Effective Treatment of Ligneous ConjunctivitisWith Topical Plasminogen

PATRICK WATTS, FRCOPHTH, PALANISAMY SURESH, FRCS (ED), EEDY MEZER, MD,ANNA ELLS, FRCSC, MANUELA ALBISETTI, MD, LAZLO BAJZAR, PHD,

VELMA MARZINOTTO, RN, MAUREEN ANDREW, MD, FRCPC,PATRICIA MASSICOTLE, MD, FRCPC, AND DAVID ROOTMAN, MD, FRCSC

● PURPOSE: The etiology of ligneous conjunctivitis isnow known to be due to an underlying type 1 plasmin-ogen deficiency. We hereby report the clinical features ofthree cases and their response to topically administeredplasminogen.● DESIGN: Observational case series.● METHODS: Two Caucasian females aged 5 years and an18-month male of north African descent presented witha membranous conjunctivitis, which recurred after sur-gical excision. Case 1 presented before the associationwith plasminogen deficiency was known with a bilateralchronic membranous mucopurulent conjunctivitis fromthe age of 14 months associated with bronchiolitis andgingival hyperplasia. A diagnosis of ligneous conjuncti-vitis was entertained and a number of drops were insti-tuted. At the age of 4 years plasminogen levels wereordered. Case 2 presented at the age of 4 years with aunilateral chronic membranous conjunctivitis. Plasmin-ogen levels were requested as soon as a diagnosis ofligneous conjunctivitis was suspected. Case 3 was bornwith congenital hydrocephalus. Conjunctivitis wastreated with antibiotics from the age of 1 month. Hepresented to the eye clinic at the age of 5 months whena clinical diagnosis of ligneous conjunctivitis was enter-tained and treated with a number of medications. Plas-minogen levels were available at 9 months of age.● RESULTS: The two female patients returned plasmino-gen levels of 0.25 U/ml and 0.3 U/ml, well below thenormal level of 0.7–1.0 U/ml. Functional plasminogenlevels in the male infant were not recordable withplasminogen antigen levels of 0.125 U/ml (normal range,

0.52–1.82). All cases have responded well to excision ofthe membranes and institution of topical plasminogendrops. There has been no recurrence with more than 12months’ follow-up.● CONCLUSIONS: With the knowledge of the etiology ofligneous conjunctivitis, efforts are underway to identifythe best method of delivery of plasminogen. Topicalplasminogen concentrate from fresh frozen plasma holdspromise as the definitive treatment for this chronicmembranous conjunctivitis (Am J Ophthalmol 2002;133:451–455. © 2002 by Elsevier Science Inc. Allrights reserved.)

U NTIL RECENTLY, THE ETIOLOGY OF LIGNEOUS CON-

junctivitis was largely unknown. Reports indicatedthat it was an autosomal recessive disorder.1 Clin-

ically, it presents as a pseudomembranous or membranousconjunctivitis with or without other mucosal involve-ment.2–5 Congenital hydrocephalus has been reported withthe more severe forms of the disease.6–10 Histologically, themembrane consists of focal deposits of fibrin and a variablecellular infiltrate with immunoglobulin fragments.11 It hasbeen suggested that a cellular-mediated immune processmay account for its multifocal mucosal involvement.12

To date, a number of therapeutic interventions havebeen reported to treat the condition. These have revolvedaround methods of lysis of the membranes, with hyaluroni-dase,13 �-chymotrypsin,14,15 heparin,15 or immune suppres-sion with corticosteroids, azothioprine, and cyclosporin.11,16

Since the demonstration of a severe type 1 plasminogendeficiency in three unrelated girls with ligneous conjunc-tivitis, efforts are underway to secure the best method ofdelivery of a plasminogen concentrate.8,17 In this report wedescribe the clinical features and response of ligneousconjunctivitis to a topical plasminogen concentrate inthree children. The clinical features and management ofcase 3 have been described in a previous report18 beforetreatment with plasminogen drops was made available.

Accepted for publication Dec 6, 2001.From the Department of Ophthalmology, The Hospital for Sick

Children and Toronto Western Hospital, Toronto, Canada (P.W., P.S.,E.M., D.R.); Department of Ophthalmology, Alberta Children’s Hospital,Calgary, Alberta, Canada (A.E.); Department of Pediatrics, Division ofHematology/Oncology, The Hospital for Sick Children, Toronto, Canada(M.A., V.M., M.A., P.M.); Hamilton Civic Hospitals Research Center,Hamilton, Ontario, Canada (L.B.).

Reprint requests to D. Rootman, MD, FRCSC, Room 009, 7EC,Toronto Western Hospital, Toronto, Ontario, Canada; fax: (416) 603-1993; e-mail: d.rootman@utoronto.ca

© 2002 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.0002-9394/02/$22.00 451PII S0002-9394(01)01433-7

METHODS

● CASE 1: This 5-year-old female was the product ofnonconsanguineous Caucasian parents. While the motherwas pregnant with the child, there was concern as to thepossibility of ventriculomegally on ultrasound scans, how-ever, this had resolved at term. Her developmental mile-stones were normal. At the age of 2, she developed anupper respiratory infection with a mucopurulent conjunc-tivitis. This was treated with topical antibiotics, whichfailed to resolve the condition. When first examined at theage of 3 years, she had a normal visual acuity with abilateral membranous conjunctivitis (Figure 1). A diagno-sis of ligneous conjunctivitis was made and she was treatedfor varying periods with either topical dexamethasonedrops, disodium chromoglycate, or cyclosporin eye dropswithout any resolution of her symptoms. The membranes,which where excised twice, quickly recurred. The histologydemonstrated focally atrophic thickened epithelium withsubepithelial focal necrosis, fibrinous eosinophilic exu-dates, amorphous eosinophilic debris, and acute andchronic inflammatory cells. At the age of 4 years afterreports indicated an association of a plasminogen defi-ciency and ligneous conjunctivitis, she was referred to thehematology department for investigation. A diagnosis ofplasminogen deficiency with ligneous conjunctivitis wasconfirmed with a level of 0.25 U/ml (normal, 0.7–1.0U/ml)

She was started on a plasma concentrate made up as eyedrops from donated plasma. Though the membranes didrecur, they were smaller and softer. The membranes wereexcised again, which was followed by therapy with aderivative of fresh frozen plasma containing high concen-trations of plasminogen prepared as eye drops. This wasinitially instilled every 2 hours for the first 3 weeks andthen reduced to four times a day. At a 6-month follow-upthere has been no recurrence of the membranes (Figure 2a, b). At 12 months the membranes are minimal and thepatient is asymptomatic.

● CASE 2: A 5-year-old girl was referred to the eye clinicwith a chronic focal lesion of the right lower lid thatoccurred after drainage of a chalazion. The lesion was

thought to be possibly a viral papilloma. The lesion wasexcised and quickly recurred within a month of excision.The pathology pointed towards a diagnosis of ligneousconjunctivitis. She was thus investigated for a systemicplasminogen deficiency. Treatment with cyclosporin eyedrops failed to improve the condition.

On examination she had a large crusting lesion arisingfrom the right lower fornix with a mucopurulent conjunc-tivitis and a mechanical ectropion (Figure 3). Her visualacuity was 6/7.5 in her right and left eye. The rest of theocular examination was normal. She was referred to theDepartment of Hematology for further investigation.Apart from a reduced plasminogen level of 0.39 U/ml, herthrombophilia screen was normal.

The membrane was excised a second time and she wasstarted on a concentrate of plasminogen eye drops preparedfrom fresh frozen plasma. Initially, the frequency of dropswas every 2 hours, which was reduced to four times a dayafter a month of therapy. At 6-month follow-up she wasfree of any further recurrences (Figure 4), and continues tobe free of membranes at 12 months.

● CASE 3: This 18-month-old infant was born at 36 weeksgestational age and was the first child of nonconsanguin-eous Libyan parents. At birth, he was diagnosed withcongenital occlusive hydrocephalus for which he wastreated with a ventriculoperitoneal shunt. At 1 month, hewas seen by a family doctor for conjunctivitis, which failed

FIGURE 1. (a), (b) Case 1, right and left eye of patient beforeplasminogen therapy showing thick fibrinous membranes.

FIGURE 2. (a), (b) Case 1, right and left eye showing resolu-tion of membranes on plasminogen therapy (6 months therapy).

FIGURE 3. Case 2, right eye with fibrous thickened mem-branes arising from the lower lid conjunctiva causing mechan-ical ectropion.

AMERICAN JOURNAL OF OPHTHALMOLOGY452 APRIL 2002

to improve with antibiotic drops. He was subsequentlyreferred to the eye clinic at the age of 5 months. He had abilateral membranous conjunctivitis with palpebral andforniceal involvement and bleeding occurred on attemptedremoval (Figure 5). The bulbar conjunctiva was notinvolved and the rest of the ocular examination wasnormal. A diagnosis of ligneous conjunctivitis was made.Subsequent referral to the Department of Hematologyconfirmed an associated plasminogen deficiency. At 9months of age, his plasminogen antigen levels were 0.125U/ml (normal, 0.52–1.82) with unrecordable functionallevels. The functional plasminogen levels recorded de-creased plasminogen activity in the parents (mother 0.61U/ml and father 0.59 U/ml [normal range, 0.7–1.0 U/ml])and borderline normal plasminogen antigen level (mother0.55 U/ml and father 0.64 U/ml [normal range, 0.52–1.82U/ml]. He was initially treated with corticosteroid dropsand surgical debridement. Histology of the membranerevealed fibrin and fibrovascular tissue infiltrated withlymphocytes, plasma cells, neutrophils, and eosinophils.Recurrent membranes were treated with cyclosporin A and

heparin (5000 U/ml) drops with no resolution of thecondition.

When plasminogen drops were made available for thechild, he underwent repeated surgical debridement withthe instillation of plasminogen drops at 2-hour intervalsuntil reepithelization occurred and maintenance withdrops four times a day. There has been no recurrence of themembranes with a 6-month follow-up (Figure 6), andremains so after 12 months follow up.

● PLASMINOGEN DROP FORMULATION: Plasma (1 U) ispassed over a 100-ml Lysine–Sepharose column previouslyequilibrated in 0.1 mol/l NaPi pH 8.0. It is washed withNaPi pH 8.0 until the absorbance at 280 nm of thecollected fractions is below 0.01. The plasminogen iseluted with 20 mmol/l Epsilon aminocaproic acid in 20mmol/l Tris pH 8.0. Peak fractions of plasminogen arepooled and precipitated with 75% ammonium sulfate.Following centrifugation, the supernatant is decanted andthe remaining pellet is dissolved in a minimum amount of0.1 mol/l NaCl in sterile water and dialyzed exhaustivelyagainst the same (4 � 4 liters overnight at 4 C). Theretained material is then subjected to filtrations using a0.45-�m filter attached to a 30-ml syringe into a steriletube. The absorbance is determined using an extinctioncoefficient of 1.61 ml/mg/cm and the plasminogen isdiluted to a concentration of 10 uM (approximately 1mg/ml).

The plasminogen is stored at �70 C. It may be trans-ported on dry ice and reconstituted by thawing in aliquotsof 4.6 ml. Before use, 1 ml of sodium hyaluronate 1% isadded and the mixture is kept refrigerated at 4 C.

DISCUSSION

THE PLASMINOGEN GENE IS LOCATED IN THE LONG ARM OF

chromosome 6.19 Mutations in the plasminogen gene have

FIGURE 4. Case 2, right eye showing resolution of membraneson plasminogen therapy.

FIGURE 5. Case 3, left eye demonstrating membranes arisingfrom the lower fornix

FIGURE 6. Case 3, left eye showing resolution of the mem-branes on plasminogen therapy.

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been associated with ligneous conjunctivitis with the moresevere forms of the disease, associated with an early onset,tracheobronchial, cervical, middle ear, and gingival muco-sal involvement with or without occlusive hydrocepha-lus.2,5,6,8,9,20–22 The severity of the disease appears to beinversely related to the level of functional plasminogenactivity. It is inherited as an autosomal recessive disorder1

with low levels of plasminogen reported in both homozy-gous and compound heterozygous individuals.9,17,20 It ispossible that those individuals with isolated ocular in-volvement may be heterozygotes with plasminogen levelshigher than those with severe disease, but well below thenormal range.23

Ligneous conjunctivitis has been reported only in type 1plasminogen deficiency where the immunoreactive plas-minogen is reduced together with reduced functionalactivity. The prevalence of type 1 plasminogen deficiencyin the United Kingdom has been reported to be 0.26%.24

It is not known why there is no increased risk of intravas-cular thrombosis in this disease. Experiments of clot lysis inplasminogen deficient mice suggest the possibility of alter-native fibrinolytic proteases.25 In addition, it has beensuggested that an alternative system might exist for disso-lution of intravascular fibrin, which is not active in theextravascular compartment.17,26

In case 1, there was involvement of the gums andbilateral ocular involvement. In case 2, there was unilat-eral ocular involvement. Higher plasminogen levels werenoted in case 2, which was associated with a more limitedform of the disease. Case 3 had no functional plasminogenactivity recordable exhibiting the more severe form of thedisease with congenital occlusive hydrocephalus, membra-nous conjunctivitis, and gingival involvement. Cases 1 and2 clinically resemble the heterozygous form of the diseasewith a later presentation and the disease limited to ocularand gingival (case 1) mucosa. Case 3 resembles the homo-zygous form of the plasminogen deficiency where the parentsrecorded heterozygous levels of plasminogen activity.

The disease was possibly initiated by a trigger, a muco-purulent conjunctivitis in case 1 and the surgical incisionof a chalazion in case 2. This phenomenon is reported inliterature where ligneous conjunctivitis has been reportedto follow an infection or surgical trauma.11,27–30 Removalof the membranes is associated with a rapid recurrence, dueto the fact that trauma associated with excision allows theformation of a fibrin clot which is inadequately lysed due toa deficiency in plasminogen and this leads to the thickfibrinous membranes.15 There was no apparent trigger incase 3, however, removal of the membranes was associatedwith a rapid recurrence within 2 to 3 days.

Although spontaneous resolution of this disease hasbeen documented after multiple recurrences, the diseasemay be potentially blinding.11 Before the association of anunderlying plasminogen deficiency with ligneous conjunc-tivitis was known, cures have been reported with topicalcorticosteroids, mast cell stabilizers,16,31 azothiprine,32 cy-

closporin A,16,33,34 and heparin,15 of which the latterseemed to be most promising.

Intravenous replacement therapy with a purified plas-minogen concentrate in an infant with a homozygousplasminogen deficiency led to a rapid resolution of themembranes from the respiratory tract and the eye.17 This,however, requires repeated intravenous administration ofplasminogen, which has a very short half-life. In addition,the fact that plasminogen concentrate manufactured inVienna, Austria, is no longer available makes therapy withthis method of administration difficult.

The fact that the three cases in this report had externaland easily accessible mucosal involvement encouraged thesearch for a topical preparation. This was prepared fromfresh frozen plasma where excellent levels of plasminogencould be assured. Over a short period of follow up, therecurrence of these membranes has been halted. Cases 1and 3 had limited gingival involvement, which did notrequire any systemic treatment. However, in those chil-dren with severe nonocular involvement, systemic treat-ment with plasminogen may be necessary.

This report reemphasizes the clinical features and thecause of ligneous conjunctivitis. It reports on the favorableoutcome of a novel treatment of the condition with topicaldrops of plasminogen in three children. As far as we areaware, this is the first report of management of thiscondition with topically applied plasminogen drops andrepresents a novel specific approach to this disorder

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