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Immunopathology of Uveitis

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Immunopathology of Uveitis British Journal of Ophthalmology 1998;82:91–96 91 PERSPECTIVE Br J Ophthalmol: first published as 10.1136/bjo.82.1.91 on 1 January 1998. Downloaded from Immunopathology of uveitis Chi-Chao Chan, Qian Li Using conventional histological (light and electron micro- surrounding the wound and foreign material. Tumours scopic examinations), immunohistological (immunofluo- may also initiate an inflammatory response. rescent and immunoperoxidase), and molecular histologi- Thirdly, the inflammatory process involves two types of cal (in situ hybridisation and polymerase chain reaction cellular components—the infiltrating inflammatory cells (PCR) in situ hybridisation) techniques, the immunopa- and the ocular resident cells. The types and subtypes of thology of uveitis has been studied using inflamed ocular inflammatory cells are easily identified by routine histology tissue.1–4 The findings usually provide helpful information and immunohistochemical stains.34 These cells release in the diagnosis and therapy of uveitis. The immunopa- numerous lymphokines, cytokines, immunoglobulins, thology of uveitis allows the visualisation of the morpho- growth factors, and inflammatory mediators, which can be logical interaction in the eye at the time the specimen is identified by immunohistochemistry.3 The messenger obtained. This information also helps in the understanding RNAs of many cytokines and growth factors can be of the immunopathogenesis of ocular inflammation. detected by molecular histological techniques.12The ocu- Three main aspects of pathological examinations are lar resident cells may undergo oedema, damage, necrosis, analysed. Firstly, the morphology of the ocular specimen or proliferation. They also respond by releasing cytokines, illustrates the lesions and specific localisations within the growth factors, and altering cellular markers including eye. These include inflammatory exudate in the anterior major histocompatibility complex molecules (MHC class I chamber, known as hypopyon, commonly located at the and II), and adhesion molecules. inferior angle, inflammatory cellular infiltration in the cor- On examining a specimen, consideration of the clinical nea (keratitis), the uvea (focal or diVuse iritis, cyclitis, presentation of the disease is extremely important. The iridocyclitis, choroiditis), the retina (retinitis), the vitreous inflammatory response depends on the host condition. (vitritis or abscess), the sclera (scleritis), and inflammation Immunocompromised patients generate less inflammatory surrounding the lens or its remnants. The following terms reaction than immunocompetent patients. Patients with indicate certain pathological findings in the eye. Endoph- diabetes mellitus or carcinoma may produce a diVerent thalmitis occurs when ocular inflammation is confined to inflammatory response. Ocular inflammation can be http://bjo.bmj.com/ three or more tissues inside the eye. Panophthalmitis, on altered by medical treatment, especially immunosuppres- the other hand, indicates that ocular inflammation involves sive medication or radiation. The genetic background and all layers of the eye including the sclera. Anterior uveitis is family history of the patient will also help clarify the ocular inflammation in the cornea, the iris, and the ciliary immunopathology of uveitis. body. Posterior uveitis is ocular inflammation in the Because the inflammatory reaction involves such a choroid, the retina, and the vitreous. Panuveitis is ocular dynamic process, there is only a short time to view the dis- inflammation in both anterior and posterior segments of ease. The pathology is based on this particular picture for the eye. the interpretation of the entire inflammatory process. The on September 26, 2021 by guest. Protected copyright. Secondly, agents that induce inflammation. Biological, situation is like being asked to tell a cartoon story from chemical, or physical stimuli can induce ocular inflamma- looking at one drawing. Thus, it is necessary to survey the tion. Various infectious micro-organisms including bacte- ophthalmic microenvironment for changes in various ocu- lar components and to properly appreciate how these ria, viruses, fungi, and parasites are capable of triggering 20 21 diVerent degrees of inflammatory response. Several ocular changes influence each other. Many clinical specimens proteins, such as retinal soluble antigen (S-Ag),5 interpho- are obtained from end stage disease, and so they may be of toreceptor retinoid binding protein (IRBP),6 and uveal little use for the treatment of individual cases. melanin associated proteins,7 are autoantigens inside the eye. These potent antigens are known not only to induce Techniques ocular inflammation in various animal models,5–7 but also Routine histology for ocular tissues may require additional may be involved in human uveitides based on clinical processing steps other than those used for other tissues in studies.8–10 Cellular responses to S-Ag, IRBP, and their the body.20 The clearing and embedding agents may be dif- peptides have been reported in patients with uveitis.11–13 ferent and need to be handled extra carefully. The Antiretinal autoantibodies have been shown in the sera of histotechnician should have a working knowledge of ocular uveitic patients.14 15 Some investigators have considered anatomy to be able to follow the instructions provided by that sympathetic ophthalmia and Vogt–Koyanagi–Harada the ophthalmic pathologist. However, the methods of (VKH) syndrome reflect autoimmunity against choroidal histological staining for ophthalmic pathology are often the melanocytes.16–18 Recently, two peptides derived from the same as those for other surgical specimens. Light and elec- human S-Ag have been found to bind eYciently to HLA- tron microscope studies are frequently complementary. A29, the predisposing allele for birdshot retinopathy.19 This In general, the immunohistochemical technique for ocu- finding demonstrates the implication of T cell epitopes lar tissues is similar to that for other tissues.3 The art of from retinal autoantigens in birdshot retinopathy. Trauma immunohistochemistry allows for the union of immuno- and foreign bodies can elicit an inflammatory reaction logy with microscopy, a specialised application of the 92 Chan, Li antigen-antibody reaction on the tissue section. A specific organism elicits diVerent kinds of responses in the host. Br J Ophthalmol: first published as 10.1136/bjo.82.1.91 on 1 January 1998. Downloaded from antibody is needed and the specimen must be prepared in These infectious agents must invade the body and target the such a way as to preserve the reactivity of the antigen. eye. Once the micro-organism enters ocular tissue, an Cryostat sections may retain tissue antigenicity better than immune response is generated. In general, Gram positive paraYn sections but they may show poor morphology. and Gram negative bacteria produce an acute inflammatory Immunofluorescence, immunoperoxidase, avidin-biotin response and abscess formation. Acid fast bacteria produce complexes, and immunogold have been commonly used as granulomatous inflammation and caseation necrosis. immunolabelling methods. Except for the colloidal gold Fungi, while targeting the choroid, produce chronic granu- methods for electron microscopy, immunohistochemical lomatous or non-granulomatous inflammation and hyper- staining for light microscopy depends upon enzyme- sensitivity reactions. Identified by viral inclusion bodies, substrate reactions that will convert colourless chromogens viruses produce chronic non-granulomatous inflammation into visible, coloured end products. and may cause resident cell transformation. Viruses tend to In situ hybridisation, the localisation of specific messen- target the cornea and the retina. Dead parasites may cause ger RNA (mRNA) or DNA in tissues and cells using an inflammatory reaction in the host. Specific stains—for nucleic acid probes, has become an increasingly valuable example, Gram and acid fast stains for bacteria, Grocott’s technique. This method is able to detect genes of foreign methenamine-silver stain for fungi, and Warthin–Starry pathogenic DNA2 and to identify a specific cytokine at the stain for spirochaetes, are required to identify micro- transcriptional level.22 There are many protocols for in situ organisms invading the eye. Electron microscopic examin- hybridisation.123Each protocol includes preparation of the ation of viral particles and immunohistochemical staining tissue section on a coated slide, tissue fixation and for viral antigens or in situ hybridisation and PCR in situ pretreatment, labelling of a specific probe, hybridisation, hybridisation for viral DNAs are required to identify virus post-hybridisation washing, and signal visualisation by in the eye. Non-infectious inflammation can present all immunohistochemistry or autoradiography. Proteolytic types of inflammatory responses—chronic or acute, and enzymes allow better penetration of the probe into paraffin non-granulomatous or granulomatous. fixed tissue. The labelling of non-radioactive probes with biotin, digoxigenin, or fluorescence can avoid the use of hazardous radioactive reagents, increase the resolution, Infiltrating cells in uveitis and shorten the exposure time needed for detection of a GRANULOCYTES 21 signal. The sensitivity of non-radioactive probes has been All three types of granulocytes can be found in uveitis. improved greatly and is now comparable with radioactive Polymorphonuclear neutrophils are the hallmark of acute 33 probes. inflammation. These cells secrete several
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