress the optic nerve or compromise its blood supply with subsequent optic atrophy [12, 24, 25]. Secondly, optic neuritis may result from direct spread of suppuration from adjacent paranasal sinuses via bone loss or bone fissure [12, 26]. Both optic nerve compression and neuritis can cause deterioration of visual acuity [12, 26]. Besides the optic nerve, other cranial nerves (abducent or oculomotor) passing through the orbital apex or superior orbital fissure may be involved, thus resulting in impairment of ocular mobility

In a review of 47 patients suffering from ethmoid or sphenoid mucoceles, Moriyama et al [28] highlighted 70 per cent of patients first sought help from the ophthalmology department. The mucocele may compress the optic canal and cause visual disturbances, leading to loss of eye sight in severe cases. Further to direct pressure, ischemia or venous congestion around the optic nerve subsequently occurs [28]. Besides compression and its local effects, inflammation due to infection of the mucocele can spread to the nerve through zones of bony erosion. Therefore, the visual loss may be due to a local inflammatory response which responds to steroid therapy [29] but further diagnosis and immediate surgical drainage are imperative. Preoperative diagnosis is usually based on CT and MRI. On CT scan, mucoceles usually fill a sinus structure and bulge against adjacent anatomical structures, but without infiltration and usually the bony margins of the lesion are well defined. MRI of mucoceles in both T1 and T2 weighted images show variable signal intensities as depicted in Fig 3. CT scans are preferable for definitive evaluation, assessment of bony involvement and presurgical planning. MRI scans are helpful in the evaluation of orbital or intracranial extension and in ruling out a neoplasm or fungus disease [30]. Therefore, CT and MRI imaging are complementary for the diagnostic evaluation of an expansile mass around the posterior ethmoid and sphenoid sinus. In the differential diagnosis, one should rule out a mucopyocele, sinus malignancy, hypophy‐ seal tumor, craniopharyngioma, meningioma or optic nerve glioma, intracranial chordo‐

An urgent surgical intervention is advocated in a paranasal sinus mucocele with vision loss. The endoscopic endonasal approach is the most convenient for the treatment of mucocele in view of easy access, lower morbidity and a reduction in potential complications compared to intracranial route [31]. Several recent literatures have reported successful results in the management of mucoceles with endoscopic marsupilization as the main choice of treatment [32]. It has the advantage of magnification of the operative field, is minimally invasive,

protecting bony wall is resorbed or if it is dehiscent congenitally.

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ma,cholesteatoma and neoplastic lesions of nasopharynx.

[12, 25, 26, 27].

The differential diagnosis of mucocele includes paranasal sinus tumors as shown in Table 4.


**Table 4.** Classification of benign lesions of the paranasal sinus tumors

### **6. Non-neoplastic**

### **6.1. Mucosal cyst**

Mucosal cyct of the paranasal sinuses are common with and incidence between 12 and 36% detected on radiography [36, 37, 38]. They are broadly classified into secretory and nonsecretary cysts [39]. Obstruction of mucosal gland leads to formation of secretory cysts which are less common. The more common non secretory cysts are presumably caused by an accumulation of exudates in the sinus mucosa lifting the epithelial lining. The aetiologic factors behind cyst formation remain unknown. They are mostly unilateral but can be bilateral in 10 to 20% cases [40], [41]. They are usually seen as homogenous, dome-shaped opacities on CT scanning and are usually a chance diagnosis on sinus radiography.

**6.3. Fungal disease**

Most sinus fungal infections are caused by Aspergillus species. Aspergilus flavus is the most common cause of sinus fungal ball. Infections by dematiaceous fungi such as Bipolaris, Curvularia or Alternaria are commonly seen in patients with allergic fungal sinusitis. Zygo‐ mycetes, such as Mucorales or Rhizopus are well-described aggressive organisms implicated in many cases of invasive fungal sinusitis [45, 46, 47].Fungal rhinosinusitis can be classified as invasive or non-invasive (Table 5). The prognosis of the fungal sinus infections is more

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**Figure 6.** A zero degree endoscopic view of right nasal cavity showing evidence of allergic mucin in an adult male

Associated nasal polyposis is seen in up to 10% due to the chronic inflammatory response. Maxillary sinus fungal ball often presents with unilateral sinus disease and unrelenting symptoms of rhinosinusitis. Allergic fungal sinusitis is characterized by the presence of allergic mucin in patients with symptoms of chronic rhinosinusitis, polyposis and an IgE-mediated hypersensitivity reaction to fungal elements resulting in a self-perpetuating inflammatory cascade (Fig 6). A high index of suspicion for invasive fungal sinusitis is necessary in patients with immunodeficiency, fever and symptoms referable to the paranasal sinuses. CT of

dependent on the manifestation of the disease than on the specific causative species.

**Noninvasive Invasive**

**Table 5.** Classification of fungal sinusitis

presenting with chronic rhinosinusitis

Saprophytic Acute invasive fungal sinusitis

Fungal ball Chronic invasive fungal sinusitis

Allergic fungal sinusitis Chronic granulomatous invasive sinusitis

### **6.2. Antrochoanalpolyp (ACP)**

ACP is a benign lesion that originates from the mucosa of the maxillary sinus and grows into the nasal cavity to reach the choana (Fig 5). ACPs account for 4 to 6% of all nasal polyps with increased incidence of 33% in children [42], [43]. ACPs are usually unilateral with only a small number of reported cases with bilateral polyps [16]. It has been suggested that most ACPs originate from the posterior-medial wall [44]. Mean age of presentation is 17 years and it is reported to be twice as common in males than females [44].

**Figure 5.** (A) A zero degree endoscope view of a left antrochoanal polyp in an adult male and (B) a coronal CT section of same patient showing a homogenous opaque mass in the maxillary sinus with opasification of the middle meatus and extension into choana.

Clinical manifestations usually start with unilateral nasal obstruction but other symptoms have been reported such as epistaxis, purulent rhinorrhea, post-nasal drip, snoring, obstructive sleep apnea, dysphonia and dysphagia [42, 44].

#### **6.3. Fungal disease**

**6. Non-neoplastic**

detected on radiography [36, 37, 38].

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**6.2. Antrochoanalpolyp (ACP)**

and extension into choana.

sleep apnea, dysphonia and dysphagia [42, 44].

Mucosal cyct of the paranasal sinuses are common with and incidence between 12 and 36%

secretary cysts [39]. Obstruction of mucosal gland leads to formation of secretory cysts which are less common. The more common non secretory cysts are presumably caused by an accumulation of exudates in the sinus mucosa lifting the epithelial lining. The aetiologic factors behind cyst formation remain unknown. They are mostly unilateral but can be bilateral in 10 to 20% cases [40], [41]. They are usually seen as homogenous, dome-shaped opacities on CT

ACP is a benign lesion that originates from the mucosa of the maxillary sinus and grows into the nasal cavity to reach the choana (Fig 5). ACPs account for 4 to 6% of all nasal polyps with increased incidence of 33% in children [42], [43]. ACPs are usually unilateral with only a small number of reported cases with bilateral polyps [16]. It has been suggested that most ACPs originate from the posterior-medial wall [44]. Mean age of presentation is 17 years and it is

**Figure 5.** (A) A zero degree endoscope view of a left antrochoanal polyp in an adult male and (B) a coronal CT section of same patient showing a homogenous opaque mass in the maxillary sinus with opasification of the middle meatus

Clinical manifestations usually start with unilateral nasal obstruction but other symptoms have been reported such as epistaxis, purulent rhinorrhea, post-nasal drip, snoring, obstructive

scanning and are usually a chance diagnosis on sinus radiography.

reported to be twice as common in males than females [44].

They are broadly classified into secretory and non-

**6.1. Mucosal cyst**

Most sinus fungal infections are caused by Aspergillus species. Aspergilus flavus is the most common cause of sinus fungal ball. Infections by dematiaceous fungi such as Bipolaris, Curvularia or Alternaria are commonly seen in patients with allergic fungal sinusitis. Zygo‐ mycetes, such as Mucorales or Rhizopus are well-described aggressive organisms implicated in many cases of invasive fungal sinusitis [45, 46, 47].Fungal rhinosinusitis can be classified as invasive or non-invasive (Table 5). The prognosis of the fungal sinus infections is more dependent on the manifestation of the disease than on the specific causative species.


**Table 5.** Classification of fungal sinusitis

**Figure 6.** A zero degree endoscopic view of right nasal cavity showing evidence of allergic mucin in an adult male presenting with chronic rhinosinusitis

Associated nasal polyposis is seen in up to 10% due to the chronic inflammatory response. Maxillary sinus fungal ball often presents with unilateral sinus disease and unrelenting symptoms of rhinosinusitis. Allergic fungal sinusitis is characterized by the presence of allergic mucin in patients with symptoms of chronic rhinosinusitis, polyposis and an IgE-mediated hypersensitivity reaction to fungal elements resulting in a self-perpetuating inflammatory cascade (Fig 6). A high index of suspicion for invasive fungal sinusitis is necessary in patients with immunodeficiency, fever and symptoms referable to the paranasal sinuses. CT of paranasal sinuses is often ordered to evaluate refractory symptoms. Complete or subtotal opacification of the involved sinus is not uncommon. Up to 41% demonstrated heterogenous opacification with calcifications (Fig 7). Bony erosion or sclerosis from mass effect can be identified in 17 to 36% [48, 49, 50].

headaches (Fig 8 A). CT shows a cyst-like opacity which does not enhance with contrast (Fig

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**Figure 8.** (A) Intraoperative view with 45 degree endoscope showing a polypoid left sphenoid sinus cholesterol gran‐ uloma in a young adult female presenting with persistent vertax headaches and (B) a CT scan coronal section showing

Hematoma of the maxillary sinus is also known as organized hematoma or hemorrhagic pseudotumor [57, 58, 59]. It is an uncommon cause of maxillary sinus mass with only a small number of reported cases from Korea and Japan [58]. Some of the hematoma have been reported in patients with bleeding diathesis such as Von Willebrand disease but there are several patients who present with what appears to be a spontaneous etiology [58, 59, 60]. Initially, a blood clot accumulates in the maxillary sinus secondary to facial trauma, operative bleeding, recurrent epistaxis or bleeding diathesis. Subsequently the hematoma develops and due to poor ventilation and obstruction of drainage it transforms into an organized hematoma by means of neovascularization and fibrosis [58, 59]. Encapsulation of the blood clot by fibrous tissue prevents reabsorption of the hematoma. Further bleeding causes increasing pressure

and progressive expansion which leads to erosion of adjacent structures [59], [60].

relatively acellular and contains some intact erythrocytes [57, 58, 62].

The most common symptom at presentation is epistaxis followed by unilateral obstruction and facial swelling [57, 58]. Symptoms due to pressure on adjacent structures such as proptosis and infraorbital hypoaesthesia have been reported [61, 62]. CT scanning shows the hematoma as a nonenhancing soft tissue mass which can be heterogeneous or homogenous. Histologically the hematoma has a peripheral wall that consists of dense fibrous tissue with a spindle-shaped myofibroblast cells. The center of the hematoma consist of loose fibrous tissue which is

a homogenous partial opacification of the affected sphenoid sinus

**6.5. Hematoma**

8B). Bony erosion or expansion has been reported in a small number of cases [53, 56].

### **6.4. Cholesterol granuloma (CG)**

CG is a histologic term used to describe the coexistence of granulation tissue with cholesterol crystals and foreign body giant cells [51].The condition is well described in the temporal bone but is rarely encountered in the paranasal sinuses [52]. The maxillary sinus is most commonly involved [52, 53]. Only one case of bilateral maxillary sinus involvement has been reported [53]. CG has been observed more in men with 3:1 male to female ratio and an average age of 41 years.Only a small number of patients had a history of previous trauma or surgery [52, 53].

The factors contributing to the formation of CG includes disturbed ventilation in a bony cavity, impaired drainage and hemorrhage [52, 53, 54, 55]. Impaired drainage would result in obstruction to venous and lymphatic circulation thus predisposing to mucosal hemorrhage. The insufficient lymphatic drainage would fail to eliminate lipid components in red blood cells and contribute to accumulation of cholesterol crystals. These act as foreign material that stimulates the granulomatous reaction in the sinus cavity [52, 53, 56].

Patients with CG present with symptoms and signs resembling chronic sinusitis [52, 53]. Most of the patients present with nasal obstruction, post-nasal drip, rhinorrhea, facial pain or headaches (Fig 8 A). CT shows a cyst-like opacity which does not enhance with contrast (Fig 8B). Bony erosion or expansion has been reported in a small number of cases [53, 56].

**Figure 8.** (A) Intraoperative view with 45 degree endoscope showing a polypoid left sphenoid sinus cholesterol gran‐ uloma in a young adult female presenting with persistent vertax headaches and (B) a CT scan coronal section showing a homogenous partial opacification of the affected sphenoid sinus

#### **6.5. Hematoma**

paranasal sinuses is often ordered to evaluate refractory symptoms. Complete or subtotal opacification of the involved sinus is not uncommon. Up to 41% demonstrated heterogenous opacification with calcifications (Fig 7). Bony erosion or sclerosis from mass effect can be

**Figure 7.** A CT scan coronal section showing heterogenous opacification of the left nasal cavity with calcification in an

CG is a histologic term used to describe the coexistence of granulation tissue with cholesterol crystals and foreign body giant cells [51].The condition is well described in the temporal bone but is rarely encountered in the paranasal sinuses [52]. The maxillary sinus is most commonly involved [52, 53]. Only one case of bilateral maxillary sinus involvement has been reported [53]. CG has been observed more in men with 3:1 male to female ratio and an average age of 41 years.Only a small number of patients had a history of previous trauma or surgery [52, 53]. The factors contributing to the formation of CG includes disturbed ventilation in a bony cavity, impaired drainage and hemorrhage [52, 53, 54, 55]. Impaired drainage would result in obstruction to venous and lymphatic circulation thus predisposing to mucosal hemorrhage. The insufficient lymphatic drainage would fail to eliminate lipid components in red blood cells and contribute to accumulation of cholesterol crystals. These act as foreign material that

Patients with CG present with symptoms and signs resembling chronic sinusitis [52, 53]. Most of the patients present with nasal obstruction, post-nasal drip, rhinorrhea, facial pain or

stimulates the granulomatous reaction in the sinus cavity [52, 53, 56].

identified in 17 to 36% [48, 49, 50].

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adult female with fungal sinusitis

**6.4. Cholesterol granuloma (CG)**

Hematoma of the maxillary sinus is also known as organized hematoma or hemorrhagic pseudotumor [57, 58, 59]. It is an uncommon cause of maxillary sinus mass with only a small number of reported cases from Korea and Japan [58]. Some of the hematoma have been reported in patients with bleeding diathesis such as Von Willebrand disease but there are several patients who present with what appears to be a spontaneous etiology [58, 59, 60]. Initially, a blood clot accumulates in the maxillary sinus secondary to facial trauma, operative bleeding, recurrent epistaxis or bleeding diathesis. Subsequently the hematoma develops and due to poor ventilation and obstruction of drainage it transforms into an organized hematoma by means of neovascularization and fibrosis [58, 59]. Encapsulation of the blood clot by fibrous tissue prevents reabsorption of the hematoma. Further bleeding causes increasing pressure and progressive expansion which leads to erosion of adjacent structures [59], [60].

The most common symptom at presentation is epistaxis followed by unilateral obstruction and facial swelling [57, 58]. Symptoms due to pressure on adjacent structures such as proptosis and infraorbital hypoaesthesia have been reported [61, 62]. CT scanning shows the hematoma as a nonenhancing soft tissue mass which can be heterogeneous or homogenous. Histologically the hematoma has a peripheral wall that consists of dense fibrous tissue with a spindle-shaped myofibroblast cells. The center of the hematoma consist of loose fibrous tissue which is relatively acellular and contains some intact erythrocytes [57, 58, 62].

### **6.6. Antrolithiasis**

Antrolithiasis are calcified bodies that are formed from mineral salt deposition around a nucleus within the maxillary sinus cavity [63]. These are synonymous with rhinoliths which are reported within the nasal cavity. Anthroliths result from either endogenous (blood clot, mucus or pus) or exogenous factors (teeth and roots or other foreign material. The majority of cases reported had tooth extraction prior to presentation. The patients can be asymptomatic and may present with symptoms of unilateral chronic maxillary sinusitis. CT scan shows antroliths as radiopaque masses of varying sizes and shapes with irregular borders.

### **6.7. Eosinophilic Angiocentric Fibrosis (EAF)**

EAF is an uncommon inflammatory fibrotic lesion that affects the submucosa of the nose, larynx and orbit [64, 65]. The pathologic process is manifested by predorminently eosinophilic perivascular inflammation and gradual replacement with progressive fibrosis [64, 67]. EAF is found with slightly higher incidence in young to middle-aged women than men [64]. The etiology of EAF is unknown but it has been closely linked to granuloma faciale [64, 68]. Majority of the lesions involve the nasal septum and lateral nasal wall with only few cases involving the maxillary sinus.

EAF is slow growing and can take many years to manifest [64, 65]. Symptoms are non specific and can initially include nasal obstruction, rhinorrhea,epistaxis and facial pain [64, 67, 68]. Due to mass expansion the patients will present later with facial swelling [64, 65]. Involvement of the orbit can lead to periorbital edema and proptosis [64]. Nasal endoscopy reveals thickening of the nasal septum with an intranasal mass [64, 65].

### **7. Neoplastic**

### **7.1. Papillomas**

Papillomas are the most common benign epithelial tumor found in the sinonasal area account‐ ing for 10% of all neoplasms in this region [66].Histologically they are divided into invert‐ ed,cylindrical and everted [67]. Everted papilloma more often arises on the nasal septum whereas both inverted and cylindrical papillomas mostly arise on the lateral nasal wall within the middle meatus (Fig 9). The age of presentation is from 35 to 60 years with a male prepon‐ derance of 3.5: 1 [66, 68]. It is more common in Caucasions compared with other racial groups. A viral aetiology has been suggested with a link to papilloma viral subtypes 6, 11,16 and 18 [68].

**Figure 10.** A coronal CT scan section showing an aggressive inverted papilloma (hybrid tumor) arising from the left nasal cavity with evidence of anterior skull base erosion in an elderly Chinese male presenting with CSF rhinorrhea

**Figure 9.** A zero degree endoscopic view of a left inverted papilloma arising from the lateral nasal wall in an elderly

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These rare tumors may be encountered in the nose and sinuses and generally present prior to

**7.2. Mesenchymal tumors: Fibroma, lipoma and myxoma**

male

adulthood. Isolated tumors within maxillary sinus are very rare.

Patients generally present with obstructive nasal symptoms, rhinorrhea and chronic rhinosi‐ nusitis [66, 68]. CT scans shows a mass in lateral nasal wall with areas of apparent calcification and there may be sclerosis of the walls of the sinus [81] (Fig 10). Both a high recurrence rate and malignant transformation have been documented. A recent review of the literature of over 200 cases calculated 7.1% synchronous carcinoma and 3.6% metachronous carcinoma [70].

**6.6. Antrolithiasis**

the maxillary sinus.

**7. Neoplastic**

**7.1. Papillomas**

Antrolithiasis are calcified bodies that are formed from mineral salt deposition around a nucleus within the maxillary sinus cavity [63]. These are synonymous with rhinoliths which are reported within the nasal cavity. Anthroliths result from either endogenous (blood clot, mucus or pus) or exogenous factors (teeth and roots or other foreign material. The majority of cases reported had tooth extraction prior to presentation. The patients can be asymptomatic and may present with symptoms of unilateral chronic maxillary sinusitis. CT scan shows

EAF is an uncommon inflammatory fibrotic lesion that affects the submucosa of the nose, larynx and orbit [64, 65]. The pathologic process is manifested by predorminently eosinophilic perivascular inflammation and gradual replacement with progressive fibrosis [64, 67]. EAF is found with slightly higher incidence in young to middle-aged women than men [64]. The etiology of EAF is unknown but it has been closely linked to granuloma faciale [64, 68]. Majority of the lesions involve the nasal septum and lateral nasal wall with only few cases involving

EAF is slow growing and can take many years to manifest [64, 65]. Symptoms are non specific and can initially include nasal obstruction, rhinorrhea,epistaxis and facial pain [64, 67, 68]. Due to mass expansion the patients will present later with facial swelling [64, 65]. Involvement of the orbit can lead to periorbital edema and proptosis [64]. Nasal endoscopy reveals thickening

Papillomas are the most common benign epithelial tumor found in the sinonasal area account‐ ing for 10% of all neoplasms in this region [66].Histologically they are divided into invert‐ ed,cylindrical and everted [67]. Everted papilloma more often arises on the nasal septum whereas both inverted and cylindrical papillomas mostly arise on the lateral nasal wall within the middle meatus (Fig 9). The age of presentation is from 35 to 60 years with a male prepon‐ derance of 3.5: 1 [66, 68]. It is more common in Caucasions compared with other racial groups. A viral aetiology has been suggested with a link to papilloma viral subtypes 6, 11,16 and 18 [68].

Patients generally present with obstructive nasal symptoms, rhinorrhea and chronic rhinosi‐ nusitis [66, 68]. CT scans shows a mass in lateral nasal wall with areas of apparent calcification and there may be sclerosis of the walls of the sinus [81] (Fig 10). Both a high recurrence rate and malignant transformation have been documented. A recent review of the literature of over 200 cases calculated 7.1% synchronous carcinoma and 3.6% metachronous carcinoma [70].

antroliths as radiopaque masses of varying sizes and shapes with irregular borders.

**6.7. Eosinophilic Angiocentric Fibrosis (EAF)**

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of the nasal septum with an intranasal mass [64, 65].

**Figure 9.** A zero degree endoscopic view of a left inverted papilloma arising from the lateral nasal wall in an elderly male

**Figure 10.** A coronal CT scan section showing an aggressive inverted papilloma (hybrid tumor) arising from the left nasal cavity with evidence of anterior skull base erosion in an elderly Chinese male presenting with CSF rhinorrhea

#### **7.2. Mesenchymal tumors: Fibroma, lipoma and myxoma**

These rare tumors may be encountered in the nose and sinuses and generally present prior to adulthood. Isolated tumors within maxillary sinus are very rare.

### *7.2.1. Fibromas*

Fibromas result from progressive inflammation or fibroblastic proliferation of the nasal mucosa [71]. They present as slow-growing, grey-white, smooth surfaced masses producing obstructive nasal symptoms.

paranasal sinuses [76, 77]. Sphenoid and ethmoid sinuses are involved more frequently than the maxillary sinus. Both sexes are equally affected and can occur at any age but often develop after the second decade. The patients usually present with epistaxis and nasal obstruction with

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**Figure 11.** (A) View with 30 degree endoscope in an adult Chinese female presenting with right nasal obstruction and maxillary sinus discomfort and (B) CT scan coronal section showing a polypoidal mass arising from the right maxillary

Leiomyoma is a smooth muscle tumor that originates in areas of abundance of muscle like the

It is extremely rare for these tumors to present in the sinonasal tract because of the paucity of smooth muscle. And only a handful of cases have been reported in the maxillary sinus [78]. The tumor seem to be slow-growing and non-aggressive and presenting with obstructive nasal

Rhabdomyomais a skeletal muscle tumor and is extremely rare in the paranasal sinus.,which

Odontogenic tumors originate either within the maxillofacial skeleton (intraosseous) or within the gingival or alveolar mucosa overlying the tooth bearing areas (extraosseous). They are usually slow growing and have been associated with non-eruption of the teeth. Patients usually

reddish submucosal nasal mass (Fig 11).

sinus and histopathology report consistent with hemangiopericytoma

has a benign behavior and low recurrence rate [79, 80].

*7.4.1. Leiomyoma*

uterus.

symptoms.

*7.4.2. Rhabdomyoma*

**7.5. Odontogenic tumors**

**7.4. Tumors of muscle origin: Leiomyoma and rhabdomyoma**

### *7.2.2. Lipoma*

Lipoma is the most common soft tissue tumor in adulthood in contrast to intraosseouslipoma which is a rare condition.The etiology of intraosseous lipoma is unknown but infaction, ischaemia, trauma and irradiation may be contributing factors [72]. Cases have been reported within the nasal cavity and very rarely in the maxillary sinus. The presentation is of nasal swelling and possible nasal obstruction.

#### *7.2.3. Myxoma*

Myxoma of the maxillary sinus is very rare but more frequent than fibromas and lipomas [73]. The age of presentation is between 2 and 15 years and may be related to dental malformations or missing teeth.

### **7.3. Vasiform Tumors: Hemangioma, Aneurysmal Bone Cyst and Hemangiopericytoma**

These benign lesions arise from vascular tissue within the mucosa or bone of the nose and sinuses.

#### *7.3.1. Hemangiomas*

Hemangiomas represent about 20% of benign non-epithelial tumors of nasal cavity and paranasal sinuses [74]. Mean age of diagnosis is 40 years and the most frequent presenting symptoms are nasal obstruction and epistaxis. Invovement of maxillary sinus have been reported less frequently [91]. Both cavernous and capillary hemangiomas have been reported.

#### *7.3.2. Aneurysmal bone cyst (ABCs)*

ABCs are expansile lesions of unknown etiology that involves long bones and vertebrae of patients younger than 20 years. About 2% of ABCs are encountered in the head and neck region with jaw being the most frequently involved site. The present with facial swelling and obstructive nasal symptoms in the age group between 5 and 23 years. ABCs consist of multiple cavities filled with blood and serous fluids which are separated by septa and surrounded by rim of bone [75]. ABCs have a "honeycomb"appearance on gadoliniumenhanced MRI studies [75].

#### *7.3.3. Hemangiopericytoma (HPC)*

HPC is a rare benign vascular tumor derived from extracapillary cells (pericytes). Less than one-third of HPC occur in the head and neck and 5% are located in the nasal cavity and paranasal sinuses [76, 77]. Sphenoid and ethmoid sinuses are involved more frequently than the maxillary sinus. Both sexes are equally affected and can occur at any age but often develop after the second decade. The patients usually present with epistaxis and nasal obstruction with reddish submucosal nasal mass (Fig 11).

**Figure 11.** (A) View with 30 degree endoscope in an adult Chinese female presenting with right nasal obstruction and maxillary sinus discomfort and (B) CT scan coronal section showing a polypoidal mass arising from the right maxillary sinus and histopathology report consistent with hemangiopericytoma

### **7.4. Tumors of muscle origin: Leiomyoma and rhabdomyoma**

#### *7.4.1. Leiomyoma*

*7.2.1. Fibromas*

*7.2.2. Lipoma*

*7.2.3. Myxoma*

or missing teeth.

*7.3.1. Hemangiomas*

*7.3.2. Aneurysmal bone cyst (ABCs)*

enhanced MRI studies [75].

*7.3.3. Hemangiopericytoma (HPC)*

sinuses.

obstructive nasal symptoms.

582 Ophthalmology - Current Clinical and Research Updates

swelling and possible nasal obstruction.

Fibromas result from progressive inflammation or fibroblastic proliferation of the nasal mucosa [71]. They present as slow-growing, grey-white, smooth surfaced masses producing

Lipoma is the most common soft tissue tumor in adulthood in contrast to intraosseouslipoma which is a rare condition.The etiology of intraosseous lipoma is unknown but infaction, ischaemia, trauma and irradiation may be contributing factors [72]. Cases have been reported within the nasal cavity and very rarely in the maxillary sinus. The presentation is of nasal

Myxoma of the maxillary sinus is very rare but more frequent than fibromas and lipomas [73]. The age of presentation is between 2 and 15 years and may be related to dental malformations

**7.3. Vasiform Tumors: Hemangioma, Aneurysmal Bone Cyst and Hemangiopericytoma**

These benign lesions arise from vascular tissue within the mucosa or bone of the nose and

Hemangiomas represent about 20% of benign non-epithelial tumors of nasal cavity and paranasal sinuses [74]. Mean age of diagnosis is 40 years and the most frequent presenting symptoms are nasal obstruction and epistaxis. Invovement of maxillary sinus have been reported less frequently [91]. Both cavernous and capillary hemangiomas have been reported.

ABCs are expansile lesions of unknown etiology that involves long bones and vertebrae of patients younger than 20 years. About 2% of ABCs are encountered in the head and neck region with jaw being the most frequently involved site. The present with facial swelling and obstructive nasal symptoms in the age group between 5 and 23 years. ABCs consist of multiple cavities filled with blood and serous fluids which are separated by septa and surrounded by rim of bone [75]. ABCs have a "honeycomb"appearance on gadolinium-

HPC is a rare benign vascular tumor derived from extracapillary cells (pericytes). Less than one-third of HPC occur in the head and neck and 5% are located in the nasal cavity and Leiomyoma is a smooth muscle tumor that originates in areas of abundance of muscle like the uterus.

It is extremely rare for these tumors to present in the sinonasal tract because of the paucity of smooth muscle. And only a handful of cases have been reported in the maxillary sinus [78]. The tumor seem to be slow-growing and non-aggressive and presenting with obstructive nasal symptoms.

#### *7.4.2. Rhabdomyoma*

Rhabdomyomais a skeletal muscle tumor and is extremely rare in the paranasal sinus.,which has a benign behavior and low recurrence rate [79, 80].

#### **7.5. Odontogenic tumors**

Odontogenic tumors originate either within the maxillofacial skeleton (intraosseous) or within the gingival or alveolar mucosa overlying the tooth bearing areas (extraosseous). They are usually slow growing and have been associated with non-eruption of the teeth. Patients usually present with swelling of alveolar process along with nasal obstruction and epistaxis. Superior displacement of globe has been reported with large odontogenic tumors.

*7.6.2. Ossifying fibroma (OF)*

*7.6.3. Fibrous dysplasia (FD)*

*7.6.4. Osteoblastoma*

OF is a well-circumscribed lesion that continues to grow after sexual maturity and can attain dramatic proportions [81, 84]. The vast majority is located in the posterior region of the mandible; those involving the maxillary sinus are uncommon [85]. Patient usually present between the third and forth decades and the lesion is more common in women [85]. The most common presentation is of painless cheek swelling but involvement of the orbit or nasal cavity may be signified by proptosis, loss of visual acuity, epiphora, nasal obstruction and epistaxis [81, 85]. Radiologically, the lesion is sharply circumscribed with an egg shell rim and central radiolucency which differentiates it from fibrous dysplasia with its indistinguishable borders.

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FD is a slow, progressive disorder where normal bone is replaced by fibrous tissue and immature woven bone [81, 84]. There are two main forms of FD: monostatic (70-85%) that involves only one bone and polystatic (15-30%) where multiple bones can be involved (Fig 13). The maxilla and mandible are the most commonly involved bones generally in the monostatic form. FD is a disease of the young where patients present in their first or second decade and is assumed to be "burnt out" as the patients reach skeletal maturity. The usual symptom is of painless facial deformity although other complaints such as loosening of teeth, nasal obstruction or epistaxis have been encountered [86]. CT scans shows lesions with

indistinct borders and a homogenous "ground glass" appearance.

**Figure 13.** An axial CT section showing a polystatic fibrous dysplasia in an adult female

Osteoblastoma is an uncommon neoplasm characterized by proliferation of osteoblasts forming bone trabeculae set in a vascularized fibrous connective tissue stroma [87]. The tumor

#### *7.5.1. Ameloblastoma*

Ameloblastomais the most common odontogenic tumor. It is slow growing, locally invasive and has a high rate of recurrence if not treated effectively. Patients between the ages of 16 and 60 years are generally affected with the region of canine tooth and maxilla being the most common sites. They are often asymptomatic but can present with a painless swelling of the cheek, gingival and palate that may reach a large size. Ameloblastoma presents as a unilocular or multilocular radiolucency that may be associated with an impacted tooth.

### **7.6. Fibro-osseous lesions: Osteoma, ossifying fibroma, fibrous dysplasia and osteoblastoma**

Fibro-osseous lesions represent a class of bony abnormalities: osteoma, ossifying fibroma, fibrous dysplasia and osteoblastoma. They are distinct but lie along a continuum from the most to the least content. They have some similarities in appearance but their clinical implications differ.

#### *7.6.1. Osteomas*

Osteomas are frequent incidental finding in up to 3% of CT scans of the paranasal sinuses [81] (Fig 12). Eighty percent occur in the frontal sinuses followed by the ethmoids and least in the maxillary sinuses. The etiology is either embryologic or secondary to trauma or an infective process. There is an association with Gardner syndrome which is an autosomal dominant condition characterized by intestinal polyposis and pigmented skin lesions in addition to osteomas [82]. Maxillary sinus osteomas are slow growing and usually asymptomatic but they may become symptomatic depending on the location and onset [83].

**Figure 12.** (A) A CT scan coronal and (B) sagittal section showing osteoma arising from the anterior ethmoid sinuses in an adult female presenting with frequent headaches

### *7.6.2. Ossifying fibroma (OF)*

present with swelling of alveolar process along with nasal obstruction and epistaxis. Superior

Ameloblastomais the most common odontogenic tumor. It is slow growing, locally invasive and has a high rate of recurrence if not treated effectively. Patients between the ages of 16 and 60 years are generally affected with the region of canine tooth and maxilla being the most common sites. They are often asymptomatic but can present with a painless swelling of the cheek, gingival and palate that may reach a large size. Ameloblastoma presents as a unilocular

Fibro-osseous lesions represent a class of bony abnormalities: osteoma, ossifying fibroma, fibrous dysplasia and osteoblastoma. They are distinct but lie along a continuum from the most to the least content. They have some similarities in appearance but their clinical implications

Osteomas are frequent incidental finding in up to 3% of CT scans of the paranasal sinuses [81] (Fig 12). Eighty percent occur in the frontal sinuses followed by the ethmoids and least in the maxillary sinuses. The etiology is either embryologic or secondary to trauma or an infective process. There is an association with Gardner syndrome which is an autosomal dominant condition characterized by intestinal polyposis and pigmented skin lesions in addition to osteomas [82]. Maxillary sinus osteomas are slow growing and usually asymptomatic but they

**Figure 12.** (A) A CT scan coronal and (B) sagittal section showing osteoma arising from the anterior ethmoid sinuses in

displacement of globe has been reported with large odontogenic tumors.

or multilocular radiolucency that may be associated with an impacted tooth.

may become symptomatic depending on the location and onset [83].

an adult female presenting with frequent headaches

**7.6. Fibro-osseous lesions: Osteoma, ossifying fibroma, fibrous dysplasia and**

*7.5.1. Ameloblastoma*

584 Ophthalmology - Current Clinical and Research Updates

**osteoblastoma**

*7.6.1. Osteomas*

differ.

OF is a well-circumscribed lesion that continues to grow after sexual maturity and can attain dramatic proportions [81, 84]. The vast majority is located in the posterior region of the mandible; those involving the maxillary sinus are uncommon [85]. Patient usually present between the third and forth decades and the lesion is more common in women [85]. The most common presentation is of painless cheek swelling but involvement of the orbit or nasal cavity may be signified by proptosis, loss of visual acuity, epiphora, nasal obstruction and epistaxis [81, 85]. Radiologically, the lesion is sharply circumscribed with an egg shell rim and central radiolucency which differentiates it from fibrous dysplasia with its indistinguishable borders.

### *7.6.3. Fibrous dysplasia (FD)*

FD is a slow, progressive disorder where normal bone is replaced by fibrous tissue and immature woven bone [81, 84]. There are two main forms of FD: monostatic (70-85%) that involves only one bone and polystatic (15-30%) where multiple bones can be involved (Fig 13). The maxilla and mandible are the most commonly involved bones generally in the monostatic form. FD is a disease of the young where patients present in their first or second decade and is assumed to be "burnt out" as the patients reach skeletal maturity. The usual symptom is of painless facial deformity although other complaints such as loosening of teeth, nasal obstruction or epistaxis have been encountered [86]. CT scans shows lesions with indistinct borders and a homogenous "ground glass" appearance.

**Figure 13.** An axial CT section showing a polystatic fibrous dysplasia in an adult female

#### *7.6.4. Osteoblastoma*

Osteoblastoma is an uncommon neoplasm characterized by proliferation of osteoblasts forming bone trabeculae set in a vascularized fibrous connective tissue stroma [87]. The tumor occur predorminantly in vertebrae and long bones and can affect craniofacial bones with the mandible being the most commonly involved. It is reported less in the maxillary bone and rarely in the maxillary sinus [88]. The majority of the patients are under 30 years and present with a facial swelling and is often painful [87]. CT scan features range from radiolucent to radiopaque lesions and are often mistaken for other fibro-osseous lesions.

**8. Conclusion**

**Author details**

**References**

Balwant Singh Gendeh\*

Mucocele of the paranasal sinuses are well described complication of chronic sinusitis in adults but they rarely occur in the pediatric population. Mucocele can be associated with ophthalmic complications or intracranial complications. Radiological imaging includes CT-scan and sometimes MRI when intracranial complications are suspected. The differential diagnosis of mucocele includes paranasal sinus tumors. Usually a wide endoscopic endonasal marsupili‐ zation of paranasal sinus mucocele is a safe and less invasive than external approaches. Thus, a good understanding of paranasal sinus mucoceles by ophthalmologists and otorhinolaryng‐

Paranasal Sinus Mucoceles – Opthalmic Manifestations, Radiological Imaging, Endoscopic…

http://dx.doi.org/10.5772/58331

587

Department of Otorhinolaryngology-Head Neck Surgery, UKM Medical Center, Jalan Yaa‐

[1] Alberti PW, Marshall HF, Black JI. 1968. Fronto-ethmoidalmucocele as a cause of uni‐

[2] Johnson JT, Ferguson BJ. 1998. Infection in: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, Rhicharson MA, eds Otolaryngology Head Neck Sur‐

[3] Maniglia AJ, Kronberg FG, Culbertson W. 1984. Visual loss associated with orbital

[4] Curtin HD, Rabinov JD. 1998. Extension to the orbit from paraorbital disease. Radiol

[5] Moriyama H, Hesaka H, Tachibana T, Honda Y. 1992. Mucoceles of ethmoid and sphenoid sinus with visual disturbance. Arch Otolaryngol Head Neck Surg 118:

[6] Wang JW, JangYT, Lee BJ. 2007. Natural course of retention cysts of the maxillary si‐

nus: long term follow-up results. Laryngoscope 117(2):341-344

ologists is essential for early diagnosis and rapid surgical intervention.

Address all correspondence to: bsgendeh@gmail.com

cob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia

lateral proptosis. Br J Ophthalmol52: 833-838

gery, 3rd edition. St Louis: Mosby1115-1116

Clin North Am 36: 1201-1213

141-146

and sinus disease. Laryngoscope 94(8): 1050-1059

### **7.7. Neuroectodermal tumors: Schwannoma and neurofibroma**

### *7.7.1. Schwannomas*

Schwannomas are benign nerve sheath tumors of which 50% occur in the head and neck region. They are very uncommon in the paranasal sinuses (only 4%) and a very small number involve the maxillary sinus [84]. The lesion slowly expands in the sinus cavity resulting in swelling, pressure symptoms and bony necrosis. The patients mostly present with nasal obstruction but other symptoms such as proptosis, epiphora, headaches, facial anesthesia and epistaxis have been reported [90]. CT scan shows a homogenous radio-opaque mass with evidence of bone remodeling (Fig 14).

**Figure 14.** An axial CT section showing a left homogenous radio-opaque mass involving the maxillary sinus and infra‐ temporal region in an adult female

### *7.7.2. Neurofibromas*

Neurofibromas are heterogenous peripheral nerve tumors that arise from the connective tissue of the nerves especially the endoneurium [91]. They may occur as sporadic lesions but are much more common in association with neurofibromatosis type 1 (NF 1). Neurofibromas of the maxillary sinus are exceedingly rare.As with schwannomas, they slowly grow and expand within the sinus cavity causing swelling, pressure symptoms and bone necrosis. Presentation is similar to other expanding masses in the maxillary sinus. CT scan shows a well-circumscri‐ bed mass with some bony erosion.

### **8. Conclusion**

occur predorminantly in vertebrae and long bones and can affect craniofacial bones with the mandible being the most commonly involved. It is reported less in the maxillary bone and rarely in the maxillary sinus [88]. The majority of the patients are under 30 years and present with a facial swelling and is often painful [87]. CT scan features range from radiolucent to

Schwannomas are benign nerve sheath tumors of which 50% occur in the head and neck region. They are very uncommon in the paranasal sinuses (only 4%) and a very small number involve the maxillary sinus [84]. The lesion slowly expands in the sinus cavity resulting in swelling, pressure symptoms and bony necrosis. The patients mostly present with nasal obstruction but other symptoms such as proptosis, epiphora, headaches, facial anesthesia and epistaxis have been reported [90]. CT scan shows a homogenous radio-opaque mass with evidence of bone

**Figure 14.** An axial CT section showing a left homogenous radio-opaque mass involving the maxillary sinus and infra‐

Neurofibromas are heterogenous peripheral nerve tumors that arise from the connective tissue of the nerves especially the endoneurium [91]. They may occur as sporadic lesions but are much more common in association with neurofibromatosis type 1 (NF 1). Neurofibromas of the maxillary sinus are exceedingly rare.As with schwannomas, they slowly grow and expand within the sinus cavity causing swelling, pressure symptoms and bone necrosis. Presentation is similar to other expanding masses in the maxillary sinus. CT scan shows a well-circumscri‐

radiopaque lesions and are often mistaken for other fibro-osseous lesions.

**7.7. Neuroectodermal tumors: Schwannoma and neurofibroma**

*7.7.1. Schwannomas*

586 Ophthalmology - Current Clinical and Research Updates

remodeling (Fig 14).

temporal region in an adult female

bed mass with some bony erosion.

*7.7.2. Neurofibromas*

Mucocele of the paranasal sinuses are well described complication of chronic sinusitis in adults but they rarely occur in the pediatric population. Mucocele can be associated with ophthalmic complications or intracranial complications. Radiological imaging includes CT-scan and sometimes MRI when intracranial complications are suspected. The differential diagnosis of mucocele includes paranasal sinus tumors. Usually a wide endoscopic endonasal marsupili‐ zation of paranasal sinus mucocele is a safe and less invasive than external approaches. Thus, a good understanding of paranasal sinus mucoceles by ophthalmologists and otorhinolaryng‐ ologists is essential for early diagnosis and rapid surgical intervention.

### **Author details**

Balwant Singh Gendeh\*

Address all correspondence to: bsgendeh@gmail.com

Department of Otorhinolaryngology-Head Neck Surgery, UKM Medical Center, Jalan Yaa‐ cob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia

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## *Edited by Pinakin Davey*

This book brings together both a review and updates in clinical and research areas. The chapters will be of interest to a wide audience. On one hand, the review and update of clinical practices will interest students and residents, on the other, cutting edge research chapters will be of interest to the researchers in the field. The book is divided into four parts: 1) Review and Updates in Diagnostic Testing, 2) Updates in Anterior Segment Diseases, 3) Updates in Posterior Segment Diseases, and 4) Updates in Research in Ophthalmology, Optometry and Vision Science. The chapters are written by experts and individuals with special interests in topics with a focus on clinical application and translational benefit to eye care.

Ophthalmology - Current Clinical and Research Updates

Ophthalmology

Current Clinical and Research Updates

*Edited by Pinakin Davey*

Photo by erllre / iStock