SUMMARY The concentrations of tear lysozyme, lactoferrin, ceruloplasmin, IgA, and IgG have been estimated in patients with dry eyes at the same time as semiquantitative bacterial culture was performed of the conjunctivae and lids. Staphylococcal isolations were quantified and biotyped. There was no increased conjunctival colonisation by any particular biotype of Staphylococcus aureus or Staph. epidermidis, and similar numbers of conjunctivae were sterile as in controls (33%); neither were any pathogens such as pneumococci or haemophili isolated. We consider that the conjunctiva of the dry eye, without the lacrimal secretion components of lysozyme and lactoferrin, has an alternative protective antibacterial mechanism which is derived from serum proteins via chronically inflamed vessels.The dry eye is often considered to be infected with staphylococci,' partly because they are easy to culture from the lids and conjunctivae2 and partly because of reduced amounts of tear lysozyme being present. However, the normal eye is usually colonised with certain types of staphylococci, so that commensals need to be distinguished from those with a pathogenic role. Different subtypes of staphylococci have recently been investigated in both normal persons and patients with chronic blepharitis by a semiquantitative culture technique.3 Certain biotypes of staphylococci were shown to exist in large numbers on normal lids and conjunctivae while only 33% of normal conjunctivae sampled were sterile. This same technique has now been used to culture organisms from patients with either keratoconjunctivitis sicca or 'questionably dry' eyes in order to investigate how the bacterial flora differs in these patients from that of normal persons and whether it relates to altered concentrations of lysozyme, lactoferrin, ceruloplasmin, or immunoglobulins found in their tears. Patients and methodsResults from 66 normal volunteers, aged 20-80 and previously described,34 have been compared with those from patients. Both groups were sampled for tear proteins and microbial culture over the same period by identical techniques. Both eyes were sampled of six patients with well established keratoconjunctivitis sicca, as were both eyes of 13 patients who were considered 'questionably dry' and who also had reduced levels of tear lysozyme and lactoferrin.The bacteriological sampling technique has been described previously3 together with the simple BairdParker scheme used to subdivide Staphylococcus epidermidis isolates into five biotypes. The enzymelinked immunosorbent assay (ELISA) method developed to measure the concentration of the various tear proteins has also been given,3 as well as the effect of age on normal levels.4 This has allowed us to compare the tear protein concentrations for each patient with expected normal values for that age. Results TEAR PROTEIN PROFILESIn the sicca patients both tear lysozyme and lactoferrin concentrations were more than 2 standard deviations below the mean of normal persons (p<0O05), while the ceruloplasmin concentration...

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SUMMARY Concentrations of lysozyme, lactoferrin, ceruloplasmin, IgA, and IgG have been measured in tears by the ELISA (enzyme-linked immunosorbent assay) technique. Tears were collected on weighed filter paper discs, after which they were eluted into buffer and transported frozen to a remote laboratory for assay. Patients with sicca, questionably dry eyes and ocular pemphigoid were sampled, as were 54 normal volunteers. Tear protein profiles were established which were unique for each condition and clearly differed from the normal controls. The assay developed is considered suitable for other proteins such as IgE, and could also be used for monitoring the effects of drugs on the lacrimal gland.We have previously described a method for assaying tear lysozyme.' 2 We used calibrated standards, an agar plate, and live Micrococcus luteus. We established normal values which decreased with age, and were able to detect early cases of keratoconjunctivitis sicca. We could show that the tear lysozyme concentration varied with the severity of this disease, and that fine particulate matter in the tear film was a sensitive marker of the dry eye in its early stages. We also established that the significant reading for our modified Schirmer I test was 6 mm or less. This agreed with Sjogren3 and von Bijsterveld4 but conflicted with Jones at 10 mm' and Schirmer himself at 15 mm.6We were also interested in early recognition of ocular toxicity to the beta blocker drug practolol (Eraldin), which was found to be capable ofproducing a dry eye together with conjunctival scarring and corneal destructive changes.7 We compared various beta blockers and showed that only practolol among them could'lower tear lysozyme.8 We were also able to demonstrate low levels of lysozyme before ocular signs of toxicity were present, and we found significantly lower levels in a few patients who did not have signs of ocular toxicity. We found that we could predict the onset of toxicity in individual patients when a drop occurred in the levels of tear lysozyme.There are many proteins in tears and we considered that there may be further diagnostic significance in alterations of these proteins in various external eye disease states.9 The development of a tear eluate transport system' allowed us to turn to the ELISA method for estimating simultaneously a number of different tear proteins using tear eluates so that we could achieve a profile. This is a new application of the ELISA technique. We decided to investigate such profiles in cases of established sicca and ocular pemphigoid as well as cases in which the diagnosis of sicca was entertained but in doubt, 'questionably dry eyes'. Materials and methodsBoth eyes of 7 patients with established sicca and 7 patients considered to have questionably dry eyes according to definitions previously given9 were examined and tear fluid collected on to discs. These were weighed before and after collection in a 200 ILI se'aled plastic pot in the clinic with a Cahn automatic portable electronic balance. 150 p1 of phosphate ...

Riolan's injections of botulinum toxin are the preferred modality of treatment for all types of blepharospasm and cost considerably less.

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